Insomnia

Insomnia is a common sleep disorder comprising low-quality sleep or not enough sleep due to trouble initiating sleep and/or maintaining sleep. Insomnia can be short term (lasting days or weeks) or chronic (lasting 3 months or longer).^[1] Insomnia occurs in 10-15% of the general population, with a greater prevalence in women during and after menopause, as well as older adults. In fact, up to 50% of older adults report insomnia or sleep disturbances.^[2][3]

Some symptoms of insomnia include:^[1]

• Lying awake for a long time before being able to fall asleep
• Only sleeping for short periods of time
• Staying awake throughout most of the night
• Feeling unrested or unrefreshed after sleep
• Involuntarily waking up too early

A healthcare provider will diagnose insomnia by taking a detailed medical history, including many questions about sleep habits. A physical exam is done to rule out other medical or mental conditions that can cause difficulty sleeping. Sometimes sleep studies can be performed to arrive at an accurate diagnosis. Insomnia is characterized as “chronic” when sleep problems occur at least 3 nights per week for at least 3 months.^[2]

Medication treatments for insomnia are indicated for improving sleep onset, sleep maintenance, or both. Examples of medications with evidence of benefit for insomnia include orexin receptor antagonists (suvorexant), nonbenzodiazepine hypnotics (eszopiclone Lunesta, zolpidem Ambien, zaleplon Sonata), certain benzodiazepines (triazolam, temazepam), melatonin agonists (ramelteon Rozerem), and certain antidepressants (doxepin Silenor). Although medications such as trazodone, tiagabine, and diphenhydramine are commonly used, experts do not recommend them for chronic insomnia due to potential harms and inadequate evidence of benefit.^[4]

Supplements studied for insomnia include melatonin, valerian root, kava-kava, chamomile, lavender, and many others. These supplements have sedating effects and can increase relaxation and induce sleep in some people with short-term insomnia.^[3] There is much less research on supplements for chronic insomnia.^[4]

A common therapeutic approach for alleviating insomnia is maintaining sleep hygiene, a part of which involves diet. Sleep hygiene techniques include not eating too much at night and not eating too late into the night. It also includes avoiding or limiting the intake of alcohol, caffeine, and caffeine-containing foods and drinks (e.g., coffee, tea, and chocolate), especially when it is close to bedtime. Following a healthy, nutrient-rich diet (e.g., high in fruits and vegetables, low in refined sugar) is also considered a part of maintaining good sleep hygiene.^[3][2][5]

For short-term insomnia, sleep hygiene techniques which involve adjusting lifestyle factors (e.g., diet, exercise) and environmental factors (e.g., light, noise, temperature) is commonly recommended, however, sleep hygiene is not recommended as a solo treatment for chronic insomnia. For chronic insomnia, cognitive behavioral therapy (CBT) has good evidence of benefit, especially when used in combination with other therapies. Sleep hygiene and CBT are usually recommended in combination with other behavioral treatments such as sleep restriction, relaxation therapy, and stimulus control.^[6]

Common causes of insomnia include work stress, relationship issues, or traumatic events. Often times, insomnia occurs in response to certain medical conditions, medicines, and other sleep disorders (e.g., obstructive sleep apnea). Caffeine, tobacco, alcohol, and other substances can also trigger insomnia. However, in some cases, insomnia is considered to be a primary problem because it does not have an identifiable cause, although risk factors include long-lasting emotional upset, stress, travel, and shift work.^[1]