17 Feb 2024

Putting insomnia to bed: Dr Alexander Sweetman

From Saturday Morning, 11:05 am on 17 February 2024

While various quick fixes are doing the rounds on social media, cognitive behavioural therapy is the best way to treat insomnia, a sleep expert says.

Dr Alexander Sweetman is a research fellow at the Adelaide Institute for Sleep Health at Flinders University and a leading figure in the field of treating people for insomnia and sleep apnoea without using drugs.

Sleep is fundamental to our survival, and yet 30 to 40 percent of the population suffer from insomnia. 

One of the first things people can do who are struggling to sleep is avoid going to bed before feeling sleepy, Sweetman told Susie Ferguson.

insomniac woman 
Woman struggling to wake up in the morning.


“Going to bed early before we start to really feel sleepy, can result in a long time spent awake trying to fall asleep.

“Or, if we wake up during the night, it can lead to more time spent awake in bed trying to get back to sleep.”

Sleep loves regularity, he says, and so getting into bed at a consistent time each night, and getting out of bed at a consistent time each morning are good habits to form.

Sleep hygiene is much talked about, and while important, it will not on its own solve the problem of insomnia, he says.

“We think that they might be helpful in preventing the development of chronic insomnia.

“But when we work with patients who have had insomnia symptoms for a long time, so for several months or several years, really often people already have really, really good sleep habits.

“So, they've already looked at lots of information online and talk to lots of friends and maybe other health clinicians and have received this sort of advice about maintaining a comfortable bedroom environment, good temperature, reducing light, reducing mobile phone usage in bed and so on.

“But despite all of this, the insomnia still persists.”

And alcohol is not your sleep-inducing friend.

"Alcohol is a sleep aid, it's heavily sedating, and help us initially fall asleep quicker. But it's a diuretic and will probably cause a more fragmented sleep.

“So, more awakenings throughout the night, and probably more awakenings to use the toilet throughout the night as well. So, it's not recommended as a sleep aid.”

And avoid large meals prior to sleep is the advice.

“Because our body will be working and active to digest food. Having the main evening meal, at least three hours if possible before bed is ideal.”

Because insomnia is so dependent on underlying psychological and behavioural causes, it means that lots of different therapy techniques can work for a short period, he says.

“That's partly because they build an expectation in the patient that it will work. So, there's strong placebo or demand effects that something's going to work, and that might improve sleep for a short time.

“But we think that if those underlying psychological and behavioural factors are still present, that insomnia really often re-emerges over time.”

The strong evidence supports cognitive behavioural therapy for sleeplessness, or CBTi, he says.

There are various strands to CBTi therapy, he says, from giving people solid information about insomnia to controlled reductions in the amount of time spent in bed.

“We can do this in a really structured way with something called bedtime restriction therapy. It aims to temporarily reduce the amount of time that we spend in bed over several nights and weeks.

“And gradually, this leads to less and less time spent awake in bed. It might initially make us feel sleepy, or in the late afternoon and evening. But that will help us fall asleep quicker and return to sleep quicker if we wake up during the night.”

There are thousands of different apps online that claim to improve sleep, he says, but the vast majority of them lack any scientific support.

“So that's what you're looking for the ones with the evidence behind them, or at least apps that are based on cognitive and behavioural principles for insomnia, if there's limited evidence, so the different white noise, pink noise, brown noise, I think that refers to different frequencies.

“So sound frequencies might be a good distraction technique in some people, and if they work for you, that's brilliant. They probably don't target the underlying psychological and behavioural causes of insomnia.

“So, for a lot of people, they probably won't work.”

An online programme, Just a Thought ,offers free CBTi insomnia management, he says.

Evidence-based guidelines don't recommend sleeping pills as the first treatment option, he says.

“They are associated with some side effects and risk of dependence that varies from medication to medication.”

And melatonin can help regulate sleep when it’s been disrupted, say with jet lag, but there’s little evidence it helps with treating insomnia, he says.

“Most clinical trials have really, really small sample sizes, I think there was only one or two studies with larger sample sizes.

“And the effect of insomnia on our sleep is actually quite small for melatonin, especially when you compare it head-to-head with something like CBTi that has this really large and sustained effect on our sleep.”

Sadly, shift workers with insomnia have a particularly tough challenge, he says.

“It can be very difficult to treat insomnia in people that are shift workers, especially rotating shifts. And really a highly tailored treatment approach from a specialist sleep physician or specialist sleep psychologist would be recommended in that instance.”