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Australasian Sleep Association position statement regarding the use ofpsychological/behavioral treatments in the management of insomniain adultsMelissa Reea,b,*,Moira Jungec,David CunningtoncaThe Marian Centre,187 Cambridge St,Wembley,Western Australia,6014,AustraliabSleep Matters,11 Hamilton St,Subiaco,Perth,Western Australia,6008,AustraliacMelbourne Sleep Disorders Centre,Level 5,100 Victoria Parade,East Melbourne,Victoria,3002,AustraliaKeywords:InsomniaCognitive Behaviour Therapy-InsomniaTreatment effectivenessTreatment guidelinesa b s t r a c tInsomnia disorder is a high prevalence condition with a high disease burden,which,left untreated,canincrease risk of poorer health outcomes.Due to Insomnias tendency towards having a chronic course,long-term treatment approaches are required to reduce the impact of Insomnia over time.Afterreviewing the available literature,The Australasian Sleep Association(ASA)recommends CognitiveBehavior Therapy for Insomnia(CBT-I)as a first line treatment in the management of Insomnia.The ASAnotes that in addition to CBT-I,there is emerging evidence for the use of Mindfulness Based Therapy forInsomnia when used in combination with behavioural techniques(MBT-I).CBT-I should be usedwhenever possible,and medications should be limited to the lowest necessary dose and shortestnecessary duration.CBT-I,whilst the most effective long-term treatment,does not work for everybodyacross all circumstances,so there will be circumstances in which other treatments are required(e.g.,pharmacotherapy).Improving access to CBT-I is an important issue which will involve raising awarenessof the effectiveness of CBT-I,increasing the number of trained practitioners,and the development ofeffective low intensity treatments that can be offered in the first instance.2017 Elsevier B.V.All rights reserved.1.Background1.1.Insomnia disorder definitionInsomnia disorder as defined in the Diagnostic and StatisticalManual fifth Edition(DSM-V,2)as longstanding(more than 3months)subjective difficulty initiating asleep,maintaining sleep,orwaking too early,accompanied by distress about the experience ofdaytime fatigue and its impact on day-time functioning.The diffi-culty occurs at least three nights per week,despite adequate op-portunity for sleep.Adjustment Insomnia/Acute Insomnia is lessthan 1 month in duration.1.2.Insomnia disorder subtypes?The DSM-V outlines five insomnia subtypes:sleep initiationinsomnia;sleepmaintenanceinsomnia,earlymorningawakening,a combination of these three core symptoms,ornon-restorative sleep.?The International Classification of Sleep Disorders-3(ICSD-3,1)outlines four chronic insomnia subtypes:psychophysio-logical insomnia(insomnia that occurs due to a learnedresponse of increased arousal whilst attempting to sleep),idiopathic insomnia(lifelong insomnia),paradoxical insomnia(sleep state misperception),and inadequate sleep hygiene(insomnia due to poor sleep habits).?According the DSM-V and ICSD-3,to receive a diagnosis ofinsomnia disorder,the insomnia should be clinically significanton its own even though it mayoccur at the same time as anotherphysical or mental condition.?The primary and secondary insomnia distinction has beenremoved in the DSM-V and ICSD-3,in order to emphasise themutually exacerbating nature of chronic insomnia with othermental and physical conditions.Insomnia disorder is nowrecognized as a condition requiring independent clinicalattention,regardless of other medical problems that may bepresent.*Corresponding author.The Marian Centre,187 Cambridge St,Wembley,WesternAustralia,6014,Australia.E-mail addresses:.au(M.Ree),.au(M.Junge),.au(D.Cunnington).Contents lists available at ScienceDirectSleep Medicinejournal homepage: Elsevier B.V.All rights reserved.Sleep Medicine 36(2017)S43eS47 o Although the primary and secondary insomnia distinction isno longer used the most common diagnostic classificationsystems,they are defined here as these terms appear widelyin the Insomnia literature.o Primary insomnia:Insomnia that is notdirectlyattributable toa medical,psychiatric,or environmental cause.PrimaryInsomnia according to the ICSD may be psychophysiologicalinsomnia(objectively verifiable impaired sleep),idiopathicinsomnia(childhood onset),or paradoxical insomnia(sleepstate misperception).o Secondary insomnia:Insomnia that is result of other causessuch as(medical condition,medication or substance,mentaldisorder,inadequate sleep hygiene).1.3.Prevalence and courseInsomnia is the most prevalent of all sleep disorders in thegeneral population 31.In terms of prevalence of Insomniasymptoms,population-based studies across various countriessuggest that approximately 30%of adults report one or more ofthe symptoms of insomnia:difficulty initiating sleep,difficultymaintaining sleep,waking up too early,and in some cases,non-restorative or poor quality of sleep.Indeed,acute Insomniaprevalence rates are higher,at approximately 30%3.Prevalenceof individuals meeting full criteria for insomnia disorder is esti-mated at 10%among the general population with increased ratesin increasing age,female gender,and presence of medical orpsychiatric illness.A recent Australian study estimated theprevalence to be 7%14.Importantly,chronic insomnia is apersistent,long-term disorder.For example,research has sug-gested that three quarters of individuals reporting insomnia atbaseline still report having insomnia 1 year later and almost halfreported having insomnia at three consecutive annual assess-ment points 26.1.4.BurdenSleep is an important component of health and has a largenegative impact on quality of life,affecting how well people think,work and interact with others(e.g.,Ref.17).Individuals withinsomnia experience fatigue,mood disturbance,and distress 25,have greater absenteeism rates,60-percent greater healthcare costsas compared to the general population,(e.g.,Refs.36,39)and anincreased risk of accidents 7.There is also an increased risk fordepression,anxiety,suicide,and substance use,with Insomniabeing an independent risk factor.The economic burden in Australiais estimated to be$5.1 billion per year 14.2.The use of cognitive behavioral treatments in insomniadisorderThe main treatment goals in insomnia are:(1)to reducenocturnal hyperarousal,(2)to improve sleep quality and quantity,(3)to reduce insomnia related daytime impairments,(4)reduce thedistress and anxiety associated with poor sleep.Psychological/behavioral treatment approaches assume that physiological andcognitive hyperarousal(tension and worry)contribute to the evo-lution and maintenance of poor sleep.Poor sleep results in un-helpful sleep habits(e.g.,irregular sleep routine,excessive caffeineuse,long daytime naps)that maintain insomnia over time.Cogni-tive Behavior Therapy for Insomnia(CBT-I)is a multicomponenttreatment that consists of an educational component,cognitiveinterventions(correctingunhelpfulbeliefs,reducingworry,reducing cognitive hyperarousal)and behavioural interventions(sleep restriction,stimulus control)which work to reduce arousaland behaviours/routines that interfere with sleep.Meta-analyses and systematic reviews support the efficacy ofCBT-I interventions for insomnia in both younger and older adults5,18,40,43.Dismantling studies suggest that both Cognitivemaximises both acute and long term effects 13.Research inves-tigating the combination of CBT-I and pharmacotherapy suggeststhis is effective as long as the pharmacotherapy is short-term andadverse effects of medications are assessed 24,26,28.As far asstand-alone treatments are concerned,CBT-I has the best efficacy43.The acute effects of CBT-I are comparable with or superior tothose of hypnotic medications and are maintained for up to 3 yearsof follow-up 23.There is emerging evidence that mindfulness-based treatment for insomnia(MBT-I)is also efficacious 11,33,34.Outcome studies support the use of both individual and groupCBT-I treatments 18,27,30.There is also evidence for the effec-tiveness of telephone,printed self help,and online cognitive-behavioural therapy(for reviews see Refs.16,41,42,46).One ran-domized controlled trial of individual face-to-face versus onlineCBT-I exists and this suggested superiority of face-to-face treat-ment 20.Thereis evidence tosuggest that brief,weeklytelephonesupport 15 or personalised motivational feedback emails 21 mayenhance outcomes for online treatments.Telephone,printed selfhelp,and internet-based options(with personalised support wherepossible)are recommended by the ASA as part of a stepped-careapproach,or in places where face-to-face treatments are unavai-lable or too costly,or when there is a low level of complexity in theinsomnia disorder 4,9,16,44.A proportion of Insomnia patients have circadian rhythm ab-normalities that can result in sleep onset insomnia(delayed sleepphase)or early waking insomnia(advanced sleep phase).Carefultiming of exposure to bright light in the morning or evening,respectively,may be a behavioural intervention that is useful insuch cases 19,22.2.1.Recommendation that CBT-I is a first line treatmentThe ASA recommends treatments with either Level I or Level IIevidence.The Australian National Health and Medical ResearchCouncil 29 and the Oxford Centre for Evidence Based Medicine35 use the following classification system when assessing evi-dence for specific treatments.The ASA recommends CBT-I as a first line treatment of insomniadisorder as it has extensive level I evidence.It is universallyaccepted as the best treatment modality for insomnia disorder,inthe long term.2.2.CBT-I descriptionThe table below provides a summary of the core components ofCBT-I(Table 1).Level I?Evidence obtained from a systematic review of all rele-vant randomised controlled trials(meta-analyses).Level II?Evidence obtained from at least one properly designedrandomised controlled trial.M.Ree et al./Sleep Medicine 36(2017)S43eS47S44 2.3.Comorbid insomniaInsomnia disorder is frequently comorbid with other physicaland mental disorders.Traditional treatment for insomnia withcomorbid conditions has focused on treating the comorbid condi-tion with the expectation that the insomnia will resolve.Recentstudies,however,suggest this approach is not the most appro-priate.Instead,treating both conditions simultaneously mayimprove the outcomes for each 38.There is extensive researchdemonstrating the effectiveness of CBT-I in the context of comorbidconditions(see Ref.12).Assessment and consideration of comorbid conditions in treat-ment planning is important.2.4.Mindfulness Based Therapy for Insomnia(MBT-I)Ong and colleagues 32e34 developed an adaptation ofMindfulness Based Stress Reduction(MBSR)tailored specifically toinsomnia that is called Mindfulness-Based Therapy for Insomnia(MBT-I).MBT-I is a program that integrates behavioural techniquesfor insomnia in addition to Mindfulness meditation techniques.Mindfulness is averypractical intervention and helps individuals tolearn to recognise and manage uncomfortable thoughts and feel-ings including those associated with poor sleep.There is emergingevidence for the effectiveness of Mindfulness as a stand-alonetreatment and in combination with behavioural techniques(e.g.,Refs.34,45).MBT-I has level II evidence,in so far as research isemerging on this relatively new treatment(for a review see Ref.11).At this point in time CBT-I remains the gold standard oftreatment.2.5.Combination therapyThere is a role for combining CBT-I with hypnotic medication,particularly when commencing treatment.An insight in to howtreatments might be combined comes from work by Morin et al.24,26,28,where 160 patients were randomised to CBT-I or CBT-Iplus the non-benzodiazepine,zolpidem 10 mg,for 6 weeks.Thegroup who used zolpidem together with CBT-I for 6 weeks,thenstopped zolpidem,did better at 6 months than those able tocontinue to use zolpidem beyond that 6-week point,or who hadCBT-I alone.Further work needs to be done in this area to clarify thesequencing of these treatments,which have different mechanismsof action and time courses of onset and offset of effect,and maywell be complementary.3.Issues of access to psychological treatmentDespite its high prevalence and burden,insomnia often goesunidentified and untreated.Many individuals with insomnia dontseek professional help,but rather use self-help remedies of limitedbenefit 25.This may be due to fatigue and reduced motivation,perceived lack of treatment success,and the perception thatInsomnia is a benign condition that can be managed without pro-fessional input.Given the potential seriousness of the condition,efforts should be made to educate patients regarding treatmentoptions.Of those Insomnia sufferers that do seek professional help,treatment is usually limited to pharmacotherapy 6,13.Data frommany developed countries show that hypnotics are the mostcommonly used insomnia treatments for people seeking help forinsomnia in primary care.Australian data from 2987 generalpractice treatment episodes of sleep disorders showed 81%of pa-tients reporting a new problem of insomnia were prescribed amedication 6.Rates of referral for advice or counselling weremuch lower than for other disorders and only 0.8%of patients werereferred for specialist care compared to an average across all gen-eral practice presentations of 8.3%.Access to CBT-I is an important issue and can be a barrier topeople being referred.However,established patterns of referral andpractice can take time to change.Training health professionals inthe delivery of CBT-I is an imperative to increase accessibility.However,using a stepped care approach,with lower intensitymethods of delivering care as the starting point may help to reduceaccess problems 9.There are not yet adequate studies incorpo-rating a stepped care approach and so it is not clear whether failureat an entry level self-help CBT-I(e.g.,online),reduces the success ofsubsequent therapist-led CBT-I.3.1.Patients and their physicians need more choices for treatinginsomniaThe National Sleep Foundation recognizes that patients andtheir healthcare providers should have access to a wide variety oftreatment choices.Patients should be empowered to ask for andreceive the best possible help for their insomnia from theirhealthcare provider.GPs and physicians should receive educationregarding evidence-based treatment options for Insomnia.Table 1Components of CBT-i.ComponentDescriptionCognitive therapyAims to identify,challenge,and replace dysfunctional beliefs and attitudes about sleep and insomnia.Such misconceptions may includeunrealistic expectations of sleep,fear of missing out on sleep,and overestimation of the consequences of poor sleep.Stimulus controlBehavioral instructions aimed at strengthening the association between bed and sleep and preventing conditioning of the patient to associatebed with other stimulating activities.Such instructions include avoiding nonsleep activities in the bedroom;going to bed only when sleepy;andleaving the bedroom when unable to sleep for
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