Introduction
Insomnia is defined as self-reported difficulty either getting to sleep or staying asleep on at least 3 nights per week, with associated daytime impairment or distress. Acute insomnia (less than 3 months) occurs in 30-50% of Australian adults and chronic insomnia (3 months or more) occurs in 10-15% of adults at any given time
Intervention
Cognitive behavioural therapy for insomnia (CBTi) is the recommended ‘first line’ treatment for insomnia. CBTi includes the following components:
- Bedtime restriction therapy,
- Stimulus control therapy,
- Relaxation therapy,
- Cognitive therapy,
- Psychoeducation about sleep and healthy sleep habits.
CBTi may be delivered face-to-face by suitably trained clinicians (including GPs, psychologists, nurses, and other allied health), via evidence-based self-guided digital programs, or using a combination of both.
Indication
Chronic insomnia is the third most common psychological reason for GP consultations. Chronic insomnia is maintained by psychological and behavioural factors. Most patients prefer not to take medication to overcome this problem. Medications offer limited benefit and may carry associated risk.
Chronic insomnia reduces quality of life and increases the risk of developing depression, anxiety, hypertension and diabetes.
Precautions/ Adverse effects
None noted.
Availability
Face-to-face CBTi may be provided by GPs, psychologists or by other suitably trained primary care and allied health clinicians.
Insomnia is an eligible condition for the Better Access scheme. GPs can refer patients to a psychologist with a Mental Health Treatment Plan for CBTi, or deliver CBTi components with Focused Psychological Strategy items (Level 2 FPS training).
However, there are very few clinicians with training and expertise in CBTi delivery.
Evidence-based self-guided CBTi programs are becoming increasingly available in Australia (e.g., online, app-based, booklets, etc.). Interactive digital CBTi programs improve insomnia and mental health symptoms and are immediately accessible to patients throughout Australia. Scientific evidence and costs vary from program-to-program. Evidence-based digital CBTi programs can be found on the Australasian Sleep Association’s online primary care resource: https://www.sleepprimarycareresources.org.au/insomnia/cbti/referral-to-digital-cbti-programs
Description
The key components of CBTi are:
Sleep psychoeducation about sleep and healthy sleep habits
Providing factual information about changes in sleep during the night and processes that control sleep quality and timing can help patients understand the rationale for behavioural treatment components, and reduce sleep-related anxiety. For example, normalise brief awakenings from sleep, describe the nature of sleep during the night, and describe sleep pressure.
Information about healthy sleep habits (also called ‘sleep hygiene’) is not an adequate stand-alone treatment for chronic insomnia. It should be provided with other CBTi components.
Bedtime restriction therapy
Bedtime restriction therapy leads to rapid and moderate-to-large improvements in insomnia symptoms. It aims to temporarily reduce time spent in bed to increase evening sleep pressure, reduce time spent awake in bed, consolidate sleep periods, and re-associate the bed/bedroom environment with a state of rest, relaxation and sleep.
- Consider contraindications for standardised bedtime restriction therapy (e.g., Epilepsy, Bipolar or Schizophrenia disorder, driver for work),
- Monitor sleep with a sleep-wake diary before and during treatment,
- Initially reduce time in bed to match perceived sleep duration (minimum of 5.5 hours),
- After sleep efficiency (percentage of time in bed spent asleep) increases to about 85% or more, gradually increase time in bed by 15-30 minute increments from week-to-week,
- Monitor daytime sleepiness during treatment, and recommend against driving if feeling excessively sleepy.
Stimulus control therapy
Aims to strengthen association between bed and sleep, and reduce ‘conditioned’ insomnia response to bedroom environment/routine. Having a pre-planned response may decrease the anxiety about getting to sleep.
Instructions to be followed each night:
- Use bed only for sleep and intimacy,
- Only go to bed if sleepy (different from fatigue),
- If not asleep within about 15 to 30 minutes, get out of bed and go to another room until sleepy,
- Repeat steps 2 and 3 until asleep within about 15 minutes,
- Get out of bed at the same time each morning,
- Avoid long naps during the day,
- Use for multiple nights to build sleep pressure and gradually re-learn association between bed and sleep.
Relaxation therapy
Any evidence-based relaxation technique that the patient finds effective can be used to reduce cognitive and physical arousal/activity before bedtime to facilitate sleep. Specific techniques that may be effective include progressive muscle relaxation, meditation, mindfulness, guided imagery and breathing techniques, and listening to music. Should be practiced during the day and out of bed.
Cognitive therapy
Aims to identify, challenge and replace dysfunctional beliefs and attitudes about sleep and insomnia. Such misconceptions may include unrealistic expectations of sleep, fear of missing out on sleep, and overestimation of the consequences of poor sleep on immediate health or daytime function outcomes.
Healthy sleep habits
General recommendations related to environmental factors, physiologic factors, behaviours and habits that promote sound sleep. For example, advise patients to maintain a comfortable bedroom environment (temperature, light, sound), avoid electronics in the bedroom, limit alcohol, nicotine, and caffeine intake in the afternoon/evening, and maintain a regular sleep schedule. Not an adequate ‘stand-alone’ treatment for chronic insomnia.
Tips and challenges
- It can be helpful to normalise brief awakenings from sleep during the night and changes in sleep with age.
- Set realistic goals with treatment. Everyone experiences an interrupted night of sleep every now and again.
- Set expectation that improvements will occur gradually over 3-5 weeks, but will persist over time (unlike sleeping pills).
- When using bedtime restriction therapy, consider anchoring the bedtime window to the time in the morning that the patient needs to get out of bed for daytime commitments. This is because many patients find it easier to delay their bedtime until later in the evening, rather than getting out of bed earlier than they normally would.
- The effectiveness of digital CBTi may be improved by clinician support so that patients engage with, and continue therapy. This can be particularly important in motivating engagement with behavioural therapy components such as bedtime restriction therapy and stimulus control therapy.
- CBTi is effective in the presence of sleeping pill use, and can facilitate reduced dependence on sleeping pills over time. Changes to sleeping pill use should occur slowly. Consult RACGP benzodiazepine resources for further information on sleeping pill prescribing and de-prescribing.
Grading
HIGH (We are very confident in this research evidence, i.e. further research is very unlikely to change the estimates.)