Datasets:

marianna13
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litarch

+{"file": "rd0039_NBK487300/context.nxml", "text": "Poor sleep quality may have an negative effect on the overall quality of life in terms of daytime physical, psychological and social well-being.1 Of the different sleep disorders that exist, insomnia is known to be the most prevalent1 with a reported rate of 10% to 25% of the adults in the general population in most countries.2 Insomnia disorder entails a subjective dissatisfaction with sleep quality or quantity characterized by difficulty falling asleep, staying asleep, or falling back asleep after early morning waking which causes clinically significant distress or impairment in daily functioning.3\nAdditionally, according to DSM-5 Diagnostic Criteria, this disturbance cannot be attributed to another sleep disorder or the physiological effects of a substance and should continue several times a week for at least three months despite having adequate opportunities to sleep.3 Treatments for insomnia can be divided into two groups: pharmacotherapy (e.g. benzodiazepines, z-drugs) and non-pharmacological therapies. Non-pharmacological therapies include psychological and behavioural options like cognitive behavioural therapy for insomnia (CBT-I) as well as complementary and alternative medicine (CAM) therapies such as dietary changes or herbal remedies.1,4 Pharmacotherapy is a common clinical approach for managing insomnia due to its appeal as providing relatively rapid relief.4 On the other hand, sleep habits and psychological problems can also be a factor when it comes to the onset and persistence of insomnia.4 According to Spielman\u2019s 3P Model for Insomnia,5 factors associated with insomnia fall within three primary categories: predisposing, precipitating and perpetuating. While several studies focus on precipitating factors (e.g. onset of medical and psychiatric illnesses) or perpetuating factors (e.g. dysfunctional beliefs about insomnia), some also allude to predisposing factors such as the tendency toward excessive worrying or biological predispositions.6 In all cases, management strategies aimed at addressing psychological, cognitive, and behavioural factors barring re-establishment of normal sleep patterns have been identified as crucial.4 For example, CBT-I has been demonstrated in some studies to produce clinical benefits and sleep improvements that are well sustained over time.1,2,4\nThe connection between treatment preference and treatment outcome is founded on the basis that patients who view treatments as providing benefit will participate and adhere to treatment, thereby increasing the therapeutic potential of a given intervention.1 Understanding patients\u2019 perspectives on treatment options can help support patients in adhering to the treatments for insomnia.1 This understanding allows clinicians to better work with patients while navigating potential treatments most suitable to their expectations and desired outcomes.1 For instance, a mixed methods study aiming to explore patients\u2019 perceptions toward pharmacotherapy and the psychological or behavioural management of insomnia, reported that patients who found treatment as \u201cannoying\u201d or \u201cboring\u201d tended to have poorer treatment outcomes compared to patients who found the therapy relaxing.1\nThe objective of this Rapid Response report is to identify, appraise and describe the current literature on patients\u2019 and their family caregivers\u2019 experiences with and perspectives on the treatment and management of insomnia to help inform decision-making in this area.", "pairs": [], "interleaved": []}
+{"file": "rd0039_NBK487300/researchquestion.nxml", "text": "What are patient, caregiver, or family member experiences with and perspectives of treatment and management of insomnia?", "pairs": [], "interleaved": []}
+{"file": "rd0039_NBK487300/conclusions.nxml", "text": "This report provides a summary of 22 primary studies and one systematic review published in the last 10 years that describe patients\u2019 experiences and perceptions of treatment for insomnia.\nMany patients indicated feeling not being understood or being misunderstood in terms of their insomnia symptoms by their peers and healthcare professionals, which led to frustrations and a feeling of not being normal. The effect on the daytime activities of patients is the major complaint of insomnia and one of the reasons that led most patients to seek medical treatment. Even though many patients state pharmacotherapy provides a faster relief of insomnia symptoms, some patients preferred to undergo psychological or behavioural treatment options in order to address long-term factors in their insomnia, avoid possible side effects and gain control over their sleep. Some patients indicated that they turned to advice from their healthcare professional and anecdotal evidence from their friends and family members when deciding on a treatment option. Comorbidity was highlighted as an important factor when treating insomnia with many patients expressing the importance of treating both morbidities to avoid exacerbation of one (most often insomnia as they felt healthcare professionals tended to dismiss their complaints about insomnia). Most patients felt that healthcare professionals should be more aware of the different treatment options that are available so that they can work with their patients to create a treatment plan which is tailored to the patients\u2019 specific needs as not all plans fit everyone. A hierarchical system to triage patients to different insomnia treatment options based on a trial-and-error process was recommended by some patients.\nIn sum, the primary implication of this review is the need to increase clinical and public understandings of and concerns with the holistic experience of insomnia. Whether demonstrated in individuals\u2019 pragmatic entanglements with pharmacotherapies or the express desire to address root causes of insomnia for those engaging in non-pharmacological options, individuals repeatedly alluded to a desire to be heard holistically. While this certainly can take the form of allowing clinical interactions to be framed by a patient\u2019s preference for pharmacotherapy or psychological or behavioural therapy treatment, it could also be informed by an improved willingness to listen to and sit with the individuals suffering in these clinical encounters.", "pairs": [], "interleaved": []}
+{"file": "rd0039_NBK487300/app1.nxml", "text": "", "pairs": [["litarch_figures_58/b7/c0/rd0039_NBK487300/app1fu1.jpg", "", ""]], "interleaved": [["litarch_figures_58/b7/c0/rd0039_NBK487300/app1fu1.jpg", "", ""]]}
+{"file": "rd0039_NBK487300/keyfindings.nxml", "text": "Only patient perceptions were available for review, there were no relevant data on caregiver or family member experiences. Patients\u2019 perceptions of and engagements with pharmacotherapy tend to vary in relation to nightly levels of fatigue, daytime responsibilities and social normalization of medical sleeping aids. While the duration and intensity of insomnia also plays a role, this review was unable to identify any consistent timeframes or severity levels that could serve as indicators. Rather, the use of pharmacotherapy tends to be informed by a certain level of pragmatism balancing need with desired outcomes. For instance, while several individuals perceived pharmacotherapy as the better choice due to its rapid relief, others were concerned with daytime side-effects and issues of long-term dependence or addiction.\nSome people living with insomnia also report trying alternatives to pharmacotherapy including cognitive behavioural therapy, mindfulness, exercise, relaxation, herbal remedies, or other complementary therapies. For many of these people, non-pharmacological treatment is viewed as a long-term solution that can address the underlying cause of insomnia and ultimately overcome the disorder. They appreciate that the personalized nature of these treatments helps them to adhere and obtain longer-term outcomes.\nMany patients appear to struggle when deciding on which treatment option to consider, and in their decision consider what is more important to them: a long-term outcome that addresses underlying factors in their insomnia or a quick short-term relief. By allowing themselves the time to sit with and listen to the patient\u2019s lived experience of suffering, perhaps clinicians could help this decision become clearer.", "pairs": [], "interleaved": []}
+{"file": "rd0039_NBK487300/summary.nxml", "text": "Quantity of Research Available\nA total of 378 citations were identified in the literature search. Following screening of titles and abstracts, 278 citations were excluded and 100 potentially relevant reports from the electronic search were retrieved for full-text review. Forty-four potentially relevant publications were retrieved from the grey literature search. Of these potentially relevant articles, 121 publications were excluded for various reasons, while 23 publications met the inclusion criteria and were included in this report. Appendix 1 describes the PRISMA flowchart of the study selection.\nSummary of Study Characteristics\nCharacteristics of the included studies are summarized below and details are available in Appendix 2,2.\nTwenty-three studies were included as relevant for patients\u2019 experiences and perspectives of interventions for insomnia. No studies were identified that described family caregivers\u2019 experiences or perspectives.\nSix used a qualitative descriptive design,1,8\u201312 seven were phenomenologies,1,2,4,13\u201316 four used a grounded theory design,6,17\u201319 one was a systematic review,20 five used mixed methods.11,21\u201324 Five of the studies were conducted in the United Kingdom,9,10,13,16,25 seven in the United States of America,8,11,14,17,19,21,23 five in Australia,1,4,12,15,24 one in Canada,20 one in China,18 one in Sweden,6 one in the Netherlands,22 one in New Zealand,26 and one in Iran.2 Two studies were published in 2017,17,24 eight in 2016,1,2,6,8,15,16,18,20 four in 2015,4,11,22,26 three in 2014,12,14,21 three in 2013,9,19,23 one in 2011,25 one in 2010,13 and one in 2008.10 The sample size ranged from 10 participants in one phenomenological study16 to 51 in another phenomenological study.1 The systematic review20 included 22 studies which used semi-structured interviews or focus groups as their primary data collection methods.\nAll studies included adults with insomnia accompanied by daytime dysfunction1,2,6,9,10,12\u201314,16\u201322,24\u201326 some with comorbidities such as schizophrenia,4,15 post-acute traumatic brain injury,8 heart failure,23 and obstructive sleep apnea.11\nTen of the studies reported patients\u2019 views, experiences and preferences with various treatments for insomnia,1,6,9,11,14,21,22,24\u201326 one included specifically a range of different types of evidence-based therapies for insomnia including standard pharmacological, melatonin-based, and psychological and behavioral-type (talking) therapies,4 and another compared a clinic group (those participants who had or were attending specialist sleep or psychology clinics) with a community group (those participants who were not attending specialist groups).1 Ten studies explored the lived experience and management of sleep problems.2,8,10,12,14\u201316,18,19,23 Four studies explored various aspects of the relationships between patients and health care practitioners and how these relations influence the uptake of insomnia treatments.9,11,13,17 The systematic review summarized evidence from a variety of qualitative studies on the experience and perceived consequences of insomnia.20\nSummary of Critical Appraisal\nOverall, studies included in this report are of moderate to high quality. There are, however, a few exceptions described below. The studies were well conducted and demonstrated congruence with respect to their chosen methodologies and the research objectives. A summary of the strengths and limitations is included below and details are available in Appendix 3 (Tables 3 and 4).\nEach of the twenty-three included studies provided a clear statement of the research objectives or purpose and all study objectives fit well for qualitative inquiry. A range of qualitative study designs were used, and in each case the research design was appropriately aligned with the research objective. The qualitative descriptive study and the systematic review were minimally informed by theories or an analytic framework, which is quite appropriate given the descriptive, versus theoretical nature of the studies.8,20 Those studies that used other designs had stronger theoretical orientations, which appropriately guided data collection, analysis and interpretation.\nPrimary Included Studies\nAll twenty-two included primary studies described a recruitment strategy however 15 studies did not identify using a purposive sampling strategy.1,6,10\u201318,21,24\u201326 Six studies did identify using a purposive sampling strategy,2,8,9,19,22,23 while one study identified using a snow-ball sampling strategy.4 Given the lack of overall reporting on purposive sampling strategies, it is possible that the studies did not include rich samples suitable to develop comprehensive descriptions of patients\u2019 perspectives. This concern is compounded, given four of the 22 primary studies mentioned sampling until data or thematic saturation was achieved,1,2,14,15 while the remaining 18 did not.\nA range of data collection methods were used, which were congruent with the research objectives in the 22 primary studies. Thirteen studies described using semi-structured interviews, which allowed for a consistent set of topics to be raised with each participant.1,4,6,8,9,11,12,16,17,19,22,24,25 Eleven studies used focus groups and mentioned having interview options available for those who felt uncomfortable discussing in a group, which is appropriate considering the discomfort that many patients describe from feeling \u201cnot normal\u201d and which may lead them to be hesitant to share their true experiences.4,9,10,13\u201315,18,21\u201323,26 Three studies reported conducting both interviews and focus groups.4,9,22 One study used unstructured interviews to capture experiences over time and to explore emergent issues in depth.2 The studies using a thematic analysis described that the interviews were conducted by a researcher,4,8,9,11,14,15,22,25,26 however, none of the included primary studies discussed how rapport was built with the participants and thus making it unclear whether a rapport was built at all.\nNine studies identified using a thematic analysis approach to analyzing their data,4,8,9,11,14,15,22,25,26 while a further five studies described a more generalized iterative data collection and analysis process to develop and cluster emergent themes.6,16\u201319 Two studies reported using a Framework Analysis technique for analysis1,12 and another study reported using the Colaizzi method for analysis.2 A further study reported using a comparative analysis,25 but failed to elucidate what this might mean or how this form of analysis was useful. The analytic strategies used in each study generally appeared appropriate for qualitative data, although one study utilized \u201cdirected content analysis\u201d21 which tends to limit a researcher\u2019s field of sight when reviewing qualitative data. A range of strategies were described to enhance rigor that focused on reliability in coding, most often coding by more than one researcher.1,2,4,8,11,14\u201317\nNone of the included studies provided an overview or detailed descriptions of the researcher\u2019s background and efforts to put aside personal beliefs during data collection and analysis. All studies likewise excluded a discussion of the relationship between the researcher and the participants, and the researcher and the topic.\nSystematic Review\nOne study used systematic review methods to identify and synthesize the findings of qualitative studies on the experiences of patients with insomnia.20 The authors reported searching PsycINFO and Medline, as well as reviewing the reference lists of included studies, although there is no mention of whether unpublished or grey literature was sought. Little information was provided regarding data analysis strategies and corresponding strategies to enhance rigor.20 The authors summarized results from 22 primary studies, which covered the experience of insomnia, management of insomnia as well as the medicalization of insomnia across a diversity of patients\u2019 experiences. Critical appraisal of included studies was conducted independently by two reviewers using the Critical Appraisal Skills Programme tool as a guide. Due to limited reporting of methodological details within the primary included studies, a comprehensive appraisal was not possible and therefore it is possible that results of the primary studies lack credibility and dependability, which would have been carried forward into this synthesis.\nSummary of Findings\nPatients\u2019 Experiences of Insomnia\nWhile the individual experience of insomnia varies along a number of heterogeneous pathways, how life with insomnia is understood and described by individuals tends to take course outside of nighttime frustration with sleeplessness.20 One common complaint in the studies analyzed for this review localized around concerns of disruption to daytime activities. Whether these activities were working, studying, engaging in social relationships or contributing to their communities,1,2,8,13,15,16,19,20,25 individuals tended to express a desire to get a good night\u2019s sleep as a way of reducing the physical, psychological and social health changes keeping them from doing what they cared about.1,2,8,15,20 This is not say that sleeplessness itself was not discussed, it was,2,9,10,16,23 just that the overall concern tended to return to hampered daytime activities.\nFor many, this inability to engage with the world in the same ways as before would lead to feelings of frustration, self-pity and isolation.2,8,10,18,23 Green et al. draw on one participant who mused: \u201cWhy am I the only person awake in the world when everybody else is sleeping soundly?\u201d10 Of course, this may be an over exaggerated expression of aloneness in the world, but that this patient felt it needed to be spoken is indicative of the powerful disconnect insomnia can bring.\nIn some cases, individuals spoke to the act of normalizing insomnia wherein it could be attributed to a natural process of aging,6,12 cultural beliefs,18 or form of spiritual punishment.2 This internal normalization either prevented the individual from pursuing treatment advice or from adhering to prescribed treatments.1,20 One participant waited fifteen years to seek help as she felt her inability to move past insomnia was one of not being tough enough.19 This use of defeated, demoralized language was not uncommon.2,8,10,13,18 Or, as Moloney highlights in her uptake of the conceptual term \u201cvirtuous non-user,\u201d one study participant pursued medical attention only to refuse adhering to the prescribed pharmaceutical regimen.17 Citing the abnormality of medical interventions, this particular individual believed they should be able to handle insomnia on their own.17\nWhile these feelings of isolation and self-deprecation were common lived experiences and barriers reported in the literature, they were not the sole barriers. For some individuals, the procedural requirements for diagnoses were perceived as time consuming and expensive due to the need to travel to another city or location to visit a specialist.2,12 And for others, when external validation for their suffering was finally sought (whether by friends, family or health care practitioners), they ran into further feelings of loneliness and social isolation as a result of not being understood, or of being misunderstood.12,13,18\u201320,23 For example, Yung et al. report that friends and family members often waived off patient concerns by commenting on how well they look or how a nap could easily resolve their tiredness.18 Though patients had learned to live with these misunderstandings, the resulting isolation was often associated with feelings of \u201ctorture and suffering\u201d (p. 424).\nIn other studies, individuals negatively perceived repeated minimizing or normalizing of the adverse influence of insomnia by some clinicians.8\u201310,13,23,26 Intended or not, by restricting space for the life altering effects of insomnia to be spoken of as outside the natural progression of life or as a symptom of some other comorbidity, individuals began to navigate deep seated, and competing, concerns of \u201ctherapeutic nihilism\u201d and desperation. Andrews et al.23 noted the failure of care providers to spend time asking about sleep quality led to further resignation and an internalized mantra of \u201cdocs don\u2019t ask, we don\u2019t tell\u201d (p. 9). Though these individuals may be ready to begin seeking treatment (in this case, non-pharmacological), the perceived disconnect between clinician concern and legitimacy of their complaint bars them from potential relief.\nAnother key theme that emerged from this review was the issue of comorbidities. Comorbidities ranged from co-occurring sleep difficulties15 to traumatic brain injuries8 or heart failure.23 Participants in some studies reported that the symptoms of their comorbidity exacerbated their symptoms of insomnia. For instance, people living with chronic obstructive pulmonary disorder (COPD) reported the fear of death due to not being able to breathe during their sleep as playing a role in keeping them awake.14 In connection with this is the role of healthcare professionals in helping to understand symptoms. Some patients perceived their healthcare professionals as giving more priority to other symptoms and less priority to insomnia symptoms, which caused them further frustration.1,20\nIn some studies, participants also highlighted the importance of the healthcare professional when it came to selecting a treatment option. In many cases, people reported feeling that their healthcare professionals were not well-informed of the various treatment options.1,20 Some patients felt that healthcare professionals tended to have a singular focus on sleep hygiene which often felt dismissive of the gravity of their complaints and delayed or prevented their referral to sleep clinics.1,20\nPharmacotherapy\nWhether a complete rejection, reluctant engagement, or piecemeal utilization, participants\u2019 experiences with and perspectives of pharmacological therapies for insomnia tended to inform a number of pragmatic entanglements. Intensity and length of lived experience with insomnia certainly play a role in these varied entanglements, but no singular cut off points could be pinned down and arranged as a determinant of perspective. Similarly, studies tended to cut across the breadth of these perspectives rather than focusing specifically on one.\nIndividuals rejecting pharmacotherapy altogether did so for a number of reasons. In a couple of cases, medications taken for comorbidities such as schizophrenia4 and COPD14 were perceived to interfere with the effectiveness of those taken for insomnia. Another pointed to potential cultural barriers18 in which there was both a lack of trust and familiarity with western medicine. And while this singular study out of China cannot be directly linked to how some immigrant groups or Indigenous Peoples living in Canada may encounter pharmacological treatments for insomnia, this disconnect observed between cultural ways of knowing is worth noting. Wholesale rejection of pharmacotherapy could also stem from perceptions of what it means to sleep naturally.1,8,12,17\nAnother entanglement with pharmacotherapy came in the form of what Maloney calls \u201creluctant medicalization.\u201d17 For these individuals, pharmacotherapy had become a \u201charsh necessity\u201d26 that would quickly be discarded in favor of any non-pharmaceutical strategy perceived as working.4 Those engaged in this form of pragmatic entanglement often attempted to cut their reliance on pharmaceuticals by modifying prescriptions or mixing and matching over the counter drugs.8,9,23,26 Caught between the desire to sleep and the fear of dependency, Andrews et al.23 report participants nibbling at their pills or exchanging their higher dose with a family member\u2019s lower dose. Matthews et al.8 note that the veterans with traumatic brain injuries interviewed for their study enacted a process of trial and error with differing degrees of reliance on prescriptions and provider instructions where decisions to engage or not engage were based on nightly levels of fatigue. And Henry et al19 point to the way in which simply knowing their medications are available nearby adds a level of nighttime comfort for some participants.\nEven for those individuals committed to the use of pharmacotherapy treatments, a certain amount of pragmatism seemed to inform their engagement. Of course this was not always the case; some individuals simply accepted the \u201cordinariness\u201d of pharmacotherapy within social groups or clinical practice at face value.17 But for other individuals, this pragmatism took the form of stockpiling prescriptions in the event that their own was cancelled.13 Or, in another case, this meant building an \u201carsenal\u201d19 of medications to be consumed circumstantially based on nightly considerations of fatigue and the next day\u2019s needs.\nThough arguably no more than a minor resistance, these decisions to align medical advice with their own perceptions could be indicative of a patient\u2019s overall desire to maintain some form of control over how their insomnia affects both daytime and nighttime suffering. For many individuals, the delicate balancing act between dose, sleep requirements and negative side effects is presented as needing daily fine tuning rather than long-term repetition. On a similar note, this partial adherence could also indicate a pushback against individuals\u2019 concerns of being misunderstood or having their suffering minimalized by clinicians as noted in the previous section. If the perception is that these pharmacotherapies are prescribed as an attempt to brush off suffering and move on to the next patient, there is a space for uncertainty or distrust of the prescription. Or, perhaps this reluctant engagement points to overall sentiments of a desire to improve or develop more interchangeable treatment regimens. Many of the individuals who modify prescriptions also speak to the desire to engage with other forms of treatment if they can find ones that work.1\nPsychological, Behavioural, and CAM Therapies\nSimilar to the pragmatic interactions individuals carried out with pharmacotherapies, those choosing (or being prescribed) to follow non-pharmacological treatment options tended to navigate and experience them from a variety of perspectives. Nonetheless, while non-pharmacological options range anywhere from behavioural and psychological methods like CBT-I to CAM therapies like mindfulness training, dietary changes or herbal remedies,1,14,16,18,19,21,24,25 several individuals note their interest in these forms of treatment as stemming from a desire to treat the underlying causes of insomnia holistically rather than attempting a band aid fix.1,18,20 Some patients also stressed that managing sleep by incorporating personalized strategies embedded in their daily routines made it easier to adhere to those strategies and thus obtain long-term outcomes.14,18,20,21\nAs an increasingly standard behavioural therapy for insomnia,25 CBT-I played a featured role in many of the included studies. Whether having experience with computerized (CCBT-I), internet based (ICBT-I) or face-to-face versions, participants typically perceived this option to be a valuable long-term strategy for addressing the root causes of their insomnia.1,6,11,24,25 However, as CBT-I requires behavioural change, several individuals found this a challenging therapy for extended adherence. In some cases, the acute severity of their insomnia decreased their ability to see outside of their immediate need for a quick fix. In this case, participants talked about the need for a pharmacological \u201cband aid\u201d fix that could be followed by a more in-depth and intensive psychological or behavioural therapy.1,4 By following this process, participants hoped to gain more control over their insomnia and eventually become active rather than passive participants in their healing. In other cases, individuals perceived the stages involved in various forms of CBT-I (e.g. sleep restriction therapy) to be overwhelming and not conducive to adherence.18,24,25 This difficulty was further exacerbated for individuals, like those in Chan et al.24 and Blom et al.,6 who explored the web-based delivery of CBT-I (defined as ICBT-I in their study) in which there was a lack of contact between clinical practitioner and participant. While participants found ICBT-I useful, they also perceived it would have been more beneficial to have some sort of interaction with a therapist \u2013 even if this was simply over the phone \u2013 something to let them know they were moving along and someone was watching their progress. In one case, difficulty adhering to CBT-I arose due to the concurrent uptake of positive airway pressure (PAP) machines for their obstructive sleep apnea.11 Trying to navigate the newness of both sleep aides was overwhelming and limited the perceived effectiveness of CBT-I.\nOutside of specific treatment options, the importance of holistic care as a way of approaching insomnia played a primary role in individual experience. Whether engaging CBT-I,6 mindfulness techniques,21 lifestyle changes or cultural medicines,18 several participants commented on the importance of their accepting of insomnia as an illness in their lives before being able to truly address its causes.\nIn addition, some patients highlighted other aspects of psychological, behavioural, or CAM therapies as beneficial. For example, some patients highlighted the importance of group sharing and support, and indicated that it was nice to be able to speak to someone who has been in their footsteps and can offer first-hand advice and support through the treatment process.20,21 Therapeutic alliance, or therapeutic relationship, was also highlighted as an important factor present in psychological or behavioural treatments.16 Some patients indicated that the active listening by the therapist or group lead as crucial to understanding their symptoms and to work with them to create a treatment plan.16\nSome of the reported barriers to psychological or behavioural therapies included the cost to see a therapist and the length of time it could take to obtain positive results.1,20 Some patients also stated not being aware of psychological or behavioural treatment options however they indicated a willingness to try them and discussed the educational needs for patients regarding the various forms of treatments available for insomnia.8\nPatients\u2019 Preferences: Pharmacotherapy Versus Psychological, Behavioural, or CAM Treatment Options\nOne theme that emerged in this review was the dilemma that most patients face when considering which treatment options to pursue. This included considering what was important to them: wanting a long-term outcome that addressed underlying factors in their insomnia or a quick short-term relief.1,20\nWhen it comes to whether patients prefer pharmacotherapy or psychological, behavioural, or CAM therapies, there were several factors that people highlighted as guiding their decision. The first was their perception of control of sleep. Some patients viewed sleep as a natural process of the body and something that should be controlled by them and not by drugs.1,4,15,17 Many people that reported this perception also reported preferring psychological or behavioural treatments, which they felt empowered them and helped them to regain control over their sleep.1,4,15\nAnother factor that emerged was consideration of potential for side effects with treatment.1,15 One of the major side effects that most patients considered was that of addiction.20 When told about the possibility of becoming addicted to a drug, some individuals perceived this to mean that they could lose control over their sleep forever and were thus more inclined to choose a psychological or behavioural treatment.20 Many people also compared treatments for similarities and differences to previous treatments they have used, considering the duration of the course of the treatment, and any foreseeable challenges to taking up treatment when considering their options.1,20 The use of anecdotal evidence from friends and family as well as advice from their healthcare practitioner was also commonly reported when considering treatment options for insomnia.1,4,20\nThe studies also highlighted a discrepancy in terms of what patients\u2019 perceived their treatment goals to be and what healthcare professionals perceived their treatment goals to be.20 It is possible that healthcare professionals believe patients are more interested in obtaining pharmacotherapy for immediate relief, when at least some patients prefer CBTs and other non-pharmacological treatments.20\nIn some studies, participants provided recommendations on how they felt the treatment process should be carried out for those suffering from insomnia. Many patients emphasized that what works for one patient does not always work for other patients.8 Thus the importance of tailoring the approaches to patients\u2019 preferences was reported as crucial.1,16,20 This bespoke approach could draw on both pharmacotherapy and psychological or behavioural treatments addressing a range of acute to prolonged experiences with insomnia.1,4,16,26 Cheung et al. note some patients as suggesting this personalization still follow some form of hierarchical system to triage the patient to different treatment options based on treatment response and symptom severity would be beneficial.1\nLimitations\nSeveral of the studies included for this review indicated that a fair concentration of their participants suffered from comorbidities. Whether these studies focused primarily on the interaction between participant comorbidities and their insomnia,4,8,11,15,23 or merely mentioned the presence of more minor comorbidities, transferability of these results to individuals with other conditions, or no comorbidities (however uncommon), could be tenuous. For instance, whether the experience and perceptions of treatment of patients who experience insomnia as a result of a significant life event would have differed is something that should be considered. Another limitation is that of the 22 primary studies included in this review, seven10,12,13,18,19,21,27 were also included in the Araujo et al. systematic review.20 This overlap in studies could have potentially led to a redundancy in the results. Further, the reality that none of the 22 primary studies (excluding the systematic review) were Canadian or Indigenous also serves as a limitation for decision making within the Canadian context. Varied cultural understandings, attitudes, health care delivery models and availability outside of Canada can impact the treatment of insomnia. The studies included in this review also tended to dichotomize insomnia treatments between pharmacologic therapies or behavioural therapies. While some1,4,26 alluded to either patients\u2019 or health care practitioners\u2019 concerns with this dichotomization, analysis of these concerns was largely absent and prevented our review from pursuing the idea further. Finally, none of the included studies presented an analysis of experiences with insomnia as they relate to a person\u2019s age, sex or prior experience with treatment. It is likely that individuals of younger or older age, or with more or less experience with a range of pharmacological or behavioural therapies would think differently of their current treatment experience, although our review was unable to explore this issue.\nAdditional areas not represented by the literature identified in this review, but that could provide insight into this topic include an understanding of patients\u2019 expectations of their healthcare professional to manage their sleep disorder, and an understanding as to whether treatment expectations differ for patients not presenting with comorbidity. These questions could help us understand what issues are important to a variety of patients when considering insomnia treatment options.", "pairs": [], "interleaved": []}