Cognitive Behavioral Therapy for Insomnia Rarely Recommended by Primary Care Providers, Survey Says

Survey data published in the Journal of Sleep Research indicated that cognitive behavioral therapy for insomnia (CBT-I) is underutilized in primary care settings. When presented with case vignettes that described patients with insomnia, the majority of primary care providers (PCPs) recommended prescribing phytopharmaceuticals or antidepressants. For both case vignettes, fewer than 10% of providers suggested CBT-I.  

PCPs working for the Institute of Primary Care at the University of Bern in Bern, Switzerland were invited to participate in an electronic survey about insomnia treatment. The survey captured practice site characteristics and PCP demographic information. The survey also presented 2 case vignettes: (1) a case of insomnia with no comorbidities; and (2) a case of insomnia with co-occurring major depression. The PCPs were asked to describe how they would treat each case. PCPs were then asked to rate their knowledge of CBT-I on a 5-point Likert scale.

Among 820 PCPs invited to participate, 395 (48%) completed the survey. After excluding incomplete surveys and PCPs who worked exclusively as pediatricians, data were available from 361 participants. Mean respondent age was 54 years, and the majority were men (70%). Nearly half (43%) of PCPs had been practicing for over 20 years. Almost all responders initiated both pharmacological and non-pharmacological treatment for the 2 case vignettes.

For the case of chronic insomnia with no comorbidities, 87% of PCPs prescribed sleep hygiene; 65% prescribed phytopharmaceuticals; 61% prescribed physical activity; and 49% prescribed antidepressants. Additionally, 18% prescribed benzodiazepine receptor agonists (BRZA) and 4% prescribed benzodiazepines (BZD). CBT-I was prescribed by just 9% of providers.

For the second case vignette, almost all PCPs (95%) prescribed an antidepressant. Phytopharmaceuticals, BZRA, and BZD were prescribed by 20%, 15%, and 5%, respectively. The most commonly prescribed non-pharmacological treatments for this case were sleep hygiene (59%), physical activity (59%), and psychotherapy (48%). CBT-I was prescribed by just 8% of PCPs.

Overall, only 35% of PCPs endorsed having “moderate” or “good” knowledge of CBT-I. Nearly half (46%) reported “poor” knowledge and 19% reported “no knowledge.” No providers endorsed “very good” knowledge.

Just over a fifth (22%) of providers reported knowing a local specialist who offered CBT-I. The majority of PCPs said they were interested in learning more about pharmacological (76%) and non-pharmacological (78%) treatments for chronic insomnia. Over half (54%) of respondents said they frequently felt that “patients with chronic insomnia expected…a hypnotic [prescription].”

Results from this study indicate that Swiss PCPs rarely follow evidence-based guidelines, which endorse CBT-I as first-line treatment. The European Sleep Research Society guidelines also recommend against phytopharmaceuticals, and only suggest BZD or BZRA as second- or third-line treatments. Outreach efforts to increase awareness about CBT-I efficacy are necessary to increase its uptake in primary care settings.

“[I]nforming PCPs about the benefits of CBT-I and connecting them with local CBT-I providers could increase the proportion of Swiss PCPs who prescribe [CBT-I] and also reduce the number of patients treated with medication, especially in the presence of depression,” the investigators wrote.

Disclosure: Two study authors declared affiliations with the pharmaceutical industry.

Please see the original reference for a full list of authors’ disclosures.

Reference

Linder S, Duss SB, Dvořák C, et al. Treating insomnia in Swiss primary care practices: a survey study based on case vignettes [published online September 20, 2020]. J Sleep doi: 10.1111/jsr.13169