The treatment of insomnia in primary care: evaluating and improving compliance to clinical practice guidelines
De behandeling van insomnia in de huisartsenpraktijk: evalueren en verbeteren van de naleving van behandelrichtlijnen
Slapeloosheid is een veelvoorkomend probleem dat bijdraagt aan de ontwikkeling van verschillende psychische en lichamelijke aandoeningen. Volgens de behandelrichtlijn voor huisartsen dient slapeloosheid primair behandeld te worden met cognitieve gedragstherapie. De brede kennis en vaardigheden die hiervoor nodig zijn, zorgen ervoor dat deze therapie in de praktijk waarschijnlijk maar beperkt wordt toegepast.
Doel en werkwijze
In het huidige project wordt met behulp van routine zorggegevens onderzocht hoe slapeloosheid momenteel behandeld wordt in de Nederlandse huisartsenpraktijk. In een klinische studie evalueren we vervolgens of slapeloosheid effectief behandeld kan worden met een kortdurende gedragsmatige behandeling zonder cognitieve componenten. De effectiviteit van een dergelijke benadering wordt ondersteund door eerder onderzoek, en biedt daarom waardevolle mogelijkheden om de behandeling van slapeloosheid te vereenvoudigen en beter te integreren in de huisartsenpraktijk.
Samenvatting van de aanvraag
Insomnia is a prevalent sleep disorder that is characterized by difficulties initiating sleep, maintaining sleep and/or early morning awakening. Around 25% of the general population reports at least one symptom of insomnia whereas approximately 10% fulfils the diagnostic criteria for a clinical diagnosis. As a result of the well-established contribution of insomnia to the development of common mental and physical conditions, the high prevalence of insomnia is increasingly recognized as a public health concern. This illustrates the importance of an adequate treatment of insomnia in clinical practice. There is international consensus in clinical practice guidelines that Cognitive Behavioural Therapy for Insomnia (CBT-I) should be the first line treatment for persistent insomnia and, hence, pharmacological agents should only be prescribed when CBT-I is ineffective or unavailable. Given the intensity of CBT-I and restricted access to specialized psychologists, the main challenge is the implementation of these clinical guidelines in routine clinical practice. Hence, while there is clear evidence for the superior long-term outcomes of CBT-I relative to pharmacological treatment, CBT-I is rarely provided and pharmacotherapy remains the primary treatment modality. In the Netherlands, general practitioners have a pivotal role in the healthcare system and are therefore crucial for the treatment of insomnia. This is particularly relevant as the prevalence of clinical insomnia ranges up to 50% in patients consulting the general practitioner. In line with international standards, the clinical practice guideline on ‘Sleep Problems and Sleep Medication’ of the ‘Dutch College of General Practitioners’ describes CBT-I as the first line treatment for insomnia. In contrast to this recommendation, CBT-I is not frequently provided in Dutch general practices and hypnotic medication remains the primary treatment modality in the majority of the insomnia patients. This presumably relates to limited instructions on how to incorporate CBT-I in routine clinical practice. Standardized treatment schedules with practical instructions are therefore highly desirable. The present project aims to evaluate and improve the treatment of insomnia in primary care as described in the clinical practice guideline on ‘Sleep Problems and Sleep Medication’ of the ‘Dutch College of General Practitioners’. To assess the present compliance to this clinical guideline, the proportion of insomnia patients that receives either CBT-I or sleep medication for the treatment of insomnia will be determined using routine primary care data. To improve the adoption of the clinical guideline, standardized procedures for the provision of CBT-I in the Dutch primary care setting will be developed in consultation with general practitioners, general practice nurses and insomnia patients. These include a treatment schedule with practical instructions that is complemented by a brief (online) educational program for patients. The effectiveness of the intervention will be compared to care as usual in a pragmatic cluster randomized clinical trial in combination with an evaluation of the different aspect of the implementation process. The proposed research provides an answer to several prioritized research questions included in the ‘National Research Agenda of General Practice’. This relates to the effectiveness and implementation of the behavioural treatment of insomnia as described in the clinical practice guideline ‘Sleep Problems and Sleep Medication’ of the ‘Dutch College of General Practitioners’ (ID: 379) as well as the effectiveness of eHealth for the implementation of interventions in primary care (ID: 55). The results of the research projects will be stratified on age (predefined groups) and gender to elucidate potential differences, thereby adhering to the importance of diversity in research and clinical guidelines for general practice (ID: 53). To ensure that the results of the proposed research reach clinical practice, there will be aimed at a widespread dissemination and implementation of the findings. In summary, the present project provides a comprehensive overview of the treatment of insomnia in primary care. The evaluation of the current treatment of insomnia using routine primary care data will elucidate the present compliance to the clinical practice guideline on ‘Sleep Problems and Sleep Medication’ of the ‘Dutch College of General Practitioners’. The clinical trial concerning the effectiveness and implementation of standardized procedures for the provision of CBT-I in primary care may reveal a practical solution to improve the adoption of this guideline in routine clinical practice. Together, these findings provide valuable insights in crucial aspects of the treatment of insomnia in primary care.