Management
Management of insomnia disorder includes non-pharmacological, cognitive and behavioural treatments Brief Behavioural Therapy for Insomnia (BBTi) and Cognitive Behavioural Therapy for insomnia (CBTi).
The evidence based non-drug interventions BBTi and CBTi administered by specifically trained health professionals including GPs and psychologists is recommended to be used as the first-line treatment for insomnia disorder by Australian and international sleep and medical guidelines.1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16
Questionnaires such as the Sleep Condition Indicator (SCI) and Insomnia Severity Index (ISI) are available to assess a patient’s insomnia symptoms and are recommended for follow-up use in combination with a 7-day sleep diary (paper or watch which monitors sleep patterns).
Management options for insomnia disorder in primary care include:
- Sleep Hygiene Education
- Brief Behavioural Therapy for Insomnia (BBTi)
- Referral to a psychologist specialising in sleep health for face-to-face CBTi
- Digital CBTi
- Referral to a Sleep Physician including when:
ii. Failure to respond to CBTi with a psychologist
Chronic insomnia commonly co-occurs with depression and obstructive sleep apnea (OSA). Polysomnography (laboratory or home testing) is not recommended as an investigation for insomnia itself, but may be helpful to exclude other sleep disorders, including OSA and periodic limb movement disorder (PLMD).
Chronic insomnia is a debilitating disorder, which may meet criteria for chronic disease management plan through the Medicare Benefits Schedule (MBS) allowing GPs/practice nurses to deliver services to patients who require structured chronic disease management. The insomnia is considered chronic when it has been present for six months or longer. Whether a patient is eligible to be managed by their GP under a GP Management Plan (item 721) and Team Care Arrangements (item 723) is a clinical judgement for the GP, taking into account the patient’s medical condition and care needs.
GPs can refer patients with insomnia to a psychologist with a Mental Health Treatment Plan (MHTP) referral, allowing a rebate for the referral appointment, and subsidising costs of psychologist sessions.17
GPs with additional General Practice Mental Health Standards Collaboration (GPMHSC) training can use Focused Psychological Strategies item numbers to deliver BBTi in the general practice setting.
AHI - Apnoea-Hypopnoea Index
BBTi - Brief Behavioural Therapy for Insomnia
BMI - Body Mass Index (kg/m2)
BQ - Berlin Questionnaire
CBTi - Cognitive Behavioural Therapy for Insomnia
CELL - Coblation Endoscopic Lingual Lightening
COPD - Chronic Obstructive Pulmonary Disease
CVA - Cerebrovascular Accident
CPAP - Continuous Positive Airway Pressure
CSA - Central Sleep Apnoea
DASS - Depression Anxiety Stress Scale
DBAS - Dysfunctional Beliefs and Attitudes about Sleep
DBP - Diastolic Blood Pressure
DIMS - Difficulties Initiating and/or Maintaining Sleep
DISE - Drug-Induced Sleep Endoscopy
DISS - Daytime Insomnia Symptom Scale
ENT - Ear Nose and Throat
ESS - Epworth Sleepiness Scale
FOSQ - Functional Outcomes of Sleep Questionnaire
FSH - Follicle-Stimulating Hormone
FTP - Friedman Tong Position
GP - General Practitioner
HANDI - RACGP Handbook of Non-Drug Interventions
HGNS - Hypoglossal Herve Htimulation
ISI - Insomnia Severity Index
K10 - Kessler Psychological Distress Scale
MAD - Mandibular Advancement Device
MAS - Mandibular Advancement Rplint
MBS - Medicare Benefits Schedule
MMA - Maxillomandibular Advancement Surgery
MRA - Mandibular Repositioning Appliance
ODI - Oxygenation Desaturation Index
OSA - Obstructive Sleep Apnoea
PLMD - Periodic Limb Movement Disorder
PT - Positional Therapy
PTSD - Post-Traumatic Stress Disorder
PSG - Polysomnography
QSQ - Quebec Sleep Questionnaire
REM - Rapid Eye Movement
RFTB - Radiofrequency Thermotherapy of the Tongue Base
SBP - Systolic Blood Pressure
SCI - Sleep Condition Indicator
SE - Sleep Efficiency
SF36 - Short-Form (36) Health Survey
SMILE - Submucosal Minimally Invasive Lingual Excision
SNRIs - Serotonin-Norepinephrine Reuptake Inhibitors
SOL - Sleep Onset Latency
SSRI - Selective Serotonin Reuptake Inhibitors
TFTs - Thyroid Function Tests
TIB - Time In Bed
TORS - Transoral Robotic Surgery
TST - Total Sleep Time
UPPP - Uvulopalatopharyngoplasty
WASO - Wake After Sleep Onset