Chronic insomnia has been linked to a variety of mental and physical illnesses. Researchers have found that cognitive behavioral therapy is often effective.
At some point, everyone has had trouble falling asleep, staying asleep or falling back sleep. When this happens more than three nights per week and lasts for at least two weeks, it’s considered acute insomnia.
About 30% of the population is affected, according to Michael Perlis, Ph.D., director of Behavioral Sleep Medicine and associate professor in the Department of Psychiatry and the School of Nursing at the University of Pennsylvania in Philadelphia.
“We are all vulnerable and likely to experience acute insomnia,” Perlis says. “It makes total sense that this would be so. More than likely, sleeplessness is part of the stress response (i.e., the fight-or-flight response).”
However, when these problems persist for longer than three months, the diagnosis changes to chronic insomnia. About 6% to 10% of the population experiences long-term sleep woes and meets the diagnostic criteria for chronic insomnia, as defined by the American College of Physicians.
A clinical guideline from the college points out that individuals with chronic insomnia are often plagued by “fatigue, poor cognitive function, mood disturbance and distress or interference with personal functioning.” The guideline also notes that “an estimated $30 billion to $107 billion is spent on insomnia in the United States each year,” and that insomnia also takes a toll on the economy in terms of loss of workplace productivity.
The Society of Behavioral Sleep Medicine says that sleep disorders and lack of sleep are an “undertreated threat to the public health.” Sleep health professionals have recognized the behavioral components of sleep disorders for decades, according to the society, yet most people with disorders never get a proper diagnosis and treatment.
Insomnia is very common in clinical practice, afflicting as many as half of primary care patients, according to Perlis and the co-authors of a review paper on insomnia, which was published in the Lancet in September 2022. They noted that insomnia can present on its own or in conjunction with a variety of other medical conditions or mental health disorders; if left untreated, it’s a risk factor for the development and exacerbation of the accompanying conditions. In 2016, the American College of Physicians recommended specifically targeting insomnia for treatment.
Allowing insomnia to spiral out of control can have negative consequences on patients’ overall well-being. “Most often, persons are aware of the more immediate effects of insomnia and a poor night’s sleep,” says Andrew Stiehm, M.D., pulmonologist and sleep medicine physician at Allina Health in St. Paul, Minnesota. “This can include difficulty with attention, memory, problem-solving and just functioning at a high level.”
In recent years, insomnia has been shown to increase the risk of suicide. “Being awake at night is a risk factor,” Perlis says. That’s because sleep loss affects daytime mood and cognition.
The incidence of insomnia is 1.4 times higher in women than in men, according to Adriane Soehner, Ph.D., an assistant professor of psychiatry at the University of Pittsburgh School of Medicine. Sex differences in insomnia become more extreme during the transition to menopause, particularly among women who experience hot flashes and night sweats. Insomnia also becomes more prevalent with age, affecting as many as one in five older adults. Additionally, rates of insomnia have been steadily rising among military personnel and veterans, with as many as 1 in 4 being affected, Soehner notes.
Cognitive behavioral therapy
Regardless of insomnia’s root cause, cognitive behavioral therapy for insomnia (CBT-I) is recommended as the first-line treatment, according to Perlis. Research and clinical experience have shown that CBT can help treat problems ranging from depression to eating disorders to martial problems. CBT-I focuses on reducing behaviors and thinking patterns that make sleep difficult, such as excessive worry about falling asleep.
More studies are finding that managing insomnia may help prevent or ameliorate other health conditions. For example, a randomized clinical trial published in JAMA Psychiatry in January 2022 showed that treatment of insomnia with CBT-I reduced the risk of incidence and recurrence of major depression in older adults. Another study that was published in JAMA Psychiatry in June suggested that CBT-I might help with alcohol use disorder.
With the growing recognition that sleep is foundational to good health, the demand for professionals trained in sleep diagnosis and treatment is increasing, according to Krishna M. Sundar, M.D., medical director of the Sleep-Wake Center and clinical professor of pulmonary, critical care and sleep medicine at the University of Utah School of Medicine in Salt Lake City. For the same reason, education about sleep is being incorporated into the medical curricula of different health disciplines, Sundar says. “There needs to be consistent reinforcement of better sleep behaviors and identification of common sleep problems, such as sleep apnea and insomnia, during clinic visits at the primary care and specialist levels.”
Good sleep habits (or sleep hygiene) can help improve sleep health, according to the Centers for Disease Control and Prevention (CDC). It’s important to be consistent by going to bed at the same time every night and getting up at the same time each morning, including on the weekends.
The CDC also recommends maintaining a quiet, dark and relaxing bedroom at a comfortable temperature. Other sleep strategies include removing electronic devices, such as televisions, computers and smartphones, from the bedroom and avoiding large meals, caffeine and alcohol before bedtime. Also, fitting some exercise into a daily routine can make it easier to fall asleep at night.
Medications are controversial
Long-term treatment of insomnia with medications is controversial. “Currently, there is no global consensus regarding which pharmacological treatment has the best efficacy or risk-benefit ratio,” Perlis and his colleagues wrote in the Lancet review paper. Both CBT-I and pharmacological intervention are thought to have similar acute effects, but only CBT-I has been shown to have durable long-term effects after treatment discontinuation, they noted.
For patients who do not respond to CBT-I alone, hypnotic medications are recommended for short-term management of insomnia, according to Soehner.
Classes of drugs approved for insomnia by the FDA include nonbenzodiazepine hypnotics benzodiazepines, selective histamine antagonists, melatonin receptor agonists, and hypocretin/orexin receptor antagonists. Some substances, especially benzodiazepines, may lead to tolerance, dose increase, abuse and dependency, according to Dieter Riemann, Ph.D., co-author of the Lancet review paper and head of clinical psychology and psychophysiology at University Medical Center Freiburg in Germany.
In the field of insomnia research, “the role of medications is one of the big areas of controversy” comments Stiehm at Allina. Although medications can be effective, they also can have negative consequences, ranging from morning sleepiness to an increased risk of automobile accidents and nighttime falls, he says.
Many people take trazodone, an antidepressant, off-label for insomnia. Melatonin and a variety of over-the-counter sleep aids are also popular. For supplements containing melatonin, a hormone the brain produces in response to darkness, the recommended dose is 1 to 3 mg around bedtime. Some people, though, rely on an excessive amount or take melatonin in the middle of the night, which makes them groggy the next day. Soehner says cannabis and CBD products are becoming popular as sleep aids, although she warns that research-based efficacy data are scarcer than for melatonin.
Susan Kreimer is a healthcare journalist in New York.