Issues and challenges in implementing clinical practice guideline for the management of chronic insomnia

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The European Guideline for the Diagnosis and Treatment of Insomnia, published in this issue of the journal (Riemann et al., 2017), describes much‐needed and timely recommendations intended to inform clinicians concerning good clinical practices for the diagnosis and management of insomnia. Based on a systematic review of more than 60 meta‐analyses, its main conclusions with regard to treatment are that: (a) cognitive–behavioural therapy (CBT) should be the first‐line treatment for chronic insomnia in adults and (b) pharmacotherapy (i.e. benzodiazepines, benzodiazepine receptor agonists and some antidepressants) may be used if CBT is ineffective or unavailable. These practice guidelines are very much in line with the conclusions of previous consensus conferences on the management of insomnia (National Institutes of Health, 2005; Wilson et al., 2010) and almost identical to guidelines prepared by the American Academy of Sleep Medicine (Sateia et al., 2017) and the American College of Physicians (Qaseem et al., 2016).
With this high level of converging evidence, we can safely say that there is consensus in the scientific and professional sleep community that CBT should be the treatment of choice for chronic insomnia. Notwithstanding, there is still a major gap between reaching consensus at the organizational level and adopting/implementing evidence‐based recommendations at the individual clinical practice level. Indeed, the current status of insomnia therapies is that CBT is used rarely in routine clinical practice and drug‐prescribing practices do not always match evidence‐based recommendations. Before addressing the issues and challenges in implementing these guidelines, let us examine first what is the typical treatment trajectory for patients with insomnia and what are important barriers to insomnia treatment, in general, and to using CBT specifically.
Insomnia is a condition that is still too often trivialized and not taken seriously, despite accumulating evidence documenting its association with negative health outcomes (i.e. depression, hypertension, work absenteeism). Not surprisingly, insomnia complaints often remain undiagnosed and untreated (Cheung et al., 2014; Ulmer et al., 2017). When treatment is initiated, treatment trajectories vary widely depending on individual and contextual factors, such as knowledge about treatment options, availability of treatment and the type of professional from whom someone seeks help (physician, psychologist, pharmacist, nurse). Even before reaching out for professional services, many patients use various self‐help remedies (over‐the‐counter substances or ‘natural products’) of unknown risks and benefits. If and when professional treatment is sought, it is typically from a primary care physician, and medication is often the first and only treatment provided (Morin et al., 2006).8 Several medications prescribed commonly for insomnia (e.g. antidepressants, antipsychotics) are not even indicated for insomnia; a practice which, of course, leads to suboptimal outcomes. By and large, very few patients with insomnia receive CBT.
There are several important barriers to insomnia treatment and to using CBT. At the individual level there is still a stigma about insomnia, and many individuals believe that it is not perceived as a real clinical problem and feel misunderstood by the medical community (Araujo et al., 2017; Cheung et al., 2016). There is also a lack of knowledge about the different treatment options, with many individuals being unaware of non‐pharmacological therapies. At the clinician level, this lack of knowledge about some treatment options (CBT) is also very common; although some practising physicians report using behavioural interventions in their practice, in reality this is often restricted to general sleep hygiene education. Because CBT is clearly more time‐consuming than writing a pill prescription, time is another important barrier in primary care. As patients often present with more than one medical problem, and physicians are already over‐extended with dealing with multiple medical problems, insomnia may not be very high on the priority list.

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