Preferred Medication and Behavioral Treatment Strategies Identified in Primary Care Patients With Insomnia


Findings from a study on primary care patients with insomnia suggest there are patient preferences for behavioral and medication treatment strategies for sleep health.

In a recent study of 200 patients from the Virginia Commonwealth University (VCU) medical center and a community health clinic, primary care patients had a preference of medication and behavioral strategies on treatments for insomnia.1 Having more of an alignment with the treatment preferences of the patient and the actual method of treatment has the potential to be beneficial as it may increase patient motivation, engagement, and treatment adherence.2

Among the participants, 46.5% preferred medication and 56.0% of patients preferred behavioral treatment strategies for their insomnia. In addition, behavioral treatment had the highest preference among those with severe insomnia (preferred, 15.2%; disliked 4.5%; P =.002).

Elliottnell Perez, MA, doctoral student, Clinical Psychology Program in Behavioral Medicine, VCU, and colleagues wrote, “the findings support the hypothesis that insomnia severity and mental health may be involved in treatment preference among primary care patients.”1

The mean age of participants was 54.92 (SD, 12.48) years. Those who were eligible for the study took part in screenings for insomnia, depression, anxiety, and insomnia treatment preference. The Insomnia Severity Index measured insomnia symptoms whereas the Patient Health Questionnaire 2 and Generalized Anxiety Disorder 2 measured depressive and anxiety symptoms. Significant differences were evaluated through a χ2 analyses in preference between the groups. The sample of the study had predominately Black female patients from primary care settings, which is typically an underserved and understudied the patient population in insomnia.

"Individuals may prefer to try non-medication approaches to disease management. In recent years, there has been a large amount of evidence suggesting that behavioral treatments for insomnia are more effective than medication treatment. This evidence should have an influence on patient preferences. Patients were also questioned about their preferences in primary care offices that are training sites for a psychology doctoral program. This may have increased patient familiarity and acceptance for behavioral treatment approaches," Joesph Dzierzewski, PhD, associate professor of clinical psychology at VCU told NeurologyLive®.

All told, medication preference was higher in patients who had elevated anxiety (preferred, 57.3%; disliked, 42.7%; P =.017). Notably, preference for behavioral treatment (preferred, 66.7%; disliked, 33.3%; P =.012) and medication (preferred, 56.8%; disliked, 43.2%; P =.016) were the highest among those with elevated depression. Treatment preference only differed by age for behavioral treatment (P =.008) as it was highest among patients younger than or 51 years of age (preferred, 67.2%; disliked; 32.8%).

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"Insomnia and mental health conditions are reciprocally and dynamically associated with one another. As sleep worsens, it is common to see mental health conditions worsen, and vice versa," Dzierzewski told.

The researchers observed that as mental health and sleep worsens, patients preferred behavioral treatment more. Another observation from the study was that older adults were significantly more likely to dislike behavioral treatment in comparison with younger adults were who were more likely to prefer behavioral treatment.

“Moreover, the proportion of preference for behavioral treatment and medication varied based on the level of depressive and anxiety symptoms,” Perez et al wrote.1 “Knowledge of patient treatment preference may facilitate shared decision making, which increases patient satisfaction with care and engagement with treatment.”

Some limitations from the study included not having any collected information in terms of previous treatment experience and how those experiences may have influenced the attitudes toward both behavioral and medication treatment strategies. Another limitation was that 2-item questionnaires measured the treatment preference and mental health symptoms which could have potentially resulted in an incomplete picture of them. Additionally, the choices of preference by the patients may have been influenced by limited health literacy or the need for more discussion on the process of the treatment along with supporting evidence for both methods.

"One potential explanation could be that younger adults may have less stigma associated with psychological or behavior treatments. Additionally, many older adults may perceive insomnia as a normal part of the aging process, and therefore not rate treatments that are more time intensive, such as behavioral strategies, as highly as more less intense strategies, such as medication management," Dzierzewski mentioned.

Perez et al concluded that, “Collectively, these findings elucidate some predispositions toward insomnia treatment approaches in patients receiving care in primary care facilities and may suggest the need for clinical education regarding evidence of insomnia treatment methods and distinctions between normal and abnormal sleep processes during aging.”1

1. Perez E, Donovan EK, Rybarczyk BD, Dzierzewski JM. Insomnia Treatment Preferences Among Primary Care Patients. Clin Ther. 2022;44(4):630-637. doi:10.1016/j.clinthera.2022.03.002
2. Cheung JM, Bartlett DJ, Armour CL, Saini B. Treating Insomnia: A Review of Patient Perceptions Toward Treatment. Behav Sleep Med. 2016;14(3):235-266. doi:10.1080/15402002.2014.981818
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