Abstract
OBJECTIVE: To evaluate the clinical and cost impact of providing cognitive behaviour therapy (CBT) for insomnia (comprising sleep hygiene, stimulus control, relaxation and cognitive therapy components) to long-term hypnotic drug users in general practice. DESIGN: A pragmatic randomised controlled trial with two treatment arms (a CBT treated 'sleep clinic' group, and a 'no additional treatment' control group), with post-treatment assessments commencing at 3 and 6 months. SETTING: Twenty-three general practices in Sheffield, UK. PARTICIPANTS: Two hundred and nine serially referred patients aged 31-92 years with chronic sleep problems who had been using hypnotic drugs for at least 1 month (mean duration = 13.4 years). RESULTS: At 3- and 6-month follow-ups patients treated with CBT reported significant reductions in sleep latency, significant improvements in sleep efficiency, and significant reductions in the frequency of hypnotic drug use (all P<0.01). Among CBT treated patients SF-36 scores showed significant improvements in vitality at 3 months (P<0.01). Older age presented no barrier to successful treatment outcomes. The total cost of service provision was 154.40 per patient, with a mean incremental cost per quality-adjusted life-year of 3416 (at 6 months). However, there was evidence of longer term cost offsets owing to reductions in sleeping tablet use and reduced utilisation of primary care services. CONCLUSIONS: In routine general practice settings, psychological treatments for insomnia can improve sleep quality and reduce hypnotic consumption at a favourable cost among long-term hypnotic users with chronic sleep difficulties.
Full Text
The Full Text of this article is available as a PDF (343.7 KB).
Selected References
These references are in PubMed. This may not be the complete list of references from this article.
- Brazier John, Roberts Jennifer, Deverill Mark. The estimation of a preference-based measure of health from the SF-36. J Health Econ. 2002 Mar;21(2):271–292. doi: 10.1016/s0167-6296(01)00130-8. [DOI] [PubMed] [Google Scholar]
- Buysse D. J., Reynolds C. F., 3rd, Monk T. H., Berman S. R., Kupfer D. J. The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Res. 1989 May;28(2):193–213. doi: 10.1016/0165-1781(89)90047-4. [DOI] [PubMed] [Google Scholar]
- Espie C. A., Inglis S. J., Tessier S., Harvey L. The clinical effectiveness of cognitive behaviour therapy for chronic insomnia: implementation and evaluation of a sleep clinic in general medical practice. Behav Res Ther. 2001 Jan;39(1):45–60. doi: 10.1016/s0005-7967(99)00157-6. [DOI] [PubMed] [Google Scholar]
- Kramer Milton. Hypnotic medication in the treatment of chronic insomnia: non nocere! Doesn't anyone care? Sleep Med Rev. 2000 Dec;4(6):529–541. doi: 10.1053/smrv.2000.0122. [DOI] [PubMed] [Google Scholar]
- Matthews J. N., Altman D. G., Campbell M. J., Royston P. Analysis of serial measurements in medical research. BMJ. 1990 Jan 27;300(6719):230–235. doi: 10.1136/bmj.300.6719.230. [DOI] [PMC free article] [PubMed] [Google Scholar]
- McHorney C. A., Ware J. E., Jr, Lu J. F., Sherbourne C. D. The MOS 36-item Short-Form Health Survey (SF-36): III. Tests of data quality, scaling assumptions, and reliability across diverse patient groups. Med Care. 1994 Jan;32(1):40–66. doi: 10.1097/00005650-199401000-00004. [DOI] [PubMed] [Google Scholar]
- Morgan K., Clarke D. Longitudinal trends in late-life insomnia: implications for prescribing. Age Ageing. 1997 May;26(3):179–184. doi: 10.1093/ageing/26.3.179. [DOI] [PubMed] [Google Scholar]
- Morgan Kevin, Thompson Joanne, Dixon Simon, Tomeny Maureen, Mathers Nigel. Predicting longer-term outcomes following psychological treatment for hypnotic-dependent chronic insomnia. J Psychosom Res. 2003 Jan;54(1):21–29. doi: 10.1016/s0022-3999(02)00569-x. [DOI] [PubMed] [Google Scholar]
- Morin C. M., Colecchi C., Stone J., Sood R., Brink D. Behavioral and pharmacological therapies for late-life insomnia: a randomized controlled trial. JAMA. 1999 Mar 17;281(11):991–999. doi: 10.1001/jama.281.11.991. [DOI] [PubMed] [Google Scholar]
- Morin C. M., Culbert J. P., Schwartz S. M. Nonpharmacological interventions for insomnia: a meta-analysis of treatment efficacy. Am J Psychiatry. 1994 Aug;151(8):1172–1180. doi: 10.1176/ajp.151.8.1172. [DOI] [PubMed] [Google Scholar]
- Morin C. M., Hauri P. J., Espie C. A., Spielman A. J., Buysse D. J., Bootzin R. R. Nonpharmacologic treatment of chronic insomnia. An American Academy of Sleep Medicine review. Sleep. 1999 Dec 15;22(8):1134–1156. doi: 10.1093/sleep/22.8.1134. [DOI] [PubMed] [Google Scholar]
- Ohayon M. M., Caulet M., Priest R. G., Guilleminault C. Psychotropic medication consumption patterns in the UK general population. J Clin Epidemiol. 1998 Mar;51(3):273–283. doi: 10.1016/s0895-4356(97)00238-2. [DOI] [PubMed] [Google Scholar]
- Raftery J. NICE: faster access to modern treatments? Analysis of guidance on health technologies. BMJ. 2001 Dec 1;323(7324):1300–1303. doi: 10.1136/bmj.323.7324.1300. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Riedel B. W., Lichstein K. L., Dwyer W. O. Sleep compression and sleep education for older insomniacs: self-help versus therapist guidance. Psychol Aging. 1995 Mar;10(1):54–63. doi: 10.1037//0882-7974.10.1.54. [DOI] [PubMed] [Google Scholar]
- Sibbald B., Addington-Hall J., Brenneman D., Freeling P. Counsellors in English and Welsh general practices: their nature and distribution. BMJ. 1993 Jan 2;306(6869):29–33. doi: 10.1136/bmj.306.6869.29. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Simon G. E., VonKorff M. Prevalence, burden, and treatment of insomnia in primary care. Am J Psychiatry. 1997 Oct;154(10):1417–1423. doi: 10.1176/ajp.154.10.1417. [DOI] [PubMed] [Google Scholar]
- Zigmond A. S., Snaith R. P. The hospital anxiety and depression scale. Acta Psychiatr Scand. 1983 Jun;67(6):361–370. doi: 10.1111/j.1600-0447.1983.tb09716.x. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.