Open Access
Feature Article

Insomnia treatment. Improved access to effective nondrug options

ALEXANDER SWEETMAN, NICOLE LOVATO, JENNY HAYCOCK, Leon Lack

Figures

© AMENIC181/ISTOCKPHOTO.COM model used for illustrative purposes only
© AMENIC181/ISTOCKPHOTO.COM model used for illustrative purposes only
Dr Sweetman and Dr Lovato are joint first authors.
Dr Sweetman is a Research Associate at the Adelaide Institute for Sleep Health and the National Centre for Sleep Health Services Research, Flinders University, Adelaide. Dr Lovato is a Senior Research Fellow at the Adelaide Institute for Sleep Health and the National Centre for Sleep Health Services Research, Flinders University, Adelaide. Ms Haycock is a PhD Candidate at the Adelaide Institute for Sleep Health and the National Centre for Sleep Health Services Research, Flinders University, Adelaide. Professor Lack is an Emeritus Professor in the College of Education, Psychology and Social Work and the National Centre for Sleep Health Services Research, Flinders University, Adelaide, SA.

Assessment of insomnia symptoms

Insomnia is diagnosed according to self-reported difficulties in falling asleep or maintaining sleep, or early morning awakenings, and associated daytime impairments.1 Insomnia can be classified as acute (less than three months) or chronic (three months or longer). There are several simple self-report tools that can be used to screen for insomnia and related disorders or symptoms in general practice (Table 1).9-17 When assessing a patient for insomnia, it is also important to consider the contribution of other co-occurring medical or psychiatric symptoms, medications, alcohol and recreational drug use and other lifestyle factors. 

The RACGP guidelines recommend that cognitive and behavioural therapy for insomnia (CBTi) strategies should be employed as the first-line treatment for both acute and chronic insomnia.8 CBTi includes a suite of therapeutic strategies employed and modified over four to 12 consecutive weekly sessions to gradually target the maladaptive psychological, behavioural and physiological processes that underpin the patient’s insomnia.7,18,19

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Because CBTi targets the specific underlying causal factors of insomnia, this treatment is associated with minimal side effects, and improvements are sustained far beyond therapy cessation.20-22 The most common side effect of CBTi is a small increase in feelings of daytime sleepiness during the initial one to two weeks of bedtime restriction therapy.20 However, these feelings of sleepiness quickly dissipate as sleep is gradually consolidated and time in bed is extended after the first two weeks of restriction. CBTi is also effective in patients with comorbid medical or psychiatric symptoms, in older adults and when administered in general practice settings.22-25

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Treatment options for insomnia

GPs, who are at the forefront of health service delivery, are ideally placed to manage insomnia. There are several evidence-based treatment approaches, including education about sleep, digital CBTi, CBTi administered in general practice and referral to a psychologist who specialises in CBTi (Figure).26 Each treatment approach is described below. It is recommended that the GP and patient work in a collaborative manner to select the treatment option best suited to the individual patient, based on his or her clinical profile and personal preferences. Table 2 provides an overview of treatment components commonly included in CBTi programs.

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Education about sleep 

There are many myths and misconceptions about sleep that make patients vulnerable to the development and perpetuation of insomnia, such as preconceptions about the amount of sleep one should obtain and the notion that awakenings during the night are pathological.27 Anecdotally, many individuals with symptoms of insomnia report education about sleep to be therapeutic. Education typically involves information about the cyclical nature of sleep, perpetuating causes of chronic insomnia and key remedies. Education about sleep is financially and time inexpensive for both practitioners and patients.28