Insomnia
Insomnia | |
---|---|
Other names | Sleeplessness, trouble sleeping |
Frequency | ~20%[8][9][10] |
Insomnia, also known as sleeplessness, is a
Insomnia can occur independently or as a result of another problem.
Although their efficacy as first line treatments is not unequivocally established,
Between 10% and 30% of adults have insomnia at any given point in time and up to half of people have insomnia in a given year.[8][9][10] About 6% of people have insomnia that is not due to another problem and lasts for more than a month.[9] People over the age of 65 are affected more often than younger people.[7] Women are more often affected than men.[8] Descriptions of insomnia occur at least as far back as ancient Greece.[15]
Signs and symptoms
Symptoms of insomnia:[17]
- Difficulty falling asleep, including difficulty finding a comfortable sleeping position
- Waking during the night, being unable to return to sleep and waking up early
- Not able to focus on daily tasks, difficulty in remembering
- Daytime sleepiness, irritability, depression or anxiety
- Feeling tired or having low energy during the day[18]
- Trouble concentrating
- Being irritable, acting aggressive or impulsive
Sleep onset insomnia is difficulty falling asleep at the beginning of the night, often a symptom of anxiety disorders. Delayed sleep phase disorder can be misdiagnosed as insomnia, as sleep onset is delayed to much later than normal while awakening spills over into daylight hours.[19]
It is common for patients who have difficulty falling asleep to also have nocturnal awakenings with difficulty returning to sleep. Two-thirds of these patients wake up in the middle of the night, with more than half having trouble falling back to sleep after a middle-of-the-night awakening.[20]
Early morning awakening is an awakening occurring earlier (more than 30 minutes) than desired with an inability to go back to sleep, and before total sleep time reaches 6.5 hours. Early morning awakening is often a characteristic of
Poor sleep quality
Poor sleep quality can occur as a result of, for example,
Major depression leads to alterations in the function of the hypothalamic–pituitary–adrenal axis, causing excessive release of cortisol which can lead to poor sleep quality.
Nocturnal polyuria, excessive night-time urination, can also result in a poor quality of sleep.[24]
Subjectivity
Some cases of insomnia are not really insomnia in the traditional sense, because people experiencing sleep state misperception often sleep for a normal amount of time.[25] The problem is that, despite sleeping for multiple hours each night and typically not experiencing significant daytime sleepiness or other symptoms of sleep loss, they do not feel like they have slept very much, if at all.[25] Because their perception of their sleep is incomplete, they incorrectly believe it takes them an abnormally long time to fall asleep, and they underestimate how long they stay asleep.[25]
Problematic digital media use
In August 2018, Sleep Science and Practice published a systematic review and meta-analysis of 19 studies comprising 253,904 adolescent subjects that found that excessive technology use had a strong and consistent association with reduced sleep duration and prolonged sleep onset latency for adolescents 14 years of age or older.[26] Also in August 2018, Sleep Science published a systematic review of 12 studies investigating associations between exposure to video games, sleep outcomes, and post-sleep cognitive abilities that found the data present in the studies indicated associations between a reduction in sleep duration, increased sleep onset latency, modifications to rapid eye movement sleep and slow-wave sleep, increased sleepiness and self-perceived fatigue, and impaired post-sleep attention span and verbal memory.[27] In October 2019, Sleep Medicine Reviews published a systematic review and meta-analysis of 23 studies comprising 35,684 subjects that found a statistically significant odds ratio for sleep problems and reduced sleep duration for subjects with internet addiction.[28] In February 2020, Psychiatry Research published a systematic review and meta-analysis of 14 studies that found positive associations between problematic smartphone use and poor sleep quality and between higher levels of problematic smartphone use and elevated risk of poor sleep quality.[29]
Also in February 2020, Sleep Medicine Reviews published a systematic review of 31 studies examining associations between screen time and sleep outcomes in children younger than 5 years and found that screen time is associated with poorer sleep outcomes for children under the age of 5, with meta-analysis only confirming poor sleep outcomes among children under 2 years.[30] In March 2020, Developmental Review published a systematic review of 9 studies that found a weak-to-moderate association between sleep quantity and quality and problematic smartphone use among adolescents.[31] In October 2020, the International Journal of Environmental Research and Public Health published a systematic review and meta-analysis of 80 studies that found that greater screen time was associated with shorter sleep duration among toddlers and preschoolers,[32] while the Journal of Behavioral Addictions published a systematic review and meta-analysis of 40 studies with 33,650 post-secondary student subjects that found a weak-to-moderate positive association between mobile phone addiction and poor sleep quality.[33] In April 2021, Sleep Medicine Reviews published a systematic review of 36 cross-sectional studies and 6 longitudinal studies that found that 24 of the cross-sectional studies and 5 of the longitudinal studies established significant associations between more frequent social media use and poor sleep outcomes.[34]
In June 2021, Frontiers in Psychiatry published a systematic review and meta-analysis of 34 studies comprising 51,901 subjects that established significant associations between problematic gaming and sleep duration, poor sleep quality, daytime sleepiness, and other sleep problems.[35] In September 2021, BMC Public Health published a systematic review of 49 studies investigating associations between electronic media use and various sleep outcomes among children and adolescents 15 years of age or younger that found a strong association with sleep duration and stronger evidence for an association with sleep duration between the ages of 6 and 15 years than for 5 years of age or younger, while evidence for associations between electronic media use with other sleep outcomes was more inconclusive.[36] In December 2021, Frontiers in Neuroscience published a systematic review of 12 studies published from January 2000 to April 2020 that found that adult subjects with higher gaming addiction scores were more likely to have shorter sleep quantity, poorer sleep quality, delayed sleep timing, and greater daytime sleepiness and insomnia scores than subjects with lower gaming addiction scores and non-gamer subjects.[37] In January 2022, Early Childhood Research Quarterly published a systematic review and meta-analysis of 26 studies that found a weak but statistically significant association with increased smartphone and tablet computer use and poorer sleep in early childhood.[38]
In May 2022, the Journal of Affective Disorders published a meta-analysis of 29 studies comprising 20,041 subjects that found a weak-to-moderate association between mobile phone addiction and sleep disorder and that adolescents with mobile phone addiction were at higher risk of developing sleep disorder.[39] In August 2022, the International Journal of Environmental Research and Public Health published a systematic review and meta-analysis of 16 studies comprising 8,077 subjects that established a significant association between binge-watching and sleep problems and a stronger association between binge-watching and sleep problems was found during the COVID-19 pandemic than pre-pandemic.[40] In October 2022, Reports in Public Health published a systematic review of 23 studies that found that excessive use of digital screens by adolescents was associated with poor sleep quality, nighttime awakenings, long sleep latency, and daytime sleepiness.[41] In December 2022, Sleep Epidemiology published a systematic review of 18 studies investigating associations between sleep problems and screen time during COVID-19 lockdowns that found that the increased screen time during the lockdowns negatively impacted sleep duration, sleep quality, sleep onset latency, and wake time.[42] In March 2023, the Journal of Clinical Sleep Medicine published a systematic review and meta-analysis of 17 studies comprising 36,485 subjects that found that smartphone overuse was closely associated with self-reported poor sleep quality, sleep deprivation, and prolonged sleep latency.[43]
In April 2023, Sleep Medicine Reviews published a systematic review of 42 studies that found digital media use to be associated with shorter sleep duration and poorer sleep quality and bedtime or nighttime use with poor sleep outcomes, but only found associations for general screen use, mobile phone use, computer and internet use, internet, and social media and not for television, game console, and tablet use.[44] In July 2023, Healthcare published a systematic review and meta-analysis of 16 studies that established a correlation coefficient of 0.56 between nomophobia and insomnia.[45] In September 2023, PLOS One published a systematic review and meta-analysis of 16 studies of smartphone addiction and sleep among medical students found that 57% of subjects had poor sleep and 39% of subjects had smartphone addiction with a correlation index of 0.3,[46] while Computers in Human Behavior published a meta-analysis of 23 longitudinal studies comprising 116,431 adolescent subjects that found that adolescent screen time with computers, smartphones, social media, and television are positively associated with negative impacts on sleep health later in life.[47]Causes
While insomnia can be caused by a number of conditions, it can also occur without any identifiable cause. This is known as Primary Insomnia.[48] Primary Insomnia may also have an initial identifiable cause, but continues after the cause is no longer present. For example, a bout of insomnia may be triggered by a stressful work or life event. However the condition may continue after the stressful event has been resolved. In such cases, the insomnia is usually perpetuated by the anxiety or fear caused by the sleeplessness itself, rather than any external factors.[49]
Symptoms of insomnia can be caused by or be associated with:
- Sleep breathing disorders, such as sleep apnea or upper airway resistance syndrome[50]
- Use of psychoactive drugs (such as stimulants), including certain medications, herbs, caffeine, nicotine, cocaine, amphetamines, methylphenidate, aripiprazole, MDMA, modafinil, or excessive alcohol intake[51]
- Use of or withdrawal from alcohol and other benzodiazepines[51]
- Use of or withdrawal from pain-relievers such as opioids[51]
- Heart disease[52]
- Restless legs syndrome, which can cause sleep onset insomnia due to the discomforting sensations felt and the need to move the legs or other body parts to relieve these sensations[53]
- Periodic limb movement disorder (PLMD), which occurs during sleep and can cause arousals of which the sleeper is unaware[54]
- Pain:[55] an injury or condition that causes pain can preclude an individual from finding a comfortable position in which to fall asleep, and can also cause awakening.
- Hormone shifts such as those that precede menstruation and those during menopause[56]
- Life events such as
- Gastrointestinal issues such as heartburn or constipation[57]
- FASD
- Disturbances of the circadian rhythm, such as shift work and jet lag, can cause an inability to sleep at some times of the day and excessive sleepiness at other times of the day. Chronic circadian rhythm disorders are characterized by similar symptoms.[51]
- Certain
- Medical conditions such as hyperthyroidism[2]
- Abuse of over-the-counter or prescription sleep aids (rebound insomnia[51]
- Poor noise or over-consumption of caffeine[51]
- A rare genetic condition can cause a fatal familial insomnia[61]
- Physical exercise: exercise-induced insomnia is common in athletes in the form of prolonged sleep onset latency[62]
- Increased exposure to the blue light from artificial sources, such as phones or computers[63]
- Chronic pain[64][65]
- Lower back pain[65]
- Asthma[65]
Sleep studies using polysomnography have suggested that people who have sleep disruption have elevated night-time levels of circulating cortisol and adrenocorticotropic hormone.[66] They also have an elevated metabolic rate, which does not occur in people who do not have insomnia but whose sleep is intentionally disrupted during a sleep study. Studies of brain metabolism using positron emission tomography (PET) scans indicate that people with insomnia have higher metabolic rates by night and by day. The question remains whether these changes are the causes or consequences of long-term insomnia.[67]
Genetics
It has been hypothesized that epigenetics might also influence insomnia through a controlling process of both sleep regulation and brain-stress response having an impact as well on the brain plasticity.[70]
Substance-induced
Alcohol-induced
Alcohol is often used as a form of self-treatment of insomnia to induce sleep. However, alcohol use to induce sleep can be a cause of insomnia.
Benzodiazepine-induced
Like alcohol,
Opioid-induced
Risk factors
Insomnia affects people of all age groups but people in the following groups have a higher chance of acquiring insomnia:[77]
- Individuals older than 60
- History of mental health disorder including depression, etc.
- Emotional stress
- Working late night shifts
- Traveling through different time zones[11]
- Having chronic diseases such as Alzheimer's, or heart disease[78]
- Alcohol or drug use disorders
- Gastrointestinal reflux disease
- Heavy smoking
- Work stress[79]
- Individuals of low SES[80]
- Urban Neighborhoods [80]
- Household stress[80]
Mechanism
Two main models exists as to the mechanism of insomnia, cognitive and physiological. The cognitive model suggests rumination and hyperarousal contribute to preventing a person from falling asleep and might lead to an episode of insomnia.
The physiological model is based upon three major findings in people with insomnia; firstly, increased urinary
Around half of post-menopausal women experience sleep disturbances, and generally sleep disturbance is about twice as common in women as men; this appears to be due in part, but not completely, to changes in hormone levels, especially in and post-menopause.[56][84]
Changes in sex hormones in both men and women as they age may account in part for increased prevalence of sleep disorders in older people.[85]
Diagnosis
In medicine, insomnia is widely measured using the
A qualified sleep specialist should be consulted for the diagnosis of any sleep disorder so the appropriate measures can be taken. Past medical history and a physical examination need to be done to eliminate other conditions that could be the cause of insomnia. After all other conditions are ruled out a comprehensive sleep history should be taken. The sleep history should include sleep habits, medications (prescription and non-prescription), alcohol consumption, nicotine and caffeine intake, co-morbid illnesses, and sleep environment.[87] A sleep diary can be used to keep track of the individual's sleep patterns. The diary should include time to bed, total sleep time, time to sleep onset, number of awakenings, use of medications, time of awakening, and subjective feelings in the morning.[87] The sleep diary can be replaced or validated by the use of out-patient actigraphy for a week or more, using a non-invasive device that measures movement.[88]
Workers who complain of insomnia should not routinely have
Some patients may need to do an overnight sleep study to determine if insomnia is present. Such a study will commonly involve assessment tools including a polysomnogram and the
In many cases, insomnia is co-morbid with another disease, side-effects from medications, or a psychological problem. Approximately half of all diagnosed insomnia is related to psychiatric disorders.[91] For those who have depression, "insomnia should be regarded as a co-morbid condition, rather than as a secondary one;" insomnia typically predates psychiatric symptoms.[91] "In fact, it is possible that insomnia represents a significant risk for the development of a subsequent psychiatric disorder."[9] Insomnia occurs in between 60% and 80% of people with depression.[92] This may partly be due to treatment used for depression.[92]
Determination of causation is not necessary for a diagnosis.[91]
DSM-5 criteria
The DSM-5 criteria for insomnia include the following:[93]
Predominant complaint of dissatisfaction with sleep quantity or quality, associated with one (or more) of the following symptoms:
- Difficulty initiating sleep. (In children, this may manifest as difficulty initiating sleep without caregiver intervention.)
- Difficulty maintaining sleep, characterized by frequent awakenings or problems returning to sleep after awakenings. (In children, this may manifest as difficulty returning to sleep without caregiver intervention.)
- Early-morning awakening with inability to return to sleep.
In addition:
- The sleep disturbance causes clinically significant distress or impairment in social, occupational, educational, academic, behavioral, or other important areas of functioning.
- The sleep difficulty occurs at least three nights per week.
- The sleep difficulty is present for at least three months.
- The sleep difficulty occurs despite adequate opportunity for sleep.
- The insomnia is not better explained by and does not occur exclusively during the course of another sleep-wake disorder (e.g., narcolepsy, a breathing-related sleep disorder, a circadian rhythm sleep-wake disorder, a parasomnia).
- The insomnia is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication).
The
Types
Insomnia can be classified as transient, acute, or chronic.
- Transient insomnia lasts for less than a week. It can be caused by another disorder, by changes in the sleep environment, by the timing of sleep, severe depression, or by stress. Its consequences – sleepiness and impaired psychomotor performance – are similar to those of sleep deprivation.[94]
- Acute insomnia is the inability to consistently sleep well for a period of less than a month. Insomnia is present when there is difficulty initiating or maintaining sleep or when the sleep that is obtained is non-refreshing or of poor quality. These problems occur despite adequate opportunity and circumstances for sleep and they must result in problems with daytime function.[95] Hyperarousal can be linked to acute insomnia since it activates the body's fight-or-flight response. When we encounter stress or danger, our bodies naturally become more alert, which can interfere with our capacity to both fall asleep and remain asleep. This heightened state of arousal can be useful in the short term during threatening situations, but if it continues over an extended period, it can result in acute insomnia.[96] Acute insomnia is also known as short term insomnia or stress related insomnia.[97]
- mental fatigue.[94]
Prevention
Prevention and treatment of insomnia may require a combination of cognitive behavioral therapy,[14] medications,[101] and lifestyle changes.[102]
Among lifestyle practices, going to sleep and waking up at the same time each day can create a steady pattern which may help to prevent insomnia.
- Avoiding or limiting naps
- Treating pain at bedtime
- Avoiding large meals, beverages, alcohol, and nicotine before bedtime
- Finding soothing ways to relax into sleep, including use of white noise
- Making the bedroom suitable for sleep by keeping it dark, cool, and free of devices, such as clocks, cell phones, or televisions
- Maintain regular exercise
- Try relaxing activities before sleeping
Management
It is recommended to rule out medical and psychological causes before deciding on the treatment for insomnia.[104] Cognitive behavioral therapy is generally the first line treatment once this has been done.[105] It has been found to be effective for chronic insomnia.[14] The beneficial effects, in contrast to those produced by medications, may last well beyond the stopping of therapy.[106]
Medications have been used mainly to reduce symptoms in insomnia of short duration; their role in the management of chronic insomnia remains unclear.[8] Several different types of medications may be used.[107][108][101] Many doctors do not recommend relying on prescription sleeping pills for long-term use.[102] It is also important to identify and treat other medical conditions that may be contributing to insomnia, such as depression, breathing problems, and chronic pain.[102][109] As of 2022, many people with insomnia were reported as not receiving overall sufficient sleep or treatment for insomnia.[110][111]
Non-medication based
Non-medication based strategies have comparable efficacy to
Non medication based strategies provide long lasting improvements to insomnia and are recommended as a first line and long-term strategy of management. Behavioral sleep medicine (BSM) tries to address insomnia with non-pharmacological treatments. The BSM strategies used to address chronic insomnia include attention to sleep hygiene, stimulus control, behavioral interventions, sleep-restriction therapy, paradoxical intention, patient education, and relaxation therapy.[113] Some examples are keeping a journal, restricting the time spent awake in bed, practicing relaxation techniques, and maintaining a regular sleep schedule and a wake-up time.[109] Behavioral therapy can assist a patient in developing new sleep behaviors to improve sleep quality and consolidation. Behavioral therapy may include, learning healthy sleep habits to promote sleep relaxation, undergoing light therapy to help with worry-reduction strategies and regulating the circadian clock.[109]
Music may improve insomnia in adults (see
Stimulus control therapy is a treatment for patients who have conditioned themselves to associate the bed, or sleep in general, with a negative response. As stimulus control therapy involves taking steps to control the sleep environment, it is sometimes referred interchangeably with the concept of sleep hygiene. Examples of such environmental modifications include using the bed for sleep and sex only, not for activities such as reading or watching television; waking up at the same time every morning, including on weekends; going to bed only when sleepy and when there is a high likelihood that sleep will occur; leaving the bed and beginning an activity in another location if sleep does not occur in a reasonably brief period of time after getting into bed (commonly ~20 min); reducing the subjective effort and energy expended trying to fall asleep; avoiding exposure to bright light during night-time hours, and eliminating daytime naps.[117]
A component of stimulus control therapy is sleep restriction, a technique that aims to match the time spent in bed with actual time spent asleep. This technique involves maintaining a strict sleep-wake schedule, sleeping only at certain times of the day and for specific amounts of time to induce mild sleep deprivation. Complete treatment usually lasts up to 3 weeks and involves making oneself sleep for only a minimum amount of time that they are actually capable of on average, and then, if capable (i.e. when
Paradoxical intention is a cognitive reframing technique where the insomniac, instead of attempting to fall asleep at night, makes every effort to stay awake (i.e. essentially stops trying to fall asleep). One theory that may explain the effectiveness of this method is that by not voluntarily making oneself go to sleep, it relieves the performance anxiety that arises from the need or requirement to fall asleep, which is meant to be a passive act. This technique has been shown to reduce sleep effort and performance anxiety and also lower subjective assessment of sleep-onset latency and overestimation of the sleep deficit (a quality found in many insomniacs).[119]
Sleep hygiene
Sleep hygiene is a common term for all of the behaviors which relate to the promotion of good sleep. They include habits which provide a good foundation for sleep and help to prevent insomnia. However, sleep hygiene alone may not be adequate to address chronic insomnia.[88] Sleep hygiene recommendations are typically included as one component of cognitive behavioral therapy for insomnia (CBT-I).[88][6] Recommendations include reducing caffeine, nicotine, and alcohol consumption, maximizing the regularity and efficiency of sleep episodes, minimizing medication usage and daytime napping, the promotion of regular exercise, and the facilitation of a positive sleep environment.[120] The creation of a positive sleep environment may also be helpful in reducing the symptoms of insomnia.[121] On the other hand, a systematic review by the AASM concluded that clinicians should not prescribe sleep hygiene for insomnia due to the evidence of absence of its efficacy and potential delaying of adequate treatment, recommending instead that effective therapies such as CBT-i should be preferred.[13]
Cognitive behavioral therapy
There is some evidence that cognitive behavioral therapy for insomnia (CBT-I) is superior in the long-term to benzodiazepines and the nonbenzodiazepines in the treatment and management of insomnia.[122] In this therapy, patients are taught improved sleep habits and relieved of counter-productive assumptions about sleep. Common misconceptions and expectations that can be modified include:
- Unrealistic sleep expectations.
- Misconceptions about insomnia causes.
- Amplifying the consequences of insomnia.
- Performance anxiety after trying for so long to have a good night's sleep by controlling the sleep process.
Numerous studies have reported positive outcomes of combining cognitive behavioral therapy for insomnia treatment with treatments such as stimulus control and the relaxation therapies.
Common forms of CBT-I treatments include stimulus control therapy, sleep restriction, sleep hygiene, improved sleeping environments, relaxation training, paradoxical intention, and biofeedback.[126]
CBT is the well-accepted form of therapy for insomnia since it has no known adverse effects, whereas taking medications to alleviate insomnia symptoms have been shown to have adverse side effects.[127] Nevertheless, the downside of CBT is that it may take a lot of time and motivation.[128]
Acceptance and commitment therapy
Treatments based on the principles of
A key distinction between CBT-i and ACT lies in the divergent approaches to time spent awake in bed. Proponents of CBT-i advocate minimizing time spent awake in bed, on the basis that this creates cognitive association between being in bed and wakefulness. The ACT approach proposes that avoiding time in bed may increase the pressure to sleep and arouse the nervous system further.[130]
Research has shown that "ACT has a significant effect on primary and comorbid insomnia and sleep quality, and ... can be used as an appropriate treatment method to control and improve insomnia".[131]
Internet interventions
Despite the therapeutic effectiveness and proven success of CBT, treatment availability is significantly limited by a lack of trained clinicians, poor geographical distribution of knowledgeable professionals, and expense.[132] One way to potentially overcome these barriers is to use the Internet to deliver treatment, making this effective intervention more accessible and less costly. The Internet has already become a critical source of health-care and medical information.[133] Although the vast majority of health websites provide general information,[133][134] there is growing research literature on the development and evaluation of Internet interventions.[135][136]
These online programs are typically behaviorally-based treatments that have been operationalized and transformed for delivery via the Internet. They are usually highly structured; automated or human supported; based on effective face-to-face treatment; personalized to the user; interactive; enhanced by graphics, animations, audio, and possibly video; and tailored to provide follow-up and feedback.[136]
There is good evidence for the use of computer based CBT for insomnia.[137]
Medications
Many people with insomnia use
The percentage of adults using a prescription sleep aid increases with age. During 2005–2010, about 4% of U.S. adults aged 20 and over reported that they took prescription sleep aids in the past 30 days. Rates of use were lowest among the youngest age group (those aged 20–39) at about 2%, increased to 6% among those aged 50–59, and reached 7% among those aged 80 and over. More adult women (5%) reported using prescription sleep aids than adult men (3%). Non-Hispanic white adults reported higher use of sleep aids (5%) than non-Hispanic black (3%) and Mexican-American (2%) adults. No difference was shown between non-Hispanic black adults and Mexican-American adults in use of prescription sleep aids.[141]
Antihistamines
As an alternative to taking prescription drugs, some evidence shows that an average person seeking short-term help may find relief by taking
Antidepressants
While insomnia is a common symptom of depression, antidepressants are effective for treating sleep problems whether or not they are associated with depression. While all antidepressants help regulate sleep, some antidepressants, such as amitriptyline, doxepin, mirtazapine, trazodone, and trimipramine, can have an immediate sedative effect, and are prescribed to treat insomnia.[146] Trazodone was at the beginning of the 2020s the biggest prescribed drug for sleep in the United States despite not being indicated for sleep.[147]
Amitriptyline, doxepin, and trimipramine all have
A 2018
Melatonin agonists
Usage of melatonin as a treatment for insomnia in adults has increased from 0.4% between 1999 and 2000 to nearly 2.1% between 2017 and 2018.[157]
While the use of melatonin in the short-term has been proven to be generally safe and it is shown to not be a dependent medication, side effects can still occur.[158]
Most common side effects of melatonin include:[159]
- Headache
- Dizziness
- Nausea
- Daytime drowsiness
Studies have also shown that children who are on the
Benzodiazepines
The most commonly used class of hypnotics for insomnia are the benzodiazepines.[58]: 363 Benzodiazepines are not significantly better for insomnia than antidepressants.[164] Chronic users of hypnotic medications for insomnia do not have better sleep than chronic insomniacs not taking medications. In fact, chronic users of hypnotic medications have more regular night-time awakenings than insomniacs not taking hypnotic medications.[165] Many have concluded that these drugs cause an unjustifiable risk to the individual and to public health and lack evidence of long-term effectiveness. It is preferred that hypnotics be prescribed for only a few days at the lowest effective dose and avoided altogether wherever possible, especially in the elderly.[166] Between 1993 and 2010, the prescribing of benzodiazepines to individuals with sleep disorders has decreased from 24% to 11% in the US, coinciding with the first release of nonbenzodiazepines.[167]
The
Benzodiazepines all bind unselectively to the GABAA receptor.[164] Some theorize that certain benzodiazepines (hypnotic benzodiazepines) have significantly higher activity at the α1 subunit of the GABAA receptor compared to other benzodiazepines (for example, triazolam and temazepam have significantly higher activity at the α1 subunit compared to alprazolam and diazepam, making them superior sedative-hypnotics – alprazolam and diazepam, in turn, have higher activity at the α2 subunit compared to triazolam and temazepam, making them superior anxiolytic agents). Modulation of the α1 subunit is associated with sedation, motor impairment, respiratory depression, amnesia, ataxia, and reinforcing behavior (drug-seeking behavior). Modulation of the α2 subunit is associated with anxiolytic activity and disinhibition. For this reason, certain benzodiazepines may be better suited to treat insomnia than others.[121]
Z-Drugs
Orexin antagonists
Antipsychotics
Certain
Other sedatives
Gabapentinoids like gabapentin and pregabalin have sleep-promoting effects but are not commonly used for treatment of insomnia.[188] Gabapentin is not effective in helping alcohol related insomnia.[189][190]
Barbiturates, while once used, are no longer recommended for insomnia due to the risk of addiction and other side effects.[191]
Comparative effectiveness
Medications for the treatment of insomnia have a wide range of
Alternative medicine
Prognosis
A survey of 1.1 million residents in the United States found that those that reported sleeping about 7 hours per night had the lowest rates of mortality, whereas those that slept for fewer than 6 hours or more than 8 hours had higher mortality rates. Severe insomnia – sleeping less than 3.5 hours in women and 4.5 hours in men – is associated with a 15% increase in mortality, while getting 8.5 or more hours of sleep per night was associated with a 15% higher mortality rate.[200]
With this technique, it is difficult to distinguish lack of sleep caused by a disorder which is also a cause of premature death, versus a disorder which causes a lack of sleep, and the lack of sleep causing premature death. Most of the increase in mortality from severe insomnia was discounted after controlling for associated disorders. After controlling for sleep duration and insomnia, use of sleeping pills was also found to be associated with an increased mortality rate.[200]
The lowest mortality was seen in individuals who slept between six and a half and seven and a half hours per night. Even sleeping only 4.5 hours per night is associated with very little increase in mortality. Thus, mild to moderate insomnia for most people is associated with increased longevity and severe insomnia is associated only with a very small effect on mortality.[200] It is unclear why sleeping longer than 7.5 hours is associated with excess mortality.[200]
Epidemiology
Between 10% and 30% of adults have insomnia at any given point in time and up to half of people have insomnia in a given year, making it the most common sleep disorder.[9][8][10][201] About 6% of people have insomnia that is not due to another problem and lasts for more than a month.[9] People over the age of 65 are affected more often than younger people.[7] Females are more often affected than males.[8] Insomnia is 40% more common in women than in men.[202]
There are higher rates of insomnia reported among university students compared to the general population.[203]
Society and culture
The word insomnia is from
.The
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