Direct to Psychology Insomnia and Stepped Care Models in a Sleep Disorders Service

The overarching aim of this project is to develop, refine, implement and report on two concurrent changes in the service model in the Sleep Disorders Centre at The Prince Charles Hospital (TPCH) to incorporate a “Direct to Psychology Insomnia” referral pathway, and a “Stepped Care” model of care within the TPCH Sleep Psychology Service, flexibly delivered across the continuum of care. The project will measure the impact of the service change in our target population. The service change will be compared to the current service models for key outcomes. An implementation science approach will be used throughout this project. We propose to trial a “Direct to Psychology” Insomnia model, whereby new referrals to our Sleep Disorders service will be triaged initially by a Sleep Physician (as is currently the case) and directed to either Standard of Care and waitlisted for a Sleep Physician initial consultation, or to the NEW “Direct to Psychology” pathway. All patients entering the service will undergo this triage process. A key goal of the project is to refine our triage criteria for determining who should assigned to the Physician Initial consultation pathway (Standard Care) or to the Direct to Psychology pathway. However, we will be modelling this triage process based on criteria developed by Krebs & Ellender (2021), who published data from the Princess Alexandra Hospital Sleep Disorders Service (Queensland, Australia) evaluating their referrals between 2016-2019. In a retrospective cohort study capturing new cases, patients were categorised as either “suitable for direct to psychology” or “required medical review”. The “direct to psychology” patients were defined as i. referred for insomnia; or ii. Insomnia Severity Index score (ISI) =15/28; or iii. diagnosed with insomnia per ICSD-3 by treating specialist; or iv. patients referred for sleep psychology. Exclusion criteria were: i. significant sleep disordered breathing (Epworth sleepiness scale >16, referral or identified significant sleep disordered breathing, ii. highly co-morbid patients (neuromuscular weakness, COPD) and iii. diagnosis of hypersomnia. These patients were categorised as “requiring medical review”. Krebs, L., & Ellender, C. (2021). Improving Patient Streaming for Chronic Insomnia: Single Centre Retrospective Cohort Study. Sleep Advances, 2 (S1), A43. All patients referred to the Sleep Psychology service, either via the traditional Physician first route (Standard Care) or through the Direct to Psychology route, will undergo a specialist clinical assessment with an advanced clinical psychologist with training in the assessment and management of insomnia, as well as the skills to identify and refer patients requiring medical intervention back to the Sleep Physician. This assessment is 60-90 minutes in duration. This assessment will include a thorough sleep history, sleep diary, detailed medical, substance use, and psychiatric history (including suicide/self-harm risk assessments, particularly for patients presenting with depression). The sleep history will cover the history of and current details regarding the sleep complaints, pre-sleep conditions, sleep-wake patterns, other sleep-related symptoms, lifestyle factors, and daytime consequences. The history helps to establish the type and evolution of sleep difficulties, perpetuating factors, and identification of comorbid medical, substance, and/or psychiatric conditions. If another sleep disorder is suspected (e.g., Obstructive Sleep Apnoea (OSA); Periodic Limb Movements of sleep (PLMs), patients will be referred back to the Sleep Physician for concurrent assessment and management. After the clinical assessment with the Clinical Psychologist, all patients (regardless of pathway into the Sleep Psychology service) will be assigned to a new Stepped Care Model pathway and. We propose that there will be 4 levels of the Stepped Care Model associated with increasing complexity, however an aim of the project is to refine these "Steps" as part of our project. At the time of clinical assessment, participants will be assigned by the Clinical Psychologist to the level most relevant to their needs upon entry to the pathway. We expect that most patients will be assessed as suitable for entry to first-line manualised and online treatment programs, increasing to progressively more time, cost and expertise intensive levels ‘upstream’ where there is an incomplete therapeutic response to a first-line intervention. Determinations of where patients should enter into the Stepped Care model, is determined by the specialist clinical psychologist at initial clinical evaluation, and reassessed throughout the treatment journey. The proposed Levels of the Stepped Care model are based on Espie's (2009) Cognitive Behaviour Therapy for Insomnia (CBTi) Stepped Care model utilised in the National Health Service (NHS). Espie, C. (2009), "Stepped care": a health technology solution for delivering cognitive behavioral therapy as a first line insomnia treatment. Sleep 32 (12): 1549-1558. A description of our proposed Levels/Steps in our Stepped Care Model are below: - Level 1: Online insomnia program - "Managing Insomnia" by "This Way Up". https://thiswayup.org.au/programs/insomnia-program/ This program is an evidence-based insomnia intervention, free by Clinician prescription, developed by "This Way Up" - a digital therapies service through St Vincent's Hospital, Sydney, Australia. This therapy consists of 4 sessions, which the client guides themselves through at their own pace. Each session takes about one hour to complete and is designed to be completed at one session per week. However, participants have up to 90 days to complete the program once they start. The sessions are presented in a comic-book like format, and patients are prompted to complete questionnaires and sleep diaries throughout the sessions to facilitate engagement with the material. The referring Clinical Psychologist is able to track the progress of the patient, including their commencement of the program and completion of each session, as well as their outcome measures collected at each session (insomnia severity index and K-10 score). If the patient has not engaged with the digital therapy within 4 weeks of being prescribed the intervention, reasons for this will be discussed and options for discharge, on-referral and/or entry to another intervention level will be provided. Level 2: Group program and sleep manual facilitated by experienced Clinical Psychologist; Our insomnia group intervention and sleep manual was developed by our Sleep Psychology team from evidence-based insomnia treatment developed at Flinders University, Adelaide, Australia. The intervention is 4 sessions and covers the key components of insomnia treatment - sleep restriction therapy, stimulus control, cognitive therapy, relaxation training and sleep hygiene. Each session is 90 minutes, and there are a maximum of 6 participants in each group session. On engagement with this treatment Level, the Clinical Psychologist, with Psychology Intern co-facilitating, will monitor participation and clinical outcomes during the group program (4 sessions of group CBTi with up to 6 participants). Depending on patient engagement and participation with the program, as well as clinical outcomes on key assessment measures; discharge, on-referral and/or entry to another intervention level will be provided. Sweetman, A., McEvoy, D., Smith, S., Catheside, P., Antic, N., Chai-Coetzer, C., Douglas, J., O’Grady, A., Dunn, N., Robinson, J., Paul, D., Williamson, P., & Lack, L. (2020). The effect of cognitive and behavioral therapy for insomnia on week-to-week changes in sleepiness and sleep parameters in patients with comorbid insomnia and sleep apnea: a randomized controlled trial. Sleep, 43:zsaa002. Level 3: 1:1 and sleep manual with Sleep Psychology Intern. Patients assigned to this level will undergo treatment 1:1 with the Psychology Intern under supervision from the Clinical Psychologist. We will monitor participation and clinical outcomes during the 1:1 intervention program (minimum 4 sessions of CBTi as described above for Level 2) with additional evidence-based strategies depending on sleep or mental health comorbidities such as CBT for depression/anxiety, dream rescripting for nightmares, Motivational Interviewing for Continuous Positive Airway Pressure (CPAP) adherence for those with comorbid OSA). Each of these additional sessions will be 60 minutes in duration, and will be delivered at a weekly to fortnightly interval between sessions. The number of sessions will depend on how many sessions the patient requires to achieve adequate symptom relief based on ongoing assessment and monitoring. Depending on patient engagement and participation with the intervention, as well as clinical outcomes on key assessment measures; discharge, on-referral and/or entry to another intervention level will be provided. Level 4: 1:1 and sleep manual with Advanced/Senior Clinical Psychologist. On engagement with this treatment Level, the Clinical Psychologist will monitor participation and clinical outcomes during the 1:1 intervention program (CBTi program described above), and provide additional evidence -based strategies depending on sleep or mental health comorbidities (as described in Level 3 above). For Levels 2 to 4 - sessions will be delivered flexibly either face-to-face or telehealth