I am moderating a virtual focus group late one evening, with four British GPs. We are discussing insomnia, and it is evident we are all tired. Since this is a virtual group, it is also evident we are all at home – tantalisingly close to our families, dinner, rest, and eventually bed.  

 But we soldier on, and for our final task of the session I boldly ask a pair from the group to “role play” an insomnia consultation. “Remember, this is idiopathic insomnia- with no clear external trigger”, I emphasise, trying to keep us focused on the indication of interest.  

 The GPs nod obediently and launch into a surprisingly compelling short play. “Doctor, I can’t sleep! The neighbours are so noisy”, says one of my lead actors. Their colleague nods sagely. “How many hours of sleep do you think you’re getting? Tell me how you feel during the day, then let’s talk about your diet, your caffeine intake, and your sleep routine”, before probing about comorbidities.  

 This short exchange highlighted some of the hallmarks of sleep medicine that we have come to recognise in our extensive work in this field: 

  • A fixation on cause and external influence: Despite my insistence on a focus on idiopathic insomnia, my doctors on this particular evening could not escape an examination into the cause of the disorder. We see this time and again – not just for insomnia, but for narcolepsy, EDS (excessive daytime sleepiness) and IHD (idiopathic hypersomnia). There is a persistent keenness to rigorously explore the drivers of sleep disorders, and the elimination of the influence of possible comorbidities, that can often delay treatment and overlook the benefit of potential drug therapy in the meantime. Twinned closely with a reticence to medicate (with stereotyped and somewhat “scary” stimulants or sedatives) our clients may face barriers and delays before the conversation even turns to their product class. 
  • Subjectivity: As with many medical conditions, physicians working in sleep disorders know that how patients feel and how they perceive their condition can be the most meaningful measure of their progress – but are simultaneously aware of the need for solid evidential proof of drug efficacy in this space. Notoriously hard to measure outside of a sleep lab, the symptoms of sleep disorders rely on highly subjective measures and scales – meaning it can be a challenge for our clients to create a compelling and impactful data story for their products that both accommodates and compensates for this inherent subjectivity.  
  • Pressure on the patient: Few topics introduce such an interesting patient dynamic as sleep medicine. As in many areas, physicians stress the importance of lifestyle factors such as smoking, diet, alcohol, caffeine, exercise, comorbidities, and sleep hygiene – placing a great deal of pressure on exhausted and highly impacted patients who may already feel they have tried “everything” before approaching their doctor. Meanwhile, patients may provide inaccurate information or an unclear picture of their symptoms – either because they simply cannot fully perceive the nature of their condition (see the topic of subjectivity above) or because they fear the impact of a diagnosis on their life (such as losing their driving license). This slightly fraught and sometimes mistrustful dynamic can also introduce barriers to prescription, and the provision of a solution to patients’ problems. 

Thinking back once again to my late-evening focus group with my four sleepy doctors, I recall how we all agreed about the importance of sleep. It is a universal and essential part of our health and wellbeing – speaking as the parent of a small and frequently nocturnal baby, I have never felt more aware of this fact. But our conversations with patients living with sleep disorders often underline how sluggish this space can feel when it comes to providing effective treatment. 

There is, however, optimism: understanding of sleep is growing – with multiple biological mechanisms and more than twelve sleep hormones being leveraged to develop novel and effective drugs (such as the harnessing of the orexin pathway in both narcolepsy and insomnia); and innovations such as AI being applied to predict outcomes in sleep apnoea.  

As the options for patients grow, so will the challenges and decisions facing prescribers – their thinking and feelings surrounding sleep disorders evolve to “catch-up” with the available suite of products, our clients will need to simultaneously work to develop updated understanding of their customers’ mindset and behaviours. 

This is a diverse and challenging space, and at HRW we love working in sleep – even towards the end of a long day! We use behavioural science, bespoke techniques, and tools and technology to get beneath the surface of the patient and prescriber experience, helping our clients to navigate a potentially murky yet endlessly fascinating space. 

Get in touch at hrw_synapse@hrwhealthcare.com to find out more about our capabilities in this area.  

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