Every morning, millions of Britons wake up from a night of broken sleep. According to a survey published by the UK’s Mental Health Foundation in 2011, 36% of us could be suffering from chronic insomnia; it is fast becoming a nationwide epidemic. Apps and fitness trackers allow us to keep note of every minute of sleep we get, so we have never been more aware of our night-time patterns. Yet there remains no proved pharmacological cure.

The 2012 Great British Sleep Survey, conducted by digital sleep-improvement service Sleepio, found that 42% of those taking medication to get some shut-eye had been suffering from broken sleep for more than a decade. Increasingly, people are reaching for medicinal remedies, despite sleeping tablets’ addictive properties and the lack of results. In a recent poll of 145 readers, C+D found that 22% of respondents refuse to sell sleeping tablets to at least one patient a day. But if patients cannot rely on a medicinal cure, what can pharmacists do to help those suffering from insomnia-related problems?

A prevalent problem

According to the British Journal of General Practice, approximately 10% of the population visit their GP with sleep problems every year. That’s about 6.4 million people seeking help.

Despite this, retired GP Martyn Lobley says his London practice received appointments from patients primarily concerned with sleeping problems only a couple of times a week. “More often there are patients with anxiety or depression who don’t sleep terribly well, but sleep is not always the first thing they mention,” says Dr Lobley.

And the problem is increasing. Alison Gardiner, the CEO of NHS-backed online insomnia treatment Sleepstation, suggests that the ubiquity of laptops, tablets and smartphones is making our habits worse. “With the increase in screen use, particularly close to bedtime, the problem is on the rise, especially in teenagers,” says Ms Gardiner.

Sleepio co-founder Peter Hames says insomnia is “one of the most prevalent problems in the population”. “It would be hard for it to go higher,” says Mr Hames, whose own experience of insomnia inspired him to create Sleepio after seeking a similar cognitive behavioural therapy (CBT) treatment.

Causes and solutions

Why are so many people affected by a bad night’s sleep? Professor Colin Espie, the clinical and scientific director of Sleepio, says the main causes of insomnia are “developing a poor sleep pattern, combined with a racing mind when you’re in bed”. “Any kind of stress can set insomnia off in the short-term, but it keeps going when a pattern is established and we find ourselves mentally preoccupied every time we are awake in bed,” he says.

As such, experts say that your bed should become a sanctuary for sleep and be used for nothing else. “If you’re not asleep within half an hour, get out of that room,” says Dr Lobley.

The distraction of technology is not the only cause of sleep trouble. Insomnia-related problems can relate to other lifestyle choices, such as drinking alcohol. Pharmacist Tony Schofield recommends caution in this area. “People think [alcohol] helps you sleep, but it doesn’t. It makes you drowsy, but as it wears off it’s an irritant. You’re more likely to have broken sleep issues consuming alcohol,” he says.

But our concerns about getting a good rest are not only down to external factors. Mr Schofield says part of the problem lies in people’s expectations of sleep. “There’s no entitlement to eight hours of sleep a night,” he says.

Mr Hames agrees: “If you think about it, we don’t expect any physical characteristics to be the same between all of us – shoe size, height, whatever. Everyone is on a normal distribution of height, and the same is said for sleep. The famous example is Margaret Thatcher, who slept four hours a night. Did she have insomnia? No, because that was all she needed to function.”

Taking into account these differing sleep needs, Sleepio allows patients to record their personal data in an app, which then provides a tailormade routine for users with the aid of an animated Scottish sleep expert, the Prof, and his dog, Pavlov. “Much in the same way that you go to the shoe shop to get your shoe fitted, what we try to do is find the right fit for your sleep window,” says Mr Hames.

The service uses CBT to help improve patients’ sleep by changing thought patterns and behavioural habits. Mr Hames, who has a master’s degree in experimental psychology, says this is “beyond sleep hygiene, which alone has not shown [itself] to be effective in [treating] insomnia”.

“Sleep hygiene is a set of rules around what you consume and what exercise you do. This is about a set of tools to fix the problem,” says Mr Hames, who considers himself fortunate to have known about CBT before developing insomnia.

“I went smugly to my doctor with a self‑diagnosis of chronic insomnia and they gave me sleeping pills,” he says. “But they are not effective, and should only be prescribed a few weeks at a time. Out of desperation, I self-administered a course of CBT from a self-help book written by Professor Colin Espie. Within six weeks, I was totally cured,” says Mr Hames.

He also believes sleep is not given sufficient attention by medical professionals. “After eight years of medical training, I think GPs get about one hour [focused] on sleep,” he says.

Sleepstation provides a similar digital service, which offers video-based therapy sessions every week through which patients can access treatment at their convenience. Ms Gardiner suggests the digital aspect makes the service – which boasts an 89% success rate – uniquely accessible compared with face‑to‑face CBT provision.

The increased acceptance of CBT has presented insomniacs with new treatment options, but should pharmacists still look for a solution in the dispensary? “Pharmacological therapy is generally not recommended for the long-term management of insomnia,” says Ms Gardiner. “CBTi [CBT for insomnia] is the most evidence-based treatment – it is highly effective and long-lasting.” Mr Schofield, who does not stock non-prescription sleeping medication in his pharmacy, says there are “no safe sleeping tablets”.

For patients asking persistently for non‑prescription sleeping medication, Mr Schofield says it is important not to cave in. “It’s negligence. You’re taking money off them under false pretences,” he says.

Professor Espie says health professionals recommend CBT as “the most effective long‑term solution ... [it] addresses both the mental and the behavioural parts of the individual’s sleep pattern by helping the person to think and behave differently in relation to their sleep”.

Greater awareness

Mr Hames believes there is a shift towards a greater awareness of sleep in society, which ultimately could help people’s awareness of solutions and expectations of sleeping patterns. “It’s public-led, so you have people like Arianna Huffington [co-founder and editor-in-chief of the Huffington Post] as a figure acknowledging the importance of sleep,” he says.

Alongside Ms Huffington’s articles looking at sleep issues, Apple announced plans in January to create a “night shift” feature on phones. The aim is to switch from harmful blue light, which suppresses melatonin, to yellow light, which is easier on the eyes.

In the long term, Mr Hames hopes that digital medicines and solutions can soon be as accessible as pharmaceutical ones, especially in the area of sleep. “It helps save the NHS money [and] it helps patients get the care they need,” he says.

“In the context of pharmacists, hopefully it can help with the frustration over a lack of accessible solutions for chronic insomnia.”

 

How can pharmacists help with sleep problems? Sion Llewelyn, pharmacy manager at Rowlands Pharmacy, Bala, offers his advice Start with the basics. Make sure there is not something obvious preventing the patient from sleeping, such as stress. Use your private consultation area to talk to them about sleep difficulties. If they are depressed and anxious, they may need to be referred to their GP. Ask them about their sleeping environment. Is it comfortable and free from noise? Is the person sharing their bed with someone who snores? If so, you can offer a nasal spray or clips to help ease their snoring. Check whether the patient is taking pseudoephedrine. This is in a lot of decongestant sprays, and one of its side effects is insomnia. Advise the patient to avoid sugary food and drinks, and caffeine, before they go to bed. People with sleeping difficulties should avoid alcohol and nicotine – they can make it harder to fall, and stay, asleep. After a bad night’s sleep, older people often sleep in the afternoon for a few hours and then can’t sleep in the evening. Advise them to reverse this cycle. A herbal sleeping tablet can aid sleep. There is no evidence that herbal remedies work, but there can be a placebo effect. Also, some patients prefer to take a herbal alternative. After going through basic counselling about sleep problems, you can advise people to take over-the-counter sleep medication for a short period – up to five days. Hopefully, a regular sleep pattern will be resumed. If they continue to have problems, refer them to their GP.

 

“It’s about living with the way I sleep, and what my body is crazy enough to do”

Oxford-based writer Anna Beer talks about how cognitive behavioural therapy (CBT) treatment has helped improve her sleep patterns

Three years ago, when I began having pre‑menopausal symptoms, I started waking a lot during the night. I found myself unable to stay asleep for more than an hour and a half. But, being the sort of person I am, I tried to ignore it.

My family and friends began to notice. I’d start the day stressed because I hadn’t had a good night’s sleep, and it was becoming emotionally and psychologically wearing. I’ve always liked a lot of sleep, and I’d have given anything to sleep for more than three hours uninterrupted.

I began going to bed an hour earlier, so I’d be in my room for at least 10 hours. But I’d only sleep for seven, and never in stints of more than two hours. My anxiety only increased as I thought about all the deep sleep I wasn’t getting.

After two years of sleeping badly, I decided to see my GP. When I explained my symptoms, she told me I was suffering from depression. I’m sure there are many people who suffer from depression or worse when they can’t sleep. But I wasn’t.

She recommended I go to a pharmacy and find a herbal remedy, but that did nothing. I was upset, because I’d plucked up the courage to talk about my insomnia and it hadn’t helped.

I started to research by myself and discovered Sleepstation. I’d tried a CBT service before, but there was no personal contact, which was ridiculously hard.

I’m coming to the end of this round of CBT, and it has been brilliant, because it has provided me with structure and perspective. I now have a toolkit, so, if things go back to the bad old days of waking every hour, I know how to step in and do things.

I’m not aiming for the perfect seven hours of sleep a night without waking. But anything over 90% of that is fine by me. It’s about living with the way I sleep, and what my body is crazy enough to do.