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Insomnia: NICE recommends digital app as treatment option

BMJ 2022; 377 doi: https://doi.org/10.1136/bmj.o1268 (Published 20 May 2022) Cite this as: BMJ 2022;377:o1268
  1. Jacqui Wise
  1. Kent

GPs should consider offering patients with insomnia the Sleepio app as an effective and cost saving alternative to sleeping pills, the National Institute for Health and Care Excellence (NICE) has recommended.1

The app will also reduce patients’ reliance on drugs such as zolpidem and zopiclone that can be dependence forming, said NICE’s medical technologies advisory committee.

The Sleepio app uses an artificial intelligence algorithm to provide tailored cognitive behavioural therapy for insomnia (CBT-I). It is primarily accessed through a website, and there is a Sleepio app for IOS mobile and Android devices.

The current recommended care pathway for people with poor sleep is to first offer advice about sleep hygiene. If this does not work and the insomnia is causing significant distress, a 3-7 day course of a non-benzodiazepine hypnotic medication can be considered. The committee heard that the gold standard treatment for clinically diagnosed insomnia that is unlikely to resolve soon is face-to-face CBT-I, but its availability is very limited in the NHS.

Clinical evidence from 12 randomised controlled trials showed that Sleepio reduced insomnia symptoms when compared with sleep hygiene and sleeping pills. However, there was limited clinical evidence to show how effective Sleepio was in comparison with face-to-face CBT-I in primary care, and more research was needed, the committee said.

At a price of £45 per person, Sleepio is cost saving when compared with usual treatment in primary care, said NICE. A data analysis of primary care use, before and after Sleepio was introduced in nine general practices, found that healthcare costs were lower at one year, mainly because of fewer GP appointments and sleeping pills prescribed.

Weekly sessions

The app provides a six week self-help programme involving a sleep test and weekly interactive CBT-I sessions. The sessions focus on identifying thoughts, feelings, and behaviours that contribute to symptoms of insomnia. Cognitive interventions aim to improve the way a person thinks about sleep, and the behavioural interventions aim to promote a healthy sleep routine.

A daily sleep diary helps users track their progress, and the data can be automatically uploaded from a compatible tracing device such as an Apple watch or a Fitbit. People also have access to articles, online tools, and a Sleepio user community for support.

The guidance recommends that before referral to Sleepio a medical assessment should be done for patients who may be at higher risk of other sleep disorders, such as those who are pregnant or have comorbidities.

NICE acknowledged that Sleepio may be difficult for some people to use. It requires access to a computer and the internet and may be difficult for people with limited English language skills.

Jeanette Kusel, acting director for med tech and digital at NICE, said, “Until now people with insomnia have been offered sleeping pills and taught about sleep hygiene, so our committee’s recommendation of Sleepio provides GPs and their patients with a new treatment option.

“Our rigorous, transparent, and evidence based analysis has found that Sleepio is cost saving for the NHS compared with usual treatments in primary care. It will also reduce people with insomnia’s reliance on dependence forming drugs such as zolpidem and zopiclone.”

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