Why strategic primary care education is key to progress

Q: You are a leading voice advocating for the identification and treatment of COMISA, the intersection of insomnia and obstructive sleep apnea (OSA). What drives your passion on this topic?

Dr. Sweetman: I was really lucky to have long-term support from excellent mentors in Professors Leon Lack and Doug McEvoy, recognized global experts in insomnia and sleep apnea, respectively. Their combined influence helped spark and nurture my early passion for this field.

There’s also a small but very passionate group of COMISA (co-morbid insomnia and sleep apnea) researchers around the world focused on improving diagnosis, refining treatment approaches and understanding how different therapies interact. It’s also been inspiring to collaborate with this small but supportive group.

But most of all, COMISA is incredibly common and has been underrecognized and underserved for a long time. It was first recognised 5 decades ago, but has only started to receive more attention in the last 15 years. Being able to help people with COMISA sleep better, feel better and function better during the day is genuinely fulfilling.

Q: Where do you see the biggest challenges when putting theory into practice for identifying and treating insomnia and COMISA? What actions are needed to address these?

Dr. Sweetman: One of the biggest challenges is increasing recognition of COMISA and its prevalence. Over the past 10 or 15 years, awareness of COMISA has grown within the sleep medicine community (among researchers and clinicians) but there's still a long way to go in the broader healthcare system.

We also need to raise public awareness so people with undiagnosed COMISA can recognize their symptoms and seek help. That kind of change takes sustained effort with small, consistent steps over time.

Another major issue is access to cognitive behavioral therapy for insomnia (CBT-I). It’s the gold-standard treatment, backed by decades of evidence, and it's effective even when sleep apnea is untreated. But despite this, only about 1% of people with insomnia can access CBT-I. For people with COMISA, the number is likely even lower.

There's such an enormous amount of evidence, and it's recommended in all of our guidelines. But it hasn’t translated into real-world access. That’s a failure on our part. We’ve focused so much on proving that CBT-I works, but not enough on making it actually available to the people who need it.

Q: When identifying COMISA, is it more common for sleep apnea to be diagnosed first, or does insomnia usually come first? Should we be screening for both conditions regardless?

Dr. Sweetman: Great question. I don’t know which pathway is more common. It probably depends on the patient’s symptoms and where they first present, whether it’s primary care or a specialist clinic. Based on that, they might get referred for suspected sleep apnea, or maybe for insomnia treatment if that's more prominent.

The reality is there’s a huge amount of heterogeneity. Insomnia varies, sleep apnea varies, and when you combine them, the complexity grows exponentially. So, we need to educate different clinician groups accordingly.

For example, sleep and respiratory physicians, who often diagnose sleep apnea, should be encouraged to assess for comorbid insomnia. Psychologists who specialize in CBT-I should also screen for symptoms of sleep apnea, including less obvious presentations. It goes both ways.

This tailored education shouldn't just target sleep clinics. COMISA is also common in pain clinics, among people with chronic illness and in many other specialty areas. So, recognition needs to happen across the entire healthcare system.

Public health campaigns are important too. Messaging needs to be adapted depending on the audience, whether clinicians, professional conferences or the general public. Consistent language across all settings can help ensure clinicians are aligned, which will ultimately support better multidisciplinary care.

This is why it must be a collaborative effort. COMISA has been overlooked for 40 years. It’s exciting to finally be making progress—really turbocharging this space.

Q: Primary care is often the first point of contact for patients with insomnia. What can be done to encourage general practitioners (GPs) to take responsibility for identifying insomnia and OSA?

Dr. Sweetman: I can speak more confidently about the situation in Australia, where I’ve worked with primary care providers for quite a while. I'm not sure how well this applies elsewhere, but here, GPs are very aware of how common sleep problems and disorders are.

Each year, the Royal Australian College of General Practitioners (RACGP) runs a large survey with hundreds of responses from GPs. Year after year, sleep problems consistently rank among the top reasons patients come in for care. And because insomnia is the most common sleep condition, a large proportion of those cases are likely insomnia.

So in terms of motivation, I think GPs are already engaged. The next step is education to help GPs, nurses, pharmacists and psychologists better identify and manage these conditions. Patients might first seek help through any of these avenues, so we need to reach all of them.

The goal is to support better recognition and ensure patients actually gain access to evidence-based treatments for both insomnia and COMISA.

Q: How can we better educate and get GPs more interested in sleep disorders?

Dr. Sweetman: For the past three and a half years, I’ve been a senior program manager with the Australasian Sleep Association. I lead a government-funded initiative to provide sleep health education to primary care providers like GPs, nurses, psychologists and pharmacists. Pharmacists, in particular, often see people with insomnia first when they come in looking for support such as over-the-counter remedies.

One thing we’ve found really effective is partnering with the professional organizations of each discipline. Instead of trying to connect directly through a sleep society, we work alongside the GP colleges, nursing groups, psychology boards and so on. We bring sleep expertise, content, speakers and workshop development, and they bring access to their members, who are the clinicians we want to reach.

That’s worked really well. Over the last three years, we’ve provided education to over 30,000 primary care clinicians. There’s been strong demand, which has made our job easier.

Another key has been offering education in multiple formats to suit different learning styles. We offer articles, podcasts, webinars, workshops, conference presentations, an online hub called Sleep Central, self-guided e-learning and even one-on-one conversations. This mix allows us to tailor both the level of detail and how it’s delivered.

And the third thing that’s worked is identifying and supporting champions within each field. Some GPs already have an interest in sleep health and we work with them to deepen it and help them to educate their peers. We’ve done the same with psychologists, nurses and pharmacists. A message from a peer resonates far more than one from an outsider like me.

Q: What are your thoughts on getting sleep to become a day-to-day priority for GPs, given the hundreds of other conditions they juggle?

Dr. Sweetman: There are hundreds of competing priorities and constant recommendations about what GPs “should” be screening for. There’s insomnia, sleep apnea and dozens of other conditions. With over 100 ‘common’ conditions managed in general practice, I imagine there is a lot of competing interest for GPs’ attention.

That said, GPs have diverse interests and many are developing interest in specific medical areas. Some are naturally drawn to sleep health, and others may not be receptive, which is okay. We’ve found the most success by starting with those who are already interested. By supporting and educating those GPs first, we’ve still managed to reach thousands.

We may never reach 100% of the workforce, but even if we reach 10%, 20% or 30%, that’s still meaningful. GPs often refer patients to each other based on special interests. So even if we don’t achieve total saturation, we can create local ecosystems where sleep health is prioritized, and that’s a big win.