Putting NICE guidance on the management of insomnia disorders into practice
Outcomes and learning
Outcomes
We manage chronic insomnia by applying tailored Cognitive Behavioural Therapy for Insomnia (CBT-I) principles as part of each person's individual management plan, delivered directly in clinic. Through this approach we have successfully transitioned people away from long-term use of nonbenzodiazepines ('Z-drugs') and benzodiazepines.
We have now prescribed daridorexant to over 200 people; either once CBT-I principles are in place, or where CBT-I is not suitable. In both scenarios it has proven an effective strategy for transitioning people away from dependency-causing medicines and onto a treatment with a fundamentally better safety profile.
Learning
This case study demonstrates that CBT-I principles can be delivered effectively in clinic, following a thorough sleep assessment. It also shows that daridorexant offers something genuinely different to other hypnotics, by virtue of its unique pharmacology.
Other key learnings include:
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Insomnia remains poorly understood as a public health issue despite its wide-ranging impact on mental wellbeing and physical health. Sleep needs to sit alongside weight management, smoking cessation and exercise as a public health priority.
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Access to CBT-I is insufficient and postcode-dependent. It is the long-term solution for most people, and there are encouraging signs. The Department of Health and Social Care has recognised this and is currently undertaking a tender process to make digital CBT-I available nationally through the NHS.
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By the time people reach a specialist sleep centre, they have tried multiple things and are exhausted. A generic protocol is not enough; time is needed to understand each person's situation and to tailor the approach accordingly. Growing the number of healthcare professionals with a specialist interest in sleep medicine, particularly in primary care, is essential given how many people in the community are yet to have treatment.
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Insomnia affects all ages and backgrounds. A service built around a single delivery model will inevitably leave the people who need it most without access. Different ways of delivering CBT-I need to be supported and encouraged.
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We need to move away from blunt-acting medicines and embrace the emerging science behind novel, targeted therapies. Sleep is a major contributor to brain health, and more investment in research to understand the key drivers of sleep physiology, and to discover new therapeutic targets, is long overdue.
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