Insomnia seems to be one of those maladies that sufferers rarely speak of. That is, until you mention the topic and suddenly almost everyone has a war story about their months of sleepless nights.
If you are someone who lives with insomnia – it's thought to afflict about one in ten of us – you are in esteemed company. Literary history is littered with writers tormented by sleep deprivation, from Charles Dickens and William Wordsworth to the Bronte sisters and Sylvia Plath.
You may also find that many people are experts when it comes to sleep disorder cures. Suggestions can range from the sensible (avoid naps), the obvious (sleep in a cool, dark place) to the irritating (have you tried counting sheep) and the downright bizarre (cherry juice).
You'll also encounter people spruiking a long list of prescription or over-the-counter sleep pills or herbal remedies.
This is what Melbourne sleep physician Dr James Trauer hears in his clinic all the time.
"A lot of people have looked for resources on the internet, they've tried supplements, herbal remedies and various sleeping tablets," he says.
In Australia about 90 percent of people who visit their GP for insomnia walk out with a prescription for a sleeping pill.
But a treatment many people haven't heard of – and one that can be equally if not more effective than medication – is cognitive behaviour therapy. CBT challenges people to change their attitudes and behaviour around sleep.
This week Trauer and his colleagues published a review in the Annals of Internal Medicine that quantifies just how effective it can be.
The review assessed twenty clinical trials, which included just over 1100 patients with chronic insomnia but no other medical issues related to the sleep deprivation. The researchers found people who receive CBT fall asleep, on average, about 20 minutes faster than people who receive no treatment. CBT patients also lay awake in bed a half hour less than non-treatment patients. These improvements are similar to some of the most popular sleeping pills on the market.
Cognitive behaviour therapy versus sleeping pills
Psychologist and insomnia specialist Dr Michael Gradisar, who was not involved in the review, says while CBT and sleeping pills have similar success rates, the benefits of psychological therapy often last a lot longer.
"When they stop medication people's sleep problems can return whereas CBT patients often maintain their improvements up to two years later," he says.
Patients can also develop tolerances to sleeping pills.
"I have patients that creep from one tablet to two because they're not as effective [anymore]," says Gradisar, an associate professor at Flinders University.
Despite the evidence that CBT is an effective "first-line" treatment for insomnia, few doctors suggest it and few patients seek it out.
"There doesn't seem to be a lot of awareness about psychological approaches, even though we understand them to be quite effective," says Trauer, who works at the Melbourne Sleep Disorders Centre
Chronic insomnia is typically defined as sleeplessness that persists for several months. As well as spending long periods of time awake or trying to get sleep, sufferers are often frustrated and dissatisfied with the sleep they do manage.
"It's also about how you feel the next morning, do you feel you're not functioning as well as you should be," says Trauer.
Chronic insomnia can have significant health effects. It's been linked with motor vehicle accidents, depression, high blood pressure and type 2 diabetes.
Trauer says one of the most important aspects of treating chronic insomnia is cutting out the time patients spend awake in bed. "That drives the frustration."
"Patients become conditioned to the bed being a really frustrating environment where they're not achieving what they want. It makes sleep worse and worse," he says.
One of the main elements of CBT is sleep restriction. Patients are told to limit the time they spend in bed to the amount of sleep they perceive they're getting.
"People with insomnia hear in the media that you need to get eight hours sleep or you're stuffed. So they think I better go to bed early to get as much sleep as possible," says Gradisar.
But that can leave an insomniac lying awake for hours. Instead, someone who averages six hours sleep a night and wants to wake up at 6AM should go to bed at midnight.
This strategy often means staying up later which can seem counter-intuitive, says Gradisar.
Bed is for sleeping
Another CBT component is "stimulus control", where patients are advised to get out of bed and go to another room if they have to spend more than 15 minutes trying to fall asleep. This ensures the bedroom becomes associated with sleeping.
Combined with these behaviour changes, patients usually spend a few sessions with a psychologist or sleep specialist.
Trauer says while CBT for chronic insomnia has been around for a few decades, it has become more sophisticated in the past 20 years.
He hopes the review will increase awareness of treatment. "We need to improve awareness and availability at the same time," he says.
While chronic insomnia affects about one in 10 people, almost one third of the population is dissatisfied with the amount of sleep they're getting.
Trauer believes part of this frustration is the expectation Western culture places on sleep.
"We have this expectation that we have to get eight hours of continuous sleep a night but that's something that's developed in modern society and isn't necessarily biological."
Before electric lighting, people would often sleep when it became dark, he says.
Although there are studies that suggest eight hours is about the right amount of shuteye, Gradisar says sleep needs vary among individuals. "Some people need 7.5 hours while other need 8.5," he says.
