New referral pathways to manage insomnia

Current RACGP guidelines recommend cognitive behavioural therapy as a first-line treatment for insomnia, which may be complemented with short-term pharmacological intervention.
 
However, many GPs report inadequate time and resources to administer cognitive behavioural therapy for insomnia (CBTi), according to Dr Alexander Sweetman, a research associate at Adelaide Institute for Sleep Health at Flinders University.
 
‘GPs commonly manage patients with insomnia … but report very limited access to CBTi treatment [or] referral options,’ he told newsGP.
 
‘Consequently, many patients with insomnia in general practice are prescribed sleeping pills such as benzodiazepines, “Z-drugs”, or melatonin. Sleeping pills are not recommended for long-term use.’
 
Academic GP and sleep disorders expert Professor Nick Zwar recently spoke to newsGP about his research to raise awareness that insomnia and other sleep disorders can form part of a GP Mental Health Treatment Plan.
 
Building on this, Dr Sweetman and colleagues, in collaboration with Professor Zwar, have developed a novel referral pathway for GPs to better manage insomnia.
 
The Flinders University trial is modelled on an online CBTi program currently being scaled in the UK through the NHS, Sleepio. Approved by the RACGP National Research and Evaluation Ethics Committee (NREEC), the Australian trial involves automatic patient identification and referral options to a six-week CBTi program.
 
The pathway also helps in facilitating reduction of sedative and hypnotic medicine use.
 
Dr Sweetman said the aim is to provide GPs with an insomnia management pathway specifically tailored to the ‘guideline recommendations, time demands, and capacity of general practice’.
 
‘We want to provide GPs with a digital CBTi pathway, improve patients’ insomnia and reduce sedative-hypnotic medicine use,’ he said.
 
‘[We hope the trial] will prompt GPs to refer patients to a well-established, evidence-based, free and effective digital CBTi program.’
 
The mixed-methods implementation trial will test the feasibility, acceptability and effectiveness of a
comprehensive digital insomnia management pathway.
 
A harm-minimisation approach uses automatic identification of patients whose health records contain recent sedative and hypnotic prescriptions, using a software management pathway and real-time notifications.
 
‘The trial distils RACGP recommendations on benzodiazepine prescribing and insomnia management into a simple digital pathway,’ Dr Sweetman said.
 
‘It helps GPs identify patients with insomnia [as well as] sleeping pill prescriptions.’
 
The Australian trial of Sleepio is accessible through the Doctors Control Panel software integrated with Best Practice and Medical Director.
 
‘GPs can refer patients to the trial and pre-appointment information is sent to the patient,’ Dr Sweetman said.
 
‘Sleepio will then send a referral notification to the GP during the appointment … and GPs are reimbursed $50 per eligible patient.’
 
Dr Sweetman said the ‘comprehensive’ insomnia management pathway is anticipated to result in an estimated 15% rate of sedative and hypnotic cessation between the trial’s baseline and 12 months, as well as reducing patients’ self-reported insomnia symptoms. It is also hoped to be a cost-effective approach to managing insomnia in primary care.
 
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cognitive behavioural therapy insomnia mental health sleep disorders