Sleep problems in psychological practice

Improving sleep with cognitive behavioural therapy for insomnia

Chronic insomnia is a debilitating condition affecting about 10-15% of the Australian adult population (The American Academy of Sleep Medicine, 2014; American Psychiatric Association, 2013; Appleton et al., 2022; Ohayon, 2002). It is associated with reduced quality of life, daytime impairments like fatigue, irritability and poor mood, and increased risk for major depression. Insomnia co-occurs with most psychological disorders (Khurshid, 2018). In the past few decades, several psychological treatments for insomnia have been developed (Edinger et al., 2021). Insomnia can be effectively managed by psychologists in the presence of comorbid conditions, and the successful treatment of insomnia commonly improves comorbidities (Sweetman et al., 2021).

Cognitive behavioural therapy for insomnia (CBT-I) is the most effective insomnia treatment (Ree et al., 2017). GP Mental Health Treatment Plans can be used to refer clients with chronic insomnia to psychologists for CBT-I (Liotta, 2021). However, despite substantial research demonstrating durable effects of CBT-I and this existing funding mechanism, very few Australian psychologists have training and experience in CBT-I. It is also under-represented in the clinical training curriculum (Meaklim et al., 2021).

The Australasian Sleep Association (ASA) Behavioural Management of Sleep Disorders education committee and Australian Psychological Society are collaborating on a series of CBT-I webinars, workshops and educational resources for existing psychologists and postgraduate psychology students. This article gives an overview of insomnia in adults, CBT-I and further education resources.

Insomnia in context

Chronic insomnia (referred to as Insomnia Disorder in the DSM-5) is characterised by difficulty getting to sleep, maintaining sleep, and/or early-morning awakening and daytime impairment, that occurs at least three times a week and for at least three months (American Psychiatric Association, 2013). People with insomnia report problems with daytime physical, mental and emotional functioning, such as fatigue, low energy, impaired concentration, irritability and depressed mood, with a consequential impact on quality of life. Indeed, most people with chronic insomnia report that daytime functional deficits are more bothersome than the night-time sleep disturbance (Carey, 2005; Harvey et al., 2008; Kyle, 2010a). Age, sleep reactivity (the likelihood of stress exposure causing difficulty sleeping) and being female are common risk factors (Drake, 2014; Ohayon, 2002). Indeed, women are almost twice as likely as men to experience insomnia, with hormonal factors likely at play (Ohayon, 2002; Zhang & Wing, 2006). The chance of having insomnia also increases with age. Normal age-related changes in sleep architecture occur as we get older (e.g. increased light sleep and decreased deep sleep), with people finding it more difficult to maintain sleep as they age (Scullin, 2017; Varma, 2019).

While these risk factors increase vulnerability, insomnia is often precipitated in at-risk individuals by major or stressful life events (Spielman et al., 1987). A current stressor is the global COVID-19 pandemic (Meaklim et al., 2021). Emerging evidence suggests the prevalence of chronic insomnia rose to 16–19% in 2020 (Morin et al., 2021). Perpetuating factors are also critical for the transition from acute to chronic insomnia, and typically include unhelpful sleep-related thoughts (e.g. “If I don’t sleep well tonight, I won’t be able to perform at work tomorrow”) and behaviours (e.g. sleeping in, napping or spending more time trying to sleep). These perpetuating factors can increase arousal and disrupt circadian rhythms (our internal body clock) and the build-up of homeostatic sleep pressure (e.g. the longer we are awake, the more pressure we have to sleep) (Cunnington, 2016; Harvey, 2002; Spielman et al., 1987).

Chronic insomnia clearly is maintained by unhelpful thoughts and behaviours around sleep, yet the most common treatment offered in Australia is pharmacological (Miller et al., 2017). Sleep medications do not address the underlying factors maintaining insomnia and because of tolerance and dependence, can worsen symptoms (Sweetman et al., 2020). There is strong empirical evidence that CBT-I is an effective alternative to sleep medications in the short-term and superior in the long-term (Riemann & Perlis, 2009; Smith et al., 2002).

Assessment and referral

Insomnia is primarily diagnosed by detailed clinical evaluation (sleep diary, medical and psychiatric histories, and risk assessments, particularly for clients presenting with depression). Standardised assessment tools are presented in Table 1. The sleep history is an important part of the clinical assessment and should cover the history of and current details regarding the sleep complaints, pre-sleep conditions, sleep-wake patterns, other sleep-related symptoms, lifestyle factors and daytime consequences. The history helps to understand the type and evolution of insomnia, maintaining factors, and any comorbid medical, substance, and/or psychiatric conditions. If another sleep disorder is suspected – for example OSA, periodic limb movements of sleep (PLMs) or hypersomnolence conditions – a sleep physician should be involved and a sleep study considered (Ree et al., 2017).

Overview of CBT for insomnia

The ASA and other professional guidelines recommend cognitive behaviour therapy for insomnia (CBT-I) as the first-line treatment for insomnia (Qaseem et al., 2016; Ree et al., 2017; Royal Australian College of General Practitioners (RACGP), 2015; Wilson et al., 2019). CBT-I is a multi-component therapy that aims to identify and treat underlying psychological and behavioural factors that perpetuate insomnia, over the course of 4-8 weekly sessions. Components of CBT-I are described in Tables 2-4, representing Essential, Desirable and Optional components, respectively.

Delivery

Historically, CBT-I has been delivered by appropriately trained clinicians. Competency in CBT-I requires clinicians to understand the science of sleep, and have specialist training in the ability to recognise common comorbid mental and physical disorders to facilitate appropriate onward referrals for treatment of these other conditions (Ree et al., 2017).

Individualised face-to-face treatment from a psychologist who specialises in sleep disorders, or referral to a sleep physician, may be indicated for those with very severe insomnia, shift workers, (suspected) comorbid sleep conditions, intellectual or learning impairment, and high-risk groups where insomnia can exacerbate mental health disorders (e.g. severe depression, post-traumatic stress disorder, bipolar disorder, schizophrenia and other psychotic spectrum disorders, as well as those at risk of suicide) (Espie, 2009; Seyffert et al., 2016). Other groups for individualised CBT-I treatment would be people with epilepsy/seizures, those at high risk of falls, pregnant women, and people with high-risk occupations where fatigue and sleepiness would need to be closely monitored such as long-haul truck and bus drivers, air traffic controllers, operators of heavy machinery and some assembly-line jobs.

As an alternative to face-to-face delivery, internet-delivered CBT-I is a readily scalable and cost-effective solution for many patients (Zachariae et al., 2016).

CBT-I and comorbid conditions

Insomnia frequently co-occurs with other mental and physical health conditions. Insomnia predicts depression (Hertenstein et al., 2019). Treating insomnia with CBT-I improves depression symptoms, and reduces rates of new onset (incident) depression (Blom, 2015; Sweetman et al., 2021).

Severe insomnia is common in the prodromal phase of complex and severe mental health conditions, mood disorders and psychosis. Significant circadian rhythm disruption is also commonly comorbid with depression (Kaskie, Graziano, & Ferrarelli, 2017). The literature demonstrates that CBT-I is effective in treating insomnia in these populations, with some modifications (Waters, Ree, & Chiu, 2017). Furthermore CBT-I enhances outcomes in psychiatric care with improved response to treatment, reduced risk of relapse, improved physical health and quality of life and regulation of 24-hour sleep/wake cycles (Freeman et al., 2015; Manber, 2008).

Sleep difficulties are common in people with chronic pain, with up to 89% of patients reporting at least one sleep complaint and 53% of patients attending pain clinics presenting with clinically significant insomnia (Selvanathan et al., 2021). There is a strong bi-directional relationship between pain and sleep, and CBT-I has been found to improve both pain and insomnia symptoms (McCurry et al., 2014; Selvanathan et al., 2021).

Insomnia and obstructive sleep apnoea frequently co-occur (Sweetman et al., 2017). For such patients, CBT-I improves insomnia, increases use of continuous positive airway pressure therapy equipment (Sweetman et al., 2019).

Behavoural therapies

Bedtime restriction, stimulus control and relaxation therapy are three evidence-based behavioural therapies that are included in CBT-I programs (Table 2). Providing clients with information about our sleep pressure and the body clock reinforces the rationale for behavioural therapies. These behavioural therapies lead to more immediate improvements in insomnia symptoms compared to cognitive therapy alone (Harvey et al., 2014).

Many people with insomnia spend a long time in bed in the hope of acquiring more sleep. However, this more commonly results in more time spent awake in bed, resulting in feelings of frustration, annoyance and worry. After repeated pairing of time awake in bed and feelings of psychological arousal, a conditioned relationship can form whereby the bed or bedroom environment can cause an arousal response.

Providing sleep education can help clients understand the factors that control the timing and quality of sleep, and the rationale for behavioural treatments.

Sleep pressure increases during wake and decreases during sleep. Delaying bedtime will increase sleep pressure and promote quicker sleep onset. Getting out of bed earlier will result in higher sleep pressure in the morning, and greater sleep pressure at bedtime on the following night. Long daytime naps decrease sleep pressure and make it difficult to fall asleep on the subsequent night.

We all have an internal body clock that controls the timing of our sleep-wake cycles. It can be difficult to fall asleep too early in the evening (before our sleep pressure starts to increase), or to stay asleep too late into the morning (after our sleep pressure is reduced). Our sleep loves regularity.

Bedtime restriction therapy aims to temporarily reduce the amount of time spent in bed each night for a number of weeks to increase sleep pressure, consolidate sleep periods and reduce time awake in bed (Sweetman et al., 2020). Time in bed is typically not restricted below 5.5-6 hours because of the risk of overly restricted sleep affecting daytime performance (Sweetman & McEvoy, 2020).

After the patient’s average sleep efficiency for the week (percentage of time in bed spent asleep) is above ~80-85%, time in bed can be gradually extended by 15-30 minutes from week to week until a comfortable and satisfying equilibrium between time in bed, sleep time and daytime/evening sleepiness is achieved. Patients need to be warned of increases in feelings of daytime sleepiness during the first 1-3 weeks of restriction therapy. More gradual initial restriction (compression) and a higher minimum time-in-bed window may be suitable for some patients (e.g. those with higher baseline sleepiness, or people who drive/operate heavy machinery for work).

Sleep education and cognitive therapy

This article focuses on behavioural therapies of CBT-I that are relatively simple to apply and rapidly improve insomnia (Sweetman, Zwar et al., 2020). Cognitive therapy elements of CBT-I are effective (Harvey et al., 2014), and some cognitive elements can be addressed by sleep education. For example, the widely held incorrect belief that normal sleep should be a long (eight hours) unbroken period of sleep (Bruck, 2015) is maladaptive by contributing to anxiety and perpetuated insomnia in those (particularly older individuals) experiencing frequent nocturnal awakenings. In these cases, sleep education about the 90-minute sleep cycles including recurring light sleep phases with brief awakenings as a normal part of the sleep pattern is a key component of understanding expectations around sleep (Sweetman, 2020).

Other dysfunctional beliefs about severe health risks of insomnia can be tempered with evidence-based research findings (Lovato & Lack, 2019). The behavioural therapies themselves help to alleviate many of the anxiety producing beliefs (e.g. unpredictability, sleep is getting worse, losing control of sleep and a poor night of sleep will usually be followed by a ‘bad’ day).

Trying to challenge the common belief that a poor sleep will be followed by a bad day may be problematic without behavioural therapy, since those beliefs accurately reflect the extensive experience of many clients (Smith et al., 2015, Lovato & Wright, 2015). In the case of chronic insomnia, it is quicker and less likely to alienate the client by changing their experience through the behavioural therapies that will improve their sleep and, in the process, change their beliefs.

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“Providing sleep education can help clients understand the factors that control the timing and quality of sleep, and the rationale for behavioural treatment”

Further education

The Australasian Sleep Association (ASA) and Australian Psychological Society (APS) are collaborating on several CBT-I education opportunities for psychologists and psychology students. The APS recently hosted a three-hour introductory webinar on assessment and treatment of chronic insomnia. In 2023, the ASA will be hosting an online 6-7 hour sleep health workshop for psychologists/psychology students. The ASA hosts an online National Centre for Sleep Health Services Research guideline on chronic insomnia and obstructive sleep apnoea management in primary care. A dedicated online CBT-I module for psychologists is currently being developed through a collaboration between the two organisations. Additional insomnia webinars are available on the APS website.

The ASA is the peak sleep advocacy organisation in Australia and New Zealand, representing about 1000 sleep clinicians, researchers, technicians and students. It hosts an annual Sleep Down Under event which showcases leading Australian and International sleep research. Interested psychologists are warmly encouraged to become involved in the sleep advocacy and education activities through the ASA.

Australasian Sleep Association (ASA) Behavioural Management of Sleep Disorders education subcommittee

¹Sara Winter, Department of Psychology, The Prince Charles Hospital

Hailey Meaklim, Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University 

Gerard Kennedy, Institute of Health and Wellbeing, Federation University

Delwyn Bartlett, CIRUS Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research

Leon Lack, Adelaide Institute for Sleep Health Flinders Health and Medical Research Institute: Sleep Health, Flinders University

James Szeto, Reconnexion, Malvern East, Melbourne

Sarah Blunden, Appleton Institute of Behavioural Science, Central Queensland University

Kurt Lushington, Behaviour-Brain-Body Centre, Justice and Society, University of South Australia

Alexander Sweetman, Adelaide Institute for Sleep Health Flinders Health and Medical Research Institute: Sleep Health, Flinders University