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Figure 4 . The Flinders University one-week sleep diary . See the ‘ case study ’ section for sleep diaries during a 4-week CBTi program . SOL = Sleep onset latency , WASO = Wake after sleep onset , TST = Total sleep time , TIB = Time in bed .
final awakening for 1-2 weeks at baseline and throughout treatment . The sleep diary allows patients to self-report the time they got into bed ( on the previous night ), the times they were awake and asleep throughout the night and the time they got out of bed in the morning . Visual sleep diaries allow for quick interpretation of a patient ’ s primary type of insomnia symptoms ( for example , difficulties falling asleep , maintaining sleep and / or early morning awakening insomnia ), night-to-night variability in sleep and time spent in bed , and the average sleep – wake parameters for the whole week .
Referral to a psychologist
GPs can use a mental health treatment plan to refer patients with insomnia to a psychologist . 54 This allows patients to access sessions with a psychologist at a reduced cost . Most Australian capital cities have sleep clinics with specialist sleep psychologists . The Australian Psychological Society hosts an online directory of psychologists who self-nominate areas of expertise , including management of patients with sleep disorders . Patients who reside remotely can access specialist psychological services via telehealth . Mental Health Treatment Plan reimbursement for telehealth services has been expanded to people in metropolitan , rural and remote settings during the COVID-19 pandemic .
Self-guided CBTi reading material
CBTi programs have also been translated to self-guided reading materials , such as booklets and ebooks . These materials are often freely available and include similar educational content and therapeutic components to those presented in online and in-person CBTi programs . The effectiveness of selfguided CBTi reading materials has
Table 3 . Components of CBTi Component
Bedtime restriction therapy 48 ( also sleep restriction )
Description
been demonstrated in research and implementation trials . 43 , 55 These interventions may be most appropriate for patients who are self-motivated to engage with therapy and
• This aims to reduce time spent awake in bed and reduce the conditioned relationship between the bedroom environment and a state of mental and physical arousal / alertness ( also called the ‘ learned ’ insomnia response or ‘ psychophysiological insomnia ’)
• Patients are guided to temporarily restrict the time they spend in bed over several consecutive nights / weeks ; this increases evening sleep pressure ( sleepiness )
• Warn patients about feelings of daytime sleepiness in the afternoon and evening , especially while driving and in the first weeks of therapy
BBTi for insomnia 39 This framework provides specific rules to guide clinicians and patients in setting and adjusting bedtime restriction therapy :
• If a patient ’ s average weekly sleep-onset latency ( SOL ) OR wake after sleep onset ( WASO ) is 30 minutes or more , time in bed can be restricted
• Bedtime should be restricted to match the average perceived nightly total sleep time ( TST ) but to a minimum of 5.5 hours
• After the first 1-2 weeks of treatment , SOL and WASO should start to decrease
• When average SOL and WASO estimates are both less than 30 minutes , time in bed can be extended by 15-30 minutes for the subsequent week ; this is known as the 30 – 30 rule
Stimulus control Instructions to help patients fall asleep more quickly at the start of the night : therapy 49 1 . Use the bed only for sleep and intimacy
2 . Get up at the same time each morning 3 . Only go to bed when sleepy ; do not ‘ try hard ’ to fall asleep 4 . If not asleep within about 15 minutes , get out of bed and go to another room until sleepy again 5 . Repeat steps 3 and 4 until asleep 6 . Avoid long daytime naps
Relaxation therapy 50
• This aims to reduce physical and mental alertness and arousal before bed
• It includes progressive muscle relaxation , meditation and mindfulness therapies
• Patients practise this over multiple nights as practice improves relaxation skills
Cognitive therapy 19 • Insomnia is often perpetuated by maladaptive beliefs about sleep ( eg , that brief awakenings from sleep are a sign of abnormal health ) and the consequences of sleep loss ( ie , that a short period of insomnia is detrimental to long-term physical health )
• These beliefs have sometimes been held and reinforced over many years
• Cognitive therapy aims to identify , test and challenge these maladaptive beliefs , replacing them with more realistic beliefs that are more conducive to rest , relaxation and sleep
Sleep hygiene and sleep education 51
Relapse prevention
• CBTi commonly begins with information about the processed that control our sleep
• Sleep pressure * refers to an increase in sleepiness while awake and decrease in sleepiness during sleep ( see figure 3 ); our circadian rhythm ** regulates changes in our alertness and sleepiness throughout the day
• Sleep hygiene is not an adequate standalone treatment for insomnia but is commonly included in CBTi programs ; it is helpful to discuss activities to avoid in the afternoon / before bed ( long naps , coffee , stimulants ) and while in bed ( watching TV , mobile phone use )
• Providing patient with information and resources to self-manage future episodes of insomnia with CBTi techniques
* Sleep pressure refers to the likelihood of falling asleep throughout the day and night . From the time that one wakes up in the morning , sleep pressure increases during each hour we are awake . When one finally falls asleep at night , sleep pressure decreases for each hour asleep , until it is depleted by the time one wake up the next morning . If one goes to bed too early , there may not be enough accumulated sleep pressure , so falling asleep will be difficult . Alternatively , if one stays up later than the normal bedtime , the sleep pressure will have more time to increase , and it will be easier to fall asleep . ** Circadian rhythm controls the timing of the sleep / wake patterns . If one tris to go to sleep too early for the internal body clock ( eg , at 7pm ) it will be harder to fall asleep because the body clock is telling one , at its peak alertness time , to stay awake . If ones goes to bed much later and tries to sleep till 10am , it will be harder to remain asleep because the body clock increasing metabolic rate and alertness at this time .
who do not require a high level of in-person support from a therapist / clinician to guide the introduction or weekly adjustment of behavioural treatment .
Sedative – hypnotic medicines
In specific cases , a brief course of medication may be required to treat the short-term symptoms of insomnia , for example , insomnia related to bereavement , acute pain , loss of employment . Reassure patients that most cases of acute insomnia do not develop PAGE 30