Everyone has difficulty sleeping at some point in their life but in most cases this is short term. However, around one in ten people suffer chronic insomnia, which occurs on a regular basis or over a long period of time. It is most commonly caused by stress and worry but can also be triggered by pain, noise, medication, depression and shift-work.
Insomnia contributes to daytime tiredness, which in turn can lead to accidents, illness and work and relationship problems.
This project aims to improve treatment for people with insomnia by promoting a range of treatment options beyond sleeping pills, which are not always the most appropriate course of action and carry the risk of side effects and addiction.
“We’ve surveyed about 1,000 patients and 40 practices in Lincolnshire, focussing on patients who’d had a repeat prescription of sleeping tablets in the previous six months,” project lead Professor Niroshan Siriwardena of Lincolnshire Primary Care Trust explains. “Nine out of ten patients were on a repeat prescription that had been started by their GP. About two thirds took it every night, which is not a good thing to do because of addiction, and half had side effects like headache, dizziness and nausea. One fifth of the patients wanted to stop their tablets and at least half of the patients said they’d tried to come off treatment.”
“We also surveyed GPs, who had beliefs about drug treatments that tended to promote prescribing of newer, more expensive sleeping tablets contrary to the evidence that these are no more effective,” he continues. “But they also had some good ideas on how to improve the situation.”
The project is trying to discourage GPs from prescribing sleeping pills as a first line response, and to encourage them to explore other treatment options first, which may be more in line with what patients actually need. “We also want to find ways of helping people who have been on sleeping pills for some time but would prefer not to be,” Niro adds.
"It’s a bit analogous to the position with antibiotics," Niro continues. "In the late 70s to 80s, it was very common for people to be prescribed an antibiotic for a sore throat or earache. When research was done into this, they found that GPs felt much more pressure to prescribe than patients actually wanted. So you got this mismatch, and that led to very high prescription rates. Nowadays, we don’t prescribe so many antibiotics for sore throats and upper respiratory infections."
Some of the alternative treatments available include sleep hygiene and sleep restriction. “Sleep hygiene is really a bundle of things which aim to regulate sleep patterns,” Niro says. “It includes avoiding things like caffeine, alcohol, exercise and eating late in the evening. Sleep restriction means initially going to sleep later to ensure good quality sleep, making sure you wake up at the same time every day, which is better for your body clock, and then gradually moving back your time to go to sleep.”
Niro believes that a multidisciplinary approach is essential to tackling the problem effectively. "When we first started to explore this issue, we found that efforts to try and improve or change the management of insomnia were more likely to succeed if there was support from the wider organisation or Primary Care Trust," he explains. "We also found that a team approach worked very well in primary care, particularly if it involved patients, clinicians, practices and pharmacy support, all of that working together to a common end."
For the next phase of the project, the team is planning to work with patients to understand what they need from a consultation for insomnia and to work with a number of practices and primary care teams to test the impact of different approaches. “There are some specific interventions that we know work for those who have been on long term sleeping tablets, like writing to patients, review consultations with GPs, self help booklets and, in some cases, psychological therapies,” Niro says. “But there may be other things that practices can do to improve people’s experiences of insomnia management and to avoid starting drug treatment in the first place.”
The team intends to present data back to practices and to analyse whether prescribing is changing as a result of their new approach. If specific measures or combinations of measures are successful in the first five or ten pilot areas, they plan to use opinion leaders to spread the changes and learning more widely. They also hope to link with commissioners in the county and to develop learning materials with the Centre for Health Improvement in Leadership in Lincolnshire.
Lead organisation: Lincolnshire Primary Care Trust
Partners: University of Lincoln, East Midlands Mental Health Research Network Hub, Lincolnshire and Nottinghamshire Mental Health Trusts, Trent Research and Development Support Unit.
Contact
Professor Niroshan Siriwardena
10 April 2007