LACK OF SLEEP IS A MAJOR ISSUE IN AUSTRALIA
Most of us know, or have experienced, how problems with sleep can make working, thinking, controlling our mood and doing everyday tasks harder.
In fact, it’s estimated that 39.8% of Australians experience some form of inadequate sleep.[i] This can lead to serious problems such as mistakes at work and car accidents.
There is also increasing evidence that a lack of sleep means you have more chance of developing other health conditions such as depression and anxiety and also substance use.[ii]
USE OF SLEEPING TABLETS IS CONCERNING
Evidence shows that the best treatment for long-term sleep problems such as insomnia is to put in place a set of strategies to change our behaviour and thinking around sleep (Cognitive Behavioural Therapy for Insomnia).
But at the moment in Australia, a study found that 81% of patients reporting a new problem of insomnia were instead prescribed a medication. Moreover, not as many people were referred to specialists as in other health areas.[iii]
It is also worrying that many people appear to be using sleeping tablets for more than three weeks, despite evidence this can cause more harm than good.
GETTING TO KNOW SLEEPING TABLETS (Z-DRUGS)
Z-drugs and their role in managing sleep problems
THE ROLE OF Z-DRUGS
Most people with short-term sleep problems are going through a stressful life event such as a break-up, losing a job or anything that might be upsetting. For these people, seeking supportive care or speaking to a doctor about using sleeping tablets for a few weeks is likely to manage their sleep problems.
With longer-term sleep problems, sleeping tablets are not recommended as the best treatment. Instead, research suggests that other treatment such as developing good sleep habits and Cognitive Behavioural Therapy for Insomnia have better results in the long run.
Importantly, using sleeping tablets for more than a few weeks can make it more likely you experience side-effects such as tolerance, dependence and ultimately get worse sleep.
Key messages
+ Sleeping tablets can be effective in managing short term sleep problems (for up to four weeks)
+ Speak to your doctor or a sleep physician about effective alternative long-term treatments if these sleep issues continue
HOW Z-DRUGS WORK
Z-drugs are a hypnotic medication which help you fall asleep quicker by increasing the body’s natural relaxing chemicals.
These medications work for about 2-4 hours before wearing off and are thought to focus more specifically on helping you to go to sleep than other sleeping tablets such as benzodiazepines.
There are two main types of z-drugs
+ Zolpidem (with brand names such as Stilnox), and
+ Zopiclone (with brand names such as Imovane)
The side-effects of using z-drugs
POTENTIAL SIDE-EFFECTS
It is important to consider the often serious side-effects of taking z-drugs, especially for a long time. Side-effects can include:
+ Feeling tired or groggy when you wake up
+ Difficulty making decisions and acting and thinking clearly – this can make you more likely to make mistakes at work or have a car accident
+ Trouble breathing or slowed breathing if they are used with other medications which have a similar effect
+ At high doses, this medication can lead to people doing things while asleep (or of which they have no memory). This can include things like texting, walking and even driving. This has been known to lead to serious harm and even death from things like falls and car accidents.
TOLERANCE AND DEPENDENCE
As described above, sleeping tablets are recommended to be used for up to four weeks and when other strategies such as improving sleep hygiene and cognitive behavioural therapy haven’t worked. This is because you are more likely to develop side-effects the longer you use this medication.
Essentially, while at the start these medications might work well, over time your body gets used to them. It develops a tolerance which means more and more medication is needed to get the same effect.
When this happens, you may start experiencing symptoms of both psychological and physical dependence.
PHYSICAL DEPENDENCE
+ Feeling sick or unwell if you stop taking the medication
+ Taking more medication to get the same effect
+ Trying to stop taking the medication and finding that you can’t
+ Withdrawal symptoms such as sweating, nausea, shaking and generally feeling sick
PSYCHOLOGICAL DEPENDENCE
+ Feeling like you can’t sleep without the medication
+ Changing your routine so that it fits in with taking the medication
+ Feeling nervous or anxious if you forget or can’t get your medication
USING MULTIPLE MEDICATIONS
Another very serious consequence of developing dependence is that because the medication doesn’t seem to be working as well, you might want to use other medication as well.
This can be really dangerous because other sleeping tablets and medications such as opioids can also work to suppress breathing and this can lead to slowed breathing and ultimately stop you from breathing, causing death.
Coming off z-drugs safely
COMING OFF Z-DRUGS SAFELY
It is important to first speak with a health professional before you reduce or stop taking your sleeping tablets. This is because you may experience serious withdrawal and other side-effects if you do stop or reduce too quickly. And you may get rebound insomnia.
Taking the steps to begin coming off sleeping tablets
1. Speak to your GP or prescriber
You GP is a good source of information for how to come off your medication safely. If your GP has not had experience in this area, or you feel you need more support, your GP can also refer you to the best service for this. This might be:
+ A sleep disorder clinic,
+ A sleep psychologist (who is trained in CBT for Insomnia) and/or
+ A sleep physician (i.e. a doctor who specialises in sleep)
2. Make sure you have alternative ways to manage your sleep problems
We know that a lot of people who decide to come off their medication have to start taking it again because they don’t have the tools and strategies to manage sleep problems in the long term without it.
Please continue reading the next section of this website to find out more about the other evidence-based and very effective ways you can find good sleep again.
GETTING GOOD SLEEP
Why you may be experiencing sleep problems
PROBLEMS WITH SLEEP
The three reasons people usually don’t get enough sleep are:
+ Sleep disorders like insomnia, sleep apnoea (trouble breathing during sleep) and restless leg syndrome (the need to move legs often)
+ Other health conditions like obesity, anxiety, depression, pain and medication-related problems
+ Other factors that affect sleep such as studying, working, staying out late and shift work [vi]
INSOMNIA
Insomnia is quite common and can create serious problems, but it is often not identified or treated. People often think they can manage insomnia on their own and that it can’t cause serious harm.
You are experiencing insomnia if you have trouble sleeping at least three nights a week for a month or longer.
The truth is that insomnia a serious condition and people need to better understand how it can be treated, and particularly that medications are generally not the recommended first treatment.
Insomnia is usually diagnosed by a GP or specialist sleep physician by speaking with you about your sleep and medical history, and through looking at a one-or two-week sleep diary.
They might also discuss other problems you might be experiencing because of your sleep problems and any other things that might be affecting their sleep (e.g. worrying or a recent experience such as a break-up).
Sometimes you might also be referred to a sleep physician, and have a sleep study conducted, to identify or rule-out any other sleep disorders (such as sleep apnoea).
OTHER IMPORTANT CONSIDERATIONS
Managing long-term sleep problems
TREATING CHRONIC INSOMNIA
COGNITIVE BEHAVIOURAL THERAPY FOR INSOMNIA
While we often think of Cognitive Behavioural Therapy as the first treatment for mental health conditions, research shows it is also the best first treatment, which gets the best long-term results, for insomnia as well.[vii] Cognitive Behavioural Therapy for Insomnia involves five components which are explained the more detail in the next tab: stimulus control, sleep efficiency, sleep hygiene, cognitive therapy and relaxation.
There are a number of ways to start CBT-I including weekly individual or group appointments or if getting to a face-to-face session is too hard, by phone or through online or printed resources by yourself[viii]
CBT for Insomnia explained
THE COMPONENTS OF CBTi
Stimulus control
Stimulus control involves strengthening the brain’s association between sleep and bed. This means that you work towards going to bed only when you’re sleepy. It also means getting out of bed if you can’t sleep within 15-20 minutes and only going back when you’re sleepy.
Sleep efficiency
Sleep efficiency involves only getting into bed for the amount of sleep you usually get (even if it’s only from 11pm until 5am, for example). This helps your brain re-learn how to sleep more efficiently, and then you can gradually increase this time
Sleep hygiene
Sleep hygiene involves advice around how to get good sleep such as
+ trying to go to bed at the same time every night
+ developing a relaxing sleep routine before bed
+ avoiding caffeine, smoking or drinking alcohol before bed (at least four hours)
+ avoiding bright lights or screens before bed
For more information, download a factsheet from the Sleep Health Foundation: Good Sleep Habits or Sleep Disorders Australia: Sleep Hygiene.
Cognitive therapy
Cognitive therapy involves unpacking unhelpful beliefs (like ‘I’ll never sleep’) and reducing worry and overthinking (like ‘I have to fall asleep in the next 10 minutes or I won’t be able to go to work’)
Relaxation
Relaxation involves finding ways to relax such as identifying a new or old hobby to start, meditation, mindfulness or breathing techniques.
CBTi treatment plan
Hear from Professor Sean P.A. Drummond about a typical treatment plan for Cognitive Behavioural Therapy for Insomnia.
Other strategies explained
MINDFULNESS
LIGHT AND MELATONIN
LIFESTYLE AND YOGA
More resources
MORE RESOURCES
The Sleep Health Foundation have created many factsheets with great information for people about getting good sleep.
Factsheets you might find useful:
+ Good Sleep Habits
+ Insomnia
+ Common Sleep Disorders
+ Depression and Sleep
+ Anxiety and Sleep
+ Sleep mistakes
+ Understanding and helping better sleep
+ Sleeping tablets
ScriptWise has also produced a community toolkit on benzodiazepines you might find useful: www.scriptwise.org.au/benzodiazepines
Getting treatment
Sleep services directory
https://www.sleep.org.au/information/sleep-services-directory
Reconnexion
Reconnexion is a statewide service funded by DHHS to provide information, support and counselling treatment for people with a tranquiliser dependency. There is no cost for services.
+ You can call Reconnexion during business hours on: 1300 273 266
+ Visit their website here: www.reconnexion.org.au
References
REFERENCES
[i] Sleep Health Foundation, ‘Asleep on the Job’, August 2017. Accessed March 2019: https://www.sleephealthfoundation.org.au/files/Asleep_on_the_job/Asleep_on_the_Job_SHF_report-WEB_small.pdf
[ii] Ree, M., Junge, M., and Cunnington, D., ‘Australasian Sleep Association position statement regarding the use of psychological/behavioural treatments in the management of insomnia in adults’, Sleep Medicine, Vol 36, 2017. Accessed March 2019: https://www.sleep.org.au/documents/item/2983
[iii] Ibid
[iv] Sleep Health Foundation, ‘Asleep on the Job’, August 2017. Accessed March 2019: https://www.sleephealthfoundation.org.au/files/Asleep_on_the_job/Asleep_on_the_Job_SHF_report-WEB_small.pdf
[v] Ibid
[vi] Ibid
[vii] Ree, M., Junge, M., and Cunnington, D., ‘Australasian Sleep Association position statement regarding the use of psychological/behavioural treatments in the management of insomnia in adults’, Sleep Medicine, Vol 36, 2017. Accessed March 2019: https://www.sleep.org.au/documents/item/2983
[viii] Ibid