Implementation of a digital cognitive behavioral therapy for insomnia pathway in primary care

Alexander Sweetman; Anton Knieriemen; Elizabeth Hoon; Oliver Frank; Nigel Stocks; Andrea Natsky; Billingsley Kaambwa; Andrew Vakulin; Nicole Lovato; Robert Adams; Leon Lack; Christopher B Miller; Colin A Espie; R Doug McEvoy

doi:10.1016/j.cct.2021.106484

Implementation of a digital cognitive behavioral therapy for insomnia pathway in primary care

Contemp Clin Trials. 2021 Aug:107:106484. doi: 10.1016/j.cct.2021.106484. Epub 2021 Jun 12.

Authors

Affiliations

¹ The Adelaide Institute for Sleep Health, A Centre of Research Excellence and Flinders Health and Medical Research Institute, Sleep Health, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia; National Centre for Sleep Health Services Research, A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia, Australia. Electronic address: alexander.sweetman@flinders.edu.au.
² East Bentleigh Medical Group, Bentleigh East, Victoria, Australia; Doctors Control Panel Pty Ltd, Australia.
³ National Centre for Sleep Health Services Research, A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia, Australia; Discipline of General Practice, Adelaide Medical School, University of Adelaide, South Australia, Australia.
⁴ National Centre for Sleep Health Services Research, A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia, Australia; Health Economics, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia.
⁵ The Adelaide Institute for Sleep Health, A Centre of Research Excellence and Flinders Health and Medical Research Institute, Sleep Health, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia; National Centre for Sleep Health Services Research, A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia, Australia.
⁶ The Adelaide Institute for Sleep Health, A Centre of Research Excellence and Flinders Health and Medical Research Institute, Sleep Health, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia; National Centre for Sleep Health Services Research, A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia, Australia; College of Education, Psychology and Social Work, Flinders University, Adelaide, South Australia, Australia.
⁷ Sleep and Circadian Neuroscience Institute, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK; Big Health Inc., San Francisco, USA; Big Health Inc., London, UK.

PMID: 34129952
DOI: 10.1016/j.cct.2021.106484

Abstract

Background Insomnia is a prevalent and debilitating disorder commonly managed by family physicians. Insomnia guidelines recommend cognitive behavioral therapy for insomnia (CBTi) as the 'first-line' treatment. However, family physicians report limited time, knowledge, access, support, and referral options to manage patients with CBTi. Consequently, many patients with insomnia are prescribed potentially harmful and addictive sedative-hypnotic medicines (e.g. benzodiazepines). Family physicians require an insomnia management pathway that is specifically tailored to the guideline-recommendations, time demands, and capacity of family practice. Methods This mixed-methods implementation trial will test the feasibility, acceptability and effectiveness of a comprehensive digital insomnia management pathway in family practice. This novel pathway includes digital recruitment of family physicians, automatic identification of patients whose electronic medical records contain recent sedative-hypnotic prescriptions using a software management pathway and real-time notifications prompting physicians to refer patients to a well-established digital CBTi program. At least 10 family physicians and 375 patients with insomnia will be recruited. Physicians will be provided with an eBook to guide gradual sedative-hypnotic withdrawal. Feasibility and acceptability will be assessed from the perspective of patients and physicians. Effectiveness will be determined by co-primary outcomes: cessation of sedative-hypnotic use, and improvement in self-reported insomnia symptoms from baseline to 12-month follow-up. Analysis of trends in costs, cost-effectiveness and cost-utility analyses will be conducted from a societal perspective. Results and discussion This implementation trial will pave the way for future scaling-up of this insomnia management pathway to improve access to CBTi and reduce reliance on sedative-hypnotic medicines in family practice. Trial Registration: This trial was prospectively registered on the Australian and New Zealand Clinical Trials Registry (ANZCTR) (ACTRN12619001539123).

Keywords: Chronic insomnia; Cognitive behavioral therapy for insomnia; Family practice; General practice; Hypnotics; Primary care.

Publication types

Clinical Trial
Research Support, Non-U.S. Gov't

MeSH terms

Australia
Cognitive Behavioral Therapy*
Cost-Benefit Analysis
Humans
Primary Health Care
Sleep Initiation and Maintenance Disorders* / therapy
Treatment Outcome

Associated data

ANZCTR/ACTRN12619001539123