As the science of sleep develops, so, too, do the business opportunities and the confusions and pitfalls of what works.
By Cathy O’Leary
It occupies about one-third of our lives and is considered a natural bodily function like breathing.
But for something that should happen with minimal effort, sleeping (or the lack of it) has become big business, with a recent explosion in self-help books, tracking apps and TV documentaries.
Increasingly we are warned about the risks of being sleep-deprived – with the acute effects likened to the impaired function and reaction time of a drunk driver, and that is before we get to the long-term effects on blood pressure and cardiovascular disease.
But people who struggle to sleep at night might argue this message only adds an extra layer of stress, as they become more anxious about not getting enough shut eye, perpetuating the insomnia cycle.
Still, a good night’s sleep is considered a restorative process for our body, particularly for the brain by helping our memory, learning and mood.
Sleeping less than six hours on average a night is associated with increased mortality risk and health conditions including hypertension, obesity and heart disease. Less than seven hours has been linked to digestive and neuro-behavioural problems.
Sleep disorders are varied, even within the umbrella of insomnia. For some people, it means difficulty falling asleep, while for others, dozing off is easy enough but they face the dreaded wake-up at 2am, leaving them unable to go back to sleep.
The result can be feeling fatigued and exhausted during the day, and this can go on for months or years, with about 15% of Australian adults stuck with chronic insomnia.
Big business
That sleep-deprived pain has fuelled a lucrative sleep health economy, with the sleep aid market reportedly worth about $65 billion a year in the US alone.
And in the digital age, tiredness has become the new norm, with companies selling aids from spooning robots and sleep trackers to calming blankets and hi-tech pyjamas with bioceramic material that is said to absorb the excess body heat that can be an enemy of sleep.
There is also a high-speed sleep research industry, as doctors and others try to find ways to help people get enough nods.
And the multi-million-dollar question is always – what actually works?
Advice for insomniacs can include anything from avoiding late-in-the-day caffeine to using breathing exercises, calming music or white noise, going to bed in a dark and quiet bedroom, and eating different foods in the evening.
Experts believe that if symptoms have lasted more than one or two months, it is likely the insomnia requires targeted treatments that focus on sleep patterns and behaviours.
Non-drug therapy such as cognitive behavioural therapy for insomnia (CBTi) has been shown to be more effective than sleeping pills. It involves education about sleep and offers psychological and behavioural treatments that address the underlying causes of long-term insomnia.
It can be done one-on-one or in small groups and is also offered online.
Some GPs are trained to offer CBTi, but it is more usual for specialist sleep psychologists to offer it. About 70-80% of people with insomnia are reported to sleep better after treatment, with improvements lasting at least a year.
Perth sleep researcher Dr Jen Walsh PhD, director of the Centre for Sleep Science at the University of WA, said insomnia was the most prevalent sleep disorder seen in people going to visit their doctor.
The explosion in reported insomnia has fuelled hundreds of studies looking at the use of possible sleep aids such as cannabinoids and melatonin, but the results so far have been a mixed bag.
Mixed results
Anecdotal reports of benefits from cannabidiols and THC did not necessarily align with some clinical trials which had not shown them to be effective.
“I’ve been involved in studies with THC, and not all findings are positive, but some outcome measures were positive, and that somewhat aligns with other studies that have included THC,” she said.
“One of the factors here could be the dose, because all the studies are looking at a dose of 150mg per day, which is what is approved by the TGA to be available over the counter as Schedule 3 (no prescription), and the companies want to capitalise on that opportunity so that’s what they’ve been using.
“And maybe that dosage is inadequate, although anecdotally prescribers will say patients report improvements in sleep with lower doses.”
Dr Walsh said another confounding factor could patient selection, with people not necessarily using CBD to treat a sleep problem or insomnia.
“It might be for pain or something else, but then they’re reporting an improvement in sleep. That might be why we’re not seeing improvements in people just with insomnia – maybe it works with co-morbidities such as pain,” she said.
She said there was also a question mark over the use of melatonin, a natural hormone released by the brain each night in response to darkness. While it is available on prescription in Australia, people aged over 55 can buy packs of 30 tablets over the counter from pharmacies.
A growing number of people are bypassing the need for a script by buying the supplement online from overseas. Some parents give it to their children, despite any evidence, as its benefits appear limited to older people who can end up with depleted levels of melatonin as they age.
“There have been quite a few studies looking at the effects of melatonin on sleep in people with insomnia or other sleep disorders, even jetlag, so lots of studies in specific populations,” Dr Walsh said.
“Therefore, there’s been meta-analyses which are interesting because they’re variable, so that’s really challenging.”
Dr Walsh said the value of melatonin might depend on the population it was being used in, and the formulation.
“In Australia, what you can buy at the chemist is modified, or slow-release, so it takes a few hours to reach its maximum concentration. So if someone is having trouble falling asleep, then that’s not going to be that useful for them. It’s going to help people who have some sleep maintenance issue,” she said.
“And if you get the tablet form and crush it and destroy the shell and coating, that will modify it, and its bioavailability increases in the short term.
“The research that’s been done is a mixture of looking at quick-release and prolonged-release products, or unspecified release, so if you’re looking at outcome measures such as time to fall asleep versus total sleep duration or the amount of time awake during the night, it’s going to be influenced by the product used.”
The added complication was people buying melatonin from overseas and self-medicating, without necessarily telling their GP.
“If it actually has sleep benefits, then it would have sedative or hypnotic properties, and of the available hypnotics traditionally used or prescribed, it would be one of the safer ones,” she said.
“But the problem is that people are self-treating and very likely it’s not the best treatment option for them. For someone with chronic insomnia, cognitive behavioural therapy is the best treatment, so that is one of the concerns with melatonin being more readily available.”
Dr Walsh said melatonin could also interact with other medications such as anticoagulants, potentially impacting their effects.
An analysis of 31 different supplements available online showed that the amount of melatonin ranged from minus 83% up to 478% of what was written on the packs, which stated doses of 1mg to 10mg, with the higher discrepancies in the lower doses.
“The rate of melatonin use in children has really spiked too, and that in itself sets kids up to think it’s not harmful and also gives them a belief that you need to take a pill to sleep,” she said.
What the evidence did show clearly was that CBTi worked for insomnia.
“Hopefully, we’re getting that message out there, but the problem is that it is typically done with a specialist sleep psychologist, and there’s just not enough, there are only about 35 in Australia.
“There is online CBTi, and for bread-and-butter insomnia that’s probably OK, but if you have any other co-morbidities, perhaps a mental health disorder or some PTSD, or someone does shift work, then it’s just not appropriate.
“But there are a lot of people working in this area, trying to progress and improve access.”
Sleeping pills’ role
Despite negative publicity about sleeping tablets, Dr Walsh said there was a place for them, when used selectively rather than as a regular go-to.
“If someone goes in and presents after poor sleep for at least three months, CBT is the best line of treatment. But if someone is in an acute situation, a death in the family or a relationship break-up, then that’s when you go with the medication, because they might have trouble sleeping, it might be for a week or two weeks. It is enough for their body to get used to them not sleeping, being awake in bed, and then they start worrying about the fact that they’re not sleeping.
“But if you can circumvent that with medication, and intervene, that’s where the medications have value.”
For some people, such as those with asthma, being sleep-deprived can be even more risky. Last month, the National Asthma Council Australia released a new health professional resource outlining steps to treat patients who present with poor asthma control and sleep disturbance.
Respiratory medicine and sleep disorders physician Associate Professor Greg Katsoulotos said it would help when patients with asthma reported persistent night-time cough.
“Asthma symptoms during sleep or on waking indicate suboptimal asthma control and frequent nocturnal symptoms indicate increased risk of acute asthma exacerbations and should not be accepted as normal,” he said.
“The resource recommends that health professionals should consider stepping up asthma treatment with anti-inflammatory therapy in a patient with sleep disturbance due to asthma symptoms.”
Nighttime cough could occur with or without wheeze and be a sign of poor asthma control that needed to be addressed, with the patient who might think their cough is due to an infection.
Research continues
Meanwhile, numerous studies are still underway to find the Holy Grail of sleep remedies.
Last month, in a world-first, Australian sleep experts were given just eight weeks to develop and run a sleep treatment program that diagnosed and treated more than 30 volunteers and achieved a success rate of more than 80%.
Lead researcher Professor Danny Eckert and a team from Flinders University used cutting edge technology and personalised clinical methods to conduct a rigorous clinical trial and treat sleep disorders through the science of sleep.
The findings are featured in the SBS documentary series Australia’s Sleep Revolution with Dr Michael Mosley, in which the medical journalist and chronic insomnia sufferer – along with politicians Barnaby Joyce and Jacqui Lambie – took part in the trial which focused on the most common sleep disorders – insomnia and sleep apnea.
Professor Eckert said people should be aware of the short- and long-term health effects of bad sleep, ranging from high blood pressure to increased risk of cardiovascular disease, stroke, diabetes, depression and chronic disease.
After participants had their sleep tracked, weekly multidisciplinary team meetings with sleep scientists, doctors and psychologists were held to tailor treatments for each person. The scientific findings will soon be published in detail in an international peer reviewed journal.
Earlier research by Flinders University found that getting the recommended 7-9 hours of sleep a night was out of reach for almost one-third of the population.
Resources
Primary care practitioners wanting evidence-based information about diagnosing and managing people with obstructive sleep apnoea and insomnia – the two most common sleep disorders – can go to www.sleepprimarycareresources.org.au
The Sleep Health Foundation has fact sheets aimed at the public but could be useful for physicians wanting to refer their patients www.sleephealthfoundation.org.au
For more advice about dealing with sleep disorders in people with asthma, go to www.nationalasthma.org.au
Sleep tips
What helps…
- try to maintain a sleep schedule that is enough to feel adequately rested, by keeping a fixed wake-up time, even on weekends, and going to bed when you feel sleepy.
- for those who have unavoidable changes in sleep routine such as shift work, catch-up sleep is recommended.
- people who feel like they might not be sleeping enough, especially those sleeping less than seven hours, could test whether allowing a longer sleep schedule or naps helps them sleep longer and results in them feeling more rested.
- for those without a sleep disorder, following good sleep hygiene can still have benefits, such as avoiding caffeine and alcohol in the afternoon and avoiding a heavy meal close to bedtime.
- people should be encouraged to talk to their GP in the first instance if they are concerned about their sleep. Treatment options are available through referrals to sleep specialists for a variety of sleep disorders such as sleep apnoea and insomnia.
What probably doesn’t…
- spending more time in bed often results in more time spent awake
in bed, which can make insomnia patterns worse. - drinking coffee and taking naps might help get you through the day but can make it more difficult to fall asleep in the evening.
- drinking alcohol might help people fall asleep quicker, but can cause more frequent awakenings, change how long they sleep and reduce the overall quality of sleep.