Improving insomnia in primary care patients: A randomized controlled trial of nurse-led group treatment

Abstract

BackgroundInsomnia is a common health problem, and most people who seek help for insomnia consult primary care. In primary care, insomnia treatment typically consists of hypnotic drugs, although cognitive behavioral therapy for insomnia is the recommended treatment. However, such treatment is currently available to few primary care patients. ObjectivesTo evaluate the effects of a group treatment program for insomnia led by nurses in primary care. Outcomeswere the Insomnia Severity Index, a 2-week sleep diary, and a questionnaire on frequency of hypnotic drug use. DesignA randomized controlled trial with pre- and post-treatment assessment and a 1-year post-treatment follow-up of the intervention group. SettingsRoutine primary health care; 7 primary care centers in Stockholm, Sweden. ParticipantsPatients consulting primary care for insomnia were assessed for eligibility. To be included, patients had to have insomnia disorder and be 18 years or older. Patients were excluded if they if they worked night shifts or had severe untreated somatic and/or mental illness, bipolar disorder, or untreated sleep disorder other than insomnia. One-hundred and sixty-five patients 20 to 90 years were included. Most were women, and many had co-existing somatic and/or mental health problems. The post-treatment dropout rate was 20%. MethodsThe intervention was a nurse-led group treatment for insomnia based on the techniques of cognitive behavioral therapy for insomnia. The nurses had 2days of training in how to deliver the program. Ninety patients were randomized to the intervention and 75 to the control group (treatment as usual). Data from 82 in the intervention and 71 in the control group were analyzed in accordance with intention-to-treat principles. Fifty-four of the 72 in the intervention group who participated in the group treatment program were followed up after 1year. ResultsMean Insomnia Severity Index score decreased significantly from 18.4 to 10.7 after group treatment but remained unchanged after treatment as usual (17.0 to 16.6). The effect size was large (1.23). Group treatment also resulted in significant improvements in all sleep diary variables (sleep onset latency, total sleep time, time awake after sleep onset, number of awakenings, and sleep quality). It also reduced hypnotic drug use. Improvements were maintained 1-year post-treatment. ConclusionsPatients with insomnia can be treated successfully with a nurse-led group treatment program in primary health care. The results support implementation of the treatment program, particularly given the need for increased access to non-pharmacological insomnia treatments.