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CONTINUING PROFESSIONAL DEVELOPMENT
THE COMPLEMENTARY APPROACH
which may result in decreased school performance. In adolescents, poor sleep quality and insomnia
are also associated with increased interpersonal difficulties, somatic and mental health problems, risk of self-harm and suicidal ideation.3
Pharmaceutical interventions generally exert a sedative effect by targeting the histaminergic arousal system.1 However, these medicines may not be suitable for children, or older people who are taking a number of medicines. In addition, concerns about dependence, tolerance and adverse effects cause many consumers to seek assistance from complementary and alternative medicine (CAM) to assist with persistent sleep disorders.6,7
The aim of the CAM practitioner is to address the underlying cause of the sleep disturbance rather than simply sedating the patient. Therefore,
there is no one-size-fits-all approach. Lifestyle recommendations are generally the cornerstone of treatment and where oral therapies, such as herbal medicines, are used they are usually recommended as individualised combinations that target the causes for that person.
For all individuals with sleep disturbance, non- pharmacological approaches such as cognitive behavioural therapy (CBT) and sleep hygiene
should be considered first-line treatment.8 Stress management techniques may also be employed to assist in improving the duration and quality of sleep. Where concerns exist regarding pharmaceutical medicines, patients may also wish to trial some of the herbal options available. However, these are more likely to be useful when they address the underlying cause of the sleep disturbance such as anxiety. This article will discuss the use of CBT, sleep hygiene and stress management techniques in sleep disorders, as well as selected herbs.
Psychological interventions
Psychological interventions are commonly recommended as first-line treatment for chronic insomnia, as they are likely to produce sustained benefits without the risk of tolerance or adverse effects.9 A meta-analysis of CBT has demonstrated improvements in sleep onset latency (around
19 minutes), waking after sleep onset, sleep efficiency and total sleep time.9 CBT has also been shown to improve sleep parameters in patients with comorbid medical and especially psychiatric conditions.10
In people experiencing persistent insomnia, CBT
is typically focused on improving the association between bed and sleep; establishing consistent sleep–wake schedules; restricting time in bed to improve sleep drive and thus sleep efficiency; reducing stressful or intrusive thoughts that impair
sleep; targeting negative beliefs about sleep; and maintaining good sleep practices.1
The Sleep Better Without Drugs program, developed by Melbourne psychologist David Morawetz, utilises CBT techniques and has demonstrated benefits
for both sleep and depression.11,12 The program recommends various strategies to assist with sleep including the need to recognise the natural waves of sleepiness, which are generally experienced every 60–90 minutes, and not delay going to bed.
“For all individuals with sleep disturbance, non-pharmacological approaches such as cognitive behavioural therapy (CBT) and sleep hygiene should be considered first- line treatment.”
Sleep hygiene
Basic elements of sleep hygiene include keeping a regular sleep–wake schedule while avoiding naps; eating small, light, and easily digested meals in the evening to avoid being hungry during the night (and avoiding large, late, or fatty dinners); avoiding stimulants in the evening (e.g. caffeinated or high sugar drinks, alcohol, drugs, and nicotine); and using the bedroom exclusively for sleep and sex.13 Attention may also need to be paid to creating an environment conducive to restful sleep, taking into consideration issues such as light, noise, temperature, and comfortable bedding.
The effects of light require particular consideration. In humans, periodic circadian (24-hour) cycles play an important role in controlling daily hormonal and behavioural rhythms including melatonin and cortisol secretion, and feelings of sleepiness and alertness. The timing of these daily rhythms can be altered by input from the environment, especially light/dark cycles.14 While light exposure during
the day can be beneficial to circadian cycles, in
the evening it can suppress melatonin production, increase alertness and delay sleep. Blue light (such as that emitted by TVs, computers, smart phones, and tablets) causes the most disruption to sleep quality and timing, as it most effectively suppresses melatonin and increases alertness.15 Recently, software programs such as f.lux have become popular, and devices such as smartphones have been equipped with night modes that shift the display to the warmer end of the colour spectrum.
Australian Pharmacist January 2017 I ©Pharmaceutical Society of Australia Ltd. 47