What works best for insomnia and sleep apnoea? Light therapy, sleeping pills, CPAP machine or surgery?

There’s a revolution going on in the bedrooms of chronic insomniacs and sleep apnoea sufferers in Australia – and its effects could make you rethink the poor sleep that you think you’re destined to have for the rest of your life. Just what causes you to toss and turn in bed, or wake up at 4am, unable to go back to sleep? Why do you feel like you haven’t slept in months, even though you regularly hit the sack before midnight?

To get to the bottom of those common sleep issues, Flinders University’s sleep health team in Adelaide diagnosed and exposed 30 individuals with varying degrees of sleeplessness to two months of personalised clinical methods and monitored their progress. Significantly, the findings may become the blueprint for sleep management in Australia.

The participants’ trials and tribulations, along with those of medical journalist Michael Mosley, are captured in a new BBC documentary. Titled Australia’s Sleep Revolution With Michael Mosley, the three-parter is premiering in Singapore on May 28 on the BBC channel. How will it impact the way you view your sleeplessness? Here’s a preview.

SLEEPLESS IN AUSTRALIA AND SINGAPORE

The research involving state-of-the-art clinical and home monitoring might have been carried out Down Under but sleeplessness is something that everyone can relate to, such as participant Priyanka Vandersman’s predicament. The scientist and mother of a toddler shared that she found it difficult to fall asleep each night, and often spent up to four hours tossing and turning in bed.

There was also Kate Hill, a mother and nurse student, who was about to embark on the next chapter in her career – and impending shift work at the hospital didn’t bode well for this insomniac who has tried everything, including sleeping pills. Comedian Jon Brooks wasn’t joking when he said he was tired of constantly feeling low in energy and mood because of his COMISA, a double whammy of chronic insomnia and sleep apnoea.

Adam Vale, a father and Christian pastor, still couldn’t find a solution for his severe obstructive sleep apnoea or OSA, the most common form of sleep apnoea, despite the rather drastic surgery he underwent. Before signing up for the research, he’d had his tonsils, uvula and a third of the base of his tongue surgically removed.

And it’s not only Australians who are feeling very sleepy. Close to three in 10 Singaporeans are not satisfied with their sleep quantity and quality, especially those aged 45 years and above, according to the 2024 Global Sleep Survey from ResMed that involved 36,000 worldwide participants, of which, 1,000 were from Singapore.

Sleep appears to elude the younger population in Singapore as well. The same survey showed that 15 per cent of those from the 18-to-24-year-old cohort had interrupted sleep ever since they can remember.

Apart from the sleep survey, the numbers from local studies aren’t looking good either: As many as 30 per cent of Singapore’s population has significant sleep apnoea, while the chronic insomnia rates can be between 10 per cent to 15 per cent, said Dr Leonard Eng, a consultant with Singapore General Hospital’s Department of Psychiatry.

“We don’t have the local data on COMISA but it is the most common co-morbidity for OSA patients and the most common co-morbid sleep disorder.”

HOW DOES LOSING SLEEP AFFECT HEALTH?

The cumulative effects of not catching at least seven hours of sleep each night is detrimental to health. And we’re not just talking about the ability to function, focus and remember things as explored in an earlier documentary by Mosley. The long-term chronic health problems also need to be addressed.

"Sleep plays a crucial role in immune function and sleep deprivation can weaken the immune system,” said Dr Eng. “It also disrupts the regulation of sugar levels, potentially leading to conditions like diabetes. Furthermore, chronic sleep deprivation is associated with high blood pressure, obesity, and an increased risk of stroke, heart disease and other serious health conditions.”

Despite the worrying health scenarios, the sleep survey showed “a relatively low level of awareness and diagnosis with sleep-related disorders among Singaporeans”, said Dr Adam Benjafield, ResMed’s vice president of medical affairs.

“Our study revealed that 74 per cent of Singaporeans have never consulted a physician for their sleep-related problems,” said Dr Benjafield. “Only 5 per cent have been tested and diagnosed with a sleep disorder, out of which 15 per cent decided to try over-the-counter solutions to combat their sleep issues.”

TREATING INSOMNIA AND SLEEP APNOEA

In the documentary, the goal of the Australian multi-disciplinary crew of doctors, psychologists and scientists was to help the subjects get at least seven hours of sleep and 80 per cent sleep efficiency. Those with sleep apnoea aimed to keep their breathing stops fewer than 10 per hour.

And it wasn’t easy. Host Mosley reported that the first week felt like "a fog of poor sleep and fatigue". Some of his fellow participants got too tired and gave up by going to bed earlier than they should or snuck in naps when they shouldn’t.

There were nights when participants such as Hill had only 2.5 hours of sleep. “It’s very lonely with insomnia,” she said. “Everyone’s asleep and you’re up all by yourself. You get caught up with your own thoughts.” However, in the subsequent weeks that followed, things began to gradually turn around.  

The team’s Associate Professor Sutapa Mukherjee, who closely monitored the participants’ health and progress, wasn’t surprised that “almost all” of the 30 volunteers were eventually “able to meet those targets” and “overwhelmingly” felt better at the end of the eight-week period. “The key element was making an accurate diagnosis and providing appropriate treatment tailored to the individual,” she said in an email to CNA Lifestyle.

But she cautioned against trying out the methods without a doctor’s diagnosis as there might be more than one sleep disorder at play. “The therapies used need to be tailored to the individual; it's not one size fits all,” she said. “It needs to be combined with clinical and research expertise to get the successful outcomes.”

Here’s a look at some of the methods mentioned in the documentary:

COGNITIVE BEHAVIOURAL THERAPY FOR INSOMNIA (CBT-I): Some of the insomniacs, such as Mosley, Vandersman and Hill, were instructed to go to bed much later than they normally would (1am, for instance), then wake up earlier, to limit their time spent in bed.

It may sound counter-intuitive but spending more time tossing and turning in bed could actually lead to more wakefulness, said psychiatrist Dr Lim Boon Leng from Gleneagles Hospital. “This technique limits the time spent in bed to increase sleep drive, and help patients fall asleep more quickly and stay asleep.”

CBT-I can vary in its effectiveness but “it is generally considered a highly effective treatment for insomnia”, said Dr Lim, with many patients experiencing sustained improvements. “Unfortunately, it is not very popular as most people get frustrated when they are not able to sleep, are not too keen to put in the effort to improve their sleep hygiene, and would rather have a quick fix for their insomnia.”

LIGHT THERAPY: The research team found that Mosley’s insomnia was caused by a circadian clock that was ahead of time, meaning he was at his sleepiest at 1am instead of 4am; and at 4am, his body was ready to wake up. By exposing him to bright light till 11pm every night, it would help to reset his circadian clock later.

Interestingly, the documentary revealed that the body's core temperature is a marker of your body clock: When your core temperature is at its lowest, you’re at your sleepiest. So, if you wish to sleep between 11pm and 7am, your core temperature should be registering its lowest around 4am.

The gradual shift, said Dr Eng, can be aided with low doses of melatonin medication and is tailored to the patient’s condition. “For someone with an advanced sleep phase disorder, for example, we will increase his exposure to light in the evenings and gradually delay his bedtime by an hour every few days or a week.”

MANDIBULAR ADVANCEMENT DEVICE: Not everyone diagnosed with OSA, such as Vale, was keen to try the continuous positive airway pressure or CPAP machine (more on that in a while). But he was game to give the customised mandibular advancement device a go. Worn during sleep, the mouthguard-like device helped to push the jaw forward and prevented the tongue from falling back and obstructing the airway during sleep.

The oral device, said Dr Tay Hin Ngan with ENT Head & Neck Thyroid Sleep Robotic Surgery at Mount Elizabeth Medical Centre, is usually more suited for mild to moderate OSA as the obstruction typically “occurs at the soft palate or behind the tongue in a front-to-back and not a side-to-side manner”. But in those with severe OSA, there may be "circumferential collapse of the airway, severe nasal obstruction and/or mouth breathing", which wouldn’t make the device a good choice.

Other caveats: You need to have good gum health and a minimum of six to 10 healthy teeth on each upper and lower jaw to hold the device in place, said Dr Phua Chu Qin, a consultant with Sengkang General Hospital’s Otolaryngology (ENT). Those with a strong gag reflex or jaw joint pain and problem may not be suitable.

POSITIONAL THERAPY: The sleep apnoea sufferers among the participants were asked to wear a buzzer at the back of their necks during sleep. The device would activate when it detected that the user was lying on his back for too long – and continued to buzz until the user turned.

“Sleeping on your side instead of your back may help prevent the collapse of the airway,” said Dr Phua. “This form of therapy is useful for patients with positional sleep apnoea, where their snoring and apnoea events are reduced when they lie on the side.”

CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) MACHINE: In sleep medicine, the CPAP machine is considered the gold standard treatment for OSA and for good reason. Dr Phua cited the example of a patient who would stop breathing as many as 144 times an hour before using the machine; that number dropped to 2.8 times an hour thereafter. "It can help normalise the patient’s sleep apnoea index where a lot of other treatment options failed."

Dr Phua sees an average of 600 to 700 prescriptions for CPAP machines every year at Sengkang General Hospital's Sleep Unit. But not everyone, including the documentary's participants, looks forward to wearing a mask attached to a machine via a tube to sleep.

In fact, a study by Singapore General Hospital noted that the one-year compliance rate was only 52.6 per cent, meaning almost half the patients are not receiving adequate treatment for OSA, said Dr Eng.

SLEEPING PILLS: Although not explored in the documentary, the use of sleep medication was an option that Hill had tried before. Her concern of becoming dependent on the pills and the morning-after grogginess stopped her from continuing.

Typically, sleeping pills are recommended for short-term use and are generally prescribed for moderate to severe insomnia, said Dr Lim. “The duration for which they are prescribed usually does not exceed a few weeks to avoid dependence,” he said. “As such, it is important to have a holistic approach and not just rely on sleep aids.”

Even the nightly use of melatonin supplements should be questioned. “It's generally safe for short-term use but the long-term effects, with use beyond three months, are less well understood,” said Dr Lim.

SURGERY: Vale’s prior surgery, which he mentioned in the documentary, may seem extreme to some but according to Dr Tay, it is “quite commonly performed on its own or as part of multilevel surgery in OSA patients, who are unable to tolerate CPAP treatment”.

“The removal of part of the tongue base is a much rarer surgery,” he said. “In Singapore, this is performed using a surgical robot through the mouth. It is useful for patients with large tonsils at the back of the tongue and a bulky tongue base.” According to Dr Tay, the overall success rate of surgery for OSA is around 60 per cent to 70 per cent. “But over time, with age-related changes and weight gain, the obstruction may recur.”

Other than tissue removal, surgery may be used to bring the jaw forward and enlarge the upper airway, said Dr Phua. Sometimes, surgically implanting a small device in the chest to provide electrical stimulation to the nerve that activates the tongue may be performed. “This stimulation will help protrude the tongue and soft palate, thereby reducing airway collapse during sleep,” she said.