Improving the primary care management of insomnia
Submitting InstitutionUniversity of Lincoln
Unit of AssessmentAllied Health Professions, Dentistry, Nursing and Pharmacy
Summary Impact TypeHealth
Research Subject Area(s)
Medical and Health Sciences: Clinical Sciences, Public Health and Health Services
Psychology and Cognitive Sciences: Psychology
Summary of the impact
Research into primary care insomnia by the Community and Health Research
Unit (CaHRU) has led to broad improvements in healthcare provision
for insomnia, improved patient quality of life, informed
national/international policy and practice in insomnia care and impacted
directly on health professional practice and insomnia sufferers, initially
in Lincolnshire spreading across the UK and internationally from 2008 to
2011. Direct effects on practice include changes in sleep management and
reduced hypnotic prescribing through seminars, workshops, conferences and
e-learning developed by the team; inclusion in UK policy, practitioner
information, training materials and guidance on hypnotics has led to
greater professional and public awareness of sleep management
Insomnia affects 30% of adults every year, 10% having chronic symptoms
leading to impaired quality of life, work absence, poor performance and
economic consequences. The effects of insomnia are often compounded by
adverse effects of hypnotic (sleep inducing) drugs. There is longstanding
evidence of inappropriate prescribing of hypnotic drugs in primary care:
hypnotics are prescribed to 10% of adults and 25% of those aged over 65
years in the UK. Previous advice fails to highlight to general
practitioners (GPs) alternatives to drugs.
A central theme of the group's activity is translational research
relating to quality improvement in health and social care, using various
methods to investigate how to improve care provision through innovation,
quality improvement and service redesign and to evaluate the effects of
interventions designed to bring about improvement.
The research programme (2005 — ongoing)
Aims: The research aims to understand and improve primary
care management of insomnia and sleep problems.
Staffing: The research was conducted by members of the
Community and Health Research Unit (CaHRU) led by Prof A Niroshan
Siriwardena (2005 -) and including postdoctoral staff (Zowie Davy 2009 -;
Jo Middlemass 2010 -; Markos Klonizakis 2009-2012), research assistants
(Fiona Togher 2009 - ; Coral Sirdifield 2008 -; Viet-Hai Phung 2011 -),
and visiting staff: Prof Roderick Ørner (Lincoln 2005 -), Dr Jane Dyas
(Lincoln 2005 -) and Prof Irving Kirsch (Lincoln/Harvard, US 2010 -). The
late Andrew Harrison was the service user representative on the Resources
for Effective Sleep Treatment (REST) project.
Research design & methods:
- Systematic reviews,1 cross-sectional,2-4 and
qualitative studies,5, 6 to identify current practice and
- Action research (modelling) and controlled clinical studies to inform
development of new approaches to primary care management of insomnia.
- Multiple case studies, non-randomised controlled trial and pilot
cluster randomised controlled trial to evaluate the new approach.
- Ongoing studies include meta-synthesis of qualitative studies of
benzodiazepine prescribing and development of a novel platform for
computerised Cognitive Behavioural Therapy for insomnia (CCBT-I).6
Key findings to date:
- GPs frequently prescribed hypnotic drugs early in treatment, despite
potential harms, especially in the elderly. They favoured newer `Z' drug
hypnotics because they mistakenly believe these are safer and more
effective. Many patients are advised to continue hypnotic drugs for
longer than recommended.3
- Patients often delay seeking help, using self-help or complementary
treatments. Despite their reluctance to take hypnotics, patients are
desperate for help and believe that drugs are the only treatment
- Despite practitioners' reluctance to recommend psychological
treatments for insomnia, patients are open to these approaches.
- Around 40% of patients suffer side effects to hypnotic drugs; 50%
tried to stop taking them, often unsuccessfully and 20% still wanted to
- A novel approach to managing sleep problems in primary care was
developed as part of the study. This involved using careful assessment
and patient focussed therapy, including cognitive behavioural treatment.4
Initial studies show that both patients and staff 4 are more
satisfied with the new approach and that there are significant
reductions in hypnotic prescribing in general practices.
- Although psychological therapy for insomnia is considered to be safer
than drugs we have conducted the first study worldwide showing the
adverse effects of sleep restriction therapy, a component of cognitive
behavioural therapy for insomnia.2
References to the research
All publications below were in peer reviewed international journals (team
1. Huedo-Medina TB, Kirsch I, Middlemass J, Klonizakis
M, Siriwardena AN. Effectiveness of non-benzodiazepine
hypnotics in treatment of adult insomnia: meta-analysis of data submitted
to the Food and Drug Administration. British Medical Journal
2012:345: e8343. (9 citations in Google Scholar)
2. Kyle S, Miller CB, Rogers Z, MacMahon KM, Siriwardena AN,
Espie CA. Sleep Restriction Therapy for insomnia is associated with
objectively-impaired vigilance: Implications for the clinical management
of insomnia disorder. Sleep 2013 (accepted paper online)
3. Siriwardena AN, Qureshi Z, Gibson S, Collier S, Latham M. GPs'
attitudes to benzodiazepine and 'Z-drug' prescribing: a barrier to
implementation of evidence and guidance on hypnotics. Br Gen Pract
2006:56: 964-967. (52 citations in Google Scholar)
4. Siriwardena AN, Qureshi MZ, Dyas JV, Middleton H, Orner
R. Magic bullets for insomnia? Patients' use and experiences of
newer (Z drugs) versus older (benzodiazepine) hypnotics for sleep problems
in primary care. Br J Gen Pract 2008:58: 417-422. (36
citations in Google Scholar)
5. Dyas JV, Apekey TA, Tilling M, Orner R, Middleton H, Siriwardena
AN. Patients' and clinicians' experiences of consultations in
primary care for sleep problems and insomnia: a focus group study. Br
J Gen Pract 2010:60: 180-200. (21 citations in Google
6. Middlemass J, Davy Z, Cavanagh K, Linehan C, Morgan K,
Lawson S, Siriwardena AN. Integrating online communities and
social networks with computerised treatment for insomnia: a qualitative
study. Br J Gen Pract 2012:62: 840-850. . (1 citation in
The funding sources for this research programme are all high quality, peer
reviewed competitive awards from National Institute for Health Research
(NIHR) or partner organisations (e.g. The Health Foundation):
•Siriwardena AN, McSorley G, Orner R, Middleton H, Dyas
J, Sach T, Sithole J, Gibson S. Resources for Effective Sleep
Treatment (REST) — A Lincolnshire Innovation and Change Collaborative
Quality Improvement Study. The Health Foundation Engaging with Quality in
Primary Care Award Scheme. April 2007 to March 2010, £396,650.
•Espie C, Kyle S, Salveta C, Siriwardena AN. Objective impact on
sleep and daytime functioning of sleep restriction therapy: a brief
behavioural intervention for persistent insomnia. CSO Scotland, December
2010 — November 2011, £49,505.
•Lawson, S, Siriwardena AN, Morgan K, Cavanagh K, and Linehan C.
ENACT: Exploring social Networks to Augment Cognitive behavioural Therapy.
EPSRC, Healthcare Partnerships EP/I000615/1, October 2010 — March 2013,
•Siriwardena AN, Davy Z, Kane R, Middlemass J,
Johnson C, Fyall A, Harrison A. Improving Primary Care Resources for
Effective Sleep Treatment (IPCREST). East Midlands Health Innovation and
Education Cluster (EM HIEC), April 2011 — March 2012, £39,833.
Details of the impact
The research has changed public and professional awareness as well as
professional policy and practice, by contributing to a better
understanding of deficiencies in care and by developing and testing
methods which have improved delivery of care for sleep problems and
insomnia, which have improved quality of life for patients. It has had a
direct benefit on primary care (general practitioners, practice nurses and
primary healthcare team) and provision for patients with insomnia and
sleep problems. Service users, the public and health practitioners have
been involved in the conception, design and dissemination of the work.7
- Initially the work had local impact in Lincolnshire in 2009, where in
a non-randomised control group study we compared development of a new
model of care for insomnia through a Quality Improvement Collaborative
with 16 GP practices, which led to improvements in frontline primary
care practice resulting in greater satisfaction for patients and staff 5
and significant reductions in inappropriate prescribing and costs of
hypnotic drugs.7 These changes in practice are reflected in
case studies published by the National Prescribing Centre to provide
information to GPs.10 The model was used in an educational
programme delivered by the team and involving a further 20 general
practices which led to improvements in care. The team have led events
for local patient groups (in 2011), for example the Sleep Interest Group
Network in Lincoln, led by a service user representative for the
Resources for Effective Sleep Treatment (REST) study.
- From 2011, the research began to have a wider regional impact on the
NHS through well-attended seminars for GPs on management of insomnia
conducted by the team in Lincolnshire (attended by 100 GPs),
Chesterfield (20 GPs), Leicester, (40 GPs) Nottingham (26 GPs) and Derby
(30 GPs and specialists).
- There was also UK-wide impact in 2011, when a national event for
doctors, `Sleep and mental health' was run by the Royal Society
of Medicine, together with the Mental Health Foundation, as part of
their Mental Health Awareness week 2011 campaign on sleep, where we
presented our findings to around 100 delegates.
- The research team also raised public awareness of insomnia and better
care for insomnia through a national UK television documentary, in which
we were featured and which covered the findings of our research (ITN
`Tonight' screened 17 November 2011 on ITV1).8 This led to a
significant increase in use of the REST website with over 1,000 hits in
the month following the documentary.
- The findings have led to national changes in health service policy and
practice, having been incorporated in policy information, educational
resources and guidance to clinicians on hypnotic prescribing developed
by the National Prescribing Centre9-11 and in reviews
conducted by others of the impact of national (National Institute for
Health and Clinical Excellence: NICE) guidance from 2008-10.12
- The research has had an international impact through a process of
dissemination and knowledge translation efforts conducted by our team
via workshops, seminars and e-learning (2009 - 2011). These have changed
clinical behaviour among GPs, practice nurses and practice teams and
changed relationship with patients. The workshops and seminars last from
one to three hours and include background information, practical
training on assessing sleep problems and providing CBT-I and videos
showing how this can be done in practice. We have conducted an
evaluation of participants, which has indicated changes in both
awareness and behaviour of clinicians in relation to their management of
patients with insomnia with greater use of psychosocial methods and
reduced use of hypnotic drugs. Clinicians have moved away from
prescribing drugs to using psychological therapies for insomnia, which
is a cultural shift in clinical behaviour towards shared care and
greater involvement of patients. The research has been cited by North
American Space Agency (NASA).13
- Our team have developed an online e-learning resource to provide
information and education to practitioners. In the first two years of
operation there were over 4,000 visits from more than 3,000 unique
visitors, who spent on average 4.5 minutes on the site from 90 countries
across all five continents (data from Google analytics). We have had
very positive feedback from GPs in the UK and internationally including
direct feedback on how they will use the learning in day-to-day
practice.14 This includes the citation and recommendation to
use the e-learning tool by GPs in New Zealand through prescribing
- There is also greater public awareness of the work through information
available to the general public through the press and online media
including Wikipedia.16 The paper by (Huedo-Medina et al BMJ
2012:345: e8343) received press and radio coverage in local (BBC Radio
Lincolnshire), national (Times, Telegraph, Daily Mail, Radio5live) and
international (US, Australasia, Asia) media.
Sources to corroborate the impact
- Health Foundation. Resources for Effective Sleep Treatment (REST).
Health Foundation. 2011. http://www.health.org.uk/areas-of-work/programmes/engaging-with-quality-in-primary-care/related-projects/resources-for-effective-sleep-treatment-rest/
- ITN Tonight. Waking up to insomnia. (Broadcast ITV1 17 October 2011)
http://communityandhealth.blogs.lincoln.ac.uk/2011/11/18/rest-project-featured-on-itn-tonight-documentary-on-insomnia/ [accessed 25-11-2013].
- Maskrey, E. Patients' experience and perception of using hypnotics.
NPCi July Drug Safety Update from MHRA/CHM. 2008. National Prescribing
- National Prescribing Centre. Patients' experience and perception of
using hypnotics. MeReC Monthly 2008:Number 6:1-2. http://www.npc.nhs.uk/rapidreview/?p=164
- National Prescribing Centre. Insomnia — Less than 60 minute e-learning
events. NPCi. 2010.
- Evaluation and review of NICE implementation evidence (ERNIE).
Insomnia — new hypnotic drugs. National Institute for Health and
Clinical Excellence. 2010.
- Wotring V. Risk of therapeutic failure due to ineffectiveness of
medication. North American Space Agency, Houston Texas, 2011.
- Siriwardena AN, Phung V-H, Davy Z. Improving primary care resources
for Effective Sleep Treatment (IPCREST) Final report to EMHIEC.
University of Lincoln 2012
- Hypnotics — safe prescribing — dying for a good sleep? SaferRx,
Waitemata District Health Board 2012. http://www.saferx.co.nz/full/Hypnotics.pdf
- 16. Wikipedia contributors. Nonbenzodiazepine. Wikipedia , Page
Version ID 343947511. 2010. Wikipedia, The Free Encyclopaedia http://en.wikipedia.org/wiki/Nonbenzodiazepine