Lifestyle
Sleep
❍ At a glance
- Distinguish the presentation type before treating: sleep-onset insomnia (anxiety-driven) vs. sleep-maintenance insomnia (depression, pain) vs. early morning awakening (depression, OSA) vs. daytime somnolence with snoring (OSA). The management differs entirely.
- OSA is significantly underdiagnosed in NZ primary care. Prevalence is markedly higher in Maori, Pacific peoples, and people with obesity - actively screen these groups with STOP-BANG. Overnight oximetry in primary care can triage before formal sleep study.
- For chronic insomnia disorder: CBT-I is first-line, not pharmacotherapy. It consistently outperforms sedative hypnotics at 6-month follow-up and does not cause dependence. Online programmes (Sleepio, CBT-I Coach) are well-evidenced alternatives to face-to-face therapy.
- If you do prescribe for insomnia: low-dose melatonin (0.5-1 mg) is the safest option, especially in older adults. Temazepam sparingly, shortest duration, with an explicit plan to stop. Do not prescribe sedating antihistamines - they impair sleep architecture and carry anticholinergic burden.
Chronic sleep insufficiency is not a personality trait. It is associated with increased risk of cardiovascular disease, type 2 diabetes, obesity, depression, impaired immune function, and all-cause mortality - with a consistent signal at less than six hours per night.1 Adults need seven to nine hours. In New Zealand, shift work, caregiving demands, and evening screen-based light exposure are among the most common modifiable contributors.
❍ Assessment: distinguishing the presentations
Three questions orient the assessment:
- Can they get to sleep? Sleep-onset insomnia is often anxiety-driven - racing thoughts, hyperarousal, difficulty switching off.
- Can they stay asleep? Frequent waking is common in depression, pain, and alcohol use (alcohol suppresses REM and causes rebound waking in the second half of the night).
- Do they wake too early? Early morning awakening is a classic feature of melancholic depression but also occurs in OSA.
A separate presentation: daytime somnolence, witnessed apnoeas, snoring, morning headaches, and unrefreshing sleep point toward obstructive sleep apnoea rather than behavioural insomnia. This distinction matters - the management is entirely different. Do not treat presumed OSA with sleep hygiene advice.
❍ OSA: screening and investigation
OSA is significantly underdiagnosed in NZ primary care. Prevalence is markedly higher in Maori and Pacific peoples, and in people with obesity - active screening in these groups is warranted.2 The STOP-BANG questionnaire (Snoring, Tired, Observed apnoeas, Pressure/hypertension, BMI, Age, Neck circumference, Gender) is well suited for identifying high-risk patients before referral. A score of 3 or above warrants investigation.
The Epworth Sleepiness Scale (ESS) quantifies daytime somnolence. Scores above 10 suggest excessive daytime sleepiness. It is useful for monitoring treatment response after CPAP initiation.
Where overnight oximetry is available in primary care, it can identify moderate-to-severe OSA efficiently before formal polysomnography. A 3% oxygen desaturation index above 15 is consistent with significant OSA. Refer to a sleep physician or respiratory physician for diagnostic sleep study and CPAP initiation.
❍ Chronic insomnia: CBT-I first
Chronic insomnia disorder is defined as difficulty sleeping at least three nights per week for at least three months, causing daytime impairment. First-line treatment is Cognitive Behavioural Therapy for Insomnia (CBT-I), not pharmacotherapy.3 CBT-I consistently outperforms sedative hypnotics at six-month follow-up and produces durable improvements without dependence risk.
CBT-I