Insomnia

Symptoms

What does an ideal night's sleep look like for most people?

Ideal sleep is characterized by falling asleep within 20 minutes of going to bed, and limiting wakeful time during the night to 30 minutes or less.

For adults under 65, seven-to-nine hours is a typical night of sleep; seven-to-eight hours is sufficient for adults 65 and older.

Stages of sleep consist of non-rapid eye-movement (NREM) and rapid eye-movement (REM), which occur in 90-minute cycles throughout the night. REM sleep is an activated state with increased breathing and heart rate, although the muscles are paralyzed.  It is associated with dreaming. NREM sleep is a slower state for most body processes, including heart rate and breathing. It is thought to be a time for the body to repair itself. The length of each sleep stage shifts throughout the night, as well as with aging.

When does “difficulty sleeping” become problematic/pathologic?

Insomnia can manifest in a couple of ways: Sleep onset insomnia occurs when someone has difficulty falling asleep. Sleep maintenance insomnia involves struggling with staying asleep through the night or experiencing early waking prior to sufficient sleep.

These kinds of difficulties become problematic when they result in impairment of daytime functioning. The diagnosis is based on the subjective experience of the patient.  

How does insomnia change with age?

Although the definition of insomnia doesn’t change with age, the risk increases. Causes for that change likely include greater frequency of medical conditions, lifestyle shifts, and alterations in circadian rhythm, all of which can contribute to sleep difficulty.

Diagnosis

What are the causes?

Beyond acute stressors leading to short-term insomnia, causes are diverse. Psychiatric conditions correlated with insomnia include depression, anxiety, alcohol and other substance abuse, and PTSD.

Insomnia is also seen in people with lung disease, high blood pressure, diabetes, cancer, chronic pain, heart failure, and Parkinson’s disease. In addition, many medications, alcohol, caffeine, and tobacco have been implicated as causes.

What kind of evaluation should be done?

A sleep history including sleep times, frequency of awakenings, naps, and daytime symptoms helps define the sleep pattern for an individual. That is often done through completing a sleep diary.  

We also encourage evaluation for depression, anxiety, sleep apnea, restless leg syndrome, and any medications or lifestyle factors that may be contributing to insomnia.

When is a sleep study needed?

A sleep study is helpful when sleep apnea (when a person frequently stops breathing during sleep due to intermittent obstruction of the airway) or another sleep disorder is suspected. This does not specifically evaluate insomnia, but rather would identify something disrupting sleep.

What are the long-term consequences?

Chronic insomnia can lead to decreased quality of life, which may include impacts on physical function, cognitive capacity and daytime performance, social relationships, and mood. In addition, it increases the risk of substance abuse, suicidal thoughts, high blood pressure, heart attack, diabetes, and possibly mortality.

Treatment

How is insomnia typically treated?

After addressing any precipitating condition, treatment for insomnia is dependent on the length of symptoms.

Acute insomnia, lasting less than a month, is most often due to physiologic or psychological stress. Treatment starts with discussing the impact of the stressor and strategizing about managing that load. If the impairment of function is severe, two-to-four weeks of medication can help relieve the added stress of being worried about the insomnia.

If the insomnia persists or is chronic, evaluation and treatment with cognitive behavioral therapy (CBT) is the first line of treatment according to all the major sleep organizations. It is the safest long term management strategy.

For those who are severely impaired by the insomnia, medication can be used adjunctively for six-to-eight weeks. In people who do not respond to CBT, medication can be used alone. These are typically benzodiazepines or non-benzodiazepine hypnotics (such as Ativan or Ambien).

How do sleeping pills typically work?

GABA is the brain’s primary inhibitory neurotransmitter (calming brain chemical), and the GABA receptor helps modulate sleep. Sleeping pills work by binding to one part of the GABA receptor in the brain, enhancing the action of GABA.  

Are there downsides to sleeping pills?

The downsides of sleeping pills are significant. Short term use carries risks such as daytime sedation, drowsiness, dizziness, lightheadedness, cognitive impairment, motor incoordination, dependence, and respiratory suppression.

Long-term use may be habit-forming and can lead to rebound insomnia if discontinued. In addition, some people may experience unusual sleep behaviors (for example, eating while not fully awake), memory loss, aggressive behavior, or severe allergic reactions.

If someone is requiring prescription sleep medicine more than a few nights a week, there is probably room for more lifestyle optimization.

How do melatonin supplements work—and are they effective?

Melatonin is a hormone naturally synthesized by the pineal gland in the brain. It is secreted in response to darkness, and levels fall in response to light. Melatonin helps synchronize our circadian rhythm with respect to the light/dark cycle, and it is involved in the regulation of sleep.  Its production naturally declines as we age.

Melatonin as a supplement has the most evidence in jet lag, instances when natural bedtime is too late to get up for daytime responsibilities, shift work, and aging. While melatonin may help at low doses, long-term use hasn’t been well studied.

That said, to date, there is little evidence of long-term harm, although taking this hormone for months to years may influence your body’s own production of melatonin. To try it, start with 0.3-1.0 mg 60 minutes before bedtime, increasing to as much as 5 mg.  

A three-week trial is reasonable to determine response, and a trial off (a break) after one-to-two months of use is recommended. In the case of jet lag, melatonin should be taken 60 minutes before the desired bedtime in the destination time zone.

How effective are herbs and supplements?

Efficacy of herbs and supplements vary by individual and most data is limited. These products do not take the place of lifestyle changes to promote better sleep, but they can be used as an adjunctive. The list of possibilities is long, but here are a few to try:

Magnesium can help reduce the time it takes to fall asleep, as well as help prevent early morning awakening (a typical dose is 400-600 mg). It works by stimulating the GABA receptor, and also by blocking the NMDA receptor, which is related to arousal.

GABA with L-theanine can improve sleep quality and duration. GABA directly binds the GABA receptor, which inhibits excitation of neurons in the brain. Theanine stimulates GABA production (which then binds to GABA receptors), and also blocks an excitatory neurotransmitter, glutamate. Both of these actions calm the brain and are potentially sleep-promoting.  

Glycine at bedtime (generally 3 g) can improve sleep quality. Glycine is an amino acid and acts as an inhibitory neurotransmitter.

Chamomile, either as a tea or tincture, also has evidence showing improved quality of sleep. It binds to multiple parts of the GABA receptor to enhance calming effects in the brain.

In your experience, does individual response to herbs and supplements vary?

Individual response to herbs and supplements is highly variable, and I have seen patients respond well to each of the products mentioned above as well as others, such as sedatives and anxiolytic herbs.

Because of this, I recommend that people try a few different products before giving up. I have seen the best effect with combination formulas including more than one herb or supplement, so that may be a good place to start.

While generally safe, the options can be overwhelming.  Discussing with your provider is wise if you don’t know where to begin or have concerns about impacting other medical problems.  

Are mind-body techniques and/or CBT useful?

Studies have shown that mindfulness-based stress reduction can be as effective as medication for improving insomnia. CBT is useful, and recommended as first line treatment for chronic insomnia.

Prevention (Sleep Hygiene)

How important is sleep environment?

Optimizing sleep environment can play a significant role in reducing insomnia.  

Sleeping in a cool room is helpful. During sleep, core body temperature drops. Research shows that exposure to excessive heat at night can result in increased wakefulness and alteration of sleep cycles.

White noise or earplugs can help minimize sleep disruption for some people. They act to diminish noise peaks and, thus, can reduce both arousal from sleep and the time it takes to fall asleep.  

Studies have shown a reduction in melatonin with late evening and nighttime light exposure. Given this, restricting artificial light at night has the potential to improve natural sleep. Using blackout shades or an eye mask can help keep your light exposure minimal.

What about screen-time?

One of the more significant sources of light at night is particularly problematic. Blue light emitted from screens mimics daylight and, thus, is particularly effective at reducing sleep-inducing melatonin production.

Therefore, minimizing exposure to that blue light for at least two hours prior to bedtime is important. If that isn’t realistic, nighttime mode on all of your screens will help and may be sufficient.

For those who continue to have sleep challenges, using blue light blocking glasses starting at least two hours before bedtime can make a significant difference. This mitigates other exposure to blue light (like general lighting in your home or LED lighting in a refrigerator) during that all-important window before sleep.    

What do you typically recommend for patients with insomnia?

After identifying any specific trigger for an acute bout of insomnia, I start with sleep hygiene. If that is insufficient, I will try herbs or supplements that are appropriate to that individual’s sleep challenges. Short-term medication is my last resort given the risks.

For chronic insomnia, sleep hygiene is still important. Beyond that, I turn to more comprehensive CBT as a primary tool. Herbs or supplements can be a helpful addition, particularly in the beginning. Medication is again my last choice, and if it is needed, I use it short-term while implementing the above measures.

Beyond what you’ve already mentioned, what are some of the most widely applicable sleep hygiene recommendations you make?

• Go to sleep and wake up at the same time every day, weekends included.
• Remove electronic devices from the bedroom, and stop using them at least an hour prior to bed.
• Reserve the bedroom for sleep and sex.
• Establish a bedtime routine which allows wind-down time before lying down.
• Avoid caffeine after lunch.
• Avoid alcohol near bedtime.
• Avoid daytime naps (if you have insomnia).
• If you are on a low carbohydrate diet, add some carbohydrates at dinner.
• Exercise regularly, but at least 4 hours prior to bedtime.
• If you can’t sleep, don’t lie in bed indefinitely. Get out of bed and read a book or magazine until you feel sleepy.

Is there any interesting new research in this area?

A recent study from the Netherlands has identified five different types of insomnia, which may help guide treatment in the future. Work is also being done to look at the genetics behind those with insomnia to hopefully develop better management strategies.

Useful Links

Recommendation against sleep medication as primary therapy (Choosing Wisely)

CBT for insomnia (AASM)

Sample sleep diary (National Sleep Foundation)

Ideal bedroom environment for sleep (National Sleep Foundation)

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