Nurse-delivered sleep restriction therapy reduces insomnia symptoms

Key takeaways:

• The effects of sleep restriction therapy remained present at 12 months.
• Researchers said the intervention could be widely implemented as a first-line insomnia disorder treatment.

A nurse-delivered sleep restricted therapy intervention within primary care was associated with decreased insomnia severity compared with sleep hygiene and likely cost-effective, according to results of a randomized controlled trial.

International guidelines recommend cognitive behavioral therapy (CBT) as first-line treatment for insomnia; however, access is limited because of a lack of expertise and resources, Simon D. Kyle, MA, PhD, an associate professor at the University of Oxford’s Nuffield Department of Clinical Neurosciences, and colleagues wrote in The Lancet.

“New models of care are needed to increase access to guideline intervention, especially in general practice, where people with insomnia seek treatment,” they wrote.

The researchers suggested that access be addressed by simplifying CBT through the implementation of sleep restriction therapy as a single component intervention. They conducted a randomized controlled trial to address uncertainties on the effectiveness, feasibility and costs of a nurse-delivered sleep restriction intervention vs. sleep hygiene.

For the sleep restriction intervention, primary care nurses received 4-hour training sessions on sleep restriction therapy, CBT and sleep insomnia. They delivered the intervention to patients during one session per week over 4 weeks. During the first session, the patients were educated on the rationale for sleep restriction therapy, reviewed sleep diaries and selected new bed and rise times. The second, third and fourth sessions included a review of progress, discussions on difficulties regarding implementation and “titration of the sleep schedule according to a sleep efficiency algorithm,” the researchers wrote.

Participants in the sleep hygiene group, meanwhile, received only the booklet.

Each intervention group included 321 participants (mean age, 55 years; 76.2% women) in the United Kingdom. The researchers measured study outcomes at 3, 6 and 12 months with the insomnia severity index (ISI) and estimated cost-effectiveness through incremental cost per quality-adjusted life year (QALY) gained.

At 6 months, Kyle and colleagues reported that the mean ISI score was 10.9 for sleep restriction therapy and 13.9 for sleep hygiene (adjusted mean difference = –3.05; 95% CI, –3.83 to –2.28), “indicating that participants in the sleep restriction therapy group reported lower insomnia severity.”

At that time, participants in the sleep restriction group also reported:

• better mental health-related quality of life;
• better sleep-related quality of life;
• lower depression symptoms; and
• lower activity impairment.

The treatment effects remained present at 12 months, and although eight participants experienced adverse effects, none were determined to be related to sleep restricted therapy, according to the researchers.

The intervention produced an incremental cost per QALY of £2,076 ($2,645.21), with there being a 95.5% probability that the intervention was cost-effective.

Kyle and colleagues noted that the study had several implications for general practice.

“We have shown that a nurse-delivered program that makes moderate demands on nursing time can be effective in routine primary care,” they wrote. “Nurse-delivered treatment could feature as part of a stepped-care management approach to insomnia and complement initiatives to increase access to digital therapies.”

They added that the intervention’s delivery model and brief training may also be ideal for nonspecialists and that it “provides a practicable approach for clinicians wanting to follow guidelines for patients with insomnia disorder.”