Insomnia: Mismatch Between Treatment Demand And Access

Australian Psychological Society

There are lots of misconceptions around insomnia, including that it’s easy for Australians to access therapy and that all psychologists know how to treat it. We spoke to a sleep expert about how psychologists can upskill in this important area.

Two to three million people in Australia live with chronic insomnia, according to Dr Alexander Sweetman, Senior Program Manager at the Australasian Sleep Association (ASA) and Researcher at Flinders University. Yet many psychologists tell us they want more training in how to address this widespread problem.

A 2021 study by Dr Hailey Meaklim, a sleep psychologist and researcher at the University of Melbourne, found postgraduate psychology students only received around one hour of sleep education, with 47 per cent reporting they received none at all.

Meanwhile, a recent audit of Australia’s psychologists by the ASA’s Psychologist Education subcommittee found only 60 to 70 are actually focused on insomnia management.

“When it comes to insomnia, there’s this huge mismatch between what best practice recommends and what actually happens,” says Dr Sweetman. “We need enhanced sleep education for clinicians to dramatically improve treatment access and mental health outcomes for people with insomnia.”

An exhausted population

Various epidemiological studies have shown that 30 to 50 per cent of adults experience acute short-term insomnia at any given time, while around 15 per cent experience chronic insomnia, which occurs for three months or more, says Dr Sweetman.

The condition affects people of all ages and genders, though females, older individuals and those with medical or psychiatric disorders have a slightly increased risk.

“Insomnia can strike anyone. And it can be triggered by various factors,” he says.

These may include physical or mental health disturbance, perimenopause, or work, relationship and lifestyle stressors.

Individuals with insomnia will experience challenges both at night, with difficulties such as falling and staying asleep, and during the day, when they may experience fatigue, lethargy, lack of concentration, poor mood and memory difficulties among other things.

“The impact of long-term insomnia on someone’s mental health and quality of life can be profound,” says Dr Sweetman.

A standalone condition

Diagnosis of insomnia relies on patient self-reporting, questionnaires, interviews and discussions, rather than overnight sleep studies, Dr Sweetman explains.

Historically, it’s been considered as a secondary symptom of other mental or physical health issues such as depression or chronic pain. However, insomnia should be considered a comorbid and completely treatable condition.

“Research has shown that people with insomnia are much more likely to develop secondary conditions such as depression, anxiety and other mental health disorders.”

Moreover, long-term insomnia can become self-perpetuating as coping strategies backfire, leaving it independent of its initial triggers, he adds.

“In an attempt to get more sleep, an individual may decide to go to bed a little earlier or sleep in later the following morning. But instead of spending more time asleep in bed, this often results in more time spent awake in bed.

“Over multiple nights, the brain and the body can start to learn that the bed is a place for feeling awake, alert, frustrated or worried. This learned association between bed and feeling awake is called ‘conditioned insomnia’.

“People with long-term insomnia will often say, ‘as soon as my head hits the pillow, my brain kicks into action’. That’s a really clear sign of conditioned insomnia.”

Improving sleep also helps ameliorate other symptoms such as pain, mental health and depression, Dr Sweetman adds.

“These are all really good reasons to treat insomnia as a standalone disorder even when it occurs alongside other mental and physical health problems.”

“Our goal is to really move the dial and help more people with insomnia to receive the evidence-based care they need.” – Dr Alexander Sweetman

Effective treatment strategies

Dr Sweetman advises people that help is available if they’ve already adopted good sleep habits (avoiding caffeine, alcohol, eating, work and screens for a few hours before bed) and are still suffering insomnia symptoms that start to impact their daytime functioning or feelings.

Through a mental health treatment plan, a GP can refer them to a psychologist who can assess symptoms, duration, any comorbid sleep conditions and possible triggers.

The first line of treatment for insomnia recommended by the APS and the ASA is Cognitive Behavioural Therapy for insomnia (CBTi).

Hundreds of studies have proven the effectiveness of CBTi, which can significantly improve symptoms of insomnia, daytime function, depression and anxiety for many years.

CBTi includes several different treatment techniques such as Stimulus Control Therapy.

This treatment aims to undo the body’s conditioned association between being in bed and being awake through a set of simple instructions the patient or client must follow each night.

These include only using the bed for sleep and intimacy (so not using it to read, eat, talk, watch TV or use their phone); only going to bed if they’re feeling sleepy; avoiding clock-watching; getting out of bed if they think 15 to 20 minutes has passed without sleep; and getting out of bed at a regular time each day.

A full CBTi program can be delivered in four to eight sessions, with most people seeing an improvement in three to four weeks.

If CBTi doesn’t work, the psychologist can consider other options such as mindful-based therapies or medication. Referral to a sleep and respiratory physician is also recommended if another underlying sleep disorder such as sleep apnoea is suspected.

Despite the efficacy of CBTi, only about one per cent of people in Australia with chronic insomnia access CBTi treatment.

The sleep community is working together to change this, and the APS and ASA are advocating for better insomnia and CBTi training for healthcare professionals.

Digital CBTi programs have an important role to play. That’s why the APS is offering a new course that enables psychologists to become certified CBTi practitioners in just six hours, in partnership with the Australasian Sleep Association.

Dr Sweetman hopes the course will lead to many more psychologists being included on the ASA’s public register of psychologists and other clinicians with training and expertise in the delivery of CBTi.

“Our goal is to really move the dial and help more people with insomnia to receive the evidence-based care they need.”

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