Knowledge and attitudes of primary care nurses about the management of patients with insomnia

Evaluation of the effectiveness of cognitive-behavioural therapy for insomnia delivered by nurses and physicians for patients in primary care (the NPD study): protocol for a cluster randomised controlled trial

INTRODUCTION

Insomnia is the most common sleep disorder, and it adversely impacts daily living and increases the risk of chronic and acute health problems. Of the few individuals who seek treatment for insomnia, most pursue help in primary care settings. The management of insomnia most commonly focuses on the prescription of hypnotics and sleep hygiene recommendations, although these are not the most effective treatments. Conversely, cognitive-behavioural therapy for insomnia (CBT-i), which is considered to be the first-line treatment for persistent insomnia, is seldom prescribed by primary care physicians (PCPs) or primary care nurses (PCNs). The hesitancy of these professionals to provide CBT-i is mainly attributed to their heavy workloads and the difficulties in acquiring the skills needed to administer this intervention.

METHODS AND ANALYSIS

A two-arm cluster-randomised study (in which patients are assigned to a PCP or PCN) will be conducted in primary health centres of Majorca Island (Spain). A total of 206 patients will be recruited. Healthcare professionals will be allocated to the intervention or control group in a 1:1 ratio. The intervention group will receive CBT-i and the control group will receive usual care. We will include patients with Insomnia Severity Index scores of 8 or more who also report that insomnia interferes with daily functioning or is noticeable to others. The CBT-i will consist of four individual structured sessions, three in person (20 min each) and one by telephone (10 min) that are administered at intervals of 2-3 weeks. An additional session will be provided for patients taking hypnotic medications. The primary outcome measure is the decrease in sleep latency, which will be measured with the Pittsburg Sleep Quality index at 6 months and 12 months.

ETHICS AND DISSEMINATION

This project was approved by the Ethical Committee of the Balearic Islands (IB 4604/21 PI) and the Primary Care Research Committee of the Department of Majorca Primary Care (PI19/24). All participants are required to provide written informed consent and no study-related procedures will be performed until consent is obtained. The trial results will be published in peer-reviewed journals and presented at conferences.

TRIAL REGISTRATION NUMBER

ISRCTN10144646.

Assessing the feasibility and acceptability of a cluster-randomized study of cognitive behavioral therapy for chronic insomnia in a primary care setting

BACKGROUND

Cognitive behavioral therapy for chronic insomnia (CBT-i) is the treatment of choice for this condition but is underutilized in patients who attend primary care. The purpose of the present feasibility-pilot study was to assess the feasibility and acceptability of a cluster-randomized study of CBT-i in a primary care setting.

METHODS

This study, performed at two primary health care centers in Majorca, Spain, was a mixed methods feasibility-pilot study of a parallel cluster-randomized design comparing CBT-i and usual care (UC). Patients were included if they were 18 to 65 years-old; had diagnoses of chronic insomnia according to the Insomnia Severity Index (ISI ≥ 8); had insomnia for more than 3 months. Twenty-five GPs and nurses and 32 patients were randomly allocated to two groups. The main outcome of the intervention was improvement of dimensions of sleep quality, measured using the Spanish version of the Pittsburgh Sleep Quality Index, at baseline and at 3 months after the intervention. Other primary outcomes of the study were the feasibility and applicability of the intervention, collected through nominal groups. A thematic analysis was performed to classify primary care provider (PCP) proposals. Additionally, we assessed the recruitment process, compliance with the intervention sessions, and patient retention.

RESULTS

We adapted the CBT-i approach of Morin to a primary care context. After intervention training, PCPs expressed the need for more extensive training in the different aspects of the therapy and the discussion of more cases. PCPs considered the intervention as adequate but wanted fewer but longer sessions as well as to discard the cognitive restructuring component. PCPs considered it crucial to prepare each session in advance and to establish a specific agenda for the CBT-i. Regular reminders given to PCPs and patients were suggested to improve study participation. Compared to the UC group, higher proportions of patients in the intervention group had short sleep latency, slept for longer than 5 h, and had fewer sleep disruptions.

CONCLUSIONS

This feasibility-pilot study identified several key issues that must be addressed before performing a CBT-i intervention in future clinical trial in a primary care setting.

TRIAL REGISTRATION

NCT04565223 . (Clinical trials.gov) Registered 1 September 2020-Retrospectively registered.

The Experience of Insomnia in Patients With Schizophrenic Disorder: A Qualitative Study

BACKGROUND

Insomnia is a health problem that particularly affects people with schizophrenia. Its repercussions go beyond the disorder itself and affect many areas of life. The aim of the present study is to explore the clinical symptoms and consequences of insomnia in patients diagnosed with schizophrenic disorder and the perceptions of these patients regarding the care they receive.

METHODS

The study takes a qualitative approach and uses semi-structured interviews to conduct a descriptive and interpretive analysis of 3 clinically different clusters of patients. These 3 clusters have been defined by using two-step cluster analysis based on the results of the ISI (Insomnia Severity Index) and EQ-5D scales (EuroQol-5D) and the presence of certain diagnostic symptoms in a sample of 170 patients. The final sample was 31 subjects. The analysis was based on a hermeneutic analysis of the patients' narratives regarding their experiences of insomnia.

RESULTS

The patients' narratives show differences in the intensity and experience of insomnia depending on the severity, as well as its impact on their quality of life. Insomnia has a huge emotional impact. Participants describe ruminations and obsessive thoughts as a key factor hindering falling asleep. Some of the everyday actions they perform encourage the chronicity of insomnia. The desired health response must include interventions that are effective, such as cognitive-behavioural therapy, and powerful, such as pharmacological solutions. Psychoeducation and advice on sleep hygiene are highly valued tools as preventive strategies.

CONCLUSIONS

To know the experience of users gives us a more comprehensive understanding of insomnia complexities and brings some new intervention strategies in patients with mental disorders. It is important that health professionals intervene preventively to stop the disorder from becoming chronic.

[Prevalence of insomnia and characteristic of patients with insomnia in a health area of Majorca (Spain)]

Objetivos

Conocer la prevalencia de insomnio y los hábitos, comorbilidades, calidad del sueño y tratamiento de los pacientes insomnes.

Diseño

Estudio descriptivo transversal.

Emplazamiento

Centro de Atención Primaria de Calviá (Mallorca).

Participantes

Sujetos entre 18-80 años con >2 años de adscripción al Centro de Salud.

Métodos

Se realizó una primera entrevista telefónica para cribado de insomnes mediante el Insomnia Severity Index. Los sujetos insomnes fueron entrevistados personalmente en el centro de salud para registrar el resto de variables.

Resultados

De la muestra de 1.563 personas, contactamos con 591 y participaron 467. La prevalencia de insomnio fue del 21,1% (IC 95% 17,38-25,01) y de insomnio clínico del 6,9% (IC 95% 4,45-9,25).

Fue más común en mujeres, viudos y divorciados, jubilados y desempleados. Dos tercios tenían sobrepeso-obesidad; un 37% dolor crónico, un 21,1% depresión y un 37,9% ansiedad. La mitad refería dificultades para realizar las actividades de la vida diaria y mantener un buen estado de ánimo. Asimismo, el 41,1% refería que habitualmente tomaba fármacos para dormir. Las medidas terapéuticas más utilizadas fueron la higiene del sueño y las benzodiacepinas; mientras que las terapias cognitivo-conductuales eran poco habituales.

Conclusiones

La prevalencia de insomnes en nuestra zona es semejante a la esperada en estudios realizados en población general. La presencia de algunos hábitos perjudiciales para el sueño y las comorbilidades pueden favorecer la cronificación del insomnio, por lo que se debe considerar el manejo de esta patología en un contexto más amplio. Predomina el tratamiento farmacológico mientras que las terapias no farmacológicas de demostrada efectividad son muy ocasionales.