Sleep is a basic and necessary biological process that demands to be satisfied as much as our need for food and drink. Inadequate sleep can occur if insufficient time is allowed for it or if a disorder is present that disturbs sleep quality. It is only recently that we have begun to understand the scale of the health and social consequences of insufficient sleep and sleep disorders. Sleep loss from these problems is associated with disturbances in cognitive and psychomotor function including mood, thinking, concentration, memory, learning, vigilance and reaction times.1,2 These disturbances have adverse effects on wellbeing, productivity and safety. Insufficient sleep is a direct contributor to injury and death from motor vehicle and workplace accidents.3 Further, relationships have been demonstrated between shortened sleep and a range of health problems including hypertension,4 type 2 diabetes,5 obesity,6 cardiovascular disease7,8 and total mortality risk.9 Specific sleep disorders such as insomnia,10 obstructive sleep apnoea (OSA)11 and restless leg syndrome12 have also been associated with increased morbidity and mortality. These sleep-related problems incur financial costs relating to health and other expenditures and non-financial costs relating to loss of quality of life. This article considers the prevalence and economic impacts of sleep problems in Australia.

There have been very few studies of the prevalence of disturbed sleep in Australia. A small survey (n = 216) of sleeping difficulties, daytime sleepiness and hypnotic medication use was conducted in Adelaide more than 20 years ago.13 A larger survey (n = 535) was conducted in Newcastle, New South Wales, in 1996 but was limited to a question about insomnia and hypnotic medications.14 Another small survey (n = 267) in rural Victoria among Australian day workers was heavily weighted to men.15 More recently, a large NSW mail survey (n = 3300) reported that 18.4% of participants slept less than 6.5 hours a night and 11.7% complained of chronic sleepiness.16 A recent study of the insomnia burden suggested a prevalence of 5.6%, with increased use of health care.17

To further characterise sleep quality in a large representative sample of Australians, in 2010, the Sleep Health Foundation (www.sleephealthfoundation.org.au) commissioned a national survey of sleeping difficulties and negative daytime consequences of poor sleep. It was modelled on the Sleep in America surveys conducted by the National Sleep Foundation, in part to allow international comparisons. A national polling organisation (Roy Morgan Research) was commissioned to perform the work. It conducted a national landline telephone survey of adolescents and adults (14 to > 70 years of age) across successive weekend evenings. The survey contained 14 questions about sleep: five about sleeping difficulty, two about snoring and OSA, one about restless legs, one about sleeping medication, three about daytime impairments usually associated with sleep disturbance, and two about nocturnal sleep duration (weekdays and weekends) (Box 1). There were 1512 respondents from all states and territories, both urban and rural, with sampling proportionate to the populations of those areas, sex and age.

Box 1 shows the proportions of respondents reporting current sleep difficulties and daytime impairments at least a few times per week (indicative of significant problem), as well as average self-reported sleep duration for the population overall, for males and females, and for each age group. The results illustrate that a considerable proportion of Australians report frequent sleeping difficulties. Overall, 20% of respondents had frequent difficulty falling asleep, which was more prevalent among females and younger age groups. Frequent waking during the night was reported by 35% overall, again more commonly among females but increasing with age. Thirty-five per cent reported waking unrefreshed and 24% reported inadequate sleep. Daytime sleepiness, fatigue/exhaustion and irritability were common issues (19%–24%).

Symptoms were examined to determine likely prevalence of insomnia by selecting those with specific self-reported sleep difficulties plus daytime impairment18 to derive a score that very closely simulates the Insomnia Severity Index, a highly reliable and valid tool to identify clinical insomnia.19 This suggested an overall presence of severe insomnia (Insomnia Severity Index, > 14) of 6.9%, 8.7% in women and 5% in men (Box 1).

Prevalence of sleep apnoea was derived by determining the proportion of respondents who snored loudly at least a few times a week and had observed breathing pauses during sleep at least a few times a month. An overall prevalence of 4.9% was noted, but in this case, prevalence was higher among males (6.4%) than females (3.6%).

While these prevalences of specific sleep disorders were derived from combinations of questionnaire responses, they are similar to the prevalences determined from other population-based studies.10,20 These findings suggest that specific sleep disorders may account for about half of the complaints of daytime sleepiness and fatigue and exhaustion noted in our survey. While other health problems can disturb sleep, particularly in older patients, much of the balance may be due to insufficient sleep duration by choice or through circumstances that result in sleep being given a lower priority than work, social or family activities. Sleep duration estimates are significantly below the putative average adolescent sleep requirement of 9 hours a night and adult sleep requirement of 7.5–8 hours a night for both men and women, particularly among those between the ages of 35 and 65 years.21 Insufficient sleep at least a few times a week was reported by 23.7% of the sample, more frequently by females, and more commonly in the younger to middle-aged groups. Perhaps relevant to this, a study of young adults has shown that those with shorter habitual sleep patterns carried the highest sleep debt, suggesting self-selected sleep restriction.22

The general point that emerges from these data is that inadequate sleep (duration or quality) and its daytime consequences are widely prevalent in Australians, either because of a specific sleep-related disorder or from voluntarily shortened sleep through choice or circumstance. Although there are limitations with telephone surveys (eg, low response rates to landline phone calls), the results are very comparable with those observed in similar surveys conducted elsewhere, such as the 2008 Centers for Disease Control and Prevention study, which reported that 28% of United States adults had insufficient sleep or rest (< 7 h/night) on most nights over a 30-day survey period.23

In 2011, the Sleep Health Foundation commissioned Deloitte Access Economics, a national economics consultancy with a strong health economics background, to undertake an analysis of the direct and indirect costs associated with sleep disorders for the 2010 calendar year.25 The methods used were similar to those that they had used in a previous evaluation.24 Such an analysis requires robust data relating to the prevalence of the sleep disorder under consideration, the prevalences and costs associated with conditions with which it has a causal relationship, and the risk ratios describing the strength of these relationships. Using these data, the proportion of each condition attributable to the sleep disorder (the attributable fraction) can be derived. Specifying the prevalences and odds ratios used to calculate attributable fractions imparts transparency to the assumptions involved in calculating them. The fraction can then be used to derive the share of the costs associated with that condition that is attributable to the particular sleep disorder under consideration. Using these methods, Deloitte Access Economics examined costs associated with the three most common sleep disorders — OSA, primary insomnia and restless legs syndrome — as the robust data required for analysis were available.25 It estimated total health care costs of $818 million per year for these conditions, comprising $274 million for the costs of caring for the disorders themselves and $544 million for conditions associated with them. Of these costs, $657 million per year related to OSA: $248 million for OSA itself and $409 million for the health costs of conditions attributable to OSA. These conditions include hypertension, vascular disease, depression, and motor vehicle and workplace accidents. The analysis suggested that 10.1% of depression, 5.3% of stroke, 4.5% of workplace injuries and 4.3% of motor vehicle accidents are attributable to a sleep disorder.

The indirect financial and non-financial costs associated with sleep disorders are much greater than the direct costs. The indirect financial costs were estimated to be $4.3 billion in 2010. These included $3.1 billion in lost productivity and $650 million in informal care and other indirect costs resulting from motor vehicle and workplace accidents. Of these indirect costs, OSA accounted for 61% ($2.6 billion), primary insomnia for 36% ($1.5 billion) and restless leg syndrome for 3% ($115 million).

The report also estimated the effect of sleep disorders on loss of quality of life in terms of disability-adjusted life-years. These costs were calculated using the proportion of total national health costs attributable to sleep disorders to proxy the proportionality of the total national disease burden attributable to these problems. A dollar cost was calculated from the product of these years lost (190 000) and the value of a statistical life-year ($165 000). This added a further non-financial cost of $31.4 billion to the total economic cost of sleep disorders (Box 2). The non-financial nature of this cost gave it less tangibility than financial costs, but the calculation does draw attention to the substantial burden associated with the loss of quality of life resulting from sleep disorders.

As large as they are, these costs are likely to significantly underestimate the total cost to the community of sleep-related problems. Deloitte Access Economics evaluated costs associated with common sleep disorders. The costs of accidents and illnesses associated with sleep loss resulting from poor sleep habits from personal choice and/or from conflicting priorities such as work, social or family activities were not considered as they are difficult to estimate. Further, the analysis used conservative estimates of the prevalence of sleep disorders. For example, the base prevalence of OSA used was 4.7%, which is below the proportion of moderate OSA observed in many contemporary studies, a proportion which is likely to increase further as the population ages and becomes more obese.20 The prevalence of insomnia used in the analysis was also low at 3%, a figure based on primary insomnia estimates.26 Secondary insomnias resulting from other causes were not considered. Our own estimate including all insomnia from a representative Australian sample (Box 1) was closer to 7%. Potential comorbidities of sleep disorders, even if reasonable evidence for an association existed (such as metabolic disorders in the case of OSA), were also excluded from consideration. Finally, the analysis did not cost some aspects of the known comorbidities of sleep disorders, such as the impact of presenteeism (being present at work but operating suboptimally) on productivity and safety. The reason for this omission was the difficulty in reliably quantifying its effects.

Poor or inadequate sleep is very common among Australian adolescents and adults, affecting over 20% on a daily or near-daily basis. Epidemiological studies suggest about half of this problem can be attributable to common sleep disorders such as OSA and insomnia, as together they affect about 10% of the community. The balance appears likely to be the result of inadequate sleep arising from other health problems or issues such as poor sleep habits or sleep loss because of competing demands on time from work, social or family activities. Economic estimates demonstrate that sleep disorders are associated with large financial and non-financial costs. Given that the greatest financial costs appear to be non-medical costs related to loss of productivity and accident risk, it is likely that inclusion of the effects of sleep restriction from poor sleep habits or choice could add considerably to these already substantial amounts.

By the time the average person reaches his or her average life expectancy of around 80 years, they will have invested 28 years of their lives in sleep. It is remarkable that an activity of this scale is so taken for granted. Ironically, it is the defining characteristic of sleep — perceptual disengagement from the environment — that may provide the explanation for our disinclination to give our need for sleep its due attention. There is a natural tendency to invest effort in activities that provide conscious reward, and sleep risks being assigned a low priority compared with activities that occur during wakefulness. Importantly, these wakeful activities suffer where sleep is impaired.

While there are numerous hypotheses regarding the precise purpose of sleep, much of what we understand comes from experimental and naturalistic studies of individuals who are subjected to, or subject themselves to, inadequate sleep. Chronic sleep deficiency is believed to be widespread in Western societies.1 Sleep deficiency adversely affects alertness, cognition, productivity, safety, learning and mood and is implicated in a raft of additional pathophysiological processes, leading to adverse metabolic, cardiovascular and mental health outcomes, and premature death. This demands programs to improve sleep habits of the community generally and to detect and treat sleep disorders where they exist.

Linking sleep loss to specific adverse physiological and psychological consequences has led to some important, although limited, instances of behavioural change at the community level. Useful examples can be found in safety-critical industries, where alertness failure can have significant and potentially catastrophic consequences. Transport, aviation and, to some extent, health care industries have attempted to improve rostering practices to allow adequate opportunity for sleep and to minimise disruption of endogenous circadian pacemaker sleep–wake cycles. The duty to provide a safe work environment through enlightened roster arrangements rests with the employer. Equally importantly, employees should act on opportunities for sleep afforded by these rostering systems to ensure that they are “fit for duty”. Although as much as 16% of the Australian workforce is employed in shift work, optimal rostering systems and evidence-based countermeasures for workplace sleepiness are not always readily available or implemented. Despite some progress, the consequences of sleep loss remain under-recognised across the majority of workplaces and much of the community. The direct relationships between healthy sleep and a healthier, more productive and safer community needs to be better understood.

The previous Labor government in Australia identified productivity and population health and wellbeing as strategic research priorities, and as being among the most important challenges facing Australia (http://www.innovation.gov.au/research/Documents/SRP_fact_sheet_WEB.PDF). Good sleep health is a core consideration in both these domains. However, there remains insufficient awareness at leadership level of the importance of optimal sleep in achieving these national goals. The issue of sleep health is yet to be addressed in our national preventive health strategy. Diet and exercise are regarded as key components of a healthy lifestyle, yet despite compelling evidence, minimal attention has been given to healthy sleep. Sleep medicine and sleep science, which are relatively new fields, have much to do to deliver this message to community leaders.

As much as improvement is required in existing practices, sleep health is also confronted by new and emerging challenges. Communities are faced with a rate of technological advancement that is historically unprecedented. The extent to which technology intrudes on our sleep routines remains incompletely defined. However, current observational evidence implicates electronic entertainment and communication devices in sleep loss, academic underachievement and obesity among adolescents.2 Further, late night exposure to the light that is emitted from these devices may disrupt the circadian pacemaker, compounding the sleep disturbance and potential health consequences. There is an urgent need to better educate adolescents and their parents about optimal sleep routines. Schools could be powerful allies in this effort.

As much as unhealthy sleep habits are pervasive in modern society, it is critical that the discipline of sleep medicine ensures that community efforts are focused on effective and cost-effective solutions. Sustainability of any health care program is best secured by establishing goals of care, defining desired outcomes and identifying high-risk groups requiring particular attention. Careful guidance is required to ensure that health care expenditure delivers on preset objectives. Such investment is likely to be richly rewarded through increases in productivity and improvements in safety alone.3 However, blank cheques are never an option, and meeting the challenge of improving sleep health will need to be done within a tight, but not self-defeating, fiscal framework. For example, given that we recognise that continuous positive airway pressure (CPAP) is a cost-effective therapy for higher-risk and symptomatic obstructive sleep apnoea sufferers, strategies for better targeting care delivery to these groups may allow for much needed and consistent CPAP-funding models across the states and territories.

There is much information already in place to inform practice. For example, guidelines are available on appropriate use of therapeutic devices such as CPAP machines.4 However, dissemination of this equipment is unregulated, with the Therapeutic Goods Administration yet to adopt the United States Food and Drug Administration principle of sale of CPAP devices by medical prescription. Guidelines have been recently updated for sleep studies in adults (http://www.sleep.org.au/information/sleep-documents) — an area of potential confusion with the increased availability of diagnostic tools of varying quality in the primary care setting. Accreditation standards among sleep health delivery services, including home and in-laboratory sleep-testing facilities, have led to the evolution an increasingly sophisticated array of benchmarks. These include a recent partnership between the National Association of Testing Authorities and the Australasian Sleep Association to ensure high standards in sleep medicine services (http://www.nata.com.au; http://www.sleep.org.au/information/sleep-documents). Balancing the principle of optimal standards against accessibility, affordability and viability of services is particularly challenging in Australia, with its unique regional and remote demographics.

The articles in this supplement summarise the current understanding of a range of highly prevalent sleep problems and their impact on individual and community wellbeing. Key learning points from the articles can be found in the Box. The articles outline the burden of common sleep problems and their substantial economic cost in the Australian community. Key bodies such as the Sleep Health Foundation and the Australasian Sleep Association play an important role in articulating these issues to the broader health profession, schools, industry, policymakers and society generally to ensure healthy sleep becomes more of an established community priority. This supplement is an expression of their intent to do so.

Insomnia is a very common disorder that has significant long-term health consequences. Australian population surveys have shown that 13%–33% of the adult population have regular difficulty either getting to sleep or staying asleep.1,2 Insomnia can occur as a primary disorder or, more commonly, it can be comorbid with other physical or mental disorders. Around 50% of patients with depression have comorbid insomnia, and depression and sleep disturbance are, respectively, the first and third most common psychological reasons for patient encounters in general practice.3 Insomnia doubles the risk of future development of depression, and insomnia symptoms together with shortened sleep are associated with hypertension.4,5

Insomnia is defined in the fifth edition of the Diagnostic and statistical manual of mental disorders (DSM-5) as difficulty getting to sleep, staying asleep or having non-restorative sleep despite having adequate opportunity for sleep, together with associated impairment of daytime functioning, with symptoms being present for at least 4 weeks.6 Having a sleep experience that does not meet our expectation, such as with some transient awakenings but with good daytime functioning, does not constitute insomnia.

Acute insomnia is defined as sleep disturbance meeting the DSM-5 definition of insomnia, but with symptoms occurring for less than 4 weeks.6 Generally, acute insomnia is triggered by precipitating events such as ill health, change of medication or circumstances, or stress. Once the precipitating event passes, sleep settles back to its usual pattern. Hence, treatment for acute insomnia is focused on avoiding or withdrawing the precipitant, if possible, and supporting the acute distress of not sleeping with short-term use of hypnotics if symptoms are significant. This is the usual approach in primary care, with 95% of general practitioner consultations for insomnia resulting in the prescription of a hypnotic, usually a benzodiazepine.7

However, if patients have repeated episodes of acute insomnia or ongoing comorbidities, insomnia symptoms can persist and evolve into chronic insomnia, which requires a different treatment approach. Once people have had difficulty sleeping for over 4 weeks, they have usually begun to behave and think about sleep differently, in ways that are maladaptive and perpetuate their sleep difficulties.8 The long-term course is then generally one of relapse and remission rather than resolution,9 which continues well after the acute precipitating circumstances have passed. Therefore, the treatment approach needs to match this, with a chronic disease management model educating and upskilling patients on how best to manage their insomnia symptoms over time. Health care providers need to see insomnia as a chronic illness and emphasise the role of strategies to prevent relapses, rather than focusing on treatment of acute episodes or crises.

The assessment and diagnosis of insomnia is formulated mainly from a systematic sleep history. To assist in establishing premorbid baseline sleeping patterns and formulating treatment goals, clinicians must ask patients about their typical sleeping pattern before they developed insomnia.

Insomnia assessment involves understanding the patient’s typical sleep pattern at night and over a time frame of weeks to months. Therefore, part of the sleep assessment is asking for the patient’s narrative of typical bedtime, time taken to fall asleep after lights out (sleep latency), frequency and rough duration of awakenings in the middle of the night, and what time the patient gets out of bed. Are there times when sleep returns to normal? Was there an initial trigger or did the symptom arise spontaneously? Was it related to a period of stress, anxiety or depression? Did it start during childhood and continue thereafter? Are there lifestyle factors contributing to insomnia, such as too much caffeine or exercise late in the day, television or pets in the bedroom, or use of alcohol or nicotine? Knowing the patient’s cognitions, beliefs and worries about sleep, which are often apparent in the language and emotion used when they describe their sleep, can assist in the formulation of specific behavioural and calming approaches to assist with sleep.

It is important to assess the effects of poor sleep on the patient. Common daytime consequences include mood lowering, irritability, poor memory, fatigue, lack of energy and general malaise. These can manifest as work absenteeism, with insomnia being one of its leading medical causes.10 It is also imperative to ask for risky consequences of insomnia, including accidents and sleepiness while driving.

Identifying the body clock type of the patient is crucial in excluding circadian rhythm disorders. A commonly undiagnosed condition, delayed sleep phase disorder is a body clock variation where the patient is biologically inclined to go to sleep much later than usual (typically after midnight), yet generally sleeps well after sleep onset, with a natural wake time that is much later than for most people and is often incompatible with normal school or work start times.

It is also important to look for comorbid conditions that can present with insomnia, such as depression and anxiety, chronic medical conditions, and other sleep disorders. Comorbid conditions have a bidirectional relationship with insomnia, with each influencing or exacerbating the other and requiring concurrent assessment and management. The Auckland Sleep Questionnaire, a validated sleep screening questionnaire in primary care, is one tool that can assist in identifying these disorders.11 Other validated questionnaires such as the Insomnia Severity Index can help to document the severity of patients’ symptoms and assess their response to treatment.12

Since many people with insomnia overestimate their sleep disruption and underestimate actual sleep time, a 2-week sleep diary is a very helpful assessment tool as it assists the sleep clinician to get a more accurate snapshot of sleep compared with a pure verbal account.13 For some, a sleep diary is revealing in that they realise that they do get some sleep, albeit fragmented or superficial. This can provide the basis for discussion. There are several downloadable sleep diaries online — for example, http://yoursleep.aasmnet.org/pdf/sleepdiary.pdf. If patients have difficulty completing a sleep diary, or there is significant misperception of sleep suspected, actigraphy (using a device worn on the wrist to monitor sleep–wake cycles) can be used to objectively measure sleep.

Although an overnight sleep study or polysomnography is not routinely indicated in diagnosing insomnia, it can be helpful in diagnosing several conditions, including obstructive sleep apnoea, sleep-related movement disorders, parasomnias, or insomnias that are treatment-resistant.13 A routine physical and mental status examination can give clues regarding comorbid medical and or mental health conditions. Other tests including laboratory and radiographic procedures are not routinely indicated in chronic insomnia.13

Cognitive behaviour therapy aimed at treating insomnia (CBT-i) targets maladaptive behaviour and thoughts that may have developed during insomnia or have contributed to its development. CBT-i is considered to be the gold standard in treating insomnia, with effect sizes similar to or greater than those seen with hypnotic drugs and, unlike with hypnotics, maintenance of effect after cessation of therapy.14,15 These effects are seen in both primary and comorbid insomnia.16

The implementation of individual face-to-face CBT-i is typically delivered by a trained health professional, which makes it expensive, labour intensive and therefore beyond the reach of many. Patients with insomnia are eligible for Medicare rebates for psychological treatment if they are referred under the Chronic Disease Management or Better Access to Mental Health Care initiatives. Telephone and online delivery of CBT-i have been shown in clinical trials to be as effective as face-to-face CBT-i.17,18 While these different treatment delivery models have the potential to markedly improve access to CBT-i, they need to be investigated further with respect to their long-term reliability and effectiveness. They might be best used as part of a stepped-care approach.19 Some patients may need little guidance, while others may need more personal treatment and guidance.

CBT-i consists of five major components: stimulus control, sleep restriction (also known as sleep consolidation or bed restriction), relaxation techniques, cognitive therapy and sleep hygiene education (Box 1). Typically, CBT-i is delivered in four to 10 sessions, either individually or in a group setting, ideally involving four to eight participants.

Stimulus control is a reconditioning treatment forcing discrimination between daytime and sleeping environments.20 For the poor sleeper, the bedroom triggers associations with being awake and aroused. Treatment involves removing all stimuli that are potentially sleep-incompatible (reading, watching television and use of computers) and excluding sleep from living areas. The individual is instructed to get up if he or she is not asleep within 15–20 minutes, or when wakeful during the night or experiencing increasing distress, and not return to bed until feeling sleepy.

Sleep restriction relates to better matching the time spent in bed to the average nightly sleep duration.21 Patients keep a sleep diary to determine average sleep duration. They are then allowed a period of time in bed equal to this plus 30 minutes, and set a regular arising time. As some patients can underperceive the amount of sleep, the time in bed should never be set at less than 5 hours. As sleep becomes more consolidated, the length of time in bed can be gradually increased in 15–30 minute increments. This effective intervention induces natural sleepiness (reduced time in bed) and gives the individual a sense of assurance that bed is now a safe place to sleep. Bed restriction has recently been shown to be an effective intervention in primary care.22

Relaxation techniques include progressive relaxation, imagery training, biofeedback, meditation, hypnosis and autogenic training, with little evidence to indicate superiority for any one approach. Patients are encouraged to practice relaxation techniques throughout the day and early evening. Even a few minutes two to four times a day is useful. A last-minute relaxation attempt minutes before sleep will not work miracles. Muscular tension and cognitive arousal (eg, a “chattering” mind) are incompatible with sleep. At the cognitive level, these techniques may act by distraction. Relaxation reduces physical and mental arousal but is less effective as a stand-alone treatment and is better used in combination with other treatment interventions.

Cognitive therapy involves enabling the patient to recognise how unhelpful and negative thinking about sleep increases physiological and psychological arousal levels. Setting aside 15–20 minutes in the early part of the evening to write down any worries, make plans for the following day and address any concerns that might arise during the night allows the day to be put to rest. It is helpful to challenge thoughts that arise at night with “I have already addressed this and now I can let go of it!”. “Time out” — some form of soothing activity before bed — can be useful in reducing arousal levels. Thought-stopping attempts or blocking techniques, such as repeating the word “the” every 3 seconds, occupy the short-term memory store (used in processing information), potentially allowing sleep to happen. Cognitive restructuring challenges unhelpful beliefs, such as “if I don’t get enough sleep tonight, tomorrow is going to be a disaster”, which maintain both wakefulness and helplessness. Another cognitive and behavioural technique is paradoxical intention. Clients are encouraged to put the effort into remaining wakeful rather than trying to fall asleep (decatastrophising), thereby strengthening the sleep drive and reducing performance effort.14

There is limited evidence to suggest that, on its own, sleep hygiene is efficacious.14 However, it is an essential component of CBT-i and involves “cleaning up” or improving an individual’s sleep environment and behaviour to promote better sleep quality and duration.23

Although psychological and behavioural interventions are indispensable and effective for most insomnia sufferers, some will still need the extra help from pharmacological agents. Current medications and natural products used for insomnia include benzodiazepine-receptor agonists, melatonin and variants, antidepressants, antipsychotics and antihistamines.

Hypnotic drugs that act on the γ-aminobutyric acid receptor include benzodiazepines, such as temazepam, as well as the benzodiazepine-receptor agonists, such as zopiclone and zolpidem. Medications of this group have been studied in randomised controlled trials, with efficacy over 6 months27 and longer in open-label extensions.28 Many doctors avoid prescribing medications from this family, mainly because of concern regarding dependence and tolerance. However, long-term trials of eszopiclone (not available in Australia) and extended-release zolpidem have shown sustained response with no tolerance and dependence after 6 months of daily use.27–29 Despite these findings, the concern remains that there are vulnerable patients who may become dependent on hypnotic drugs. To limit the risk of tolerance and dependence, the prescriber can instruct the patient to use the medication on a scheduled basis; for example, only on alternating nights, or three times a week and at the lowest effective dose possible for a limited time (ie, a month).27 Zolpidem has been associated with parasomnias, so clinicians need to warn patients about unusual sleep behaviours as a side effect. Sudden discontinuation of this class of medications can result in a rebound insomnia that can be mitigated by a gradual taper.

Despite the similarity in the mode of action and pharmacokinetics of these agents, patients react differently to each product. Lack of response to one agent does not mean that others of the same group will not work. Similarly, an adverse effect of one does not mean that others will cause the same reaction. The decision whether or not to prescribe hypnotics should rely on a careful risk–benefit analysis by both the doctor and the patient. In addition to the perceived risk of dependence and tolerance, clinicians should consider the risks of untreated insomnia.

Melatonin has been shown to be effective in treating insomnia, particularly among people aged over 55 years.30 However, melatonin is more effective as a chronobiotic for treating body clock conditions like jetlag and delayed sleep phase disorder than as a treatment for chronic insomnia.31

Sedating antidepressants (eg, doxepin, amitriptyline, mirtazapine, trimipramine), sedating antipsychotics (eg, quetiapine, olanzapine) and antihistamines are used off-label as sleep medications, despite insufficient evidence.13,32,33 Many clinicians prefer prescribing these medications over hypnotics, because of perceived concerns regarding the risks of dependence and tolerance associated with hypnotics, and despite antidepressants, antipsychotics and antihistamines also having serious side effects including weight gain, anticholinergic side effects and diabetes. The decision to prescribe this group of medications for insomnia should be based on a careful risk–benefit analysis, not solely on concerns regarding the risks associated with hypnotics.

Among herbal and alternative medication choices for treating insomnia, valerian has the most evidence showing possible mild improvements in sleep latency, with inconsistent effects on the rest of the objective sleep parameters.13 Although valerian shows some promise in improving sleep latency without side effects, the clinical trials are poorly designed and generally of short duration.34

Insomnia is complex and usually chronic by the time the individual consults a health practitioner, with cognitive, behavioural and social factors involved in its maintenance. Simple instructions, such as avoiding stress, or short-term use of hypnotics are usually not effective. CBT-i is an effective intervention with long-term efficacy that enables patients to better manage and live with their insomnia symptoms. The development of online delivery of CBT-i markedly improves access to treatment and can be readily used in primary care as first-line treatment for most patients, with specialised sleep services managing more complex cases, those with ongoing symptoms and those who require person-to-person care.

Sleep problems, including problems at bedtime and frequent night waking, affect 30%–40% of infants and children before school age.1 Effects of sleep disorders on the health of the child may include poor growth, adverse behavioural and learning effects and, for the child and family, worsened mental health, and poor quality of life.2 The likelihood that important and treatable sleep disorders go unrecognised is increased because many parents do not mention their concerns to their general practitioner, or the doctor does not ask about or identify the issues.3,4 Simple management strategies can be effective at a primary care level. An important role of the GP or general paediatrician is to identify children’s sleep problems and to differentiate those who would benefit from referral to specialty services.

Average sleep times vary with age, and community surveys indicate considerable variability in sleep requirements, to the extent that normative values are sometimes debated. However, systematic review of the literature can guide general recommendations for sleep duration at different ages.5 Newborn infants sleep 16–18 hours per day in cycles of 3–4 hours (day and night). After 6 months of age, healthy infants can sleep for more than 6 hours at night without a feed. By 18 months of age, sleep patterns usually mature to overnight sleep plus one daytime nap. By school age, sleep consolidates into a single night sleep of 11–12 hours. Sleep duration continues to slowly reduce from about 10 hours in prepubescent children to 8 hours by 16 years of age. Individual children and adolescents may benefit from longer sleep times than these average figures, and enquiry about daytime functioning is an important part of assessing adequacy of sleep.5,6

Initial screening is an important aspect of identifying sleep issues in children and the first step in providing timely advice and intervention. An example of a mnemonic to remind physicians of important aspects of history-taking regarding sleep quality in children is BEARS: B = bedtime (settling) problems; E = excessive daytime sleepiness; A = night awakenings; R = regularity and duration of sleep; S = snoring.7 Parents define the presence of children’s sleep problems, so evaluation of the validity of parental expectations is also important. Age-specific common non-respiratory sleep problems are tabulated in Box 1.8

Sleep disorders are common in childhood and are associated with significant consequences for children and parents. Behavioural disorders include sleep onset delay, sleep interruptions, early morning waking and combinations of these elements. Parasomnias are very common and can be frequent and severe enough to warrant specialist referral. Access to tertiary and specialist assessment services is limited, so good triage of sleep disorders by primary care services and general paediatricians is essential. Identification and treatment of OSA is important in children. Immediate risk for respiratory compromise can be identified before adenotonsillectomy, and there are high rates of cure after surgery. Untreated, OSA is associated with risk of cardiovascular, neurodevelopmental and ongoing respiratory health problems. For triage purposes, Box 3 highlights situations where referral for specialist services with access to polysomnography is suggested in cases of suspected OSA. Finally, children with persisting symptoms despite surgery will often benefit from polysomnography and specialist evaluation to determine the severity of ongoing disease, identification of cause, and need (or not) for ongoing treatment. Childhood presents an opportunity for effective, early intervention in sleep disorders.