Sarah Reid Karma GalyerSummer research project undertaken with the support of The Psychology Centre - HamiltonFunding from Waikato Clinical School
According to the DSM-IV-TR predominant complaints Difficulty initiating or maintaining sleep, or experiencing non-restorative sleep. Experienced symptoms for at least one month, although many experience chronic sleep disturbances. Clinically significant distress or impairment in social, occupational, or other important areas of functioning due to sleep disturbance or associated daytime fatigue must be reported. For a diagnosis of primary insomnia differential diagnoses (other sleep disorders, mental disorders, general medical conditions, direct physiological effects of a substance) must be ruled out. If insomnia is a result of these factors then it is considered to be secondary insomnia. Epidemiological reviews estimate the prevalence of DSM-IV diagnosable insomnia as between 4-6% of the general adult population. Very little NZ ResearchA New Zealand study of 4000 adults randomly selected from the electoral roll found that 25% reported a sleep problem lasting more than six months, with more Maori (29%) reporting sleep difficulties than non-Maori (26%).
In New Zealand and Australia insomnia is managed at a primary care level. However, assessment and intervention resources for insomnia are limited. Medications such as hypnotics are the most accessible treatments for primary care patients. Hypnotics are not recommended as a first line or long-term intervention for chronic insomnia and concerns have arisen about widespread and potentially inappropriate use of these medications. A review undertaken in the US found that most hypnotic medications are consumed by a group of patients with chronic insomnia who use this medication daily for a number of years. This review found that while patients may find it easier to fall asleep with medication, they do not experience improved day-time function when medication use is long-term. Withdrawal of medications can be problematic as patients may experience a temporary re-bound insomnia and associated psychological distress and poor sleep at the time medication is withdrawn, which is thought to encourage hypnotic medication use for some patients. The Thoracic Society of Australia and New Zealand (TSANZ)5 have recommended the development of alternative treatment options in primary care, particularly those offered by psychologists.
Any person with self defined insomnia/sleep difficulties could answer the questionnaire. Data Collection: People seeking assistance for sleep difficulties were invited to complete a survey about treatment choices for sleep problems. The project was advertised via posters and handouts in 16 medical centres, 16 pharmacies, 5 natural health providers, and the hospital sleep clinic in the Hamilton area. Recruitment dates covered November 2010 to January 2011. Respondents could complete the survey on-line using a Survey Monkey link, or complete a pen/paper copy which could be returned via freepost or to a survey box at the health care provider.
Athens Insomnia Scale (AIS) : The AIS was developed based on ICD-10 insomnia criteria, as a self-report tool for sleep research and clinical practice. It measures sleep difficulties (sleep induction, night time awakenings, final awakening, total sleep duration, and sleep quality) and related daytime consequences (wellbeing, functional capacity, and daytime sleepiness). The scale asks respondents to indicate the level of difficulty experienced for each item, provided it occurred at least three times per week during the last month. Each of the eight items is scored from 0-3, with a maximum total scale score of 24. Further analysis confirmed that a cut-off score of 6 on the scale provided an optimum balance between sensitivity and specificity in terms insomnia diagnosis.Dysfunctional Beliefs and Attitudes about Sleep Scale (DBAS-16):The DBAS-16 is self-report scale designed to measure sleep related cognitions, including beliefs, attitudes, expectations and attributions. It asks the respondent to rate sixteen items on a scale of zero (strongly disagree) to ten (strongly agree), with higher numbered responses indicating a greater level of dysfunctional beliefs and attitudes about sleep. The scale presents a four factor structure which includes perceived consequences of insomnia, 2) worry and helplessness about sleep, 4) medication and biological attribution of insomnia. 3) expectations about sleep requirements, and Further research found that a mean score of 3.8 was associated with clinically significant insomnia.Treatment Options: Respondents were asked to indicate if they had tried the following treatment options for sleep difficulties: sleep diary, sleep hygiene (e.g. no coffee/alcohol, daily walk), sleep routine (e.g. reading before bed, set bed time), relaxation (e.g. relaxing music, muscle relaxation), talking therapy (e.g. psychologist/counsellor), specialist sleep clinic (e.g. nurse/doctor at the hospital), prescription medication for sleep from a doctor, over the counter medication for sleep from a chemist, natural products for sleep (e.g. tea), other (e.g. homeopathy, hypnotherapy). If respondents had used a prescription medication, over the counter medication, or a natural product they were asked to specify the type and longest use period. For each treatment option tried, respondents were asked to indicate whether it made their sleep worse, had no effect, or made sleep better. Respondents were also asked to indicate their preferred and current treatment choices.
194 respondents177 reported a current sleep difficulty meeting insomnia (a score of 6 or more on the Athens Insomnia Scale).
Eighty seven percent of people were classified as presenting with chronic insomnia due to their symptoms persisting for a period greater than six months duration (as per International Classification of Sleep Disorders criteria). One to five years was the most commonly reported duration (44%). Twenty five percent reported experiencing sleep difficulties for more than ten years.
2-3 mins Prescription Medication Use: Over half (53%) had tried a prescription medication for their sleep problem. Of those, 76 were able to specify the prescription medication they had tried. Seventeen did not specify the prescription medication type. Unclear delivery of some e.g. Hygiene, routine, relaxation. Google, Dr telling to stop caffeine???????????????Thirteen respondents had tried more than one prescription medication for their sleep difficulties. Zopiclone (non-benzodiazepine hypnotic) was the most common prescription medication used (n=49). Triazolam (n=9), Amitriptyline (n=9), Melatonin (n=7), Seroquel (n=5), Temazepam (n=5), Lorazepam (n=5), Diazepam (n=2), Hypnovel (n=2), Nortriptyline (n=1), Promethazine (n=1), and Citalopram (n=1). Over half (n=47) of those who had used prescription medication used it on a short term basis (less than 4 weeks(n=39) reported long term use (more than 4 weeks). Prescription medication had the highest ratings of all treatments for both improving sleep (74%), and making sleep worse (19%). Over the Counter Medication and Natural Products Tried: A wide range ofover the counter medications and natural products were used by respondents. Often products (e.g. rescue remedy) were included in both categories. Over the counter medications used included pills designed to treat sleep difficulties (e.g. Unisom, Easy Sleep, Tranquil Sleep) (n =19), Paracetamol (n=4), Rescue Remedy (n=2), 5htp (n=2), and Valerian (n=2). The natural products most commonly used were tea (n=37) (Chamomile, Green, and Sleep Tea), Lavender (n=9), and Rescue Remedy (n=5). This sample was accessing a wide range of possible sleep treatments with most having tried at least one component of psychological treatments (sleep hygiene, sleep routine, relaxation). However these interventions were rated as ineffective by most people used had tried them. Very few indicated that they had been reviewed by a specialist professional in sleep or accessed specialist psychological intervention. Overall these findings suggest that primary care patients are not accessing effective alternatives to medication for insomnia as recommend by TSANZ.
Sleep Beliefs: Sleep beliefs were measured using the Dysfunctional Beliefs and Attitudes about Sleep Scale (DBAS-16A mean total score of 3.8 is associated with clinically significant insomnia. The mean total score for the current sample was 5.85. Overall results indicate that the current sample expressed unhelpful/dysfunctional beliefs about sleep to a level that has been associated with clinically significant insomnia.Consequences (m=6.0), Worry (m=6.2), Medication (m=4.8), Expectations (m=6.2). Respondents were classified into three groups on the basis of their historical (ever used) use of prescription medication for sleepnever used, short-term,long-termThe timeframe of 4 weeks was used to distinguish short and long-term prescription medication use as according to Medsafe this is the maximum recommended prescription timeframe for Zopiclone (the most commonly used prescription medication in the current sample). Figure 1 shows the mean/median values for each group for the total DBAS-16 score and each of the factor scores. Statistically significant relationships were found between prescription medication use pattern and unhelpful sleep beliefs. Significantly greater overall endorsement of unhelpful sleep beliefs was found in the group who reported long-term use of prescription medication for sleep. In particular, this group held stronger beliefs about the negative consequences of insomnia. They were also most likely to believe the cause of insomnia to be biological and view medication as the best treatment option.
Define GroupsInsomnia Symptoms: Insomnia symptoms were measured using the Athens Insomnia ScaleA total score of 6 or greater indicates clinical insomnia. The median AIS total score for the current sample was 12 (out of a maximum possible score of 24). The median score for sleep difficulties was 8 (out of 15) and for Median daytime functioning was 4 (out of 9). Overall, median item scores were higher for sleep difficulty items than for the daytime symptoms items.Respondents were classified into three groups based on their current treatment choice. no current treatment, 2) current prescription medication use, 3) use of a non-prescription treatment (e.g. sleep hygiene, relaxation, natural product). Figure 2 shows the median values for each group for AIS total and the sleep difficulties and daytime consequences scales. People currently using a prescription medication for sleep reported significantly more severe insomnia symptoms overall and specifically greater night-time sleep difficulties than those using a non-prescription treatment. Those using a non-prescription treatment reported significantly lower night-time sleep difficulties than those using no treatment or those using a prescription medication. There was no relationship between current treatment and daytime consequences (wellbeing, functioning, and sleepiness).
These findings support the recommendation by the Thoracic Society of Australia and New Zealand that validated treatment alternatives to prescription medication be made available to people presenting with chronic insomnia in a primary care setting5. Current use of prescription medication for sleep was not related to decreased insomnia symptoms, decreased sleep difficulties or daytime functioning. Instead people currently using a prescription medication for sleep had the greatest perceived current sleep difficulties. The current use of a non-prescription treatment method was related to less severe perceived sleep difficulties.Specifically, within the current as a treatment strategy. Long-term medication use as seen in this sample is not a recommended treatment approach. TSANZ The results of this study are consistent with previous research linking people’s beliefs about sleep and the treatment choices they make.
Psychological interventions could be most useful for the group who continue to use medication for longer than recommended. Cognitive behaviour therapy for insomnia has been found to be effective in a primary care settingand in assisting patients cease chronic hypnotic medication use11. Research has also shown that changes in sleep related beliefs brought about using cognitive behavioural techniques have resulted in maintained improvements in sleep efficiency10.The Australasian Sleep Association recently discussed the lack of clinical research into non-respiratory sleep disorders and sleep-related public health issues relevant to the populations of Australia and New Zealand. The provision of alternatives to prescription medication for the treatment of insomnia amongst primary care patients remains an area in need of future research and development. The potential benefits associated with providing effective treatment are significant in terms of reducing both the individual1 and societal costs associated with insomnia. Primary care therapies developed to date tend to have more behavioural strategies (e.g., sleep restriction, sleep hygiene) and less content aimed at changing cognitions. The distinction is an important one as people with chronic insomnia are more likely have dysfunctional beliefs about sleep than good sleepers.Changing dysfunctional thoughts via cognitive restructuring interventions has been shown to be beneficial amongst long-term hypnotic users when stopping medication. CBT intervention provided at the time of withdrawal from sleep medication has been found to result in decreased misconceptions about insomnia, decreased faulty beliefs about sleep promoting practices, and improved perception of control and predictability of sleep. At one year follow-up 72% of participants were no longer using hypnotics, the remainder reported intermittent anxiolytic use. The majority reported an improvement in the quality of their sleep overall. Others have found a decrease in maladaptive beliefs about sleep to be associated with better maintenance of improved sleep in a CBT intervention group.
Treatment Options for Insomnia in the New Zealand Primary Care Setting: What do people find effective? Sarah Reid Karma Galyer 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
Research Questions 1. How do people with chronic insomnia view the treatment options available to them? 2.What is the relationship between sleep beliefs and use of prescription medication for sleep? 3. What is the relationship between current treatment choice and current insomnia symptoms?
Treatment Choices for Sleep Problems Survey 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.
Measures 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.
177 respondents reported a current sleep difficulty. 88% female 86% NZ/Other European. 8% Maori. 3% other. Respondents
2. What is the Relationship Between Sleep Beliefs and Use of Prescription Medication for Sleep?
Treatment Choices and Sleep Beliefs 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 Figure 2: Relationship between current treatment choice and insomnia symptoms.
Conclusions 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.
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
References 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
Dysfunctional Beliefs and Attitudes about Sleep Scale 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.