Insomnia : treatment needs, effectiveness, and experiences

Background and aim: The sleep-wake disorder insomnia reduces daytime functioning and quality of life and increases the risk for mental and physical illness. Most people with insomnia who seek treatment do so in primary health care (PHC). Although the recommended first-line treatment is cognitive behavioral therapy for insomnia (CBT-I), the most common treatment remains hypnotics. The aims of this thesis were to investigate the need for treatment for sleep difficulties in the general population (study I), evaluate whether a nurse-led group treatment for insomnia is more effective than treatment as usual in improving insomnia in PHC (studies II and III), and to explore patients' experiences of the group treatment (study IV).

Material and methods: Study I was a telephone survey investigating factors associated with self-reported need for treatment for sleep difficulties. Participants were 1115 people randomly selected from the general population of Sweden. Studies II and III were based on a randomized controlled trial (n = 165) that investigated the effects of a group treatment program for insomnia. The 10-week program (seven sessions) was based on the techniques of CBT-I and led by district nurses in routine PHC. The control condition was treatment as usual. Patient-reported outcome measures were used to assess outcomes at baseline and post- treatment. Additionally, patients who received group treatment were assessed 1 year after group treatment. In study IV, patients’ experiences of the group treatment were explored via five focus group interviews that were transcribed and analyzed with qualitative content analysis.

Results: Study I showed that 12.5% of the general population reported a need for treatment for sleep difficulties. Difficulty initiating sleep was the factor most strongly related to need for treatment. Other important factors were nonrestorative sleep, mental disorders, and fatigue. Study II showed that the nurse-led group treatment for insomnia was more effective than treatment as usual in reducing insomnia severity, improving sleep, and reducing patients' use of hypnotics. Study III showed that the group treatment was more effective than treatment as usual in improving the daytime symptomatology of insomnia (fatigue, depressive symptoms, psychological distress, health-related quality of life, general daytime functioning, specific daytime symptoms, and dysfunctional beliefs). All improvements found after group treatment in studies II and III were sustained 1 year later. In study IV, the qualitative analysis revealed four themes that described patients' experiences: involvement and trust open the door for change, competence arising from deeper understanding, struggling with vulnerability and failure, and tailoring treatment to individual needs.

Conclusions: Many people in the general population feel that they need treatment for sleep difficulties. An important factor behind this need is difficulty initiating sleep, followed by nonrestorative sleep, mental health problems, and fatigue. Nurse-led group treatment can effectively improve insomnia, is feasible to implement in routine PHC, and has the potential to increase patients’ access to recommended first-line treatment (CBT-I). Patients' experiences of group treatment illuminate what motivated them to change, what helped them improve, and the challenges they faced.

List of scientific papers

I. Sandlund C, Westman J, Hetta J. Factors associated with self-reported need for treatment of sleeping difficulties: a survey of the general Swedish population. Sleep Med. 2016 Jun;22:65-74.
https://doi.org/10.1016/j.sleep.2016.03.016

II. Sandlund C, Hetta J, Nilsson GH, Ekstedt M, Westman J. Improving insomnia in primary care patients: A randomized controlled trial of nurse-led group treatment. Int J Nurs Stud. 2017 Jul;72:30-41.
https://doi.org/10.1016/j.ijnurstu.2017.03.007

III. Sandlund C, Hetta J, Nilsson GH, Ekstedt M, Westman J. Impact of group treatment for insomnia on daytime symptomatology: Analyses from a randomized controlled trial in primary care. Int J Nurs Stud. 2018 Sep;85:126-35.
https://doi.org/10.1016/j.ijnurstu.2018.05.002

IV. Sandlund C, Kane K, Ekstedt M, Westman J. Patients' experiences of motivation, change, and challenges in group treatment for insomnia in primary care: a focus group study. BMC Fam Pract. 2018 Jul;19(1):111.
https://doi.org/10.1186/s12875-018-0798-2