Insomnia

Overview

Insomnia is difficulty in getting to sleep, difficulty maintaining sleep or early wakening which occurs despite adequate opportunity for sleep. It is associated with poor daytime functioning including poor concentration, mood disturbance and fatigue.

There is increasing evidence linking insomnia to significant physical health conditions including cardiovascular disease and diabetes, mental health conditions including depression and anxiety, as well as an earlier onset of dementia. It is associated with high rates of absenteeism and a significant number of road and work place accidents.

Insomnia can be considered short term if present for less than 3 months, and chronic if longer than this.

Guidelines

• BNSSG insomnia pathway(links to BNSSG Central Nervous System guidelines - scroll to bottom of this page to find the pathway).
• Clinical Knowledge Summaries - Insomnia for further information regarding assessment, management and prescribing.

Short term insomnia 

Short term insomnia is more associated with stressful life events and may terminate when the situation is resolved. It may become chronic if mechanisms intended to compensate for excessive daytime sleepiness, such as daytime napping, lie-ins and use of stimulants, actually lead to propagation of the insomnia.

Chronic insomnia 

Chronic insomnia may be associated with mental health conditions. There is a clear bidirectional relationship between poor sleep and poor mental health. 

Sleep diary

A two-week sleep diary can give useful information on a patient’s sleep pattern

• Sleep onset latency (the time to fall asleep) should be between 10 and 20 minutes. A long latency can be associated with anxiety.
• Waking after sleep onset – if occurring at consistent times may relate to environmental noise, or the wearing off of eg analgesic medications. Other sleep disorders like parasomnias and periodic limb movements in sleep can cause awakenings that may appear to be insomnia.
• Early morning waking is often associated with depression
• Sleep efficiency is the time spent sleeping divided by the total time in bed.

When accurately completed it can direct simple interventions. The commonest cause of excessive daytime sleepiness is ‘voluntary’ sleep deprivation, either due to lifestyle factors, responsibilities such as young children, or by interrupting healthy sleep with an alarm clock.

Insomnia Severity Index (ISI)

An ISI score can help assess severity of sleep problems and provide a guide to treatment effectiveness:

• Insomnia Severity Index (ISI) | QxMD (5)

Self Care

Self Care should always be part of management of insomnia and there is useful advice below:

Sleep hygiene

Fall asleep faster and sleep better - NHS (www.nhs.uk) -advice for patients and links to videos to support sleep hygiene.

Sleep hygiene is the name given to the routines and practices that encourage good sleep. It involves getting your mind and body into a favourable state for sleep, and making the bedroom the best possible environment for sleeping in. Measures can be broadly divided into three categories

Scheduling – the sleep-wake phases are controlled by the circadian rhythm. Certain practices reinforce this rhythm, allowing sleep and wake to be promoted at appropriate times. Promoting the wake phase during the day encourages the sleep phase to occur naturally at night.

• Keep a fixed wake up time and do not vary it by more than one hour at weekends.
• Spend the initial waking part of the day outside or in bright light
• Take regular moderate exercise during the day

Sleep preparation

• Avoid stimulants such as caffeine and nicotine (though not everybody is susceptible to the stimulating effects of caffeine)
• Avoid alcohol – alcohol can reduce sleep onset latency in some people, but often leads to fragmented sleep and poorer sleep quality. It also reduces the time spent in REM sleep which can affect emotion regulation during the day.
• Use dim lights in the evening. Warmer toned lights do not promote the wake phase of the circadian rhythm in the same way as colder daylight tones.
• Reduce screentime before bed for the same reason.
• Anxiety is a key cause of delayed sleep onset. Stressors such as work emails should be avoided before bed. Mindfulness techniques can assist with this and apps such as Headspace, while not available on the NHS, are reasonably priced and have specific courses aimed at sleep hygiene.
• If sleep onset is delayed, then patients should be discouraged from ‘trying’ to sleep. A more productive course of action after 15 minutes of being unable to sleep, is to leave the bed, find a distracting, relaxing activity, such as reading, and wait for the urge to sleep to naturally return.

The sleeping environment

• A cool, dark and quiet environment promotes sleep
• Pets should be discouraged from sleeping on beds
• The association of the bed meaning sleep should be strengthened by only using the bed for this purpose, and not for watching films or relaxing on during the day

Management - non-pharmacological

Manage underlying conditions

Insomnia may exist as a secondary phenomenon, eg to chronic pain, anxiety or another sleep disorder such as restless legs syndrome. Treatment of these conditions should improve sleep quantity and quality.

• NHS Talking Therapies offer CBT for patients with anxiety or depression. However, please note that the local Talking Therapies service does not otherwise provide specific treatments for insomnia.
• Obstructive Sleep Apnoea -If sleep apnoea is suspected then consider referral for sleep studies (restrictions apply).
• Restless Leg Syndrome - Patients with suspected restless legs can normally be managed in primary care.

CBTi

CBT for insomnia, known as CBTi, has an excellent evidence base and is recommended as a first line treatment for chronic insomnia by NICE, the British Association of Psychopharmacology and the American Academy of Sleep Medicine, amongst other organisations.

CBTi can be delivered by face-to-face therapy, or increasingly via online or app based platforms.

The CBT-i programme consists of six sessions covering

1. Sleep education

2. Sleep hygiene and sleep restriction

a. Most of the evidence base for CBT-i comes from sleep restriction, whereby the waking time is fixed, but the patient goes to bed eg four hours prior to the waking time. The intention is that in a few days the sleep pressure increases leading to reduced sleep onset latency and increases sleep efficiency. The time in bed is then gradually increased.

3. Stimulus and cognitive control

a. Stimulus control is reducing the negative associations between the bedroom and anxieties around sleep

b. Cognitive control is reducing unwanted thoughts that can disrupt attempts to sleep

4. Paradoxical intention

a. Instead of trying to sleep, getting into bed and trying to stay awake.

5. Reducing dysfunctional beliefs

a. Reducing false beliefs that can propagate insomnia, such as it having a genetic cause that cannot be treated, or having unrealistic expectations of sleep eg needing eight hours in order to function properly the next day, or believing one night of poor sleep will upset your sleep schedule for a whole week.

6. Mindfulness and relaxation techniques.

Silver Cloud Programme

Patients registered with a BNSSG GP practice can access the online 'Space for Sleep' programme run by Silver Cloud which uses a CBT approach. Patients can create an online account and once registered can scroll down to the 'sleep better' option to access this module.

The sleep package on SilverCloud contains evidence based low-intensity CBT self-help resources for improving sleep. This includes psycho-education, sleep diaries, sleep association training, sleep hygiene (including bedtime routine, sleep environment and relaxation) and resources to support the reduction of worry/anxiety where it is impacting on sleep. 

Otherwise NHS Talking Therapies will only treat sleep problems as part of a common mental health problem and are not commissioned to treat sleep problems as a stand-alone disorder.

Services that are not routinely available on the NHS in BNSSG

• Sleep Station - Sleep Station is not commissioned for all BNSSG practices. However, some PCNs in BNSSG  have secured funding and so practices may have access to this service.  To find out if patients at your practice are eligible then please go to: NHS access to Sleepstation
• Sleepio - Sleepio is also an app that is available and recommended by NICE (3)) but is not funded in BNSSG.
• Secondary Care Sleep Disorders Clinic - There is no specific sleep service for insomnia commissioned by BNSSG ICB and the sleep disorders clinic at the Rosa Burden Centre does not accept referrals for insomnia alone.

Management - pharmacological

Short Term Insomnia

If initial self care treatment fails, a short course (3-7 days) of a hypnotic medication (z-drug) can be tried. See the BNSSG formulary - Sleep Disorders page for further advice.

Chronic Insomnia

Hypnotics

Hypnotics are generally not a first-line treatment for chronic insomnia, though may be considered on a sparingly PRN basis to treat acute-on-chronic exacerbations and avoid periods of severe sleep deprivation.

Daridoxerant

Daridoxerant has recently been approved by NICE (4) for treating chronic insomnia in adults (symptoms lasting for 3 nights or more per week for at least 3 months, and whose daytime functioning is considerably affected), only if cognitive behavioural therapy for insomnia (CBTi) has been tried but not worked, or CBTi is not available or is unsuitable. It can be prescribed in primary care.

A BNSSG insomnia pathway has been developed and includes advice on appropriate use of Daridoxerant.

Melatonin

Melatonin is not currently on the BNSSG formulary for treatment of insomnia.in primary care. Please see the BNSSG formulary - Sleep Disorders. for further details.

Deprescribing

Please see the following document which is a support document consolidating national guidance, expert opinion and local resources to aid local practice including prescribing, de-prescribing/withdrawal and self-care. 

• BNSSG Benzodiazepines and Z drug Prescribing (including withdrawal) Support Document.

Resources

(1) Clinical Knowledge Summaries - Insomnia

(2) BNSSG Benzodiazepines and Z drug Prescribing (including withdrawal) Support Document.

(3) Sleepio to treat insomnia (NICE)

(4) Daridorexant for treating long-term insomnia | Guidance | NICE

(5) Insomnia Severity Index (ISI) | QxMD

Patient leaflet

An insomnia patient information leaflet from patient.co.uk is available for use in primary care to support with self-care tips for patients. This is accessible through EMIS via the Mentor resource. This can be emailed, texted or printed.

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.