Implementation of a digital cognitive behavioral therapy for insomnia pathway in primary care

'Let's talk about sleep health' within primary care: a qualitative study of patients' willingness to engage in psychological interventions for insomnia

BACKGROUND

Cognitive behavioural therapy for insomnia (CBT-I) is recommended as the first-line treatment for insomnia yet remains underutilised in general practice. Understanding patient motivations and barriers to engaging in psychological interventions for insomnia is critical. Theoretical frameworks, such as the theory of planned behaviour, are needed to identify variables related to intentions and behaviour change.

AIM

To explore key influences that motivate individuals' intention to engage with psychological interventions for insomnia.

DESIGN AND SETTING

Qualitative study consisting of an online survey and interviews with 20 community-dwelling participants with insomnia aged 26-75 years residing in Victoria, Australia.

METHOD

Guided by the theory of planned behaviour, reflexive thematic analysis was used to identify factors influencing participants' intention to engage with psychological interventions for insomnia.

RESULTS

Participants reported positive attitudes towards psychological interventions for insomnia, stemming from negative beliefs about pharmacological sleep aids and the perceived benefits of a structured and evidence-based intervention. Important others positively influenced participants' intention to engage; however, the GP influence was less consistent and often indirect. Participants believed in the efficacy of psychological interventions, but several barriers hampered their ability to benefit from them. Accessibility was identified as a key facilitator, whereas lack of knowledge and clear referral pathways were the main barriers having an impact on uptake.

CONCLUSION

This study highlights key factors influencing patients' intention to engage in psychological interventions for insomnia as well as opportunities for GPs to support uptake and engagement. Routine conversations about sleep health are essential to reduce the burden of untreated insomnia in the community, and the active promotion of evidence-based psychological interventions is needed.

Current Therapeutic Strategies for the Management of Benzodiazepine (BZD) Withdrawal Syndrome: A Review

Benzodiazepines are commonly prescribed drugs for numerous indications such as epilepsy, anti-anxiety, sleep aids, sedatives, and hypnotics. Although the well-tolerated effects of benzodiazepine are seen in many clinical instances, the severity of side effects reduces its quantifiable use. Benzodiazepines, which are medically useful but theoretically unsafe, are frequently recommended by medical practitioners for psychotic patients but have misuse and dependence liabilities. It is impelled as a debateable topic globally about which no one talks. These drugs are also known as silent killers because abruptly stopping them can result in tremors, muscle spasticity, and life-frightening seizures. These drugs are beneficial as well as risky. Nonclinical treatment is simple and well suited and provides support for patients suffering from side effects generated by benzodiazepine withdrawal. This review mainly focuses on antipsychotic drugs and their mechanisms, mortality, withdrawal, abuse, and management via clinical and nonclinical therapies.

Perspectives on increasing the impact and reach of CBT-I

Cognitive behavioral therapy for insomnia is now recognized as the front-line treatment for chronic insomnia, yet many challenges remain in improving its impact and reach. This manuscript describes our perspective on some of these challenges. Based on the literature that maladaptive cognitions predict low adherence and that high levels of cognitive-emotional hyperarousal may be associated with poor outcomes, we propose added focus on cognitive therapy strategies in CBT-I. Specifically, we propose broadening the range of traditional cognitive therapy strategies, utilizing acceptance-based strategies, and fuller integration of the broadened range of cognitive strategies into CBT-I throughout the course of treatment. We also highlight a few other promising emerging approaches to enhance the impact of CBT-I. These include involving partners to promote adherence with CBT-I treatment recommendations, using culturally relevant treatment adaptations to increase retention of patients in treatment, and using strategies for timely identification of barriers to engagement. We propose broadening the public health impact of CBT-I by integrating support for reduction in long-term use of hypnotic sleep medications, which is in line with current medical guidelines. We advocate for a case conceptualization-based approach for implementing CBT-I in a patient-centered manner, flexibly, yet with fidelity, to enhance its impact by addressing the factors above. For increasing the reach of CBT-I, we discuss the need to train more clinicians and ways to combine therapist and digital deliveries of CBT-I, highlighting stepped care strategies.

Trends and patterns of benzodiazepines and Z-drugs prescriptions in Australian general practice: A national study (2011-2018)

INTRODUCTION

We aimed to explore trends and sociodemographic patterns in benzodiazepine (BZD) (by half-life) and Z-drugs prescribing in Australian general practice.

METHODS

This open cohort study used de-identified electronic health records of 1.4 million patients (50,812,413 consultations) from 402 Australian practices (MedicineInsight 2011-2018). Annual prescribing frequency and changes over time were estimated according to sex, age, socioeconomic position and rurality.

RESULTS

Between 2011 and 2018, the prescribing of very short-acting BZD increased from 0.10 to 0.29 per 1000 consultations (average annual change +17.2% [95% CI 9.6; 25.3]), while it declined for short-intermediate (from 38.5 to 26.6 per 1000 consultations; annual change -5.1% [95% CI -5.6; -4.5]), long-acting BZD (from 24.1 to 21.6 per 1000 consultation; annual change -1.5% [95% CI -2.2; -0.8]) and Z-drugs (from 4.6 to 4.0 per 1000 consultations; annual change -1.9% [95% CI -3.0; -0.7]). Short-intermediate-acting BZD prescribing was three times more frequent among women aged 65+ years than younger women, and long-acting BZD three-to-four times more likely among younger than older men. Z-drugs prescribing was higher among women aged 45-64 years than younger or older females. Short-intermediate- and long-acting BZD were more likely prescribed for patients from more disadvantaged areas, and Z-drugs in more advantaged areas. There were no disparities by rurality.

DISCUSSION AND CONCLUSIONS

Although most BZD and Z-drugs prescriptions declined over time, short-intermediate BZD prescriptions remained higher among older women and long-acting BZD more frequent among younger men, especially for those living in more disadvantaged areas. Targeted interventions could reduce the prescribing of BZD and Z-drugs in these groups.

Thematic trends and knowledge structure on cognitive behavior therapy for insomnia: A bibliometric and visualization analysis

OBJECTIVE

To find publications trend about cognitive behavior therapy for insomnia (CBTI) using bibliometric and visualization analysis. In this study, the authors sought to identify the publication trends of peer-reviewed articles about CBTI.

MATERIALS AND METHODS

Analyses were focused on the past 18 years from 2004 to 2021. All searches were performed on the Web of Science Core Collection database. The search was repeated to include structural cognitive behavior therapy for insomnia. Quantitative analysis was assessed using the bibliometric tool. Visualization analysis was carried out using VOSviewer.

RESULTS

In the 736 articles reviewed, the number of publications has been increasing every year for the past 18 years. Behavioral sleep medicine and sleep were the most active journals published on CBTI. The United States and Canada had the highest scientific publications in the field. Morin CM and Espie CA were the most active authors. The study type mostly observed were randomized controlled trials, meta-analyses, and epidemiological. Publications on digital-based cognitive behavior therapy and accessibility to primary care settings represent the future trends of research on CBTI.

CONCLUSION

Possible explanations for CBTI publication trends were discussed, including the emergence of the evidence-based therapy, feasibility, and scalability. Potential CBTI publications trends in the future and clinical implications were also discussed.