Treatment Options for Insomnia in the New Zealand Primary Care Setting:

Sarah ReidKarma Galyer

What do people find effective?

Waikato Clinical School

Insomnia

• DSM-IV diagnosable insomnia: 5-6 % of general adult population (Ohayon, 2002).

• New Zealand Study - 25% reported sleep problem lasting 6 months duration (Paine, et al, 2004).

• Negative impact on daily functioning is well established (Mai & Buysse, 2008).

• Assessment and intervention resources are limited.

• Medications e.g. hypnotics are the most accessible form of medication.

• Recommendations have been made for the development of alternative treatment options in primary care, particularly by psychologists (TSANZ, 2004).

Insomnia: Management at Primary Care Level

3. What is the relationship between current treatment choice and current insomnia symptoms?

Research Questions

2. What is the relationship between sleep beliefs and use of prescription medication for sleep?

1. How do people with chronic insomnia view the treatment options available to them?

Treatment Choices for Sleep Problems Survey

• Data collection– November 2010 – January 2011.

– Survey monkey online link.

– Posters and survey placed in: • 16 medical centres. • 16 pharmacies.• 5 natural health provider. • Hospital Sleep Clinic.

Treatment Choices for Sleep Problems Survey

Measures

• Athens Insomnia Scale (AIS) (Soldatos et al, 2000).– Cut-off score of 6 = likely insomnia diagnosis.

• Dysfunctional Beliefs and Attitudes about Sleep Scale (DBAS-16) (Morin et al, 2007).– Consequences– Worry– Medication– Expectations

• Treatment Options– Treatment options tried.– Effect on sleep.

Measures

• 177 respondents reported a current sleep difficulty.

– 88% female

– 86% NZ/Other European. – 8% Maori.– 3% other.

Age Group Sample%

15-29 16%

30-39 13%

40-49 10%

50-59 25%

60-69 24%

70-79 3%

80+ 4%

Respondents

Duration Sample % Under 1 month 1%

1-5 months 9% 6-11 months 5%

1-5 years 44% 6-10 years 14%

More than 10 years 25%

Sleep Difficulty Duration

1. How do People with Chronic Insomnia View the Treatment Options Available to Them?

Type of Treatment Had Tried Effect On Sleep

Made Sleep Worse No Effect on Sleep Made Sleep Better

Sleep Hygiene 86% 2% 72% 26%

Sleep Routine 84% 2% 67% 31%

Relaxation 76% 1% 61% 38%

Natural Product 58% 4% 66% 30%

Prescription Medication 55% 20% 6% 74%

Over the Counter Medication 34% 2% 65% 33%

Other (e.g. hypnotherapy) 22% 0% 64% 36%

Sleep Diary 21% 6% 91% 3%

Talking Therapy 19% 0% 73% 27% Specialist Sleep Clinic 5% 0% 75% 25%

2. What is the Relationship Between Sleep Beliefs and Use of Prescription Medication for Sleep?

Treatment Choices and Sleep Beliefs

DBAS Total Consequences Worry Medication* Expectations* 0

1

2

3

4

5

6

7

8

9

10

Never Short-term Long-term

Figure 1: Relationship between prescription medication use and sleep beliefs.

3. What is the relationship between current treatment choice and current insomnia symptoms?

Treatment Choice and Insomnia Symptoms

AIS Total AIS Sleep Difficulties AIS Daytime Con-sequences

0

2

4

6

8

10

12

14

No Current Treatment Non-prescription treatment Prescription Medication

Figure 2: Relationship between current treatment choice and insomnia symptoms.

• Primary care patients are not accessing effective alternatives to medication.

• People using prescription medication for sleep had the greatest perceived current sleep difficulties.

• Consistent with previous research, sleep related beliefs impact treatment choice (e.g. Sanchez-Ortuno & Edinger, 2010).

• Greater endorsement of unhelpful sleep beliefs was related to longer term use of prescription medications.

Conclusions

• Effective in a primary care setting (Edinger & Sampson, 2003).

• Effective in assisting patients cease chronic hypnotic medication use (Pat-Horenczyk, 1998).

• Changes in sleep beliefs through cognitive behavioural techniques resulted in maintained in sleep efficiency (Morin et al, 2002).

Cognitive Behavioural Therapy for Insomnia

Edinger, J. D., & Sampson, W. S. (2003). A primary care "friendly" cognitive behavioural insomnia therapy. Sleep, 26, 177-181.

Mai, E. M., & Buysse, D. J. (2008). Insomnia: Prevalence, impact, pathogenesis, differential diagnosis, and evaluation. Sleep Medicine Clinics, 3, 167-174.

Morin, C. M., Blais, F., & Savard, J. (2002). Are changes in beliefs and attitudes about sleep related to sleep improvements in the treatment of insomnia? Behavior Research and Therapy, 40, 741-752.

Morin, C. M., Vallieres, A., & Ivers, H. (2007). Dysfunctional beliefs and attitudes about sleep (DBAS): Validation of a brief version (DBAS-16). Sleep, 30 (11), 1547-1554.

Ohayon, M. M. (2002). Epidemiology of insomnia: What we know and what we still need to learn. Sleep Medicine Reviews, 6, 97-111.

Paine, S. J., Gander, P. H., Harris, R., & Reid, P. (2004). Insomnia risk factors: implications for treatment services. Annual Scientific Meeting of the Australasian Sleep Association. Auckland, NZ, October 10-12th, 2003. Internal Medicine Journal, A20.

Pat-Horenczyk, R. (1998). Changes in attitudes toward insomnia following cognitive intervention as part of a withdrawal treatment from hypnotics. Behavioural and Cognitive Psychotherapy, 29, 345-357.

Sanchez-Ortuno, M. M., & Edinger, J. D. (2010). A penny for your thoughts: Patterns of sleep-related beliefs, insomnia symptoms and treatment outcome. Behaviour Research and Therapy, 48, 125-133.

Soldatos, C. R., Dikeos, D. G., & Paparrigopoulos, T.J. (2000). Athens insomnia scale: Validation of an instrument based on ICD-10 criteria. Journal of Psychosomatic Research, 55, 263-267.

Thoracic Society of Australia and New Zealand (2004). Standards for Adult Respiratory and Sleep Services in New Zealand. Retrieved 10 August, 2010, from http://www.moh.govt.nz/moh.nsf/pagesmh/3756?Open

References

Sleep Problems. Read the sleep problems below and decide which ones (if any) you have had at least three times per week during the last month. For each problem you have had, please circle the number that best describes your experience of the sleep difficulty.

Sleep induction (time it takes you to fall asleep after turning-off the lights).

Awakenings during the night.

0: No problem1: Slightly delayed2: Markedly delayed3: Very delayed or did not sleep at all

0: No problem1: Minor problem 2: Considerable problem3: Serious problem or did not sleep at all

Final awakening earlier than desired. Total sleep duration (the length of time you slept).

0: Not earlier1: A little earlier2: Markedly earlier3: Much earlier or did not sleep at all

0: Sufficient1: Slightly insufficient2: Markedly insufficient3: Very insufficient or did not sleep at all

Overall quality of sleep (no matter how long you slept).Sense of well-being during the day.

0: Satisfactory1: Slightly unsatisfactory2: Markedly unsatisfactory3: Very unsatisfactory or did not sleep at all

0: 1: Slightly decreased2: Markedly decreased3: Very decreased

Functioning (physical and mental) during the day. Sleepiness during the day.0: 1: Slightly decreased2: Markedly decreased3: Very decreased

0: None1: Mild2: Considerable3: Intense

Worry• I am concerned that chronic insomnia may have serious consequences on

my physical health.• I am worried that I may lose control over my abilities to sleep.• When I sleep poorly on one night, I know it will disturb my sleep schedule

for the whole week.• I can’t ever predict whether I’ll have a good or poor nights sleep.• I have little ability to manage the negative consequences of disturbed

sleep.• I feel insomnia is ruining my ability to enjoy life and prevents me from

doing what I want. Expectations• I need 8 hours of sleep to feel refreshed and function well during the day. • If I don’t get the proper amount of sleep on a given night, I need to catch

up on the next day by napping or on the next night by sleeping longer.

Dysfunctional Beliefs and Attitudes about Sleep Scale

Consequences• Without an adequate night’s sleep, I can hardly function the next day• I avoid or cancel obligations (social, family) after a poor night’s sleep. • When I feel irritable, depressed or anxious during the day, it is mostly because I

did not sleep well the night before.• When I feel tired, have no energy, or just seem not to function well during the

day, it is generally because I did not sleep well the night before. • After a poor night’s sleep, I know that it will interfere with my daily activities on

the next day. Medication • Medication is probably the only solution to sleeplessness.• I believe insomnia is essentially the result of a chemical imbalance.• In order to be alert and function well during the day, I believe I would be better

off taking a sleeping pill rather than having a poor nights sleep.

Dysfunctional Beliefs and Attitudes about Sleep Scale