Open Access
Feature Article

Insomnia treatment. Improved access to effective nondrug options

ALEXANDER SWEETMAN, NICOLE LOVATO, JENNY HAYCOCK, Leon Lack

Figures

© AMENIC181/ISTOCKPHOTO.COM model used for illustrative purposes only
© AMENIC181/ISTOCKPHOTO.COM model used for illustrative purposes only
Dr Sweetman and Dr Lovato are joint first authors.
Dr Sweetman is a Research Associate at the Adelaide Institute for Sleep Health and the National Centre for Sleep Health Services Research, Flinders University, Adelaide. Dr Lovato is a Senior Research Fellow at the Adelaide Institute for Sleep Health and the National Centre for Sleep Health Services Research, Flinders University, Adelaide. Ms Haycock is a PhD Candidate at the Adelaide Institute for Sleep Health and the National Centre for Sleep Health Services Research, Flinders University, Adelaide. Professor Lack is an Emeritus Professor in the College of Education, Psychology and Social Work and the National Centre for Sleep Health Services Research, Flinders University, Adelaide, SA.

A comprehensive eBook, How to Sleep Better, has been developed to assist GPs and patients with education and is freely available (see Box8,29-31). Although the efficacy of education as a standalone treatment for insomnia is inferior to that of more comprehensive treatment methods, such as CBTi, its relative efficacy when compared with the other methods more suitable for deployment in general practice is unknown. 

Digital CBTi

With the rise in popularity of technology and portable devices, a range of digital sleep improvement programs have been developed, which may be suitable for use in general practice. These programs are delivered via the internet and mobile devices, whereby the user participates in four to six interactive weekly sessions. The efficacy of these programs relative to credible placebo programs of similar duration has been shown, with the magnitude of reductions in insomnia symptoms akin to those observed after CBTi delivered in person.32-34 The ease of accessibility of digital programs promotes CBTi-based treatment throughout the community. 

Although the most widely investigated digital CBTi programs (Sleepio and SHUTi) are not currently available in Australia, other digital programs based on the same CBTi evidence and strategies are available (see Box). Digital CBTi programs are highly effective among patients who complete the full four- to six-week course, but about 40 to 60% of patients do not complete the full program. These patients may either require motivational support or contact to encourage adherence or may be more suitable for a face-to-face CBTi option.35

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CBTi administered in general practice 

CBTi is the gold-standard treatment for insomnia and has great potential for insomnia management in general practice. Although CBTi produces robust and durable improvements in sleep, it is traditionally administered over six to 12 weeks on an individual basis, with consultations varying from 15 to 50 minutes. This limits its feasibility for use in general practice, particularly given the significant time and financial costs for both the patient and clinician.36  

A step-by-step approach for GPs to manage insomnia using a brief CBTi program, tailored to the Australian general practice time and funding model, has recently been developed.29 Our group has also shown the clinical efficacy of a brief, group-based treatment program, conducted over four weekly sessions, whereby improvements in sleep and daytime functioning were notably superior to those of some longer, one-on-one programs.21,24,37 This program is the shortest face-to-face CBTi program to date, and the standardised nature of the treatment program ensures effective administration by individuals who are not extensively trained. This program is ideally suited for administration by upskilled GPs, practice nurses or other healthcare workers (an important component to ensure delivery to rural and remote patients who are unable to access intensive clinical services). 

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Referral to a psychologist for CBTi

Referral to a psychologist who specialises in CBTi is best practice for insomnia management.38 The Australian Psychological Society ‘Find a Psychologist’ search tool may be used to find local psychologists who specialise in CBTi and the management of insomnia (see Box).