Chronic insomnia management using non-pharmacological practices

The gold standard to treat chronic insomnia is cognitive behavioural therapy for insomnia (CBTi). However, most patients in the primary care setting with insomnia are initially managed with sedative hypnotics (benzodiazepines or non-benzodiazepines) or provided with ‘sleep hygiene’ recommendations. Only around 1% of patients are referred for CBTi.

Sleep hygiene (also known as healthy sleep habits or healthy sleep behaviours) involves the use of good sleeping practices and environmental conditions that promote healthy sleep. Examples include getting out of bed at a consistent time every morning, avoiding late and/or excessive caffeine consumption, and avoiding the use of electronics in bed.

Evidence-based guidelines such as the insomnia guideline produced by the American Academy of Sleep Medicine, do not support the use of sleep hygiene as a stand-alone treatment for chronic insomnia.

CBTi is a multi-component treatment that includes several cognitive, behavioural and educational strategies that aim to identify and gradually treat the underlying psychological and behavioural perpetuating factors of insomnia. Evidence based CBTi components include:

• Stimulus control therapy (reinforcing the bedroom as a stimulus for sleep)
• Bedtime restriction therapy (temporarily restricting the time in bed to consolidate sleep periods and reduce time spent awake in bed)
• Sleep education (education on factors that control the timing/quality of sleep)
• Relaxation techniques (techniques to reduce mental and physical arousal)
• Cognitive restructuring (identifying and challenging of thoughts, feelings and behaviours which impact sleep)

Patients can be referred to their GP for a Mental Health Treatment Plan which may facilitate access to a psychologist at a subsidised cost to access to CBTi. Another option would be trying self-guided digital CBTi programs like, This Way Up, Sleep Better Without Drugs and A Mindful Way.

In some cases, a condensed brief behavioural therapy for insomnia (BBTi) program can be considered. This can be delivered by GPs and typically consists of four sessions that uses foundational components of CBTi (sleep education, sleep hygiene, stimulus control therapy, bedtime restriction therapy). Suitably trained pharmacists may also be able to deliver certain evidence-based components like stimulus control therapy.

The Sleep Health Foundation is a not-for-profit Australian sleep advocacy and consumer facing organisation that develops and promotes evidence-based sleep health resources.

CBTi can help people fall asleep faster and wake up less during the night. This means they spend more time sleeping while in bed, which is called sleep efficiency. CBTi has been shown to improve insomnia symptoms in up to 80% for people with this problem, and 90% of them also reduce or stop using sleep medications. It may also benefit people who do not have insomnia but have trouble sleeping, and for those with mental health issues such as depression, anxiety or post-traumatic stress disorder, as well as other health conditions like cancer.

CBTi has very few side effects. The potential negative effects are limited and usually mild, such as feeling uncomfortable when dealing with unhelpful thoughts and behaviours. Unlike sleep medications, the CBTi addresses the underlying causes of insomnia, so the benefits tend to continue after therapy ends. Sleep may keep improving if the strategies learned are maintained.

In summary, simple information about healthy sleep habits may have an important role to play in preventive sleep health (before a sleep problem occurs), and in the management of short term or subthreshold insomnia symptoms. However, patients with insomnia that has started to become maintained by psychological and behavioural factors or a state of conditioned insomnia generally require CBTi in addition to simple sleep hygiene information.