Insomnia
OVERVIEW
Insomnia is a sleep disorder which is characterized by an inability to initiate or maintain sleep.[1] According to the National Sleep Foundation, the average American adult gets 6.9 hours of sleep on weeknights and 7.5 hours on weekends. Approximately 70 million Americans sleep poorly, and for more than half, it's a long-term problem.[2]
Often debilitating, insomnia is exhibited with one or more of the following behaviors:
Difficulty falling asleep.
Waking up often during the night and having trouble going back to sleep.
Waking up too early in the morning.
Having sleep that is not refreshing.[3]
This common sleep disorder can make it difficult to fall asleep or remain staying asleep, or cause you to wake up too early and not be able to get back to sleep. These actions lead to one becoming chronically tired; insomnia depletes one’s energy level, mood, health, work performance and quality of life.[4] Excessive daytime sleepiness characteristically results in functional impairment throughout the day.[5] Even in the short term, insomnia causes difficulty concentrating and lowers cognitive ability. Further, insomnia lessens physical coordination leading to a higher likelihood of falling or having a road accident.[6] Chronic, long-term sleep disorders affect millions of Americans each year. Thus, sleep disorders account for an estimated $16 billion in medical costs each year, plus indirect costs due to missed days of work, decreased productivity, and other work-related economic factors.[7]
A highly complex function, sleep is essential for health and life, providing rest and restoration for mind and body. Sleep is divided into two major phases: rapid eye movement (REM) sleep and non-rapid eye movement (non-REM) sleep. Those experiencing optimal sleep fall asleep quickly, usually within 15 minutes. Non-REM sleep transitions gradually from light sleep (Stage 1) to deep sleep (Stage 4). During non-REM sleep, the mind and circulatory system slow down as heart rate and blood pressure fall; breathing slows and steadies and muscles relax. Sleep then shifts into REM phase after about 45 to 60 minutes. Although the eyes remain closed, they move rapidly in all directions. In contrast, the limb muscles are completely limp and immobile. Breathing is very slow and may even pause briefly. The brain is activated during this phase; dreaming occurs only during REM sleep. Although the body is entirely relaxed, the heart rate and blood pressure fluctuate from low to high; the heart pumps less blood to the body but more to the brain. The sympathetic nervous system is active, stimulating production of the stress hormone adrenaline. After about 30 to 45 minutes, sleep shifts back from REM to the non-REM pattern. The two states continue to alternate, with four to six 90- to 110-minute cycles occurring during the course of a typical night's sleep.
While most middle-aged people function best on seven to nine hours of sleep, primary importance is on the quality, not the quantity, of sleep one experiences. Sleep requirements change during the course of a lifetime; most children need more sleep, most older adults, less.
Incredibly complex, the body responds to a 24-hour circadian rhythm, responding to cycles of light and darkness. Sleep-wake cycle and several other bodily functions cycling throughout a day. For example, normal body temperature is lowest at about 5 a.m., when it averages 97° F, and highest at about 5 p.m., when it averages 99.4° F. Similarly, sodium excretion and urine output are normally higher during the day than at night. Hormone levels fluctuate with cortisol secretion highest during the morning; testosterone production peaks in the morning, growth hormone at night. Further, melatonin produced by the brain's pineal gland during the night.[8] Disruptions in the body’s normal sleep-cycle can result in bouts of acute or chronic insomnia.
SYMPTOMS
One of the most common sleep complaints, insomnia leads to sleepiness during the day, general tiredness, irritability, and problems with concentration or memory.[9] 33% of adults suffer from acute insomnia, characterized by fitful sleep lasting a few days at a time.[10] Acute insomnia lasts less than four weeks and can be linked to a specific cause such as stress or trauma.[11] Conversely, chronic insomnia plagues one-in-ten adults. This form of insomnia is characterized by ongoing difficulty sleeping three of more nights a week for over a month and lasts for at least six months.[12] Without an easily identifiable cause, chronic insomnia is believed to be perpetuated over time by changes in behaviors, cognitions, and associations that patients make as they attempt to compensate for poor sleep. Co-morbid insomnia accounts for the majority of chronic insomnia cases.[13]
Insomnia may be the primary problem, or it may be co-morbid and associated with other medical conditions or medications.
Insomnia symptoms may include[14]:
Difficulty falling asleep at night
Waking up during the night
Waking up too early
Not feeling well-rested after a night's sleep
Daytime tiredness or sleepiness
Irritability, depression or anxiety
Difficulty paying attention, focusing on tasks or remembering
Increased errors or accidents
Ongoing worries about sleep
Snoring, restless sleep, and morning headaches are indicators of sleep apnea, which is most common in overweight men, particularly in those with necks measuring 17+ inches. While most people experience short pauses in breathing during REM sleep, individuals with sleep apnea stop breathing for longer periods. Sleep becomes so fragmented that daytime sleepiness is experienced at a level of diagnosed insomniacs. Over time, sleep apnea increases the risk of hypertension, heart disease, and stroke. However, effective treatments for obstructive sleep apnea exist and range from weight loss, utilizing a nighttime breathing mask and corrective surgery.[15]
CAUSES
Insomnia can be caused by a multitude of factors which translate into acute (short-term) or chronic (long-term) sleep-loss.[16,17]
Causes of acute insomnia can include:
Significant types of life stressors (e.g. job loss or change, death of a loved one, or moving)
Illness (e.g. seasonal cold or flu)
Stimulants such as caffeine and nicotine
Medications, including decongestants, bronchodilators, certain antidepressants, steroids, beta blockers, and diuretics. Improper use of sleeping pills can cause rebound insomnia.
Emotional or physical discomfort
Environmental factors such as noise, light, or extreme temperatures (hot or cold) that interfere with sleep
Occurrences interfering with a normal sleep schedule (e.g. jet lag or switching from a day to night shift)
Causes of chronic insomnia include:
Psychological conditions, including depression, anxiety or generalized anxiety disorder (GAD), chronic stress, post-traumatic stress disorder (PTSD), and over-stimulation or overload
Medical illnesses, including gastroesophageal reflux, chronic obstructive lung disease and asthma, congestive heart failure, hot flashes, arthritis and other causes of chronic pain, benign prostatic hyperplasia (BPH) and other urinary conditions, and overactive thyroid
Sleep disorders, including obstructive sleep apnea, periodic limb movement disorder, and restless legs syndrome
Neurological disorders, including Parkinson's disease, strokes, and dementia
Associated conditions
Chronic insomnia can have significant systemic health impacts, both raising the risk of certain health problems while making existing conditions worse.
The NIH and Harvard Health list several of these conditions, including[18,19]:
Breathing problems such as asthma
Heart problems such as arrhythmia, heart failure, coronary heart disease, and high blood pressure (raising the risk of heart attack and stroke.)
Mental health conditions such as anxiety, depression, and thoughts of suicide. Insomnia can also increase difficulty of maintaining treatment for a substance use disorder.
Pain. People who have chronic pain and insomnia may become more aware of, and distressed by, their pain.
Pregnancy complications such as increased pain during labor, preterm birth and low birth rate, and increased likelihood of required cesarean section.
Problems with your immune system. Immune issues can lead to inflammation as well as increase difficulty in fighting infections.
Problems with your metabolism. Sleep deprivation decreases levels of leptin, a satiety-promoting hormone, and boosts levels of ghrelin, an appetite-promoting hormone. This can raise the risk of overweight and obesity, metabolic syndrome, and diabetes.
While medications for co-morbid conditions may perpetuate insomnia, the sleep disorder may actually worsen the following co-morbid conditions or intensify their symptoms:
Brain disorders, such as Alzheimer’s disease, dementia, epilepsy, Parkinson’s disease, and traumatic brain injuries
Chronic (long-term) pain
Heart and lung diseases, such as asthma and heart failure
Mental health conditions, such as anxiety, depression, substance use disorder, and post-traumatic stress disorder (PTSD)
Other sleep disorders, such as restless leg syndrome, sleep apnea, and circadian rhythm disorders
Other health conditions, such problems with digestion, problems with your thyroid hormones
DIAGNOSIS
If you suspect you have insomnia, it may be helpful to keep a sleep diary for one to two weeks before seeing your doctor. Sleep diaries typically include records of: when you go to bed, wake and take naps as well as how fatigued you feel. Time and amount of alcohol and caffeine consumed as well as duration and type of exercise is also recorded in a sleep diary. To reference what a typical sleep diary looks like, the National Heart, Lung and Blood Institute (NHLBI) offers a printable sleep diary.
To diagnose insomnia, doctors will utilize the patient’s sleep diary, examine their medical history and may order one of more of the following tests[20]:
Sleep studies confirm or rule-out other sleep problems, such as circadian rhythm disorders, sleep apnea and narcolepsy.
Actigraphy utilizes a small motion sensor for three to 14 days and measures how well a person sleeps.
Blood tests check for thyroid issues or other medical conditions which affect sleep.
Classifications
Insomnia is classified in the following ways:
Whether it is associated with another condition or occurs as a primary condition (e.g. primary or secondary/co-morbid insomnia)
Duration of occurrence (e.g. acute or chronic)
Primary insomnia is defined when someone has sleep problems that are not directly associated with any other health condition or problem.[21] Prior to a 2005 National Institutes of Health (NIH) state of the science conference, insomnia was defined as primary or secondary.[22,23] If insomnia symptoms were related to another physical or psychologic condition, that condition was considered the primary diagnosis and insomnia deemed the secondary diagnosis.[24] Thus, treatment focused on the primary diagnosis, assuming successful treatment of the primary condition would resolve the secondary insomnia. Currently, no evidence supports this assumption, and in the case of depression, some evidence suggests that treating the primary condition does not result in remission of insomnia.[25]
Secondary (co-morbid) insomnia is defined when a person is having sleep problems because of another factor, such as an ongoing health condition (e.g. asthma, depression, arthritis, cancer, or heartburn) side effect of a medicine or substance consumed (such as alcohol.)[26]
Prevalence studies have estimated that secondary insomnia accounts for up to 90% of insomnia cases.[27,28] The NIH conference recommended that the term “secondary” be dropped in favor of the term “co-morbid.” This recommendation was made for several reasons. First, when insomnia co-occurs with another condition, it can be difficult to establish which condition is causing the other. Additionally, the relationship between insomnia and some conditions is likely to be reciprocal in nature (e.g. pain contributes to poor sleep and vice versa). Second, the factors that perpetuate insomnia over time often are different from those that precipitated it in the first place. (e.g. poor sleep may begin in response to cardiac disease but is maintained over time by the behaviors such increased caffeine use and worried thought patterns patients develop in an attempt to cope with their sleep difficulties. Finally, when insomnia is deemed to be secondary, it is unlikely to receive direct treatment. Conceptualized as “secondary” is problematic since effective treatment of chronic insomnia often requires direct intervention to correct the behaviors, thought patterns, and associations that maintain it.[29]
Co-morbid insomnia does not have to be caused by or change with the co-existing disorder. Most cases of insomnia belong to this category. Sometimes, having insomnia can make the underlying medical or psychiatric condition worse and hinder its treatment. For example, people with depression and insomnia do not respond as well to depression treatment as depressed people without insomnia.[30]
Co-morbidity between chronic insomnia and depression or anxiety is high and insomnia is a risk factor for both.[31,32] Controlling for psychologic disorders and other sleep disorders, chronic insomnia is also highly co-morbid with most major medical conditions such as hypertension, cardiovascular events and sleep-disordered breathing (SDB.)[33]
Acute insomnia is short-term and can range in duration from one night to a few weeks. This form of insomnia is often a direct result of a stressful experience or trauma (e.g. the loss of a job, death of a loved one, environmental disaster, etc.)[34]
Chronic insomnia is diagnosed when a person suffers from ongoing insomnia. The CDC defines chronic insomnia lasting at least three nights a week for a month or longer.[35] The NIH, however, has more stringent requirements for this classification and seems insomnia as chronic when it is experienced for a minimum of six months.
Chronic insomnia is the most common sleep disorder, affecting 6% to 10% of adults in the general population, with even higher rates in patients with co-morbid conditions (e.g. hypertension, 44%; cardiac disease, 44.1%; breathing problems, 41.5%). Traditionally, chronic insomnia occurring with another condition has been considered secondary and rarely received direct treatment because treatment of the primary condition was expected to improve the insomnia. This methodology often failed because chronic insomnia is maintained by behaviors, cognitions, and associations that patients adopt as they attempt to cope with poor sleep but actually hinder improvement (e.g. increasing caffeine, spending more time in bed and trying harder to sleep).[36]
A further way of classify insomnia is whether or not it is psychophysiological. This form of insomnia is one of the most-common classifications; characterized as being "mind-body insomnia,” this is a sleep disorder of learned, sleep-preventing associations, such as not being able to sleep because either your body or your mind is not relaxed. Persons with this form of insomnia usually have excessive, ongoing concerns about not being able to fall or stay asleep when desired and worry that their efforts to fall asleep will be unsuccessful. Stress is the most common cause of psychophysiological insomnia. While sleep problems are common when experiencing a stressful time period, some people continue to have sleep problems long after the stressful event is over. A cyclical pattern of stress and sleeplessness occur, resulting in ongoing psychophysiological insomnia. Individuals with this condition may sleep better when not in their own beds.[37]
PREVALENCE
Statistically, certain cohorts are more-likely to experience insomnia than others. General estimates vary depending on the criteria used to define insomnia, and prevalence rates tend to decrease as the stringency of the criteria increases.[38] Thirty percent of adults have insomnia when defined as reporting at least one insomnia symptom.[39] When daytime impairment or distress is a required criterion, prevalence drops to 10%.[40] When the most stringent diagnostic criteria are applied,[41] prevalence remains substantial, but further drops to about 6% of adults.[42,43]
Overall, sex, age, and health and mental conditions appear to be the most significant risk factors for insomnia.[44,45] Older age has been associated with increased risk of insomnia.[46,47] However, research suggests that age itself is not the risk; instead, the risk is related to inactivity, sleep changes, decreased social activities, and increases in health conditions associated with aging.[48,49] Women are at least two times more likely to have insomnia than men,[50] and an increased prevalence of insomnia has been seen in adolescent girls compared with boys of the same age.[51] The presence of a health or mental condition increases the risk, with insomnia seen in 37.8% of individuals with a co-morbid condition but in only 8.4% of those without a co-morbid condition.[52] Although there are numerous epidemiologic studies of insomnia, criteria for insomnia classification are highly varied among these studies.
The few studies examining racial differences in prevalence have reported rates of 16.4% to 28.3% in whites, 15.3% to 23.7% in blacks, and 13.4% to 17.1% in Hispanics.[53] Further, when separated into age categories, blacks appear to have a greater prevalence of insomnia in middle age (30-59 years), whereas whites have a greater prevalence of insomnia across the life span.[54]
Additionally, prevalence studies have estimated that secondary insomnia accounts for up to 90% of insomnia cases.[55,56]
THEORETICAL MODEL OF INSOMNIA
The most commonly used model in understanding the development of chronic insomnia includes predisposing conditions, precipitating circumstances, and perpetuating factors (3-P model)[57] In this theoretical model, predisposing conditions do not produce chronic insomnia; they precede the onset and increase the likelihood of its occurrence. For example, anxious personality traits may result in hyperarousal, predisposing a person to sleep problems. Precipitating circumstances co-occur with the onset of acute insomnia (e.g. stressful personal events and declines in health). According to this theory, insomnia is maintained by perpetuating factors, which include the changes in daytime behaviors, cognitions, or sleep/wake schedules that patients adopt to compensate for poor sleep. The development of chronic insomnia occurs with a combination of predisposing (e.g. anxious personality type) and precipitating factors (e.g. cardiac disease). Over time, a feedback loop of perpetuating factors may develop, maintaining or even exacerbating one’s insomnia. Predisposing and precipitating factors of insomnia decline as perpetuating factors exert a more direct impact on a nightly basis. These perpetuating factors are targeted during the course of cognitive behavioral treatment of insomnia (CBT-I).
Associations
As patients experience sleep problems over time, they may begin to associate bed, bedtime, and the bedroom environment with difficulty falling asleep.[58] After repeated negative experiences, typical sleep cues morph into cues for arousal. Spending an excessive amount of wakeful time in bed (during the night, while attempting to sleep in during the morning, or during the day) is a common response to poor sleep. This additional wake time strengthens the association between the bed/bedroom and wakefulness, anxiety, and frustration.
Cognitions
Cognitive distortions related to sleep are related to elevated emotional arousal and worsening sleep problems.[59] Negative beliefs, attitudes, and interpretations related to sleep problems exacerbate and maintain insomnia by stimulating the sympathetic nervous system and increasing arousal. Worries about sleep, physical health, or other stressors may increase both cognitive and physiologic arousal, perpetuating one’s insomnia.[60]
These factors highlight the need to change one’s cognitive distortions to diminish insomnia; cognitive behavioral therapy is therefore an effective a primary line of treatment.
TREATMENT OPTIONS
Health care providers may recommend any of the following treatments for insomnia: use cognitive-behavioral techniques, implementing lifestyle changes and pharmacologic with the use of sedative-hypnotic or sedating antidepressant medications.[61]
Cognitive-Behavioral Therapy
Cognitive behavioral therapy for insomnia (CBT-I) is a structured program that helps you identify and replace thoughts and behaviors that cause or worsen sleep problems with habits that promote sound sleep. CBT-I can help people who have primary insomnia as well as people with physical problems, such as chronic pain, or mental health disorders, such as depression and anxiety.[62] Usually recommended as the first line of treatment for chronic insomnia, CBT-I is a 6- to 8-week detailed treatment plan to help you learn how to fall asleep faster and stay asleep longer.[63]
Key benefits of this modality to combat insomnia are the lack of side effects experienced by many sleep medications as well as increased duration of efficacy since CBT-I helps you overcome the underlying causes of your sleep problems.[64] Further, because CBT-I does not carry the risks associated with some sleep medications (e.g. dependency, polypharmacy, cognitive and psychomotor impairment), it is an attractive option for patients with co-morbid conditions.[65]
CBT-I can be conducted in person, via telephone or telehealth. The cognitive part of CBT-I teaches you to recognize and change beliefs that affect your ability to sleep. This type of therapy can help you control or eliminate negative thoughts and worries that keep you awake. The behavioral part of CBT-I helps you develop good sleep habits and avoid behaviors that keep you from sleeping well.
Depending on your needs, your sleep therapist may recommend some combination of the following CBT-I techniques[66-69]:
Stimulus control therapy. This method helps remove factors that condition your mind to resist sleep. For example, you might be coached to set a consistent bedtime and wake time and avoid naps, use the bed only for sleep and sex, and leave the bedroom if you can't go to sleep within 20 minutes, only returning when you're sleepy.
Sleep restriction. Lying in bed when you're awake can become a habit that leads to poor sleep. This treatment reduces the time you spend in bed, causing partial sleep deprivation, which makes you more tired the next night. Once your sleep has improved, your time in bed is gradually increased.
Sleep hygiene. This method of therapy involves changing basic lifestyle habits that influence sleep, such as smoking or drinking too much caffeine late in the day, getting enough light/sunlight during the day, drinking too much alcohol, or not getting regular exercise. It also includes tips that help you sleep better, such as ways to wind down an hour or two before bedtime.
Sleep environment improvement. This offers ways that you can create a comfortable sleep environment, such as keeping your bedroom quiet, dark and cool, not having a TV in the bedroom, and hiding the clock from view.
Relaxation training. This method helps you calm your mind and body. Approaches include listening to soothing music, meditation, imagery, muscle relaxation and others.
Remaining passively awake. Also called paradoxical intention, this involves avoiding any effort to fall asleep. Paradoxically, worrying that you can't sleep can actually keep you awake. Letting go of this worry can help you relax and make it easier to fall asleep.
Biofeedback. This method allows you to observe biological signs such as heart rate and muscle tension and shows you how to adjust them. Your sleep specialist may have you take a biofeedback device home to record your daily patterns. This information can help identify patterns that affect sleep.
Given that multiple factors can contribute to insomnia, using a multi-component approach such as CBT-I enhances the likelihood that one or more of the treatment elements will target the factors contributing to a patient’s poor sleep. CBT-I has been shown to be more effective than stand-alone treatments[70] and to provide a more durable treatment response than medication.[71] There is considerable evidence for the effectiveness of CBT-I across patient populations. For example, CBT-I has been found to produce clinically significant improvement in insomnia symptoms in patients with breast cancer, chronic pain, fibromyalgia, and other medical co-morbidities.[72,73] Additionally, behavioral interventions have been shown to be effective for middle-aged and older adults and older caregivers, populations in which co-morbid medical conditions are more likely (e.g. SDB, hypertension, cardiac disease).[74]
For some populations, the standard CBT-I recommendations should be tailored. For example, among caregivers for individuals with dementia, standard CBT-I recommendations have been combined with stress management, linkage to community resources, management of problem behaviors in patients with dementia, and communication skills.[75] Some empirical evidence[76,77] suggests that concurrent medical treatment of SDB and psychologic treatment of chronic insomnia can result in clinically significant improvements in both conditions. However, these two studies had relatively small samples sizes and lacked true control groups. When addressing insomnia co-morbid with symptoms of another psychologic disorder, it may be appropriate to pursue adjunctive treatment of both conditions.[78]
Medications
In cases of acute insomnia, medication can often help one sleep. However, these medications are not medically advised for long-term/chronic treatment of insomnia. A negative component to many sleep medicines are the causation of side effects, such as low blood pressure, anxiety, and nausea. It is important to note these medicines also may become less effective as your body gets used to them and withdrawal symptoms may arise upon cessation.[79]
Further, some insomnia medicines can be habit-forming and may cause dizziness, drowsiness, or worsening of depression or suicidal thoughts. All of the medicines listed below may cause insomnia. Before starting any medication for insomnia, please talk to your doctor about the benefits and side effects of these prescriptions and only take them under the direct supervision of your physician.[80]
Harvard Health recommends the following basic guidelines regarding sleep medications[81]:
Use medication only as a backup to behavioral changes.
Use the lowest dose that is effective.
Don't take a pill every night. Instead, use medication only when an uninterrupted night's sleep is really important. Even then, restrict yourself to two to four tablets per week.
Try to stop using medication after three to four weeks.
Discontinue medication gradually to avoid rebound insomnia.
Your doctor will decide if you need a sleeping medication, then determine which drug is best for you and instruct you in its proper use, precautions, and potential side effects. The FDA has recently required stronger warnings about daytime sedation, untoward behavior such as sleep-driving, and allergic reactions. Many medications are available. The older barbiturates and sedatives have been almost entirely replaced by safer and more effective drugs. Certain antidepressants can help promote sleep, particularly if depression is also present. Examples include trazodone (Desyrel), doxepin (Sinequan and Adapin) and amitriptyline (Elavil and others). But doctors today usually choose among three groups of medications:
Benzodiazepines: Temazepam (Restoril), oxazepam (Serax), estazolam (ProSom), and many others. These older drugs were once the mainstays of insomnia therapy. But excessive use can be habit forming, and some of the longer-acting preparations can cause daytime sedation.
Nonbenzodiazepines: Eszopiclone (Lunesta), zaleplon (Sonata), zolpidem (Ambien). These newer medications act on the same receptor in the brain as the benzodiazepines, but they tend to act more quickly and to leave the body faster. They are less likely to cause daytime sedation, habituation, and rebound insomnia.
Melatonin receptor agonist: Ramelteon (Rozerem). This medication acts on the same brain receptors as the hormone melatonin. It is fast acting but very short lasting. It does not appear to cause habituation or rebound insomnia.
Over-the-Counter Medicines and Supplements
Some over-the-counter (OTC) products that contain antihistamines are sold as sleep aids. Although these products might make you sleepy, talk to your doctor before taking them as antihistamines can be unsafe for some people and may not be the best treatment for your insomnia.[82] Most sleep experts discourage the use of antihistamines such as diphenhydramine or doxylamine as a sleep aid, particularly for long-term use. Side effects include daytime sedation, dry mouth, constipation, and difficulty urinating. A number of dietary supplements are heavily promoted to improve sleep. However, none are subject to FDA standards for purity, safety, or effectiveness.[83]
Melatonin supplements are lab-made versions of the sleep hormone melatonin. While melatonin supplements are a popular sleep-aid, and may be helpful for some people with acute insomnia or sleep problems caused by shift work or jet lag, research has not proven that melatonin is an effective treatment for insomnia.[84] Side effects of melatonin may include daytime sleepiness, headaches, upset stomach, and worsening depression. It can also affect your body's control of blood pressure, leading to hypertension or hypotension.[85]
Various herbs and dietary supplements sometimes used as sleep aids, including valerian, kava, chamomile, and L-tryptophan and 5-hydroxytryptophan (5-HTP) have not been shown to be effective for insomnia, and important safety concerns have been raised about a few. For example, the use of L-tryptophan supplements has been linked to eosinophilia-myalgia syndrome (EMS), a complex, potentially fatal disorder with multiple symptoms including severe muscle pain. Kava supplements have been linked to a risk of severe liver damage.[86]
Talk to your doctor before using dietary supplements as they may be beneficial to your health, but can also pose serious negative health risks.
Other Treatment Methods
Your doctor may recommend that you use light therapy to set and maintain your sleep-wake cycle. With this treatment, you plan time each day to sit in front of a light box, which produces bright light similar to sunlight.[87]
Current evidence regarding other mind and body approaches such as mindfulness-based stress reduction (a type of meditation), yoga, massage therapy, and acupuncture is either too preliminary or inconsistent to draw conclusions about whether they are helpful for sleep disorders. These mind and body practices are generally considered safe for healthy people and when performed by an experienced practitioner.[88]
If you are considering a complementary health approach for sleep problems, talk to your health care providers. Trouble sleeping can be an indication of a more serious condition, and some prescription and over-the-counter drugs can contribute to sleep problems. It is important to discuss your specific sleep-related symptoms with a health care provider before trying any complementary health product or practice.[89]
For more information, click here to access an interview with Psychiatrist David Neubauer regarding Insomnia & Anxiety.
Contributed by: Jennifer (Ghahari) Smith, Ph.D.
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24 Ibid.
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33 Williams J, Roth A, Vatthauer K, McCrae CS. (2013)
34 “Key Sleep Disorders: Insomnia,” Centers for Disease Control and Prevention (CDC)
35 Ibid.
36 Williams J, Roth A, Vatthauer K, McCrae CS. (2013)
37 “Key Sleep Disorders: Insomnia,” Centers for Disease Control and Prevention (CDC)
38 Lichstein KL, Taylor DJ, McCrae CS, Ruiter ME. Insomnia: epidemiology and risk factor. In: Kryger MH, Roth T, Dement WC, eds. Principles and Practice of Sleep Medicine. 5th ed St. Louis, MO: Saunders; 2011:827-837.
39 Ancoli-Israel S, Roth T. Characteristics of insomnia in the United States: results of the 1991 National Sleep Foundation Survey. I. Sleep. 1999;22(suppl 2):S347-S353.
40 National Institutes of Health. State of the science conference statement on manifestations and management of chronic insomnia in adults, June 13-15, 2005. Sleep. 2005;28(9):1049-1057.
41 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR®). Washington, DC: American Psychiatric Association; 2000
42 Lichstein KL, Taylor DJ, McCrae CS, Ruiter ME. (2011)
43 Ohayon MM. Prevalence of DSM-IV diagnostic criteria of insomnia: distinguishing insomnia related to mental disorders from sleep disorders. J Psychiatr Res. 1997;31(3):333-346.
44 National Institutes of Health. (2005)
45 Klink ME, Quan SF, Kaltenborn WT, Lebowitz MD. Risk factors associated with complaints of insomnia in a general adult population. Influence of previous complaints of insomnia. Arch Intern Med. 1992;152(8):1634-1637.
46 Ibid.
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82 “Insomnia,” NIH: National Heart, Lung and Blood Institute
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87 “Insomnia,” NIH: National Heart, Lung and Blood Institute
88 “5 Things to Know About Sleep Disorders and Complementary Health Approaches,” NIH: National Center for Complementary and Integrative Health
89 Ibid.