Typically, someone is diagnosed with insomnia when they are experiencing difficulty falling asleep and staying asleep and also feeling unrefreshed. These symptoms need to be occurring every other day for at least two weeks. When people start developing insomnia, the symptoms tend to persist for quite a long time (anywhere between six months to a year). This is what we call chronic insomnia. Studies show that chronic insomnia tends to occur more frequently in people who have chronic conditions, such as arthritis, compared to in the general population where symptoms may subside within a few weeks.

Insomnia is difficult to cope with. It negatively impacts a person’s ability to function, concentrate and focus. It also makes people more irritable. And when someone has arthritis, it can exacerbate symptoms they are already struggling with, such as pain, increased fatigue, depressed mood and difficulty tolerating stressors. Lack of sleep can also reduce overall quality of life.

Up to 70% of people with arthritis experience symptoms of insomnia. In the general population, 20-30% of people experience insomnia.

While it has become increasingly recognized that insomnia is something that physicians should be treating and screening for in the context of rheumatic care, it tends to go unrecognized and untreated.

When insomnia is treated, hypnotics are typically prescribed. This is a type of medication that induces sleep and is only intended for short-term use. However, many people rely on it for a prolonged period of time, resulting in side effects. People also become tolerant, so the drug stops helping them sleep.

Cognitive behavioural therapy for insomnia, also known as CBTI, is the first line of treatment for insomnia.

Cognitive behavioural therapy for insomnia (CBTi) is a behavioural type of intervention that does not involve the use of medication. It helps people learn new strategies, behaviours and ways of thinking about sleep that can help promote sleep.

When people develop chronic insomnia, they also develop behaviours that are meant to help them compensate for or cope with insomnia. In reality, those behaviours only make the situation worse. CBTi is about identifying what those behaviours are and replacing them with helpful ones. For example, many people with insomnia take naps, which can be okay depending on time of day and duration. Taking a nap at four o’clock to get through the rest of the evening is not as helpful as taking one earlier in the day and for a shorter period of time (less than an hour). It’s also important not to stay in bed for more than 15-20 minutes if struggling to fall asleep during a nap. Instead, go into a different room and sit on a couch or chair and rest. These are the types of behaviours that can impact someone’s night sleep.

Another part of cognitive behavioural therapy is the cognitive part, which is the thinking part. There are certain ways that we start to think about sleep that are not helpful to inducing sleep. We start to worry that we’re not going to fall asleep, that we’re not going to be able to function the next day, that a lack of sleep will have a negative impact on our work and we might get fired. These types of ruminating thoughts happen when people are lying in bed trying to fall asleep. CBTi can be used to teach people different strategies to change their way of thinking about sleep.

Sleep disturbances impact people with various types of arthritis. As part of our research, we will look at patients with rheumatoid arthritis, lupus, scleroderma and ankylosing spondylitis. We really don’t see that much difference in terms of prevalence of insomnia among these diseases. So, we think CBTi will be applicable to the various forms of arthritis.

The problem is that CBTi is not widely available. There aren’t many experts across Canada who are trained to deliver it. There is a cost involved if accessing CBTi privately. There are also waitlists.

We need a better solution for delivering CBTi. In the last five years, we’ve seen an increase in studies evaluating whether CBTi can be delivered online without a healthcare professional. The studies are very promising in terms of seeing long-lasting improvements in sleep.

Ultimately, we hope that this research will provide an evidence-based CBTi program to help patients learn to better manage their sleep problems. It will be a program that will be accessible, delivered online and completely self-guided. We hope to see sleep improve, as well as other symptoms that tend to cluster together around sleep such as fatigue, pain and depressive symptoms.

Interestingly, depression and sleep tend to co-occur. We often see that, even when depressive symptoms improve with treatment, if sleep issues are not addressed, the depressive symptoms tend to re-occur. So, addressing sleep problems may actually be a very important way of addressing some of these other symptoms that people with arthritis experience.