Choosing Wisely - Insomnia

Sleeping pill use carries long-term health risks and you might be better off giving drug-free options a go instead.

Issues with sleeping pills

Staring at the ceiling while it seems the rest of the world sleeps soundly? You’re not alone. Up to 30% of adults have trouble going to or staying asleep at some point.

Some find the struggle with sleepless nights goes on for years, even if they’ve tried medication (from hypnotics and sedating antidepressants to melatonin). One Consumer member who preferred not to be named described his 3 years of insomnia as “crippling”.

“I would have periods where it would be unbearable, where I would have to take sick days,” he says.

He was prescribed sleeping medication, but was concerned about dependency. “While it was effective, I found that on nights I didn’t use it, it was twice as hard to get to sleep … It was getting to the point where I was beginning to lose it,” he says.

As he found, treating insomnia solely with sleeping pills can swap one issue for another.

Studies show sleeping pills only help people fall asleep about 8 to 20 minutes faster, adding less than 35 minutes to an overall night’s sleep compared with those who don’t take the medicine.

The pills can help you through stressful times. However, regular use comes with the risk of side effects such as daytime drowsiness, dizziness, hallucinations, sleepwalking and sleep-eating.

People who use sleeping pills regularly can also struggle with rebound effects when they stop taking the medication, University of Auckland Professor Bruce Arroll says.

These patients may need their doctor’s help at this point, he says. “People can experience excessive dreaming and wake up feeling completely wrecked. Because of this, some people end up on sleeping pills the rest of their lives. GPs are pretty careful about giving them.”

What else can be done?

Sleeping pills should be a last resort, but that doesn’t mean your doctor has nothing else to offer. Insomniacs shouldn’t feel like they need to simply soldier on, Dr Arroll says. “There’s an acceptance in the community that insomnia is normal. But there’s a lot that can be done.”

Dr Arroll says if insomnia is interfering with your ability to function, contact your GP. The first step is determining whether your insomnia is a symptom of another condition, such as sleep apnoea or iron deficiency.

Many cases of insomnia are linked to depression and anxiety, he says.

To understand the likely cause of your restless nights, your GP will ask about the frequency of your sleeping troubles and how long they’ve lasted. It may be worth keeping a sleep diary for a week or two before your appointment.

You’ll also be asked about your general health and mental wellbeing, sleeping environment, work schedule, daytime and evening habits – from naps and device use to intensive exercise and alcohol consumption.

Other clues to the cause may come from how you feel the day after a bout of insomnia or your tendency to snore. You may want to ask your partner if they’ve noticed any interruptions to your breathing during the night (as this indicates sleep apnoea) or other behaviours, such as unconscious leg movements.

If related conditions are ruled out, your doctor will likely diagnose you with chronic insomnia. They may recommend a form of cognitive behavioural therapy (CBT) tailored for insomnia. The therapy may also be used alongside treatments for anxiety or chronic pain.

Cognitive behavioural therapy

A drug-free therapy that can even help insomniacs who suffered for decades may sound too good to be true. But the science for CBT stacks up, says Massey University Sleep/Wake Research Centre clinician Dr Bronwyn Sweeney.

Four out of 5 chronic insomniacs experience improved sleep following treatment, she says.

CBT uses a set of well-researched techniques and is the Australasian Sleep Association’s recommended initial treatment for insomnia.

Typically, a specialist will tailor CBT techniques to a patient in individual or group therapy sessions. The techniques aim to rebalance your sleeping and waking cycle, and may involve relaxation exercises and visualisations before you hit the sack alongside stress-reduction techniques during the day. CBT clinics charge between $100 and $200 a session.

Dr Sweeney says the therapy, which is applied over 3 to 8 sessions, can require discipline and commitment. “People usually get worse before they get better. Some people can’t handle that.”

One of the tougher exercises requires insomniacs to go to bed later than they would normally, while still getting up at the usual time. Although this seems counter-intuitive, the technique (known as time-in-bed restriction) trains the person to sleep in a continuous block.

Spending 9 hours in bed but only getting 6 hours of broken sleep leaves you worse off than spending 6 hours sleeping continuously – even if the block is shorter than the recommended amount (7 to 9 hours each night).

The technique should be introduced with the help of a GP or CBT specialist, who will discuss the safest and most appropriate ways to implement it (they’ll never recommend fewer than 5 hours and may advise you to try it when you’re on leave from work). Once unbroken sleep is achieved, the insomniac can then gradually increase the hours they spend in bed.

Unlike with medication, patients undergoing CBT typically keep improving after they finish, Dr Sweeney says. Patients who complete the course then have techniques to tackle insomnia in case it returns.

Digital CBT programmes that use algorithms to suggest techniques for improving your sleep are also available. Some you’ll have to pay for, such as SHUTi. The Health Navigator website suggests the free CBT-i Coach app, developed by the US Department of Veterans Affairs and Stanford University.

Although Dr Sweeney recommends an in-person approach, she says scientifically validated courses such as SHUTi are great resources for those who don’t have access to a cognitive behavioural therapist.