suspect the presence of a learned insomnia component ( see table 2 ).

There are several brief tools to assess for daytime symptoms and comorbid conditions commonly associated with insomnia ( see box 2 ). These may be used to guide the most appropriate treatment approaches .

It is also important to assess for other comorbid sleep and mental health conditions — such as obstructive sleep apnoea ( with the OSA50 screening questionnaire , see figure 2 ), depression and anxiety , which may require treatment — and

Box 2 . Brief questionnaires

• Patients with high levels of daytime sleepiness ( especially sleepiness while driving ) may require referral to a specialist sleep psychologist or sleep physician . The Epworth Sleepiness Scale is an eight-item self-report measure of likelihood of falling asleep in different situations during the day . ³³ Patients with excessive daytime sleepiness ( scores greater than 16 )

22 , 29 may have comorbid conditions , such as depression or sleep apnoea .

• The Patient Health Questionnaire-9 ( PHQ-9 ) is a nine-item self-report questionnaire to measure depression . ³¹ Scores range from 0 to 27 , with higher scores indicating greater depression . A score of 10 or greater indicates at least moderate depression .

• Insomnia and sleep apnoea commonly co-occur and may require referral to a sleep specialist . ²⁹ The OSA50 ( see figure 2 ) is a four-item tool to screen for those at high risk of obstructive sleep apnoea . ³⁰

use . ^{12 , 44 , 45} Evidence suggests that CBTi improves insomnia as well as the management of comorbid conditions , including depression , anxiety and stress , pain and sleep

6 , 46 , 47 apnoea .

REFERRAL TO ONLINE CBTI PROGRAM CBTi has been translated to digital programs . This Way Up ’ s managing insomnia is a freely available linear online program based on CBTi evidence . It includes four text- / comic-based sessions to guide users

settings ( for example , general practice ). A four-session brief behavioural therapy for insomnia ( BBTi ) program that includes the most effective behavioural treatment components has been developed .

39 , 53

CBTi is generally administered over the course of longer sessions that include treatment components focused on identifying , testing and restructuring maladaptive sleep-related beliefs , while BBTi consists of one initial longer session and 3-4 subsequent 15-minute booster sessions .

to determine the best treatment

to enact the principles of CBTi .

Australian GPs can administer

approach for insomnia . ^29-32

One study reported this program

BBTi . In 2021 , the Adelaide Institute

TREATMENT

CBT for insomnia

CBTi is the most effective treatment

for insomnia and is the recommended first-line therapy . ^7-9 CBTi is a multi-component therapy ( see table 3 ) that aims to identify , tar-

Figure 2 . OSA50 screening questionnaire — scores of 5 or greater indicate high risk for sleep apnoea .

OSA50 screening questionnaire

Obesity Waist circumference *: (> 102cm for males or > 88cm for females )

If YES , score

3

improves symptoms of insomnia and distress in the Australian context . ⁵²

About 50 % of patients referred to online CBTi interventions do not complete the full program . ³⁴ GPs may therefore need to provide encouragement and motivational support to patients to persevere and com-

for Sleep Health ( Flinders University ) published a step-by-step guide for GPs to enact a 4-5 session CBTi program in the context of Australian general practice appointments . ³⁹ This includes one longer initial session to introduce the concepts of sleep pressure and circadian influ-

get and treat / modify the underlying psychological , behavioural and physiological processes and factors that perpetuate the insomnia . ³⁴ During treatment sessions , patients are

Snoring

Apnoeas

Has your snoring ever bothered other people ?

Has anyone noticed you stop breathing during your sleep ?

3

2

plete the sessions . Offer access to another CBTi option ( CBTi from a GP or referral to a sleep psychologist ) to patients who do not complete the full CBTi program or who do not

ences on sleep , the rationale behind behavioural treatments and to start bedtime restriction therapy and stimulus control therapy ( see table 3 ). The subsequent 3-4 sessions

provided with information , allowing them to continue managing future

50 Are you aged 50 or over ? 2

experience remission of insomnia following online CBTi .

can be delivered during 15-minute weekly / fortnightly appointments to

periods of insomnia with the cognitive and behavioural techniques . By targeting these underlying factors and providing patients with the

TOTAL SCORE / 10

* Waist circumference should be measured at the level of the umbilicus ( males 102cm = size 40 [ inches ] and females 88cm = size 16 )

Neither of the digital CBTi programs with the greatest amount of scientific support — Sleepio ( UK ) and Somryst ( US ) is available in Australia .

gradually titrate time in bed , encourage adherence and overcome any barriers to using bedtime restriction therapy . Provide patients with sleep

tools to overcome future episodes

diaries to complete between sessions

of insomnia , CBTi leads to improve-

weekly / fortnightly sessions that

well as when self-administered by

BRIEF BEHAVIOURAL THERAPY FOR

to guide the adjustment of time in

ments in sleep , daytime function ,

last 45-60 minutes . However , CBTi

patients through interactive online

INSOMNIA

bed and other treatment recommen-

mental health and quality of life that persist far beyond therapy

has now been adapted to a range of treatment providers / modalities . It

12 , 37-43 programs or reading materials . CBTi is an effective treatment

A full 6-8 session CBTi program delivered by a psychologist may

dations during subsequent sessions . The one-week sleep – wake diary

35 , 36 cessation . CBTi has historically been admin-

is effective when provided in small group settings , via telehealth , in pri-

for insomnia in the presence of comorbid mental and physical

not be required by all patients with chronic insomnia . Furthermore ,

( see figure 4 ) is a useful tool in the management of insomnia . During

istered by trained therapists / psy-

mary care by GPs and practice nurses

health conditions and in patients

these 6-8 session programs may

BBTi , ask patients to complete the

chologists over 6-8 individualised

in brief four-session programs , as

with a history of sedative – hypnotic

not be appropriate in all treatment

sleep diary each morning on their