Information provided by Dr Keith Hariman, Specialist in Psychiatry
Treating Chronic and Acute Insomnia
For those who have acute insomnia, treatment includes identifying the stressor, along with understanding how it affects an individual. Some sedating medications may be given in the short run to minimise any problems with daily functioning, though it’s important to be mindful of how long the medications are taken, to avoid dependence on them.
The treatment of chronic insomnia involves a combination of changes to sleep practices, optimisation of sleeping environments, cognitive behavioural therapy, and medications (if needed). Research has shown that a combination of these factors is more useful than simply taking medications, along with fewer side effects in the long term1. As with acute insomnia, treatment of chronic insomnia also includes the identification of the precipitating and perpetuating factors affecting sleep.
There are 4 medically proven ways to treat both types of insomnia:
1. Change Your Sleep Routine
2. Optimise Your Sleeping Environment
3. Cognitive Behavioural Therapy For Insomnia
4. Medications for Insomnia
1. Changing Your Sleep RoutineNowadays, many people spend much of their time awake on their beds, disrupting sleep practices and the ability to fall asleep.
Simple lifestyle modifications to improve sleep include:
- Only go to bed when you feel sleepy and go to sleep and get up at the same time every day.
- Leave the bed when you wake up.
- If you fail to fall asleep within twenty minutes, it would be helpful to leave the bed and do something else before returning.
- Avoid naps during the day.
- Avoid caffeine after lunch and heavy meals during dinner.
- Get adequate amounts of physical exercise.
- Avoid drinking alcohol. While some individuals drink for sleep promotion, alcohol disrupts the sleep architecture and makes you wake up more quickly in the middle of the night.
- Take a warm shower before sleeping. This will increase your core temperature, and the down cooling effect is helpful towards sleep promotion.
2. Optimise Your Sleeping EnvironmentThe following changes to the sleeping environment also help with a good night’s sleep:
- Minimise ambient light and noise in the bedroom.
- Decide which bed partners to keep (including your dog and cat).
- Avoid looking at screens (such as TV and mobile phones) before going to sleep. Screens emit blue light that tricks our brain into thinking that it’s still daytime.
- Remove clocks where you can easily check the time at night. Frequently looking at the clock when failing to fall asleep will heighten anxiety levels and make it harder to fall asleep.
- Maintain a comfortable ambient temperature in the bedroom. For most people, this is around 22℃.
3. Cognitive Behavioural Therapy for InsomniaCognitive Behavioural Therapy (CBT) is a type of psychological therapy that has shown to effectively combat insomnia, with patients finding it easier to fall asleep faster. The use of CBT to treat insomnia is endorsed by research and national clinical guidelines 2,3.
CBT can be split into two aspects that combine together to bring effective treatment: cognitive therapy and behavioural therapy.
- Cognitive therapy helps to quell the excessive worries present before sleep, clarify the correct expectations about sleep and educate on proper sleep practices4.
- Behavioural therapy uses relaxation-based strategies, such as progressive muscle relaxation, diaphragmatic breathing and mindfulness, typically given in conjunction with other interventions for sleep promotion.
This psychological therapy is also used for patients trying to manage without hypnotics5.
4. Medications for InsomniaThere are 3 main types of medications commonly prescribed for patients with insomnia in Hong Kong.
- You can buy drugs acting on the histamine receptors (such as medications for the common cold)
- You can also buy drugs that act on the melatonin receptors. These drugs are available over the counter without a doctor's prescription. However, while they are considered first-line therapy, many patients develop tolerance to these medications, and the sleep-promoting effects eventually wear off after prolonged use.
- The third type of drug acts on the benzodiazepine receptors, including Z drugs such as zopiclone and zolpidem, and traditional benzodiazepines such as diazepam (Valium) and lorazepam (Ativan), which are also valuable for sleep promotion and maintaining sleep throughout the night. However, they also lead to dependence and other side effects such as sleepwalking. As such, they are only available with a doctor’s prescription.
There are other medications that doctors might prescribe for sleep promotion purposes, for example if a patient has a co-morbid mental illness. In this case, the doctor might choose to prescribe a medication to treat the underlying mental illness with a sedating side effect to treat co-existing insomnia.
Insomnia is a widespread condition that has commonly led to damaging effects on an individual’s health and productivity. The management of insomnia involves identifying the precipitating and perpetuating factors of insomnia, adopting the relevant lifestyle modifications, and optimising the sleeping environment. Medical professionals can also advise you on cognitive behavioural techniques to manage insomnia and prescribe the appropriate medications, so you can stay fresh and alert every day.
- Beaulieu-Bonneau, S., Ivers, H., Guay, B., & Morin, C. M. (2017). ‘Long-term maintenance of therapeutic gains associated with cognitive-behavioral therapy for insomnia delivered alone or combined with zolpidem.’ PubMed. 1 March 2017. Available at: <https://pubmed.ncbi.nlm.nih.gov/28364426/> [Accessed 10 June 2021].
- Brasure, M., Fuchs, E., MacDonald, R., et al. (2016). ‘Psychological and behavioral interventions for managing insomnia disorder: an evidence report for a clinical practice guideline by the American College of Physicians.’ PubMed. 19 July 2016. Available at: <https://pubmed.ncbi.nlm.nih.gov/27136619/> [Accessed 10 June 2021].
- Wilson, S. J., Nutt, D. J., Alford, C., et al. (2010). ‘British Association for Psychopharmacology consensus statement on evidence-based treatment of insomnia, parasomnias and circadian rhythm disorders.’ PubMed. 24 November 2010. Available at: <https://pubmed.ncbi.nlm.nih.gov/20813762/> [Accessed 10 June 2021].
- Ballesio, A., Bacaro, V., Vacca, M., et al.. (2020). ‘Does cognitive behaviour therapy for insomnia reduce repetitive negative thinking and sleep-related worry beliefs? A systematic review and meta-analysis.’ PubMed. 11 September 2020. Available at: <https://pubmed.ncbi.nlm.nih.gov/32992228/> [Accessed 10 June 2021].
- Morin, C. M., Bastien, C., Guay, B., et al. (2004). ‘Randomized clinical trial of supervised tapering and cognitive behavior therapy to facilitate benzodiazepine discontinuation in older adults with chronic insomnia.’ PubMed. February 2004. Available at: <https://pubmed.ncbi.nlm.nih.gov/14754783/> [Accessed 10 June 2021].