Issues and challenges in implementing clinical practice guideline for the management of chronic insomnia

The European Guideline for the Diagnosis and Treatment of Insomnia, published in this issue of the journal (Riemann et al., 2017), describes much-needed and timely recommendations intended to inform clinicians concerning good clinical practices for the diagnosis and management of insomnia. Based on a systematic review of more than 60 meta-analyses, its main conclusions with regard to treatment are that: (a) cognitive–behavioural therapy (CBT) should be the first-line treatment for chronic insomnia in adults and (b) pharmacotherapy (i.e. benzodiazepines, benzodiazepine receptor agonists and some antidepressants) may be used if CBT is ineffective or unavailable. These practice guidelines are very much in line with the conclusions of previous consensus conferences on the management of insomnia (National Institutes of Health, 2005; Wilson et al., 2010) and almost identical to guidelines prepared by the American Academy of Sleep Medicine (Sateia et al., 2017) and the American College of Physicians (Qaseem et al., 2016). With this high level of converging evidence, we can safely say that there is consensus in the scientific and professional sleep community that CBT should be the treatment of choice for chronic insomnia. Notwithstanding, there is still a major gap between reaching consensus at the organizational level and adopting/implementing evidence-based recommendations at the individual clinical practice level. Indeed, the current status of insomnia therapies is that CBT is used rarely in routine clinical practice and drug-prescribing practices do not always match evidence-based recommendations. Before addressing the issues and challenges in implementing these guidelines, let us examine first what is the typical treatment trajectory for patients with insomnia and what are important barriers to insomnia treatment, in general, and to using CBT specifically. Insomnia is a condition that is still too often trivialized and not taken seriously, despite accumulating evidence documenting its association with negative health outcomes (i.e. depression, hypertension, work absenteeism). Not surprisingly, insomnia complaints often remain undiagnosed and untreated (Cheung et al., 2014; Ulmer et al., 2017). When treatment is initiated, treatment trajectories vary widely depending on individual and contextual factors, such as knowledge about treatment options, availability of treatment and the type of professional from whom someone seeks help (physician, psychologist, pharmacist, nurse). Even before reaching out for professional services, many patients use various self-help remedies (over-the-counter substances or ‘natural products’) of unknown risks and benefits. If and when professional treatment is sought, it is typically from a primary care physician, and medication is often the first and only treatment provided (Morin et al., 2006).8 Several medications prescribed commonly for insomnia (e.g. antidepressants, antipsychotics) are not even indicated for insomnia; a practice which, of course, leads to suboptimal outcomes. By and large, very few patients with insomnia receive CBT. There are several important barriers to insomnia treatment and to using CBT. At the individual level there is still a stigma about insomnia, and many individuals believe that it is not perceived as a real clinical problem and feel misunderstood by the medical community (Araujo et al., 2017; Cheung et al., 2016). There is also a lack of knowledge about the different treatment options, with many individuals being unaware of non-pharmacological therapies. At the clinician level, this lack of knowledge about some treatment options (CBT) is also very common; although some practising physicians report using behavioural interventions in their practice, in reality this is often restricted to general sleep hygiene education. Because CBT is clearly more time-consuming than writing a pill prescription, time is another important barrier in primary care. As patients often present with more than one medical problem, and physicians are already over-extended with dealing with multiple medical problems, insomnia may not be very high on the priority list. Finally, there are important economic barriers at the health-care system level. Although the economics of health plan coverage for insomnia vary a great deal around the world, in general there is little financial incentive to conduct CBT. Finally, another major barrier, and not the least, is that there are few providers with adequate training to provide CBT for insomnia. Given this huge gap, what can be done to ensure that guidelines are more widely adopted and implemented in clinical practices? As a first step, we (insomnia experts and professional sleep organizations) need to do a better job of educating the general public and health-care providers about insomnia, its long-term consequences and evidence-based treatment options. Public education programmes about healthy sleep practices are just as important for sustainable health as those promoting the benefits of healthy diet and exercise, and that information needs to be conveyed more efficiently to the general public. Patient support groups can serve as important partners to disseminate new knowledge about insomnia and its treatment to the general public. Because primary care is the first point of care for most patients with insomnia, more integrated efforts are needed to provide training and support to primary care physicians and other health-care providers so they feel competent to do the initial evaluation of patients and, through a shared decision-making process, to determine the best course of treatment. Given the high prevalence of insomnia, it is probably unrealistic to expect that primary care physicians can deal with all patients with insomnia. Having clinical psychologists or behavioural sleep medicine specialists within every primary care practice would be ideal, although perhaps unrealistic. Related to the previous point, and given the limited number of hours devoted to sleep medicine training, we need to expand postgraduate training programmes to reach a larger number and broader diversity of health-care providers who can achieve clinical competency in assessing and managing insomnia with evidence-based therapies. In order to improve access to CBT, it will be essential to broaden the range of treatment providers (psychologists, physicians, nurses), treatment venues (primary care, community health clinics, pharmacy, sleep disorders centre) and treatment delivery models (in-person individual or group therapy, telemedicine, online therapy). It is important to recognize that not all patients with insomnia require the same level of care. While more complicated cases may need a higher level of expertise from a behavioural sleep medicine specialist, many patients with less severe insomnia could benefit from abbreviated behavioural interventions delivered by non-psychologists/CBT experts. Also, we need to make CBT for insomnia more user-friendly by non-sleep specialists. Increasing evidence suggests that self-help and eCBT is a cost-effective treatment for insomnia (Zachariae et al., 2016). Such low-intensity interventions should be seen as a first level of care, or else as complementary to the more traditional in-person consultation model. More efficient lobbying at the government and health-policy decision making levels could help to improve reimbursement for CBT. Although economic issues may vary widely throughout countries, the cost of CBT for insomnia, when available, remains an important barrier in many areas of the world. For instance, in Canada, a country with universal health-care access, the public health system pays for medical consultations and some sleep medications, but CBT is covered only by some private insurance carriers. Perhaps insomnia researchers need to do a better job of documenting the cost–benefits of CBT. Once it is demonstrated clearly that an investment of 500 Euros, as an example, for treating insomnia can save twice as much in reducing morbidity (e.g. work absenteeism), perhaps government, health-care decision-makers and payers will see insomnia as a real problem that deserves clinical attention with evidence-based therapies. Professional sleep medicine associations could also contribute to improving access to competently delivered CBT for insomnia. An efficient way of achieving that would be to make it mandatory that all accredited sleep clinics have on their staff a psychologist or behavioural sleep medicine specialist with CBT expertise to treat insomnia. This would be no different to requiring a board-certified specialist (physician) to read and interpret polysomnography (PSG) studies. How can a sleep disorders centre be accredited by its professional societies without qualified professionals to treat insomnia? In summary, the European insomnia guideline is a much-needed and timely resource to inform clinicians about optimal practice for insomnia management. While dissemination of this guideline is a first step, it does not guarantee that it will actually change practices. Concerted efforts from all stakeholders (patients, policy-makers, professional societies) will be necessary to make sure that these evidence-based guidelines are actually adopted and implemented in the day-to-day clinical care of patients with insomnia.

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