What happens when patients are unable to get the help recommended by their doctors? That’s the dilemma often faced by people with insomnia when they’re told to try cognitive behavioral therapy. Even though this option is strongly recommended as first-line treatment, a severe shortage of therapists means many patients can’t follow through on doctors’ advice.
Some will return to their primary care physicians to discuss other options—but many more end up searching for OTC sleep aids in your pharmacy. You can help these exhausted and frustrated patients by reaching out with expert guidance.
Guidelines for Managing Insomnia
When physicians examine patients with insomnia, they are faced with a complex puzzle. They must rule out a wide range of medical and psychiatric conditions, consider medications that could interfere with sleep, and assess for a host of lifestyle variables. Practitioners have seen an increasing number of patients who require this type of in-depth assessment:1
Insomnia occurs in 33 to 50 percent of all adults.
Primary insomnia disorders—sleeplessness with distress or impairment in functioning—occur in 15 percent of patients.
Secondary insomnia disorders—sleep disturbance caused by an underlying disorder—are found in 5 to 10 percent of adults.
Patients with comorbid psychiatric or chronic pain disorders have insomnia prevalence rates of 50 to 75 percent.
Here are a few other key pieces of information about the patients you’re likely to encounter:
The risk of insomnia is higher for women, older patients, shift workers, those with any type of comorbid disorder, and those struggling with substance abuse.
Insomnia predisposes patients to psychiatric disorders such as depression.
Temporary acute insomnia lasts up to one month and is usually caused by situational stress.
Chronic insomnia persists in 50 to 85 percent of patients.
In May 2016, the American College of Physicians (ACP) released clinical practice guidelines for insomnia. They strongly recommend cognitive behavioral therapy for insomnia (CBT-I) as the initial treatment for all patients, noting that medications should only be considered when CBT-I fails.
By comparison, guidelines established by the American Association of Sleep Medicine (AASM) encourage psychological and behavioral interventions as initial therapy only when appropriate—otherwise, treatment strategies are individualized and should deal with the underlying etiology.2
The difference between the two sets of recommendations is subtle but important—patients may end up waiting indefinitely for CBT-I if their physicians strictly follow ACP guidelines.
Barriers to First-Line Treatment
There’s no doubt that CBT-I is an effective treatment. Numerous studies show it improves sleep in virtually every group of patients, from older adults and breast cancer patients to menopausal women and teachers who can’t sleep because they’re ruminating about work. Whether it’s implemented face-to-face, digitally, or over the telephone, CBT-I relieves insomnia—although face-to-face is preferable and often required for insurance coverage. In fact, CBT-I is successful in 70 to 80 percent of patients, usually without supplemental medication.3 It’s easy to see why it’s recommended as first-line treatment.
However, CBT-I is only successful when patients can actually find a therapist, and when patients are committed to participating in the work required by CBT-I. Even representatives of the American College of Physicians concede the following barriers to treatment:
Physicians’ lack of awareness regarding CBT-I’s effectiveness and bias against psychological intervention.
Insurance policies that often don’t pay for CBT-I.
A shortage of CBT-I-trained and certified mental health providers.
The willingness of patients to commit to as many as eight sessions, participate in the process, and maintain a strict sleeping regimen.
While the ability to pay for therapy is a big roadblock, the most significant issue on the list is the shortage of trained CBT-I providers. To start, there’s already a general shortage of mental health providers in the United States: only half of all patients who need help have access to a therapist.4 Additionally, patients can’t simply go to any provider of cognitive behavioral therapy. CBT-I therapists must become certified in Behavioral Sleep Medicine by the American Board of Sleep Medicine. This shortage of CBT-I providers has existed for more than a decade—and ways to solve the problem have been discussed—but the issue remains unresolved.5
How Pharmacists Can Support Patients with Insomnia
If they fail to find a CBT-I therapist, insomnia patients will hopefully discuss other options with their physicians. But don’t assume that will happen. Depending on doctor-patient communication, patients may believe that CBT-I is the only option and figure there’s no sense in going back. Or patients might find a therapist only to be told the earliest availability is in six months—so they settle in to wait without asking for help in the interim. Some of these patients will head to their local pharmacy to look for OTC sleep aids. This gives you the chance to reach out and offer advice:
Suggest they may want to consult a sleep specialist or an accredited sleep disorder center. Patients may need help with sleep apnea and other complex problems such as advanced sleep-wake phase disorder or intrinsic circadian rhythm sleep-wake disorder.
Encourage them to talk to their doctor again to discuss other treatment options, including approved sleeping aids, such as benzodiazepines, nonbenzodiazepine sedatives, melatonin agonists, antidepressants, and orexin antagonists.
Ask whether the doctor counseled them about basic sleep hygiene—be prepared with a handout that lists good sleep habits.6
Make sure patients understand that light emitted from electronics disrupts the sleep-wake cycle.
Review patients’ OTC and prescription medications to be sure they’re not causing insomnia.
Talk with them about over-the-counter sleep aids. Antihistamines should be time limited, but melatonin and gamma-aminobutyric acid are safe and effective.
Barriers to Care Provide Opportunities for Outreach
Patients with insomnia have an increased risk of obesity, type 2 diabetes, heart attack, and stroke—not to mention the chance of nodding off behind the wheel and the sheer frustration of daily sleepiness that interferes with enjoying life.7 Whether you reach out to people buying sleeping aids at the check-out or create a display of sleep products—along with a poster suggesting they “ask the pharmacist”—your intervention is a welcome support to those suffering from chronic insomnia.
Pharmaceutica North America provides natural OTC sleep aids, topical solutions for chronic pain, and high-quality active pharmaceutical ingredients. Contact us today to talk about how we can help support your patients with insomnia and meet your other pharmaceutical needs.
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