Insomnia: scalable evidence-based solutions Prof Colin A. Espie PhD, DSc, FBPsS ,

1. Insomnia: scalable evidence-based solutions Prof Colin A. Espie PhD, DSc, FBPsS, Professor of Sleep Medicine Fellow, Somerville College HSRF, Dept of Psychiatry University of Oxford Emeritus Professor, University of Glasgow

2. Sleep is ubiquitous

3. Everyone has experienced some poor sleep

4. We have a poor relationship with the Big 4

5. 30% of the population has insomnia symptoms

6. Sleep is ubiquitous and essential • Everyone has experienced some poor sleep • We have a poor relationship with the Big 4 • 30% of the population have symptoms of insomnia • Insomnia is the most common expression of mental ill health • Insomnia Disorder affects 10-12% of the population on a chronic basis • Insomnia Disorder is a risk factor for illnesses • Insomnia Disorder is very badly managed in practice • There are scalable solutions for Insomnia Disorder • Treating Insomnia Disorder effectively may improve mental health

7. From Public Health  Clinical considerations • Sleep is ubiquitous and essential • Everyone has experienced some poor sleep • We have a poor relationship with the Big 4 • 30% of the population have symptoms of insomnia • Insomnia is the most common expression of mental ill health • Insomnia Disorder affects 10-12% of the population on a chronic basis • Insomnia Disorder is a risk factor for illnesses • Insomnia Disorder is very badly managed in practice • There are scalable solutions for Insomnia Disorder • Treating Insomnia Disorder effectively may improve mental health

8. To treat Insomnia Disorder Evidence-based solutions are required: These do not include • Tabloid tips or tricks • Wrist bands, head bands or other kinds of sleep ‘toys’ • Special beds, mattresses or pillows • Crystals or magnets • Whale noise or white noise • Trace elements, homeopathies or aromatherapy • Pseudo-neuroscientific therapy practices • Sleep hygiene education (alone) • OTC products • Sleep apps Our patients deserve clinically effective treatment

9. Insomnia is the most common expression of mental ill health In men and women, of all ages, of all ethnic groups, across all demographics and in all regions of the UK

10. Insomnia Disorder affects 10-12% of the population on a chronic basis DSM-5 Espie, C.A., et al. BMJ Open 2014

11. Insomnia Disorder is a risk factor for illness Insomnia Disorder leads to a 2x risk for developing depression

12. Insomnia Disorder is very badly managed in practice

13. There are scalable solutions for Insomnia Disorder

14. There are scalable solutions for Insomnia Disorder

15. DRUGS = SCALABLE + AFFORDABLE + EVIDENCE-BASED + STANDARDISED

16. Insomnia treatment guidelines 2005 2010 2019 1999 2006 2016 2017

17. Qaseem et al. Annals of Internal Medicine 2016

18. Qaseem et al. Annals of Internal Medicine 2016

19. Qaseem et al (2016) Annals of Internal Medicine

20. European Insomnia Guideline 2017 • CBT is recommended as first-line treatment for chronic insomnia in adults of any age (strong recommendation, high-quality evidence). • A pharmacological intervention can be offered if CBT is not effective or not available Riemann et al JOSR (2017) DOI: 10.1111/jsr.12594

21. CBT for insomnia – a system of therapies Based on Espie & Kyle (2012) Chapter 12: Cognitive Behavioral and Psychological Therapies for Chronic Insomnia; Therapy in Sleep Medicine ed. Barkoukis et al.

22. Traditional CBT delivery channels in healthcare settings

23. Psychologists are not ‘scalable’ … … however, psychology is The constructs, concepts and procedures associated with psychological theory and practice are not intrinsically limited to in-person communication

24. = algorithm molecule

25. DIGITAL MEDICINE? = SCALABLE + AFFORDABLE + EVIDENCE-BASED + STANDARDISED

26. Examples of evidence-based digital CBT Meta-analyses Van Straten & Cuijpers. Sleep Medicine Reviews 2009 Cheng & Dizon. Psychotherapy and Psychosomatics, 2012 Seyffert et al. PloS ONE 2016 Zachariae et al. Sleep Medicine Reviews 2016

30. 11 RCTs • Total of 1460 participants • Effects comparable to face-to-face CBT • Maintained at 4-48 wk F-up “Internet-delivered CBT appears efficacious” “May be a viable option in the treatment of insomnia” Zachariae et al, 2016

31. 11 RCTs • Total of 1460 participants • Effects comparable to face-to-face CBT • Maintained at 4-48 wk F-up “Internet-delivered CBT appears efficacious” “May be a viable option in the treatment of insomnia” Zachariae et al, 2016

32. 8 published RCTs n ~ 6,900 participants 7 published RCTs + 1 in press n ~ 2,100 participants

33. Treating Insomnia Disorder effectively may improve mental health

35. Interventionist-causal relationships

39. Digital CBT for insomnia disorder: a scalable solution to a ubiquitous problem • Effective • Potentially offers choice of evidence-based treatment to all patients • Potentially enables clinical guidelines to be enacted • Implementation and commissioning pathways being developed

42. “The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being” WHO Constitution (1948)

43. Insomnia: scalable evidence-based solutions Prof Colin A. Espie PhD, DSc, FBPsS, Professor of Sleep Medicine Fellow, Somerville College HSRF, Dept of Psychiatry University of Oxford Emeritus Professor, University of Glasgow