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.

Sedative-hypnotic withdrawal

Sedative-hypnotic medications increase sleep time initially but are associated with increasing risks of cognitive and psychomotor side effects, serious adverse events, patterns of long-term dependence and mortality when used for longer periods.8,39-41 Furthermore, the rapid development of pharmacological tolerance results in reduced effectiveness and a tendency for dose escalation, while attempts to reduce the dose lead to rapid onset of withdrawal and rebound symptoms.8,40 Many patients with insomnia managed in general practice may require support in withdrawing from sedative-hypnotic medications. Gradual withdrawal from these medications may reduce withdrawal or rebound symptoms, and NPS MedicineWise has developed a gradual withdrawal plan to assist with this (see Box).8

CBTi facilitates successful withdrawal from sedative-hypnotic medications in general practice patients.42,43 For example, CBTi may facilitate withdrawal by reducing withdrawal or rebound symptoms that often complicate the withdrawal process, providing patients with the initial confidence to withdraw from sedative-hypnotics, or resulting in sustained reduction in insomnia after withdrawal to help prevent relapse of sedative-hypnotic use. A recent review of 95 studies including over 10,000 patients supports the use of digital, nurse-administered and psychologist-administered CBTi strategies in facilitating sedative-hypnotic withdrawal.44 CBTi may be initiated in combination with sedative-hypnotic medications, to improve sleep and prevent rebound or withdrawal symptoms, as patients are provided with support to gradually reduce medication use over the course of several weeks.

Research opportunity

The translation of best-practice management of insomnia to the general practice setting is the basis of an NHMRC-funded National Centre for Sleep Health Services Research Excellence program: Positioning Primary Care at the Centre of Sleep Health Management (2018–2022). GPs who are interested in becoming involved in this research program or in research outputs from the program, or who would like  to contribute any feedback on this article or experiences from their own practice, are invited to contact the authors at  www.ncshsr.com/contact.

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Conclusion

As the most common sleep disorder and one with significant associated health risks, reduced quality of life and economic burden, insomnia is problematic for general practice. Pharmacotherapy continues to be the default treatment because it is simple, quick and can be prescribed in the most common 15-minute consultations. However, its limited symptomatic relief rarely provides long-term remission, and it is associated with significant adverse side effects, including drug dependence. RACGP guidelines have recognised this problem and recommend the use of CBTi as first-line treatment, instead of drugs.8

Many GPs also recognise the need for effective nondrug therapies but lack the training and time needed to administer CBTi.36 However, there are a variety of CBTi options, ranging in cost, availability and evidence-based effectiveness, that can be used by GPs. These include sources of useful educational information about sleep and insomnia, online or digital CBTi programs, brief behavioural therapies that can be administered in general practice settings and referral pathways to registered psychologists experienced in CBTi.      MT

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COMPETING INTERESTS: None.