Insomnia Management in the Digital Age
Insomnia is a common condition in which patients experience difficulty initiating sleep, maintaining sleep and/or wake earlier than desired. It can cause significant distress and impaired functioning.
Population surveys suggest that approximately 33% of the population experience at least one insomnia symptom, with only 1 in 10 seeking treatment. Female gender, older age, pain and psychological distress have all been associated with increased prevalence rates.
There is a strong association between insomnia and psychiatric disorders, such as depression, anxiety, and drug abuse. Rates of psychiatric comorbidity as high as 80% have been reported, with insomnia predating the onset of mood disorder in approximately half of cases. Insomnia has also been independently associated with increased healthcare utilisation, increased workplace injuries and absenteeism, and reductions in quality of life. A number of studies have demonstrated an association between insomnia and increased cardiovascular risk.
The management of insomnia can broadly be categorised into pharmacological and non -pharmacological therapies. Although pharmacotherapy is often used first by doctors and as primary therapy, it is not indicated long term and should not be used in isolation. Pharmacotherapy is only indicated for short term use. Benzodiazepines, non-benzodiazepine hypnotics, melatonin, sedating anti-depressants and antipsychotics have all been used. The majority of these agents have been shown to be more efficacious than placebo in short term randomised controlled trials, however their use is often tempered by extensive side effect profiles, detrimental effects on sleep architecture and the risk of tolerance and dependence.
Non-drug treatments for insomnia, namely Cognitive Behavioural Therapy (CBT) for sleep are very effective both acutely and for the longer term. CBT for sleep should be initiated in all patients. CBT is effective as a sole treatment for insomnia or it may reduce the reliance on medications in the longer term. CBT addresses dysfunctional behaviours and beliefs about sleep and consists of sleep hygiene, stimulus control, sleep restriction, and cognitive restructuring.
In the past, access to CBT for sleep has been a challenge, with limited trained providers and poor availability. However, recent studies of computer based (online) CBT for sleep have been encouraging with comparable efficacy to conventional CBT for sleep. Online CBT can be accessed in Australia through the US based SHUTi program if referred by GP’s or Specialists (http://www.sleepcentres.com.au/online-insomnia-cbt-program.html). Online CBT for sleep is convenient, effective and easy to access, and arguably is a good option for non-drug insomnia management for all patients.