Patients’ and clinicians’ experiences and perceptions of primary care for insomnia in Health Expectations


A new interview study from members of the CaHRU team, 'Patients’ and clinicians’ experiences and perceptions of the primary care management of insomnia: qualitative study’ provides further insights into primary care management of insomnia. The study team interviewed 28 patients and 23 health professionals (GPs, nurse, mental health workers and community pharmacists) and analysed the transcripts of these discussions.

They found that practitioners focused on treating the cause of insomnia rather than the insomnia itself, used sleep hygiene (which patients often disregarded) rather than cognitive behavioural therapy for insomnia and were ambivalent towards hypnotic drugs. They often prescribed hypnotics in ‘collusion’ with patients to prescribe to avoid confrontation or express empathy. Patients sometimes took hypnotics in ways that were not intended by their doctors, for example together with over-the-counter medication.

Both practitioners and patients were sometimes but not always concerned about addiction which led practitioners to sometimes prescribe despite these concerns but at other times withdraw hypnotics abruptly. Both patients and practitioners wanted more options and better training for the management of insomnia in primary care. The authors concluded that a better understanding of the current approaches and difficulties in the management of insomnia will help to inform more therapeutic options and health professional training. These findings build on previous work as part of the REST project ( which also led to development of an e-learning programme on insomnia (


New study on published on GP experiences and attitudes to benzodiazepines


A new study has been published in BMC Family Practice on ‘General practitioners’ experiences and perceptions of benzodiazepine prescribing: systematic review and meta-synthesis’. The study was conducted by teams of researchers from the Universities of Lincoln (Coral Sirdifield, Susan Chipchase, Niro Siriwardena), Antwerp (Sibyl Anthierens) and Ghent (Hanne Creupelandt, Thierry Christiaens) who have been working on benzodiazepine and sleeping tablet prescribing by family doctors over the past decade.

The investigators systematically reviewed and synthesised the qualitative literature on benzodiazepine prescribing by family doctors. The analysis of eight studies from seven countries published between 1993 and 2010 showed that prescribing decisions for benzodiazepines were complex, uncomfortable, and demanding. There was variation between GPs and in individual GPs in the extent to which they were willing to prescribe benzodiazepines. GPs were ambivalent and inconsistent in attitudes towards benzodiazepines prescribing because of the changing context of prescribing, differing perceptions of the role and responsibility of the GP, variation in GPs’ attitudes to benzodiazepines, perceived lack of alternative treatment options and GPs’ perception of patient expectations and the doctor-patient relationship.

The model developed by the research team could be used to inform future interventions to improve adherence to benzodiazepine prescribing guidance and improve prescribing. This could be brought about through various means including education and training of professionals on benzodiazepine use and withdrawal, greater provision of alternatives to drugs, reflective practice, and better communication with patients.


New meta-analysis of Z drugs published in the BMJ by REST team


Members of the REST team have published a new meta-analysis of Z drugs in the British Medical Journal (

The effectiveness of newer sleeping tablets, the Z drug (or non-benzodiazepine) hypnotics has been questioned because of publication and reporting bias in previous meta-analyses and the extent of the placebo response to hypnotics.

The study team analysed data submitted to the US Food and Drugs Administration (FDA) for drug approval. Publication bias was eliminated by combining the results of all pharmaceutical industry (‘pharma’) studies, published or unpublished, where a Z drug was compared to placebo. There were 13 studies containing 65 different comparisons of drug-placebo by type of outcome, type of drug, and dose, with 4378 participants from different countries, treatment lengths (mostly up to 30 days), and study years.

The study showed that Z drugs reduced the time to fall asleep in people with primary insomnia, both subjectively and measured in a sleep lab but the effects were relatively small (about 22 minutes). The placebo response was similar to the drug effect and the two together produced a reasonable clinical response. Around half the effect of the drug was a placebo response, which means the placebo response is important in this type of treatment.

There was no demonstrable effect of Z drugs on other outcomes, mainly because these studies tended not to measure sleep quality, daytime sleepiness or other outcomes which may be just as or more important to patients. Z drugs were more effective with larger doses but, more surprisingly, had greater effects in younger or female patients regardless of type of drug. Pharma trials tend to be more positive than non-pharma trials so we have to bear in mind that they tend to overestimate drug effects.

Around a fifth of older people get side effects from sleeping tablets and around one in a hundred will have a fall, fracture or road traffic accident after using them short-term. Cognitive behavioural therapy for insomnia works as well as sleeping tablets in the short term and is better and safer in the longer term so increasing access to these treatments for those who would benefit from them continues to be a priority.

Huedo-Medina TB, Kirsch I, Middlemass J, Klonizakis M, Siriwardena AN. Effectiveness of non-benzodiazepine hypnotics in treatment of adult insomnia: meta-analysis of data submitted to the Food and Drug Administration. BMJ 2012:345: e8343 (


New study on social networking platforms for computerised CBT-I


A new study investigating how computerised cognitive behavioural therapy (CCBT) can be enhanced through the use of social networking platforms was published in the British Journal of General Practice in December 2012.  This qualitative study, funded by the EPSRC and conducted by members of the CaHRU team, Jo Middlemass, Dr Zowie Davy and Professor Niroshan Siriwardena, explored patient and practitioner perspectives on CCBT programmes for insomnia (CCBT-I) which would included social networking.

The objectives of the interview study were:

  • To explore patient and professional perspectives, attitudes, expectations and beliefs towards online health care programmes;
  • To identify participants’ preferences for content, style and information disclosure to health professionals or fellow sufferers;
  • To investigate barriers and facilitators of access, use and adherence to CCBT with a focus on sleep problems and insomnia.

Two meta-themes emerged as key to enhancing uptake and adherence to a potential new CCBT-I package: the need for trust (in the programme, in the patient-professional relationship and in online peer support) and the functionality of the CCBT-I package, with potential users expressing a preference for it to be interactive, individualised and easily navigable.

The findings from the interview study have been incorporated into a novel online CCBT-I package which is currently undergoing testing, designed by a team led by Professor Shaun Lawson who leads the Lincoln Institute of Social Computing (LiSC) with co-investigator Dr Conor Linehan, both based in the School of Computer Science, University of Lincoln.

The study was published in the Br J Gen Pract December 2012; 62 (605): 642-643 with the full-length article available through open access: Middlemass J, Davy Z, Cavanagh K, Linehan C, Morgan K, Lawson S, Siriwardena AN. Integrating online communities and social networks with computerised treatment for insomnia: a qualitative study of service user and primary health care professional perspectives. Br J Gen Pract 2012; 62:e840-e850 doi: 10.3399/bjgp12X659321.


National insomnia expert comments on REST project

01/07/2012 Professor Espie commenting recently on the REST project said: "I think the REST project is a tremendous initiative. For years, sleep has been a rather neglected topic in the NHS, although GPs know full well how common a problem insomnia is in every practice! This project provides practical evidence based help, and I would encourage GPs to make full use of it." Print

First placebo controlled trial of online CBT for insomnia published

11/06/2012 The first placebo controlled trial of online CBT for insomnia has been published in the journal Sleep. The trial, led by Professor Colin Espie of Glasgow University, showed that CBT delivered using a media-rich web application with automated support and a community forum was effective in improving sleep and daytime functioning in adults with insomnia disorder.  Print

Improving Primary Care Resources for Effective Sleep Treatment (IPCREST)

13/01/2012 Is enough being done to help people with insomnia? Insomnia is highlighted on the BBC News. This week EMHIEC have launched a video explaining Improving Primary Care Resources for Effective Sleep Treatment (IPCREST) which is a learning program for primary care practitioners to provide better assessment and cognitive behavioural therapy for insomnia (CBTi): the e-learning package is available at the REST website. Print

REST project highlighted in ITV Tonight documentary: 'Waking up to insomnia'

17/11/2011 Insomnia and work conducted as part of the REST project was highlighted on ITVs Tonight programme, 'Waking up to insomnia' Further details are available at:

REST presented at RSM & MHF event on Sleep and mental health

29/07/2011 The REST project was presented at a one day event hosted by the Royal Society of Medicine and the Mental Health Foundation which focused on 'Sleep and mental health' as part of their Mental Health Awareness Week 2011 campaign on sleep. To see the lecture click here



Niro Siriwardena talks to Prof Colin Espie about insomnia in primary care

19/04/2011 Niro Siriwardena talks about how learning from the REST project has led to improvements in how people with insomnia can be helped by GPs and nurses in primary care using better assessment methods and psychological approaches including CBTi. Interview by Professor Colin Espie, November 2010. Print

REST leads to new EPSRC funded study: ENACT

19/04/2011 ENACT: Exploring social Networks to Augment Cognitive behavioural Therapy is led by Prof Shaun Lawson with co-investigators Prof Niroshan Siriwardena, Prof Kevin Morgan and Dr Kate Cavanagh is funded through the EPSRC "Healthcare Partnerships" programme to improve the uptake, adherence and completion rates of those referred to Computerised Cognitive Behavioural Therapy (CCBT) interventions using the power of online social network (OSN) platforms, social computer games and mobile technology. See BBC news article:


REST educational programme supported by EMHIEC

19/04/2011 The REST team has been awarded funding through East Midlands Health Innovation Educational Cluster (EMHIEC) to deliver a programme of blended learning for primary care practitioners in the management of insomnia and sleep problems: Improving Primary Care Resources for Effective Sleep Treatment (IPCREST).   Print

REST provides alternatives to sleeping tablets

18/04/2011 The REST project is included the Mental Health Research Network Magazine, 'Mental health research can help all of us' (page 5, February 2011).



Rest launches Clinician Newsletter


The REST team have compiled a clinician newsletter to raise awareness of the REST project, the work the team have completed to date and the future aims of the project available to download on the Information for Primary Care Teams page.


REST highlighted in University Newsletter


The University of Lincoln chose to highlight the REST project in the Autumn edition of their newsletter Investigate: