Background
Methods
Study design
Setting
Recruitment strategy
Data collection
Data analysis
Results
Participant characteristics
Participant | Rurality | Age group | Gender | Years practising as a GP |
---|---|---|---|---|
P1 | Rural | 25–34 | Female | 3.0 |
P2 | Rural | 35–44 | Male | 4.0 |
P3 | Metropolitan | 25–34 | Male | 5.0 |
P4 | Metropolitan | 25–34 | Female | 2.0 |
P5 | Rural | 25–34 | Female | 3.0 |
P6 | Metropolitan | 35–44 | Male | 1.0 |
P7 | Metropolitan | 55–64 | Female | 29.0 |
P8 | Metropolitan | 35–44 | Female | 6.0 |
P9 | Metropolitan | 55–64 | Female | 26.0 |
P10 | Metropolitan | 35–44 | Female | 6.0 |
P11 | Metropolitan | 55–64 | Male | 35.0 |
P12 | Metropolitan | 55–64 | Male | 42.0 |
P13 | Metropolitan | 35–44 | Male | 10.0 |
P14 | Rural | 25–34 | Female | 5.0 |
P15 | Metropolitan | 45–54 | Female | 20.0 |
P16 | Metropolitan | 35–44 | Female | 17.0 |
P17 | Metropolitan | 35–44 | Female | 0.3 |
P18 | Metropolitan | 35–44 | Female | 3.0 |
P19 | Metropolitan | 35–44 | Female | 14.0 |
P20 | Rural | 55–64 | Male | 30.0 |
P21 | Remote | 45–54 | Male | 20.0 |
P22 | Rural | 55–64 | Male | 30.0 |
P23 | Rural | 55–64 | Female | 30.0 |
P24 | Rural | 25–34 | Male | 4.0 |
P25 | Remote | 25–34 | Male | 5.0 |
P26 | Metropolitan | 25–34 | Female | 5.0 |
P27 | Metropolitan | 45–54 | Female | 26.0 |
P28 | Rural | 25–34 | Female | 2.0 |
Theme 1: responsibility for insomnia care
For insomnia, I probably don’t see that as a referral out of general practice very often. Unless there’s a very significant mental health component to it. (Participant 7)I can’t remember ever referring someone for insomnia. Maybe once I’ve referred someone to a psychologist, but not – generally, no. That’s something that to me sits in the scope of general practice. (Participant 22)
It depends on the severity and depends on if there’s…a comorb with psychiatric illness then I would probably be referring on to my psychiatric colleagues. (Participant 5)I think when it gets to that sort of [chronic] level I would probably outsource it, so I would probably speak to a sleep clinic or a sleep psychologist, if that were the case. (Participant 8)
If…someone were to come in for a 10 min appointment and go through insomnia, that would take about 15 to 20 min, and the pressure of running late, keeping someone else waiting tends to start playing on you at some point down the line. (Participant 10)Teasing out the things that are contributing to it takes a lot of time, and then if you’re wanting to change particular behaviours and then doing the motivational interviewing to go with that then that takes time. (Participant 18)
In terms of time limitations, it’s often brought up in the context of multi-disciplinary comorbid care, so it takes a long time to sort these things out and trying to disentangle it from all the multiple presentations, and patients very rarely present with insomnia as their sole issue. (Participant 7)
You’re kind of taking on a time bomb [providing insomnia management], because…if you can put through three people every 15 min, you’re going to get paid a lot more than those really long extended consults. So while it’s rewarding, it’s not financially rewarding. That’s the sticking point. (Participant 16)
Unless there was…a stellar rebate for it…I’m not doing that on a – on the Medicare, what, 36 bucks or whatever they pay us. (Participant 6)
Theme 2: complexities in managing insomnia
Often they’re hard…patients [to see] as well, because there’s often a lot of other complex issues going on as well. It’s not just [that they] can’t sleep. (Participant 26)
It’s normally, “And by the way, I’m having trouble sleeping. I’ve come in for this, but by the way…” So it tends to be…the bigger of the two issues, but they don’t perceive it as that. (Participant 10)
Some, if they are depressed, part of their screening is you ask about their sleep and things, when they are anxious…if there is any mental health complaint as part of the screening, you could ask about sleep, and you realise it’s a lot of that. (Participant 1)
If they keep coming in – if it’s due to an underlying depression, then…you go, “How’s the sleep? And how’s your mood?” So it’s very much interrelated. You can’t sort of separate it. (Participant 10)
A lot of doctors ended up taking, you know, the fatigue, the depression, but that’s not the real cause of the problem. That’s a consequence of the chronic insomnia. (Participant 1)
Insomnia isn’t actually a disease. It’s a symptom only…insomnia doesn’t happen by itself. (Participant 11)
I really, really try to avoid it [prescribing benzodiazepines]. Just knowing the harm that it can potentially do, and I just feel like it’s quite a Band-Aid. It doesn’t solve the issue at hand. It’s not a long-term solution. Yes. And I certainly make that very clear up front with my patients these days. (Participant 14)
Even though sometimes you can’t find – even if you find the reason, you still end up having to use some sort of a chemical medication like a benzodiazepine sometimes. (Participant 11)
I very, very, very rarely use benzodiazepines. I think basically, my use for benzodiazepines would be restricted to a grief type scenario…then I might actually just give them three tablets or something. I’m quite a miser with such things. (Participant 8)With shift work insomnia, I may use a benzodiazepine, and I give them at the start of a – you know, when they finish their nightshift, and they’re trying to get their sleep/wake cycle back to normal. (Participant 21)
And 20 or 30 years ago the practice of using benzos was obviously a lot more prevalent, and so we’ve inherited people who have been on their Temazepam or their Serepax for 30 years, and you try to get them off of it, but it just doesn’t work, because they’re so dependent. (Participant 16)
Well, back in the sixties, everyone got that, so everyone was addicted, and so you have a lot of people in their seventies…[that] have been on things like that for 20 years, and you are a brave person to try and change the direction the wind blows. (Participant 13)So I just have to try and establish some trust and rapport with them, so that they can trust what I’m saying…There has been one doctor that prescribed for maybe a long time, and then maybe that doctor has retired or they will see someone else for whatever reason, and then…suddenly, they find they’ve got trouble getting the medication…the patient feels like it’s their fault that they’ve become addicted to the medication or that they’re seeking it when…in their mind, a doctor prescribed it to treat their insomnia, so the patients will get a little bit defensive as well. (Participant 4)
So if I don’t give them what they want, after my 22 min in a 15 min booking, they will go to the 6 min medicine man around the corner and get what they want. (Participant 15)I just feel like I have to continue, but I will only agree to be their doctor – part of the deal is we try and wean [benzodiazepines] down. So – have had some – you lose a bunch of patients, because of that. (Participant 6)
But with benzos, we’ve definitely had…threatened violence, threatened use of weapons…losing a litre of blood, because they didn’t get the medications they’re after. So we’re in a very confronting kind of situation. (Participant 27)
I referred a few people to the psychiatrists, because we’ve had – like they’re wanting long term prescription for benzodiazepines, and I felt that I reached the end of what I could offer. (Participant 4)
And then for all those troublesome patients who are in their 70 s and who are now on two tablets of Temazepam and have been for 50 years maybe there is somewhere that I can refer them to do this in a joint [way] between the specialists and I, and go, right, let’s get this down. That would be useful. (Participant 10)If there was a service available to help with benzodiazepine, like addiction and withdrawing slowly, that would be excellent…even if the patient didn’t want to engage with them…If there was a decision-making tool that could help with making a withdrawal plan that would be excellent. (Participant 4)
Theme 3: navigating treatment pathways
Sleep hygiene I recommend to everyone. So I’ve got some handouts and stuff for sleep hygiene that I give out to people if it’s clear that their sleep hygiene is poor. (Participant 21)
There’s this expectation that you’re going to fix and clearly insomnia is not something that you’re going to fix today, but having something to give to patients as like a takeaway pack of written down instructions of sleep hygiene, that would be really helpful. You would feel like you’ve given them something, and it’s almost like a deflector for the requests for benzos. (Participant 16)Sometimes we give advice that, to us, seems ridiculously simple and the patient comes back and says they’re totally cured, and it’s all wonderful, and we feel we haven’t done much. (Participant 12)
Often there’s an element of anxiety…so you run them through mindfulness and a bit of CBT and meditation and that sort of stuff to help them chill out a bit and relax. (Participant 25)
Sometimes I would do something like sleep restriction with them, getting them to work out how many hours of sleep they’re actually getting and then delaying bedtime until that and bringing it back however many stepwise. (Participant 8)
Probably consider a sleep physician, but then again, I don’t know. It depends what I feel like they might be able to offer. (Participant 14)I wouldn’t necessarily refer someone to a sleep physician for this. I don’t even know if they – now, that I’m talking to you, maybe they do it, maybe they don’t. I actually have no idea. (Participant 10)If I’m not getting anywhere with all of that, I guess, referring for specialist in – but I would very, very rarely refer to a sleep specialist just for insomnia. (Participant 28)
I would say that’s probably like less than five per cent of my patients would actually go to someone to talk about their sleep issues, because of the cost, the cost limiting factor. (Participant 15)It’s much easier to pay $6.90 for Temazepam than going to see a psychologist for my sleep. (Participant 4)
On the mental health plan that I am sending with them, the diagnosis is probably not primarily insomnia, because that doesn’t fit within the guidelines for mental health care plans. (Participant 23)
I’ve referred someone for mental health issues that were contributing to insomnia, but that’s a referral not for the insomnia, that’s for the mental health condition. (Participant 22)I think I’ve probably got a lot of patients – well, a reasonable number of patients who have insomnia who are on a mental health care plan for their depression or their anxiety or anything like that, but purely – I don’t think I have put them on for insomnia. (Participant 24)