Carly Gibbs reports that behavioural therapy is considered the most effective treatment for people struggling to fall or stay asleep.
Did you sleep last night?
Madeline Wright did, but for seven years, she woke in the middle of the night.
At the peak of her insomnia, she didn’t sleep at all and lived off the stress hormone cortisol. The sleep-disturbing effects left her in a constant state of fight or flight.
She had depressive episodes, hallucinations, social anxiety and struggled to make decisions. Her weight plummeted, and her skin suffered. She feared going to bed.
The Rotorua single mum was working fulltime and dealing with post-traumatic stress, which frequently left her wakeful. When she was burgled twice back-to-back while she slept, her insomnia skyrocketed.
She would toss, turn, get up, and drink herbal tea until sunrise. Then carry on with her day.
Her sleep only improved a year ago after dialectical behaviour therapy (DBT), an evidence-based therapy that originated from cognitive behavioural therapy (CBT). DBT helps patients build mentally healthy lives by improving their ability to manage emotions.
The 35-year-old worked with a psychologist and a GP, who prescribed a low dose of a sedative. And she fell in love with her now fiancee, Kylie. “It all helped, but it was debilitating for a very long time,” she says.
The elusive slumber sweet spot
Nearly all New Zealanders experience some degree of acute insomnia throughout their lifetime.
In most cases, it is short-lived, caused by things like stress. However, 10 per cent of the population will have chronic insomnia, which means difficulty falling or staying asleep at least three times a week for three months or longer.
There are several treatments for insomnia, but first, it’s important to understand its cause. Fifty per cent of people with long-term insomnia have mental health issues. Twenty per cent have physical health conditions such as restless leg syndrome, reflux or pain. And 30 per cent have no identifiable mental or physical disorders, don’t use alcohol excessively and don’t have body clock issues. This is psychophysiological insomnia or “pure insomnia”.
Auckland’s Dr Tony Fernando is the only psychiatrist in New Zealand and Australia specialising in treating insomnia. He trained in the Philippines and the United States and says New Zealand lacks insomnia doctors due to limited training despite insomnia being a common problem.
How to stop the cycle
There is a proven insomnia treatment called cognitive behavioural therapy for insomnia or CBT-i. Yet, Kiwis tend to default to prescription sleeping tablets.
This is mainly because CBT-i isn’t publicly funded, unlike other countries.
There is also a shortage of people in New Zealand and Australia who are trained to deliver CBT-i. However, availability has increased via psychologists, online group sessions, and the Sleepio, Somnio, and Sleep School: Insomnia Help apps. Fernando also recommends the book Sleep Easy by Bernice Tuffery.
CBT-i includes learning about sleep hygiene—the routines, thoughts, and environment conducive to good sleep. It also includes stimulus control - techniques to help maintain sleep - and sleep restriction - limiting the time spent in bed to sleeping only. The therapy also addresses anxieties and negative beliefs about sleep and realistic expectations about sleep habits.
Studies have found that CBT-i is as effective as using sleep medications in the short term and more effective in the long term.
However, Fernando says CBT-i does not always work. In some cases, sleep medications may have to be used.
He has severe patients who, without sleep medication, are “non-functional”.
Little or no sleep also places a person at higher risk of depression and suicide.
“They don’t have energy, relationships have collapsed, they cannot work. If the only thing that works is traditional sleep medications that have a risk for dependence, we also have ways to manage the addiction.”
For example, some patients use sleep medications intermittently or every other night.
GP-turned-sleep specialist and founder of Sleep Well Clinic Dr Alex Bartle says stopping prescription sleeping tablets can “abruptly result in rebound insomnia”.
He says there is a degree of placebo effect regarding over-the-counter sleep supplements, and anything a person takes won’t address the underlying causes of insomnia. For example, he says 40 per cent of people with insomnia have sleep apnoea, which causes intermittent pauses in breathing throughout the night. “If you treat sleep apnoea, you treat insomnia.”
Sleep apnoea is diagnosable with overnight oximetry and monitoring respiration at home.
Tame the stress
For most people, occasional bouts of insomnia are normal. However, it can become chronic if stress isn’t addressed early through the likes of counselling.
Typically, most at risk of insomnia are women because of hormones and the overlap of caregiver and work responsibilities.
Sleep physiologist at EdenSleep Terri Candy says new behaviours in response to stress can perpetuate insomnia. She gives the example of having a bad night’s sleep, so the next night, you drink alcohol to relax.
“It worked okay, so you need a few glasses of wine the next night and the next. All of a sudden, you’ve got this other underlying dependence issue, which can happen with sleeping tablets and other [relaxants]. It’s behavioural changes that then turn it into a chronic issue.”
Insomnia is treatable, but when it’s ingrained or related to extreme stressful events, some people can struggle with it for “years”.
‘It’s an addiction’
Alison - not her real name - is someone who has battled insomnia for 20 years. She is addicted to the most frequently prescribed sleeping tablet, Zopiclone, the same drug her mum used to take for sleep troubles. She tries not to take more than half a tablet nightly.
“Whether it’s a hereditary thing, I’m not sure,” the 77-year-old says.
There was no initial stressful event in her life that sparked insomnia. Fifteen years ago, she spent a fortnight at Queen Elizabeth Hospital (now QE Health), where sleep tests were run without conclusive results. She has tried mindfulness, CBT-i, “natural” melatonin, and relaxation techniques like taking herself on a mental journey to the beach. Yet, none work.
“I start my sleep in the marital bed, but then my husband snores, so I get up, make a cup of tea, and sit around and watch the world go by. Then, I’ll go into another bedroom. I try hard not to look at my phone or watch TV.”
Last week, she had no sleep at all for two nights and still went to work.
Her body is relaxed the next day, but her mind isn’t. She fears insomnia is a “bad habit” that won’t change, and the same goes for relying on sleeping tablets. She has tried going cold turkey but can’t sleep without at least a quarter of a pill. “It’s an addiction.”
“On a good night, three to four hours would be my maximum [sleep]. It is a very serious, difficult problem.”
Madeline Wright says “living on stress” from sleep deprivation saw her hit rock bottom with adrenal fatigue, and she spent hours at a time on the couch.
Her inner work on herself had a more positive impact on her sleep than anything.
Don’t overthink it
For many, inner thoughts are ultimately the key to breaking the insomnia cycle.
Fernando says if you combine sleeplessness with a perfectionist tendency, it’s a “disaster”.
“The more you have rituals, the more you follow the rules, by the time you get to bed, you’re already very tense because you’re preparing for war.”
Pressure to “perform” or worry about insomniacs’ increased risk of diabetes, heart attack, Alzheimer’s, or depression overtakes the best chamomile tea, warm bath or meditation.
“Many people now are becoming what you call ‘sleep anxious’.
“When there’s a threat, it’s normal for the brain not to want to sleep because the brain is wired to protect the individual.”
Fernando says people also feel “entitled” to sleep for long periods, which makes their brains tense.
It’s common to wake up in the middle of the night, and quite usual. “Have a cup of tea, read, pray, meditate, and chances are, sleep will come. Sleep will naturally come when you are not thinking about it.”
“Catastrophising” means that being awake will mean no sleep.
“When people work themselves up because of a sleep issue, they suffer much more than just their insomnia. Our attitude towards insomnia is critical.”
According to Pharmac data, the total number of prescriptions dispensed for sleeping tablets in the 2022/23 financial year was 796,676. This includes melatonin, temazepam, triazolam and zopiclone (most prescribed).
Dr Alex Bartle’s tips
# Go to bed later: The kneejerk response by most people with insomnia is to go to bed earlier. “If I go to bed at 10pm and can’t sleep until midnight, I’ll go to bed at 9pm and be asleep at 11pm”. It doesn’t work like that, says Bartle. Go to bed at midnight, and you’ll sleep quicker.
# Get outside in the morning: Immersing yourself in outdoor light is helpful for sleep, especially in the morning. Outside light is the key to changing the circadian rhythm.
# Avoid too much alcohol: Three to four units of alcohol will get you to sleep earlier, but it will wake you more.
# Avoid screen time: 30-60 minutes before bed unless you’re reading on an e-reader.
# Don’t clock watch: Most people wake two to three times a night without recalling waking. The thing that gets in the way of this is looking at the clock. Clock-watching has an emotional response, which is not helpful for sleeping.
# Practice journaling: Externalise your worries by writing them down before bed. In addition, writing a to-do plan for the next day is also helpful.
Carly Gibbs is a weekend magazine writer for the Bay of Plenty Times and Rotorua Daily Post and has been a journalist for two decades. She is a former news and feature writer, for which she’s been both an award finalist and winner.