By Laura Schocker
BBC News Magazine
One out of 10 Britons can't fall asleep at night. But do new online treatments for insomnia mean a cure is just a few clicks away?
Midnight's not so bad. Some quick number crunching and you figure you can still get six hours of shut-eye before facing the morning.
Two in the morning is a little bleaker. You're down to four hours - and that's if sleep comes right away.
At three, those glowing red numbers on the alarm clock seem to be screaming one thing: "You're not getting more than three hours tonight."
By four, you're ready to give up, grab a laptop and while away the remaining hours with some mindless web surfing. But maybe it's not such a bad idea - that computer screen could just be the solution for insomniacs.
Help with sleeplessness is available on the NHS, but places can be limited and waiting lists long. But these are free, and the online courses are currently offered on a commercial basis from the United States.
It's a promise that reads rather like an e-mail spam subject: "End sleepless nights once and for all - at home." But over the past few years, researchers have been developing internet-based courses designed to do exactly that.
Not a time you want to see at night
Now some US studies claim that on-screen therapy may be just as effective as face-to-face cognitive behavioural therapy.
Everyone who has had a few bad nights of sleep knows the folk remedies. Drink warm milk, take a hot bath, sip herbal tea, or count sheep.
No luck? It used to seem like the only option was to hope sleep would come, or to place yourself on a waiting list for a cognitive behavioural therapist, suffering through wakeful nights and groggy days in the meantime.
"We're talking about the most common mental health problem in the UK, and probably the world," says Colin Espie, director of the University of Glasgow Sleep Centre. "But less than half of people with insomnia mention it to their doctors."
Many feel insomnia is too trivial to mention to their GP, or they think it's something they can manage on their own, says Derk-Jan Dijk, Professor of Sleep and Physiology at the University of Surrey.
How many sheep does it take to sleep?
"It's a cultural thing that sleep is not important," he says. "You may not want to admit that you didn't sleep very well during the night because you were worried about that meeting with your manager."
And even if people are ready to talk about it, they may not have the resources to do so. Millions of people in the UK have chronic insomnia, but only several hundred psychologists are trained in this type of therapy. The NHS is working to make treatment easier to find. The Department of Health says more than 800 cognitive behavioural therapists are now in training, and 3,600 are expected to be trained by 2011.
And online treatments may have the potential to ease this pressure. It's a little more modern than, say, sheep counting, but researchers are focused on bringing insomnia treatment to the internet. It's about accessibility, says Dr Espie, who has examined the approach taken by online courses.
To the masses
With online automated courses, therapy that is typically only available on an individual or small group basis can be multiplied to reach many more, says Dr Richard Bedrosian, an American researcher who developed an online insomnia program.
TIPS FOR GETTING TO SLEEP
Stay positive - if you worry about not sleeping, you won't sleep
Good sleepers try to stay awake - don't dwell on falling asleep
One bad night isn't the end of good sleeping patterns - there's always tomorrow
From Colin Espie, University of Glasgow Sleep Centre
"We're trying to provide the service to as many people as we can," he says. "You can offer these things to millions of people almost as easily as you can offer them to dozens of people."
Yet whether it's dozens or millions, how, exactly, do these courses attempt to tackle insomnia?
These typically take several weeks, include downloadable lessons and, ultimately, mimic the doctor/patient relationship.
"I basically took the treatment programme that we delivered in a face-to-face format and turned it into an online format," says Gregg Jacobs, an insomnia specialist at the University of Massachusetts Medical School, and founder of an online therapy programme.
Dr Jacobs' five-lesson, five-week course starts by teaching patients about insomnia and then offers goals for each week ahead. Patients learn to keep to a sleep schedule, reduce negative thoughts about sleep and practise relaxation techniques for day and for night.
"It's a very safe, very anonymous way of treating their insomnia," he says of the $25 course.
This is not a good night's sleep
In week one, for instance, participants learn to give the minute-by-minute clock watching a rest.
Week two is spent establishing a regular rising time - a tough task for insomniacs who try to binge on sleep over the weekends to make up for those sleepless weeknights.
But a bit of commitment - remembering to only lie down when drowsy, to use the bed for sleep only so no reading or TV watching, and to never spend more than 20 or 30 minutes awake in bed - can eventually regulate sleep. Dr Jacobs says about 75% of his patients report significant improvement.
With success rates similar to face-to-face interventions, will online treatments become a widespread and viable option?
"In many ways, they have advantages over face-to-face care, certainly in the ability to reach larger audiences and reduce travel time," says Lee Ritterband, a psychologist at the University of Virginia Health System, who developed a nine-week online course for a university study. His findings were published in July's issue of the Archives of General Psychiatry, a medical journal.
The advantages are reflected in the numbers, says Dr Ritterband. About three-quarters of the participants - who all had moderate to severe insomnia at the start - finished the course without diagnosable insomnia.
Patients also saw improvements in how long it took to fall asleep, how long they stayed asleep, and how many times they woke through the night.
Don't nap - the bed shouldn't be for anything but sleep and sex
Don't stay in bed longer than 20 minutes. If you're not asleep, get up and do something else until you feel tired
Create a pre-sleep routine, like taking a bath or watching TV
From University of Virginia
A similar study at the University of Manitoba in Winnipeg, Canada, also had similar findings, published earlier this year in the medical journal Sleep. Some 80% of participants noticed an improvement in their insomnia.
Some experts aren't yet convinced, though. While Dr Espie, of the University of Glasgow Sleep Centre, says automated systems can help make insomnia treatment widely available, others think effective treatment requires the human touch.
"I'm a bit sceptical. I think many people with insomnia really would like to have more human contact than they would over the internet," says Jim Horne, director of the Sleep Research Centre at Loughborough University. "The more personal the approach between the person who is the sufferer and the therapist, the better."
Below is a selection of your comments.
I've never quite understood insomnia. If I'm still awake a minute after my head hits the pillow, I've had a tough night, and in fact, I frequently don't even manage to turn the light out before I'm asleep. This may sound like paradise to insomniacs, but it doesn't only happen at night, and I frequently fall asleep at my desk, in my car, etc. I don't fit narcolepsy, and I just think my natural state sits lower on the circadian rhythm than most. Everyone's tired, so what are insomniacs worried about? Surely you're not in danger of falling asleep at your desk, in almost every meeting, at traffic lights etc. I'm not trying to sound unsympathetic, I genuinely want to know what day to day problems it causes, so I can be sympathetic. Maybe the grass is just greener...
I work as a Primary Care Mental Health Worker for NHS Central Lancashire. We help people with sleep problems using the above techniques. We see people face to face and patients are referred via their GP. The maximum waiting time is about six weeks, most wait about two/three weeks to see us. (We help people with more than just sleep problems.) Most PCTs have this service, so places are not limited and there is not a long waiting list for the NHS to deal with most sleep problems. These services are also free.
Paul Clarkson, Ormskirk
I welcome not being asleep in the middle of the night - I write my best code curled up in the dark away from the computer: come morning all I have to do is type it in without further thought.
Megan, Cheshire UK
I'm being treated for sleep problems at the Edinburgh sleep centre - well, when I say I'm being treated, I had my first appointment 13 months ago, I had a sleep study in April, and I'll wait till November for the results so an action plan can be made. This is not a criticism - as you say, places are very limited, and I'm very grateful for the chance to be treated, but as you also say it's a common problem that needs more resources spent on it.
I stopped having bad nights when I gave up stressful jobs.
Online insomnia treatment sounds like a really good idea. Hell, after a few hours lying awake, I might even be prepared to shell out money for a cure. I have never actually spoken about my lifelong, intermittent insomnia to anyone in person, for the reasons mentioned. Although I know I am so much better in every way after some good sleep than the shadow version of myself when I have had a bad night, I shy away from going to a GP. I imagine they will just shrug if off as unimportant. Also, I imagine that they are time-poor, and would just prescribe sleeping tablets - which I am reluctant to take. I currently dose up on over-the-counter treatments for the problem, although it's not always successful.
Emma Pritchard, Leeds
I can see how these programs can help many people, but there is danger in "one size fits all" approach. When I developed insomnia, my GP practice suggested the book by Dr Espie, a kind of "low-tech" version of the online program. I tried to follow it, but some suggestions didn't apply, or I took them the wrong way. As a result, I only grew more discouraged, and started thinking that I will never make it work. I am thankful that I had a GP who believed me when I said that this wasn't working out, and helped me put together a more personalised program, which used some of Dr Espie's suggestions, but in ways that I could manage, and combined it with hypnotherapy CD course for managing anxiety. The more individualised program worked much better, and I can now manage to sleep normally, without the use of sleeping pills.
The only way to cure insomnia is to stop worrying about. Easier said than done, but CBT (cognitive behaviour therapy) can help immensely and my doctor recommended Dr Espie's book. You have to follow it strictly and it's not always easy but it really helped. I disagree that one-on-one therapy is better. What is more important is that the patient learns to cure themselves, which gives a much greater sense of achievement and the confidence to fight it on their own if it recurs.
Laura Farmer, London
I have taught sleep hygiene and anti-insomnia to people in the course of my work and the recommendations above are pretty typical (including the paradoxical intent method which removes anxiety about sleeplessness). In my experience people often don't believe the recommendations can help - or they are unwilling to do without alcohol, cigarettes or the TV in the bedroom. Unless the problem is solved immediately, interest is soon lost. Perhaps people who have to pay for treatment - by CBT or whatever - are more likely to comply and therefore see benefits.
Maurice Green, Burton, Staffs