Researchers from the University of Oxford have found that a brief form of cognitive behavioural therapy (CBT) for insomnia, delivered by nurses in GP surgeries, significantly improves sleep and quality of life compared to sleep hygiene alone.
Insomnia, a widespread condition, negatively affects quality of life and leads to substantial costs for society. Impacting around 10% of adults, insomnia also heightens the risk of developing other conditions, including psychiatric disorders, type 2 diabetes, and cardiovascular disease. Despite its high prevalence and burden, access to the recommended treatment – CBT – is extremely limited.
The HABIT trial, published today in The Lancet, involved 642 adults with insomnia recruited from 35 GP surgeries across England. The participants were split into two groups and randomly assigned to receive either four sessions of brief nurse-delivered sleep restriction therapy (along with a sleep hygiene booklet), or sleep hygiene booklet on its own (the control condition).
Sleep restriction therapy, or SRT, involves a nurse reviewing the patient’s sleep-wake pattern and supporting them to implement a new personalised sleep schedule over several weeks. The new sleep-wake pattern leads to an initial reduction in time spent in bed, to consolidate sleep – making it deeper and more efficient. The treatment advises against daytime napping, and establishes a regular bed and rise-time each night to improve the consistency of sleep. These behavioural changes to the sleep schedule are thought to act on biological mechanisms that regulate the sleep-wake cycle.
The sleep hygiene booklet provided behavioural recommendations on how to improve sleep, for example by making changes to one’s lifestyle or sleep environment.
After 6 months, the group receiving sleep restriction therapy reported significantly lower scores on a scale measuring insomnia severity. 42% of those receiving the nurse intervention experienced a clinically meaningful improvement in their insomnia, compared to only 17% of the sleep hygiene control group.
The sleep restriction therapy group also reported greater improvements in mental health-related quality of life, depressive symptoms, work productivity and insomnia at the one year follow up.
The study also looked at cost-effectiveness, which considered costs of training nurses in the treatment, costs to deliver the treatment, and any change in healthcare costs (e.g., appointments with the GP), as well as the effect on quality of life. It was found that sleep restriction therapy had a high probability (95.3%) of being cost-effective from an NHS perspective.
The implications of this research are potentially far-reaching. Training nurses to treat insomnia in primary care may be an effective and scalable way to increase access to evidence-based treatment for insomnia.
While the study offers promising results, the authors note some limitations. Participants in the study primarily consisted of well-educated individuals from White ethnic backgrounds, limiting generalizability to the entire UK insomnia population. The pandemic also affected data collection for some of the secondary sleep outcomes.
Simon Kyle, Associate Professor in the Nuffield Department of Clinical Neurosciences and Chief Investigator of the study, said: ‘Insomnia is a serious condition because it’s highly prevalent, has a major effect on quality of life, and increases risk for developing other physical and mental health problems. The key issue is that people with chronic insomnia rarely receive evidence-based treatment.
The HABIT trial shows that nurses without any formal experience of sleep disorders or psychological therapy can be trained to successfully deliver a brief behavioural intervention for insomnia in primary care.
The brief treatment involved less than 1.5 hours of nurse time over 4 weeks, and led to sustained improvements in sleep, mental health, and work productivity over the 12-month study period. The treatment was also highly likely to be cost-effective from an NHS perspective.’
Writing in a linked commentary, Professor van Straten and Colleagues, who were not involved in the research, said:
‘The study of Kyle and colleagues shows that SRT [sleep restriction therapy] is a simple and effective treatment for at least part of the population of people with chronic insomnia and can be carried out by nurses in primary care. This is an important contribution in tackling the public health burden of insomnia. Urgent efforts are needed to adapt treatments for underserved populations and to educate primary care staff in recognizing insomnia.’
Dr Kyle added: ‘Future research is needed to understand how the nurse-delivered programme could be implemented in the NHS, for example as part of a stepped care approach to insomnia management, and whether this may lead to reduction in prescriptions for sleep medication.’
The HABIT trial was a collaboration between researchers at the Universities of Oxford, Manchester, and Lincoln, and was funded by the Health Technology Assessment Programme from the National Institute for Health and Care Research.