Primary care management of chronic insomnia: a qualitative analysis of the attitudes and experiences of Australian general practitioners

Abstract

Background Chronic insomnia is a highly prevalent disorder, with ten to thirty percent of Australian adults reporting chronic difficulties falling asleep and/or staying asleep such that it causes significant daytime impairment. Current Australian general practice guidelines recommend cognitive behavioural therapy for insomnia (CBTi) as first line treatment for insomnia, however research suggests that most general practice consultations for insomnia result in a prescription for hypnotic or sedative medicines. Although the first point of contact for patients experiencing symptoms of insomnia is often general practice, little is known about the current role, experiences and capacity of Australian general practitioners to manage insomnia. This study aimed to address that gap by exploring the attitudes and opinions of general practitioners regarding insomnia management, to inform the development and implementation of new models of best practice insomnia care within general practice. Methods A descriptive, pragmatic qualitative study. Purposive sampling was used to recruit practising Australian general practitioners, varying in age, years of experience and geographic location. Semi-structured interviews were conducted, and data analysed using thematic analysis. Results Twenty-eight general practitioners participated in the study. Three major themes were identified: 1) Responsibility for insomnia care; 2) Complexities in managing insomnia; and 3) Navigating treatment pathways. Whilst general practitioners readily accepted responsibility for the management of insomnia, provision of care was often demanding and difficult within the funding and time constraints of general practice. Patients presenting with comorbid mental health conditions and insomnia, and decision-making regarding long-term use of benzodiazepines presented challenges for general practitioners. Whilst general practitioners confidently provided sleep hygiene education to patients, their knowledge and experience of CBTi, and access and understanding of specialised referral pathways for insomnia was limited. Conclusions General practitioners report that whilst assessing and managing insomnia can be demanding, it is an integral part of general practice. Insomnia presents complexities for general practitioners. Greater clarity about funding options, targeted education about effective insomnia treatments, and referral pathways to specialist services, such as benzodiazepine withdrawal support and psychologists, would benefit insomnia management within general practice.

Long‐term benzodiazepines and z‐drug prescribing in Australian general practice between 2011 and 2018: A national study

“…The 2020 study highlighted the challenges faced by GPs when they treat patients with long-term medication dependence, especially given that support services and referral pathways can be difficult to access. 33 The increase in long-term BZD prescribing in this study may partly help us understand why the number of Australian deaths S1. a Individuals aged 18+ years with at least three visits in two consecutive years.…”

“…These findings are consistent with evidence of a recent qualitative paper examining GPs perceptions on managing insomnia. The 2020 study highlighted the challenges faced by GPs when they treat patients with long‐term medication dependence, especially given that support services and referral pathways can be difficult to access 33 …”

Assessment, referral and management of obstructive sleep apnea by Australian general practitioners: a qualitative analysis

“…This study was designed to explore the role of GPs in managing two sleep disorders, OSA and insomnia, however this paper reports only the findings relating to OSA. The findings derived from this work related to insomnia have been recently accepted for publication [27]. This study employed in-depth interviews and thematic analysis to collect and interpret the data [28].…”

Attitudes and Difficulties Associated with Benzodiazepine Discontinuation

“…Previous surveys examining attitudes toward BZD prescriptions have focused on GPs, not psychiatrists [ 31 , 32 , 33 ]. Since psychiatrists have more opportunities to treat patients with anxiety and insomnia symptoms and perform cognitive behavioral therapy, potentially facilitating BZD discontinuation in patients with psychiatric disorders [ 34 ], comparisons of BZD discontinuation strategies and difficulties between psychiatrists and non-psychiatrists and investigation of the factors related to difficulties in BZD discontinuation may be worthwhile.…”