Holes found in primary care insomnia management

Sep 9 2013

By Lucy Piper, Senior medwireNews Reporter

Better education and training for management of sleep problems is needed, including a clear primary care pathway to treatment, suggests the experience of patients and clinicians in the UK.

This conclusion arises from interviews and focus groups conducted with 28 patients with insomnia and 23 healthcare professionals, including general practitioners (GPs), nurses, pharmacists, and mental health professionals, by researchers at the University of Lincoln.

Their data show that GPs’ first approach to a patient presenting with insomnia is to explore and treat the underlying cause, which leaves some patients feeling frustrated that their insomnia is not being prioritized or taken seriously, despite them agreeing on the connections found.

Otherwise, GPs and patients alike described a stepped-care approach to the treatment of their insomnia. Ways to improve sleep hygiene was most commonly the initial advice, despite many GPs believing most patients would not attempt it.

But evidence from pharmacists indicated that many patients had already been advised about sleep hygiene at their pharmacy and had consequently already tried it.

The study researchers, led by Aloysius Siriwardena, note that “rarely, if ever,” was referral or access to cognitive behavioral therapy (CBT) offered as treatment for primary or comorbid insomnia.

This appeared to be largely due to GPs being unconvinced of its benefits, having had little or no personal experience of patients using CBT, despite it being recommended as a first-line treatment.

Hypnotics were prescribed for insomnia, often in collusion with patients, which some GPs said was to avoid confrontation or to express empathy in cases such as bereavement.

Most GPs indicated that they would prescribe one-off short-term courses of hypnotics, but often patients returned for more and the researchers’ data indicate that prescribing was often more long term than suggested.

The researchers also note in Health Expectations that some patients sporadically self-medicated, rather than taking hypnotics as prescribed.

“We found little evidence, except in a few cases, where GPs and patients used a concordance approach to hypnotic drug regimens involving honest information sharing about their use,” they report.

Both patients and GPs voiced concern about addiction with long-term hypnotic use, although some GPs were less concerned about addiction for elderly patients and the terminally ill.

GPs’ worry about addiction was also reported by some patients to lead to abrupt withdrawal of their hypnotics, with other patients feeling it was not always sensitively handled and alternative support rarely offered.

Overall, patients and all healthcare professionals expressed “that more options should be available to treatment and that health professionals should have better training in treating insomnia,” say Siriwardena and team.

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