It is a common sleep-related problem with serious consequences, but most Canadians are not getting the treatment they should for
insomnia
disorder, according to Canadian sleep expert Rébecca Robillard.
And the advice most commonly given to patients
struggling with chronic insomnia
might be making their sleep issues worse, said the director of clinical sleep research at the University of Ottawa Institute of Mental Health Research at The Royal and co-chair of the Canadian Sleep Research Consortium.
More than 16 per cent of Canadians struggle with insomnia disorder — chronic difficulty getting to sleep or staying asleep that occurs at least three times a week for at least three months.
It goes well beyond the occasional sleepless night, said Robillard. “We all have bad nights.”
Chronic insomnia is different. It
can impact people’s health, safety, thinking skills and interpersonal relationships
, among other things, she said.
It is a serious concern for individuals and society. But, even in a world that seems at times obsessed with getting a good night’s sleep, there is a disconnect when it comes to making sure patients with the condition get access to effective treatment, said Robillard.
Ontario Health recently released quality standards for treatment of insomnia disorder. Quality standards are a set of recommendations based on the best available evidence designed to improve patient care.
Those standards recommend cognitive behavioural therapy (CBT) as the first line of treatment for people with insomnia disorder. It is a form of psychotherapy that focuses on changing thoughts and behaviours that disrupt sleep.
CBT is considered the most effective and lasting treatment
for insomnia
, but despite the guidelines, it is not generally being recommended by primary caregivers, said Robillard.
Instead, some 98 per cent of primary care providers in the country recommend patients with insomnia improve their sleep hygiene as a first approach, she said.
Sleep hygiene is a popular concept, frequently referred to on social media, that recommends people maintain a consistent sleep schedule, limit screen time and avoid large meals and stimulants before bed, among other things.
The problem is, there is no evidence that it works for chronic insomnia. In fact, Robillard said, it can make things worse by causing them to blame themselves and creating more thoughts and behaviours that create insomnia.
That is a growing concern for sleep experts because sleep hygiene as a treatment for sleep problems is so prevalent.
“Sleep hygiene doesn’t work,” she said. It often strengthens people’s beliefs that their sleep system is broken and they just need to try harder, which can create cycles of “unhelpful thoughts and behaviours that create insomnia.”
Ontario’s quality standards include five recommendations: that people suspected of having insomnia disorder receive a comprehensive assessment to inform diagnosis; that individual, comprehensive care plans are developed for those with insomnia disorder; that patients with insomnia disorder get timely treatment for insomnia and other health conditions; crucially, that people with insomnia disorder are given timely access to cognitive behavioural therapy for insomnia as a first-line treatment; and that medications should be offered at the lowest possible dose for the shortest amount of time only after cognitive behavioural therapy has been tried. Patients should be warned about benefits and risks.
One potential problem with the treatment is access. Not only do many Canadians not have access to primary care, but studies have shown that a large percentage of primary care physicians say they feel unprepared to effectively treat insomnia disorder and the vast majority turn to sleep hygiene as a first line of treatment.
Robillard said advising “heathy sleepers” to pay attention to practices such as use of screens close to bedtime is not a bad thing, but promoting sleep hygiene as a cure to clinical insomnia could be harmful.
“It just reinforces the notion that you are not trying hard enough. We are especially concerned about people with insomnia, they are constantly exposed to this.”
She said some 43 per cent of people surveyed said they have had a previous diagnosis of insomnia disorder, but many others don’t get assessed. Some self-medicate with over the counter treatments or alcohol.
One issue with cognitive behavioural therapy as evidence-based treatment is access. Many people don’t have access to primary care, nor are there enough therapists trained in the treatment.
The
Canadian Sleep Research Consortium
is working on developing digital self-help tools that would be more accessible for patients struggling to get to sleep and to stay asleep.
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