Managing insomnia in primary care

Welcome to the Australian Prescriber Podcast. Australian Prescriber, independent, peer-reviewed, and free.

Hello, I'm Jo Cheah, and this is the Australian Prescriber Podcast. Joining me today is Dr David Cunnington, a sleep physician based in Melbourne. Welcome to the podcast, David.

Yeah, hi, Jo.

It's great to have you on. So to begin, let's talk about the main signs and symptoms of insomnia.

So while some people think of insomnia as just difficulty either getting to sleep or staying asleep, really we've got to think of insomnia as having those core symptoms, either difficulty getting to sleep, difficulty staying asleep, but it's paired with impairment of daytime functioning. So that's where it's a bit different from what a lot of people may have is sleep not being quite what they wish it is, but they're actually functioning okay. So that's not insomnia because we all have this idealised version of what we think sleep should be. And very often, it's not going to meet that. We've got other comorbidities or other health conditions that may modify sleep. So think of insomnia as the combination of the sleep disturbance together with the impairment of daytime functioning.

You mentioned just then maybe some risks or comorbidities. So what are some risk factors for developing insomnia?

So any of the physical or mental health conditions can impact on sleep. So often, we don't think about it this way, but sleep's actually a biological function. And to sleep well, you need an intact body and a intact mind, if you like. So anything that's going to impair some of the autoregulatory processes in the brain is going to interfere with sleep. Anything that's going to cause issues in the body like pain or difficulties with movement's also going to interfere with sleep. So the more typical things when people think about having insomnia and comorbid conditions are mental health issues like depression and anxiety, but it can also be seen in prior trauma and can be seen in some of the personality disorders, particularly borderline personality disorder where people can have difficulty switching off. Some of the other mental health issues, including developmental issues, can also cause difficulty with sleep.

In terms of physical conditions, many chronic physical conditions can impact on sleep. Arthritis and joint pains can interfere with sleep, but so can chronic inflammatory disorders. Again, if you think of it as a biological process, you've got a chronic inflammatory process going on in the body. That's actually going to interfere with some of those autoregulatory processes in the brain, which are very important in regulating sleep. So think of it as any physical or mental health condition.

I like to think of sleep as a bit of a barometer for health. So to sleep well, you need to have sound body and sound mind. And if sleep's not working well, it's not specific. It's not going to tell you what's wrong. And that's where our clinical acumen has to come in. We've got to have that clinical assessment to look at physical and mental health and then pair that, we'll look at the sleep disturbance and say, "Okay, do those things match up?"

Yeah. Very interesting to look at sleep as a biological activity.

Yeah. Because sometimes we think of sleep in a social way. We've got all these social norms around sleep, cultural norms around sleep, beliefs around sleep. So sometimes we don't think of it as a biological function. An example of that is I might see someone in their 70s, in fact, I saw someone today in their 70s, who is upset that they don't sleep for eight hours continuously like they did when they were in their 20s. And it was a postmenopausal woman. I'm saying, "Biologically, are you different to when you're in your 20s?" She's like, "Oh, absolutely. I'm totally biologically different." Well then sleep should be different if we think about it as a biological thing. Whereas she's thinking of it as a social construct, "I always go to bed at 10:30. I always get up at seven o'clock in the morning." That sort of a behavioural and social way of thinking about sleep rather than thinking, "Okay, life circumstances have changed. My whole health circumstances have changed. So sleep is going to evolve across life.”

It's a really interesting perspective. Thanks for sharing that story. So in your article, you've written about cognitive behavioural therapy and how this should be recommended as the first-line therapy in insomnia. So can you discuss the importance of each of the different types of cognitive behavioural therapy that you've mentioned in managing insomnia?

Absolutely. So cognitive behavioural therapy's got a very good evidence base behind it, including many meta-analyses showing it's an effective therapy for insomnia. Now, we do have to recognise there is a type of insomnia called acute insomnia, think of that as situational insomnia. So there's an acute set of circumstances, which will predictably throw sleep out. Now, in that situation, we don't necessarily go for cognitive behaviour therapy as the first thing, we'll try and work out what's the precipitant that's thrown sleep out. But once people have had trouble with sleep for a month or more, they start to think about sleep differently. They start to behave differently around sleep. And that's when we'll be using cognitive behaviour therapy for what we call chronic insomnia, when symptoms have persisted, despite that acute precipitant having passed. Now, just by its very name, cognitive behaviour therapy has some behavioural components and some cognitive components.

Now, the behavioural components are sleep hygiene, sleep restriction, and stimulus control. And most people have heard of sleep hygiene. So think of that as healthy sleep habits. So they're the things to avoid before going to bed, like not having caffeine too late or large meals too late, or not exercising too late, making sure the bed environment's conducive to sleep. Importantly, though, sleep hygiene as a sole therapy's never been proven to be an effective strategy for insomnia. So we've got to pair it with some of these other strategies.

The next strategy is sleep restriction. So that's really trying to match how much time someone spends in bed to how much sleep they're actually getting. Now one of the behaviours of people with insomnia is that they tend to go to bed wishing for sleep to fill that space, even though it won't necessarily fill that space and we can't make sleep come. And think of that as almost people have this aspirational behaviour around sleep. And it sets up then lots of time in bed awake, wishing they are sleep, which then becomes frustrating and people develop a conditioned arousal response about being awake in bed and frustrated. So sleep restriction is looking at how much sleep someone's actually getting and better matching their time in bed to that.

An example might be someone who's sleeping six hours per night, but spending nine hours in bed wishing for sleep. It would then be truncating that amount of time they're spending in bed to around 6.5 hours.

We combine that with another behavioural strategy, the third behavioural strategy, which is stimulus control. In some respects, think of that as removing the stimulus of trying to get to sleep. So if people are in bed awake at night, rather than lying there tossing and turning, "Come on, how come I'm not asleep? I really need to get back to sleep." It's recognising that people are awake and mentally active. You've got to do something else. You've got to stop trying to sleep. So that may be sitting up with the light on, read quietly until, again, you feel sleepy, that may be getting up and going and sitting in a quiet chair in another room until you feel sleepy and then going back to bed. But it really is just stopping trying to sleep, is really the essence of stimulus control.

Now, that package of the sleep hygiene, sleep restriction, stimulus control is actually been put together as a therapy called brief behavioural therapy, which is a subset of CBT for insomnia. And there's good evidence base about that being used in primary care, both by GPs and practice nurses and that's supported by the Royal Australian College of General Practitioners. And again, a good research base behind brief behavioural therapy for insomnia as a management strategy in primary care.

The last two components of cognitive behavioural therapy that focused more on the C, the cognition part, are a little harder and often need a little bit more specialised intervention from someone like a sleep psychologist or a sleep specialist, because one of them is cognitive therapy, challenging people's beliefs around sleep.

So when people have had trouble with sleep, they start to think about sleep differently and get some beliefs, "If I don't sleep, there'll be these consequences. For me to function well during the day tomorrow, my sleep needs to meet these parameters. If I'm not sleeping well, it's going to have impacts on my long-term health." These sort of beliefs that really fuel this ongoing difficulty with sleep. So that requires challenging some of those beliefs about sleep. An example may be someone who says, "Well, if I can't get six hours of sleep, the next day is just a write off and I may as well not try to do anything." So, well, in actual fact, you can remember a time when you may have had even less sleep, but actually functioned okay through the day and gotten through the day. So it's trying to challenge some of that change thinking and beliefs around sleep.

And then the fifth of the strategies in cognitive behaviour therapy is relaxation strategies. Not so much getting people to have some magic turbo switch off that they can be just busy, busy, busy all day, and then master switching off in the five minutes before they go to bed, but more developing the skill of being okay with just resting quietly. A lot of us in today's busy life can't sit still for a minute or more before we're sort of looking, "Where's my phone and what's going on? What have I missed?" And we don't cultivate that skill of quiet resting wakefulness. And if you think about it, to sleep well, you've actually got to be comfortable with resting quietly because if you rest quietly and are able to just be at ease with that, your brain and body will take the sleep it needs as long as you don't get in the way of it.

But often, we get in the way of it by, "I'm not asleep yet. I got to do this. I've got to change this condition to make myself sleep." So when we're trying to train people in relaxation strategies around sleep, we think of it as a skill development. And it really is practicing this skill during the day of either meditation or relaxation or progressive muscular relaxation or visualisation strategies, some sort of strategy that someone can work on, develop a skill in that, so that over time, it is something they could introduce. So when they wake at night, they could use that same technique to just be okay with it being quiet resting wakefulness, and being okay with, "Well, the sleep will come when it comes," rather than getting that frustration and needing to control that process.

We've talked about cognitive behavioural therapy. So when would drug therapy be considered?

So although there's a really good evidence base for cognitive behaviour therapy, unfortunately, there are times when it won't work as well as what we wish. Now, that doesn't mean we don't do cognitive behaviour therapy, but sometimes we'll get people's symptoms reduced, but not reduced enough that they're sleeping well and it's not impacting on their function during the day. So that's the time we may look at medication therapy. The other time we look at medication therapy is if someone's presenting with a high degree of distress. So in that situation, there is good research showing that it's difficult for people to fully participate in a CBT approach if they're highly distressed. And that may be a role for short-term use of medication to help reduce distress, whilst in parallel, beginning to work on the cognitive behaviour therapy strategies.

If we are using medications, it is important to try to use them for a shorter period as possible. But it's also important to recognise it's a tricky balance for someone who's in a high level of distress becoming very anxious about sleep. The more poor sleep they're exposed to is going to just amplify their anxiety about sleep and going to take longer for that to defervesce or longer for that to settle. Whereas, if they get some relief from that exposure to poor sleep with use of a medication in the short to medium term, it helps already to start to reduce that anxiety and that conditioned arousal response around sleep.

And there's also some research suggesting that once people are more comfortable with their sleep, think of it as you've got a holding strategy that's managing their sleep, they can better participate in CBT. They're more willing to try new things. And then important, as people get more confident using those non-drug strategies to help manage their sleep that the medication’s then gradually withdrawn and faded out.

And what are some of the drug options available you may prescribe or that primary health care providers can prescribe or recommend in the community?

Yeah. There's a number of different groups of medications that can be used for insomnia. So melatonin is registered to treat insomnia in adults over the age of 55. There are the benzodiazepines and benzodiazepine receptor agonists, such as zolpidem and zopiclone, which are also effective therapies for the short-term treatment of insomnia. And there's a medication called suvorexant, a dual orexin receptor antagonist, which is a new class of medication. Orexin's been found to be a neurotransmitter that's important in promoting alertness. So an orexin receptor antagonist can help reduce that alertness. And that's something that can also be used with insomnia.

And you touched on it briefly before that some of these medications might be effective in the short-term and then slowly weaned off. So which drug classes are you referring to in those settings and where may it be dangerous to stop a medication used for sleep quickly or without medical advice?

In pretty much all of those medication classes as a general rule, I want to gradually be reducing the medication, be that gradually reducing the dose or reducing the frequency. Sometimes there's concern about immediately stopping the medication. That's more so for benzodiazepines, if people have been on them for a period of time. But it's a lot more about some of the psychology around insomnia. Again, if someone's had difficulty with sleep, they're very fearful of going back to that really challenging time. So if you're making forward progress and you want to maintain their engagement, it is a matter of gradually reducing the medication, allowing people to maintain their confidence about, "Oh, yeah, I can do it. It's going okay." Whereas if the medication's withdrawn too quickly, there's a higher chance of relapse and getting those symptoms back and then flaring up sleep-related anxiety, and then it takes a long time to sort of get back to where you were.

So yes, we want to gradually withdraw the medications, for the benzodiazepines that's important, both in a sort of withdrawal sense. We don't want to get the withdrawal if people have been on them for a while. But it is just making a gradual transition where you're essentially relying on someone to manage their sleep themselves, with some new skills and new way of thinking about sleep that they've learned via CBT, and no longer relying on the medication to do all the work, and you sort of make a transition between those two things.

2Sort of to sum up our talk today, what are your main takeaway points that you have for primary health care providers, such as general practitioners or community pharmacists who encounter patients with sleep disorders in their day-to-day practice?

Yeah. So certainly think about, "Is somebody describing sleep disturbance," or another way of thinking about that, "sleep dissatisfaction?" They're just not happy with their sleep, or is it actually impacting on their daytime functioning? So is it more of an insomnia disorder or just sleep dissatisfaction? Because we do have to approach those things differently.

If someone's got insomnia disorder, then try to think about, "Is it a short-term thing that's being precipitated by an acute set of circumstances." Because that's going to have one particular management strategy trying to address those circumstances versus, "Has this been going on for a long period of time and really become a chronic disorder with that change thinking and behaviour around sleep that's going to need a more CBT type approach?"

Don't be frightened to try, particularly the behavioural components of cognitive behaviour therapy like brief behavioural therapy, incorporating sleep hygiene, sleep restriction, stimulus control, or sleep restriction as a sole therapy because each of those have been shown to work well in a primary care setting. And then recognise, if that's not working, you can absolutely refer on to either psychologists with some expertise in sleep or to sleep physicians. And they can take things from there.

For everyone listening and are interested in all those behavioural therapies and cognitive therapies you talked about, you've got a great table in your article that goes into all of them in detail as well, and good for our colleagues in primary care who can refer to those and give them a go if they're feeling confident to do that. So that brings us to the end of our episode. Thank you so much for chatting with me today, David.

A pleasure.

[Music]

The views of the host and the guests on the podcast are their own and may not represent Australian Prescriber or NPS MedicineWise. I'm Jo Cheah. Thanks for listening to the Australian Prescriber Podcast.