In summary:
- Around 3.5 million adults live with chronic insomnia in Australia.
- Despite its prevalence in the community, only a small minority of psychologists are trained in insomnia management.
- Diagnostic schema no longer differentiates between 'primary' and 'secondary' insomnia. This is because insomnia can quickly become self-perpetuating.
- Cognitive behaviour therapy for insomnia (CBTi) is a multi-component treatment program and the recommended first-line treatment for chronic insomnia.
- The program is effective and requires little adaptation for comorbid conditions, lifestyle factors and people of different life stages.
- CBTi-trained psychologists are vital in identifying and managing sleep issues but they should be part of a multi-disciplinary approach.
- You can learn more about CBTi in our six-hour course offered with the Australasian Sleep Association, which aims to provide psychologists with everything they need to start delivering CBTi in practice.
Between a third and a half of Australian adults struggle to fall asleep or stay asleep, while 15 per cent experience chronic insomnia. But despite cognitive behaviour therapy for insomnia (CBTi) being a widely effective first-line treatment, few psychologists are trained to deliver it.
Everyone experiences occasional episodes of night-time wakefulness but for some, those difficult small hours can quickly turn into a long-term challenge. For millions of Australians, chronic insomnia is debilitating.
Chronic sleep problems not only impact mood, cognition and quality of life, but also exacerbate conditions like depression, anxiety, alcohol abuse and psychosis.
"Insomnia co-occurs with another comorbid mental or physical health condition in about 80 per cent of cases," explains Dr Alexander Sweetman, Senior Program Manager and chair of the psychologist education subcommittee with the Australasian Sleep Association.
Numerous clinical trials and meta-analyses have shown that CBTi is effective in improving sleep and reducing symptoms of depression and anxiety — often for several months or years after treatment.
But despite the prevalence of insomnia and the proven success of treatment, many psychologists don't feel confident delivering it.
In 2020 and 2021, the Australasian Sleep Association found only 65 psychologists in Australia who specialise in insomnia management, equivalent to about 30 full-time roles, says Dr Sweetman.
Fortunately, this number has gradually increased to around 150, thanks in part to training on CBTi offered by the Sleep Association and the APS.
Diagnosing insomnia
Around 30 to 50 per cent of Australian adults live with short-term insomnia at any given time, with around 15 per cent (3.5 million) fulfilling the diagnostic criteria for chronic insomnia disorder.
Diagnosis depends on the frequency of sleep problems, their duration, and their impact on daily functioning.
"When sleep difficulties start to occur on at least three nights per week and they impair mood, psychological wellbeing, productivity or physical health, we can define it as a short-term disorder," says Dr Sweetman.
"If those difficulties and impacts have occurred for three months or more, it's a chronic condition. Many people live with chronic insomnia for years before they find treatment that works."
Historically viewed as secondary to other conditions like depression or anxiety, diagnostic schema now categorises it as 'insomnia disorder', without distinguishing between 'primary' and 'secondary'. Even if triggered by another issue, insomnia can quickly become self-perpetuating.
"The more time people spend awake in bed, the more their brain and body starts to associate their bed with wakefulness, which can very quickly create feelings of anxiety and depression," says Dr Sweetman.
"There's a really strong bi-directional relationship between insomnia and other mental and physical health conditions, making it important to treat as a comorbid condition."
Insomnia is one of many sleep disorders, including obstructive sleep apnea, restless leg syndrome, REM behaviour disorder and narcolepsy.
"These disorders can occur comorbid with insomnia and psychologists need to assess for them," Dr Sweetman adds.
Sleepcentral.org.au offers interactive screening questionnaires for insomnia to be administered in psychological settings that take just a few minutes to complete.
Administering CBTi
CBTi is a multi-component treatment program and the recommended first-line treatment for chronic insomnia.
Sleep hygiene — such as avoiding large meals, electronics, caffeine or alcohol before bed, maintaining a regular sleep schedule and creating a comfortable sleep environment — is just one component.
The other components are:
- Stimulus control: weakening the association between the bed and wakefulness — by using it only for sex and sleep, and getting up if you don't fall asleep within 20 minutes
- Cognitive restructuring: challenging negative thoughts around sleep
- Sleep restriction: limiting time in bed to improve sleep quality
- Relaxation techniques: like deep breathing and visualisation
"The overall aim of CBTi is to identify and treat all those underlying psychological and behavioural factors causing long-term insomnia," says Dr Sweetman. "That's why we think it's effective in the long term."
"The helpful thing about CBTi is that it rarely requires adaptation for comorbid conditions, lifestyle factors or different life stages." - Dr Alexander Sweetman
CBTi is typically delivered over four to eight weekly or fortnightly sessions by a psychologist or clinician trained in insomnia management, and can be incorporated into broader treatment plans.
"Delivering CBTi to clients with long-term insomnia is really fulfilling," says Dr Sweetman. "The program is succinct and effective, improving insomnia symptoms in 70 to 80 per cent of clients. After treatment, around 40 to 50 per cent experience complete remission, even if they've had insomnia for years."
Tailoring CBTi to client needs
Dr Sweetman says standard CBTi programs are suitable in about 95 per cent of cases without adaptations, including for those with comorbid psychological conditions such as depression, anxiety or stress.
"The helpful thing about CBTi is that it rarely requires adaptation for comorbid conditions, lifestyle factors or different life stages," he says.
However, certain groups need careful consideration. For example, shift workers and adolescents (who tend to stay up later and sleep in later) may need recommendations adjusted, while older adults should understand frequent waking is normal with age.
For those with bipolar disorder or schizophrenia, clinicians should avoid sleep restriction therapy, which may trigger episodes. Instead, they can use sleep regularisation therapy (establishing a consistent routine) and if needed, sleep compression therapy (gradually reducing bed time to match actual sleep duration).
Looking to the future
Dr Sweetman says CBTi-trained psychologists will remain vital as first-line responders in identifying and managing sleep issues.
"I would love to see 500 to 1,000 CBTi providers spread across the country, in both regional and metropolitan areas and also capable of offering treatment via telehealth. But realistically, there will never be enough to provide in-person care to all who need it."
But training more psychologists is "just one part of the jigsaw", he adds.
Ideally, psychologists should be part of an interdisciplinary team including GPs and other primary care clinicians who are equipped to assess insomnia for mental health treatment plans and can deliver components of CBTi, along with nurses and pharmacists.
Dr Sweetman also advocates for increased public awareness around CBTi as well as self-guided digital versions of the program to expand accessibility.
"Given the number of people seeking treatment for insomnia, there'll be immense demand for CBTi-trained specialists over the coming years," he says.
"It's going to be incredibly important to improving the health and wellbeing of Australians."
Further reading