Around 15% of Australian adults meet the criteria for chronic insomnia, and sleep problems are among the top three reasons people see a GP. Treatment can improve not only the insomnia itself, but also the symptoms of other common conditions—even alleviating depression by up to 50%.

Insomnia often comorbid and warrants treatment in its own right

Historically, insomnia that occurred alongside other mental health, physical health or sleep disorders was considered a secondary symptom. However, a plethora of research has shown it is actually a comorbidity of these conditions, says Dr Alexander Sweetman, a Senior Program Manager with the Australasian Sleep Association.

“Although short-term insomnia symptoms can initially result from other conditions such as depression or pain, sleep difficulties quickly develop functional independence from these initial causes, and can become a self-maintaining chronic insomnia disorder,” Dr Sweetman explains.

“Even if another disorder is present, and even if it’s another sleep disorder, it’s still quite important to view the chronic insomnia as a comorbid condition that warrants assessment and potentially treatment.”

Cognitive behavioral therapy for insomnia is first line

The most effective treatment for insomnia is cognitive behavioural therapy for insomnia (CBTi).

CBTi consists of:

• general sleep education – covering basic information about the structure of sleep, factors that impact the timing and quality of our sleep, and healthy sleep habits
• bedtime restriction therapy – to build a stronger relationship between being in bed and being asleep by temporarily restricting time spent in bed
• stimulus control therapy – to strengthen the relationship between bed and sleep by breaking ‘learned insomnia’ habits (e.g. by going to bed only when sleepy, getting up at the same time each day and only using the bedroom for sleep and intimacy)
• relaxation techniques – such as muscle relaxation exercises, mindfulness, meditation and breathing techniques
• cognitive restructuring – to detect, challenge and replace unhelpful ideas and attitudes towards sleep and insomnia.

CBTi sessions are usually delivered weekly or fortnightly over six to 10 weeks.

CBTi can be delivered by any health professional with appropriate training, including GPs, practice nurses, psychologists and other allied health professionals, Dr Sweetman says. Online programs are also available.

CBTi safer and more effective long-term than sleeping pills

Research has shown sleeping pills and CBTi are similarly effective in the short-term, and CBTi is much more effective in the long-term. CBTi is also associated with fewer side-effects and no risk of dependence, Dr Sweetman says.

“In an ideal world, people with chronic insomnia would get CBTi as the first line treatment as recommended. And there would be less need for sleeping pills.”

However, he acknowledges patients can have trouble accessing CBTi, with common roadblocks including a limited number of clinicians trained to deliver it, large copayments for psychology services, waiting lists, and limited support for digital CBTi programs.

“That means there are a lot of patients currently using sleeping pills, or a lot of patients trying over-the-counter medicines of some kind before presenting to their GP for management,” Dr Sweetman says.

Benzodiazepines are only recommended for short-term use, he adds.

“Anything beyond four weeks is generally not recommended in the guidelines, because these pills can become associated with some side-effects, patterns of dependence and withdrawal effects or rebound insomnia in some users.”

In people who’ve been taking benzodiazepines long term, CBTi is still an effective treatment for insomnia and can support patients to gradually reduce medication dependence. In these patients, the effectiveness of CBTi can vary depending on the patient, the medication, and patterns of dependence to that medication, so a nuanced team-care approach can be useful, Dr Sweetman says.

He notes older adults may be more sensitive to benzodiazepines and metabolise long-acting agents less efficiently, resulting in protracted clearance from the body. Therefore, some will experience ‘next-day’ side effects—including falls and motor vehicle accidents. Due to these risks, along with the risk of misuse and dependence, the American Geriatrics Society Beers Criteria® advise avoiding benzodiazepines in this group.

Treating insomnia can improve symptoms of other disorders

CBTi not only improves insomnia, it can also improve the symptoms of comorbid conditions such as depression, anxiety, and pain, Dr Sweetman says.

“We know that sleep is bidirectionally related to pretty much every area of our health. So a lot of the time, there’s this halo effect of improving sleep. There’s about a 50% reduction in depressive symptoms, improved symptoms and intensity of pain, and it might also improve the management of some other sleep disorders.”

Given the frequent association between insomnia and other sleep disorders—including sleep apnoea, restless legs syndrome, and circadian rhythm disorders—it’s important to identify and manage these, too, Dr Sweetman adds.

How can patients access CBTi?

To help doctors and patients access CBTi, the Australasian Sleep Association has developed an online registry of psychologists with training and expertise in this approach.

Importantly, insomnia is an eligible condition for a GP Mental Health Treatment Plan referral.

GPs wanting to deliver CBTi can complete a training module developed by the Australasian Sleep Association in conjunction with the Australian Psychological Society.

“That’s a six-hour interactive course that teaches clinicians everything they need to know to start delivering this therapy the next day,” Dr Sweetman says.

GPs with level two Focused Psychological Strategies training may be able to access higher rebates for longer consultations, Dr Sweetman says.

Additionally, several digital CBTi programs are being tested in Australian general practice research studies, he adds. You can find and refer patients to evidence-based Australian digital CBTi programs here.

What if CBTi doesn’t work?

Although CBTi is the recommended first line treatment for all people with chronic insomnia, it doesn’t resolve insomnia in about 20% of patients, Dr Sweetman says.

In these cases, it can be helpful to consider other potential underlying causes including:

• comorbid sleep disorders (which can be further assessed via a sleep study or specialist sleep physician referral)
• other chronic conditions
• lifestyle/work factors that might be contributing to insomnia
• other medicines that can interact with sleep-wake patterns.

Additionally, some patients may have had difficulty engaging with some of the behavioural components of CBTi, such as bedtime restriction therapy and stimulus control therapy. These patients may benefit from more support, motivational interviewing, or getting family members involved to facilitate engagement with and effectiveness of CBTi, says Dr Sweetman.

In a minority of patients, sedative-hypnotic medicines may be indicated after ruling out other underlying causes, carefully considering the risks and benefits, and according to evidence-based guidelines, he adds.

Other non-pharmacological therapies such as mindfulness therapies can also be considered if CBTi has not been effective.

Key messages:

• Insomnia is a common comorbidity and can be treated alongside other mental, physical, and sleep disorders.
• Cognitive behavioural therapy for insomnia is first line.
• CBTi can improve the symptoms of comorbid disorders.
• CBTi can be delivered by trained health professionals and digitally.
• Insomnia is eligible for treatment under a GP Mental Health Treatment Plan.

More information

AJGP | General practitioner assessment and management of insomnia in adults
AJGP | June 2024 sleep special issue
Australasian Sleep Association | Sleep Health: Primary Care Resources
Australasian Sleep Association | Webinars, podcasts, events, and networking opportunities