Dr Alexander Sweetman ( left ) Research associate , Sleep Health , National Centre for Sleep Health Services Research , Flinders University , Adelaide , SA .

Professor Sally Redman ( centre ) CEO of the Sax Institute , Sydney , NSW .

Professor R Doug McEvoy ( right ) Senior researcher , Adelaide Institute for Sleep Health , National Centre for Sleep Health Services Research , Flinders University , Adelaide , SA .

Professor Nick Zwar ( left ) Executive dean of the faculty of health sciences and medicine , Bond University , Gold Coast Queensland .

Professor Leon Lack ( right ) Senior researcher and psychologist , Adelaide Institute for Sleep Health , National Centre for Sleep Health Services Research , Flinders University , Adelaide , SA .

Copyright © 2022 Australian Doctor All rights reserved . No part of this publication may be reproduced , distributed , or transmitted in any form or by any means without the prior written permission of the publisher . For permission requests , email : howtotreat @ adg . com . au .

This information was correct at the time of publication : 1 April 2022

BACKGROUND

INSOMNIA is a highly prevalent ,

debilitating and costly sleep disorder commonly managed by Australian GPs . ¹ Around 10-15 % of Australian adults fulfil the diagnostic criteria for chronic insomnia disorder ( see figure 1 ). ^1-3

Chronic insomnia ( three or more months ) costs Australia $ 11 billion annually in healthcare use and reduced quality of life . ⁴ Insomnia often co-occurs with other mental and physical health problems , where it is considered a comorbid condition — for example , comorbid insomnia and depression , comorbid insomnia and pain — rather than a secondary symptom . ⁵ This is because insomnia responds to targeted treatments in the presence of comorbid conditions and treating insomnia often improves the symptoms / management of comorbidities . ⁶

Evidence-based guidelines recommend CBT for insomnia ( CBTi ) as first-line treatment . ^7-9 CBTi targets the underlying psychological and behavioural causes of insomnia and results in improvements in sleep , mental health and daytime function that are sustained long after therapy cessation . Sedative – hypnotic medicines — for example , benzodiazepines — however , remain the most

10 , 11 common treatment for insomnia .

Box 1 . Managing insomnia in general practice

• GPs can use the Sleep Condition Indicator ( an eight-item rating scale based on DSM-5 ) to assess for insomnia .

• Insomnia can be an acute ( less than three months ) or chronic ( three months or more ) disorder .

• CBTi is the most effective treatment for chronic insomnia .

• GPs can administer a brief behavioural therapy for insomnia ( BBTi ) over five weekly GP appointments ; the main components are bedtime restriction therapy and stimulus control therapy .

• GPs can refer patients to self-guided online CBTi programs or trained sleep psychologists using a mental health treatment plan .

While producing similar short-term improvements in sleep to CBTi , they are associated with patterns of tolerance , dependence and side-effects

7 , 12 , 13 when used for extended periods . Guidelines recommend that sedative-hypnotics should be prescribed at the lowest effective dose for a maximum of four weeks . ⁷

It is important for Australian GPs to be aware of the high prevalence of acute and chronic insomnia in the general population , and the presenting symptoms , assessment , evidence-based treatment ( see box 1 ) and referral pathways for insomnia . This How to Treat aims to provide GPs with an overview of chronic insomnia , and different evidence-based non-drug treatment and referral options .

PREVALENCE AND AETIOLOGY

INSOMNIA is defined according

to patient self-reported nocturnal sleeping difficulties and associated daytime symptoms ( see table 1 ). ¹ Insomnia may be defined as an acute ( less than three months ) or chronic ( three or more months ) condition . Around 30-50 % of Australian adults report at least one acute nocturnal insomnia symptom at any given time , while chronic insomnia occurs in 10-15 % of Australian adults ( see figure 1 ). ^1-3

Psychological problems , including sleep disorders and depression , are the most common reason for presentations in Australian general practice . ¹⁴ There is evidence that the prevalence of sleep disorders ,

including insomnia , has increased during the COVID-19 pandemic . ¹⁵

The International Classification of Sleep Disorders and DSM-5 list specific diagnostic criteria for chronic insomnia . ^{1 , 16}

The ‘ 3P model ’ ( see table 2 ) is frequently used to describe the aetiology of insomnia . ¹⁷ This model describes the development of chronic insomnia from a range of predisposing factors ( that increase the likelihood sleep will be impaired ), precipitating factors ( that ‘ trigger ’ the initial sleep problem ) and perpetuating factors ( that allow the insomnia to develop functional independence of the initial precipitating factors and become a self-maintaining condition ).

Chronic insomnia is often conceptualised as a disorder of chronic ‘ hyperarousal ’, characterised by increased physiological ( increased heart rate , cortisol , basal metabolic rate and core body temperature ) and cognitive ( anxiety , alertness , catastrophising , an overactive / racing mind ) arousal symptoms during the day

18 , 19 and night .

Insomnia commonly co-occurs with depression . ⁶ For example , up to 50 % of patients with insomnia report symptoms of depression , and up to 90 % of people with depression report insomnia . ⁶ Evidence