Abstract

Insomnia disorder is the most common of all sleep disorders, affecting night time sleep pattern and quality and having daytime consequences. There is growing evidence that insomnia is implicated in the psychogenesis of mental disorders, particularly depression, and increasing evidence that the active treatment of insomnia in parallel with other disorders can improve not only sleep, but improvement in the associated condition.

Traditionally, insomnia has been treated using pharmacotherapy, particularly hypnotic drugs, although there is an increasing trend to the “off-label” use of sedative anti-depressants. Pharmacotherapy for insomnia appears to be efficacious, with the greatest amount of evidence available for short-term use. In clinical practice however, insomnia is often long lasting, and may often be treated with hypnotics for long periods of time. It is possible that intermittent dosing may reduce risks of tolerance and dependence. Recent contemporary guidelines published by the British Association for Psychopharmacotherapy provide an excellent overview.

The principal alternative to sleeping pills is Cognitive Behaviour Therapy (CBT). This approach is based upon altering patterns of maladaptive behaviour and dysfunctional thinking which tend to maintain insomnia disorder, and is a collaborative approach between the patient and the therapist. Although there are many ingredients to CBT, there is substantial evidence now that it can be delivered in group format and other simplified ways such as guided self help, and even on the internet. There is a very sizeable research evidence supporting long term efficacy of CBT for Insomnia, however the challenge for CBT is that it is difficult to deliver on a large scale, even though in head-to-head comparison studies, it may appear preferable to pharmacotherapy and is often more acceptable to patients and their doctors than longer term use of medication. It should be noted that sleep hygiene is not an active psychological therapy, and has no proven efficacy for persistent insomnia. Sleep hygiene is not a substitute for CBT, but is often used as a placebo intervention in research trials.

Despite the prevalence and impact of insomnia and the availability of these alternate forms of treatment, 50% or more of people with insomnia seldom if ever consult their doctor about it. There is, therefore, an important public health agenda around insomnia, much in the same way as there was historically around diet and exercise, which have now become much more part of mainstream healthcare provision. “Stepped Care” models of service delivery may help to address that public health agenda.