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Insomnia
In this topic:
Introduction
Treatment
Management of underlying problems
Good sleep practices
Advice on good sleep practices (Box 8.2)
Psychological and behavioural interventions
Relaxation therapies
Cognitive therapy
Stimulus control
Sleep restriction
Example of a sleep restriction program (Box 8.3)
Pharmacological treatment
Management of long-term hypnotic use
Management for older people

Introduction
Insomnia is defined as the inability to initiate or maintain sleep, or lack of refreshing sleep. It may be a symptom of other
disorders (eg depression, problem drug use), due to somatic symptoms (eg pain), or a primary disorder in itself. Insomnia
is also seen as part of some organic disorders such as sleep apnoea, and episodic movement disorders such as restless
legs syndrome.
Whether primary or secondary, insomnia is often associated with daytime sequelae (eg fatigue, irritability, impaired
concentration and memory, pervasive malaise), which affect many aspects of daytime functioning. Despite the known
strong relationship between sleep loss and subsequent sleepiness, patients with insomnia do not have a greater
propensity to fall asleep during the day. There may be an association between chronic insomnia and subsequent
development of depression.

Population-based studies suggest about 30% of the general population has complaints of sleep disruption, while
approximately 10% has associated symptoms of daytime functional impairment consistent with the diagnosis of insomnia.
Acute insomnia may occur in anyone. It commonly occurs in healthy people, who were previously good sleepers,
following a short-term stressor (eg emotional or financial stress, physical illness), which triggers the insomnia. The
distinction between acute and chronic insomnia is not clear, but the disorder is generally regarded as chronic if the
duration is greater than 30 days.

A sleep diary can assist patients with persistent insomnia to monitor their sleep habits, and provides valuable information
for the clinician [Note 1].

Treatment
Aim to improve sleep quality and quantity, and relieve insomnia-related daytime impairment.
Primary treatment goals are to improve sleep quality and quantity, and to relieve insomnia-related daytime impairment.

Management of underlying problems

Common causes of insomnia include psychosocial and environmental stressors, medical disorders (eg dyspnoea,
oesophageal reflux, nocturia, pain), psychiatric disorders (eg depression, anxiety), problem drug use (eg alcohol, caffeine,
nicotine, illicit drugs), and adverse effects of prescribed drugs. When insomnia is related to other illnesses, treatment is
usually directed at the underlying medical or psychiatric problem. Management of any underlying problem can often
improve insomnia; however, secondary insomnia may still require treatment. Insomnia related to medications or problem
drug use needs attention to the substance in question. The latter may not be apparent unless a drug and alcohol history is
taken.
Sleep disturbance secondary to intrinsic sleep disorders (eg restless legs, sleep apnoea) requires specific treatment.
Referral to a sleep specialist may be indicated if:
the diagnosis is unclear

further investigation and advice on treatment is required

the patient has a long history of sleep difficulties
the patient fails to respond to therapy

the patient has an intrinsic sleep disorder.

Good sleep practices

It is important to educate patients about normal sleep and provide counselling about good sleep practices and habits (see
Box 8.2).

Advice on good sleep practices (Box 8.2)

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Sleepwake activity regulation

go to bed at the same time each day

arise at a regular time

avoid lying in bed for long periods of time worrying about sleeping
avoid oversleeping

avoid napping (if necessary, limit to afternoon 'powernap' of 10 to 15 minutes)

Sleep setting and influences

avoid bright light exposure in late evening or night

seek exposure to bright light after rising

avoid heavy meals within 3 hours of bedtime

undertake regular daily exercise but avoid vigorous physical activity within 3 hours of bedtime
ensure a quiet, dark room for sleeping (remove TV, music player, laptop, mobile phone)
avoid having pets and highly illuminated digital clocks in the bedroom
use a suitable mattress and pillow for comfort and support
reserve bedroom for sleep and intimacy

avoid alerting, stressful ruminations before bedtime. Allocate time earlier in the evening to go through worrying
issues
avoid caffeine after midday

reduce excessive alcohol intake

avoid tobacco, especially in the evening

avoid illicit drugs

Sleep-promoting adjuvants

have a light snack or a warm milk drink before bed

have a warm bath before bed

ensure a comfortable temperature for sleep and maximal darkness

Psychological and behavioural interventions

Psychological and behavioural interventions are effective in treatment of insomnia.
Psychological and behavioural interventions are effective in the treatment of insomnia. They are most often used for
chronic insomnia as they do not work immediately and require practise and persistence. However, relaxation therapy is
easily taught and can be of benefit for both acute and chronic problems.

Relaxation therapies

Relaxation therapies such as hypnosis, meditation, deep breathing and progressive muscle relaxation are effective in
reducing physiological hyperarousal. They are useful for people who have trouble relaxing or winding down for a range of
reasons such as stress, worry or overactive mind after work.
Relaxation techniques are most effective if practised during the day, before going to bed and also in the middle of the
night if the person is unable to go back to sleep. Usually several weeks of practise are required to improve sleep.

Cognitive therapy

People with insomnia often have dysfunctional beliefs and attitudes and unrealistic expectations about sleep. It is
important to reassure them that most people with insomnia get more sleep than they perceive and that insomnia does not
cause major physical health problems. Cognitive therapy targets the anxiety-producing maladaptive beliefs and attitudes
about sleep and sleep loss that serve to maintain insomnia. Beliefs about the negative effects of not sleeping are very
common and often people with insomnia develop a vicious cycle of 'worry about not sleeping' and 'not sleeping'.

Stimulus control

Stimulus control is useful for people who have difficulty falling asleep because they have come to associate the bed or
bedroom with frustration, worry and poor sleep. The main aim of stimulus control is to have the person limit the amount of
time spent in bed awake and for them to learn to associate the bed and bedroom with sleep and nothing else. They
should exclude from the bedroom activities that do not go well with sleep such as reading, eating, using computers,
watching TV, and worrying.

This therapy requires the person to go to bed only when sleepy and to get out of bed if worrying or sleepless for more
than 15 to 20 minutes, rather than remain in bed while awake. The person returns to bed when sleepy, and leaves if they
again remain awake. The role of the bedroom for sleeping and not for worrying is reinforced; they are instructed to do any
worrying in another room.

Sleep restriction

Sleep restriction programs are suitable for people who have difficulty staying asleep due to poor sleep drive. They are
designed to build on the body's natural drive to sleep. Their goal is to reduce the amount of time spent awake in bed.

An example of a sleep restriction program is shown in Box 8.3. Sleep restriction is based on information from a sleep
diary in which the person records the amount of time they estimate they are asleep [Note 1]. The time spent in bed is then
restricted to the total sleep time estimated from the diary. Initially this results in sleep deprivation, but after a few nights
this sleep deprivation helps consolidate sleep thus improving sleep efficiency. Eventually, the length of time in bed can be
increased, with increments based on improved sleep efficiency.

Example of a sleep restriction program (Box 8.3)

A person with insomnia feels they sleep only 4 hours per night, despite generally being in bed from 10.00 pm until 8.00
am.
Instruct the person to start restricting their sleep to only 4 hours per night, as this is the length of time they think they
are sleeping (eg go to bed at 2.00 am and wake up at 6.00 am).
The person must comply with this schedule until they are regularly sleeping solidly throughout the 4 hours and feel
increasingly sleepy, wanting to go to bed earlier.

Once this target is reached, they can increase the time in bed by 30 minutes until they are sleeping through and
craving sleep at an earlier time. Again the reward of an extra 30 minutes sleep will occur when the person is sleeping
through their allocated time.

Pharmacological treatment

Pharmacological treatment with a hypnotic drug (a benzodiazepine, zolpidem or zopiclone) or melatonin may be indicated
for short-term management of acute insomnia, and for chronic insomnia when the nonpharmacological strategies
described above are not effective.
The decision to prescribe a hypnotic or melatonin for acute insomnia should be guided by consideration of:
the cause(s) of the insomnia (see Management of underlying problems, above)
the level of distress caused by lack of sleep

the degree of impairment due to the daytime sequelae of insomnia

the likely benefits balanced against the possible harms of prescribing hypnotics.

Before starting treatment, the limitations and potential problems of hypnotics, including the risk of impaired daytime
alertness, tolerance and dependence with long-term use, should be explained. Unlike the hypnotics, melatonin does not
appear to cause impaired daytime alertness or have potential for abuse.

If hypnotics or melatonin are prescribed, the duration of therapy should be for the shortest time possible (preferably dosed
intermittently and for less than 2 weeks) and a definite duration of use agreed with the patient at the outset. When
prescribing hypnotics limit the quantity prescribed. For further information on precautions when prescribing
benzodiazepines, see Anxiety and associated disorders: general information. Patients with acute insomnia should be
reviewed regularly and provided with support and, if appropriate, specific interventions to address the causes underlying
their acute sleep problem.
Continuous treatment with hypnotics, if needed at all, should normally be limited to less than 2 weeks. Intermittent therapy
may be considered for those with severe longstanding insomnia that is not relieved by nonpharmacological management.
Explain to the patient that broken sleep with vivid dreams may occur when hypnotics are stopped and that it takes several
days or weeks for a normal sleep rhythm to be re-established. This rebound insomnia may indicate falsely to the patient
that a further prescription is needed.
If pharmacological treatment is considered necessary, use:

temazepam 10 mg orally, before bedtime

zolpidem controlled-release 6.25 mg orally, at bedtime

or zolpidem immediate-release 5 mg orally, at bedtime

1
2

OR

OR

zopiclone 3.75 mg orally, before bedtime

OR

melatonin prolonged-release 2 mg orally, before bedtime [Note 2].

When taking hypnotics, many people find their sleep is not refreshing. Benzodiazepines, particularly those with longer
duration of action (eg diazepam), may cause impairment of daytime alertness and performance including impairment of
driving. Zolpidem and zopiclone have similar sedative properties to the benzodiazepines but minimal anxiolytic, muscle
relaxant and antiepileptic properties. Compared with benzodiazepines, they generally cause less morning sedation and
have less disruptive effect on normal sleep patterns.

Zolpidem, and possibly all hypnotic drugs, can induce potentially dangerous complex sleep-related behaviours, and can
cause paradoxical reactions (eg hallucinations, acute rage, agitation). Stop treatment if these effects occur [Note 3]. Avoid
taking hypnotics with alcohol or other drugs that depress the central nervous system because they can increase the risk
of these potentially serious adverse effects.
Melatonin, an endogenous hormone associated with the control of circadian rhythms and sleep regulation, is available in
Australia as a prolonged-release formulation for treatment of primary insomnia characterised by poor sleep quality in
patients aged 55 years or older. Data from clinical trials showed that some patients gain clinically significant
improvements in quality of sleep and morning alertness with prolonged-release melatonin, but many patients in the
clinical trials did not respond to treatment. At present there is insufficient evidence to support treatment beyond 3 weeks.

Sedating antidepressants, such as the tricyclic antidepressants, mirtazapine and agomelatine, are sometimes used to
improve sleep. Generally, evidence of effectiveness of antidepressant use in treating insomnia unrelated to depression is
lacking. Avoid using antidepressants in the absence of a depressive disorder.
Sedating antihistamines are frequently used to improve sleep. There is no evidence for efficacy and they may cause
significant adverse effects including daytime sedation, impaired cognitive function, delirium and paradoxical agitation
(especially in children). The long-term effects of regular use have not been evaluated. Rapid tolerance to the sedative
effect has been reported with diphenhydramine.

Antipsychotic drugs are sometimes prescribed for the treatment of insomnia. They can cause serious adverse effects and
have no role in the management of insomnia.

Management of long-term hypnotic use

Often clinicians encounter people who have been taking hypnotics for a prolonged period, especially older people (see
Management for older people, below). These people are likely to have unwittingly become dependent. Stopping long-term
hypnotic therapy should be discussed and trialled whenever possible.
Cessation will require a tailored dose reduction, regular contact between the patient and the treating clinician, and the
provision of nonpharmacological alternatives to assist with sleep (see Psychological and behavioural interventions,
above). A dose reduction plan can be downloaded from the National Prescribing Service (NPS) at [URL].

Patients may need a lot of support and encouragement to help them through the period without medication, while their
sleep cycle stabilises.

Continued treatment with a hypnotic may be acceptable for a small number of people who continue to sleep well with the
same dose of medication and for whom:
a detailed history shows there are no adverse effects present
the patient is aware that they may be dependent

a reduction program has repeatedly been unsuccessful or is against the patient's wishes.

Such patients should have regular reviews considering any lifestyle and health changes that may reduce their need for, or
increase the risk of continued use of, hypnotics. Should they wish to stop the drug, this needs to be done gradually, as
explained above.

Management for older people

The same general principles (see Treatment, above) apply to the management of older people with insomnia. Good sleep
practices and nonpharmacological approaches should always be first-line therapy. Often, hypnotic drugs in the older
person are initiated during a hospital admission or in residential care facilities when nonpharmacological approaches are

unavailable or impractical. When this occurs it is essential to ensure the drug is not inadvertently continued when the
person is discharged from hospital or when they settle into a new care routine.

The highest rates of benzodiazepine use are in the older population even though they are most at risk of harm from
adverse effects of benzodiazepines, such as falls and cognitive impairment. Dependence, confusion and incontinence
can also be associated with long-term use. Discontinuing long-term benzodiazepine use can often be achieved gradually,
with cooperation from the patient, family, carers and/or nursing staff. Behavioural therapies, above, can assist older
people to stop.
Older patients with dementia often experience marked sleep fragmentation, dozing during the day and sundowning (ie
becoming agitated, wandering and wakeful in the early evening or at night). Endeavour to manage sundowning through
nonpharmacological interventions.

Note 1: A sleep diary can be downloaded from the National Prescribing Service (NPS) website
Note 2: At the time of writing, melatonin prolonged-release is only approved by the Australian Therapeutic Goods
Administration (TGA) for short-term treatment of insomnia in patients aged 55 years or more. See the TGA website for current
information.
Note 3: See the Therapeutic Goods Administration warning for zolpidem at [URL]

Related topics:
Parasomnias
Jet lag
Key references for this topic:
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Key references for this chapter

Revised June 2013. Therapeutic Guidelines Ltd (etg45 July 2015)