Family doctor

Overview:

• Insomnia affects up to 95 percent of the population at some time in their lives
• Insomnia can take several different forms such as difficulty falling asleep, non-refreshing sleep, or waking too early in the morning
• Causes of persisting insomnia include environmental noise, shift work, stress and depression.
• Behaviour therapy, relaxation, sleep restriction therapy and various medications can be used in the treatment of insomnia
• The long-term use of sleeping pills (benzodiazepine class) for insomnia should be avoided as they can be habit-forming.

What is it?

Insomnia is defined as inadequate or poor quality sleep and includes problems with falling asleep, waking in the middle of the night and not being able to go back to sleep, or waking too early in the morning.

It is estimated insomnia affects up to 95 percent of the population at some time in their lives. About 40 percent of adults will experience some form of insomnia in any one year, with up to 15 percent experiencing severe problems.

Insomnia is more likely in over 60 years olds, women, and when there is a history of depression. The problem is exacerbated when a person becomes anxious about sleep and expects to have trouble sleeping.

The condition can lead to irritability during the day, problems concentrating, fatigue and lack of energy.

There are several different types of insomnia. These include:

Acute insomnia

This is caused by emotional stress, environmental factors (noise, heat), and jet lag. This type of insomnia lasts between one night and a few weeks.

Chronic insomnia

This involves abnormal sleep-wake rhythms and often occurs in relation with other health problems. With chronic insomnia there is difficulty sleeping for at least three nights a week for one month or more.

Insomnia associated with medical or psychiatric disorders

Mental health illness is a common cause of insomnia, with mood and anxiety disorders the most likely to be related to insomnia.

Health conditions such as asthma, gastroesophageal reflux, pregnancy and menopause can also lead to problems with sleeping.

Insomnia associated with medications or drug abuse

Several prescription and non-prescription medicines can cause insomnia. Drugs commonly associated with insomnia include steroids, alcohol, nicotine, caffeine, and recreational drugs such as amphetamines (speed).

Insomnia associated with sleep disorders

Some sleep disorders can cause insomnia and unrefreshing sleep. These include:

• Sleep apnoea - associated with excessive snoring and tiredness during the day.
• Circadian rhythm sleep disorders - these occur when the body's natural sleeping pattern is interrupted such as with shift work or when there is difficulty falling asleep at the desired time and difficulty waking, or going to sleep too early at night and waking too early.
• Restless leg syndrome - this is associated with sensations in the legs or feet and can be accompanied by periodic limb movements and twitching.

Primary insomnia

This is diagnosed when other causes of insomnia have been ruled out. It can be related to severe stress, poor sleeping patterns and over stimulation.

How is insomnia diagnosed?

A sleep diary is useful for obtaining a history of a person's sleeping patterns and what may contribute to the insomnia.

Occasionally, a sleep study in a sleeping laboratory is required when sleep apnoea or narcolepsy (excessive sleeping) is suspected.

What can be done to help?

Several behavioural possibilities to help improve sleep should be tried before considering medication.

Behavioural therapy

This treatment aims to change bad sleeping habits and alter an individual's beliefs and attitudes which may contribute to insomnia.

Relaxation

This is based on the belief that insomniacs find it difficult to properly relax both during the day and at night.

Relaxation therapy aims to teach relaxation techniques that can be used before sleep. These may include breathing techniques, muscle relaxation and meditation to help limit racing thoughts.

Sleep Restriction Therapy

This involves restricting the amount of time spent in bed to the amount of time spent asleep. Therefore, if a person is only sleeping six hours a night, they are initially required to just spend this amount of time in bed. The amount of time spent in bed is increased by 20 to 30 minutes each night until an acceptable level of sleep is achieved. It is better to go to bed later and get up at the same time in order to maintain normal sleeping rhythms. Do not spend any less than five hours in bed.

Drug treatment

Hypnotic medications (sleeping pills) are used in the short-term management of insomnia and may be combined with other psychological therapy. The most commonly used medicines are from the benzodiazepine class. In general, these medicines are prescribed at the lowest dose possible to produce the desired effect. Because of the risk of being habit forming, these medications should not be taken for prolonged periods. A few days is usually fine however.

These medicines should not be used by pregnant women, those with untreated obstructive sleep apnoea and people with a history of substance abuse.

It is common for antidepressants with a sedative action to be used in a low dosage (less than a full antidepressant dose) to help improve sleep, particularly early morning waking.

If the insomnia is due to an underlying clinical depression, treatment of this with full therapeutic doses of an antidepressant can be helpful.

It is worth noting that antidepressants are not habit forming and offer a safe option if medication is needed for a while.

Over the counter sleeping aid products often include antihistamines which have been shown to improve insomnia with short-term treatment.

Melatonin has also been used in the treatment of insomnia. A 5 mg dose of melatonin has been shown to help with sleep in the elderly, shift workers and those with jet lag, however no large studies have been undertaken. The long-term safety of using melatonin has not been established.

Other drugs such as barbiturates and older drugs such as chloral hydrate, methyprylon and meprobamate have been used for insomnia in the past but they are no longer recommended because of their potential for abuse and addiction.

Hints for getting a good sleep:

• Go to bed at the same time each night and wake at the same time
• Do not drink coffee or caffeine drinks up to six hours before bedtime
• Do not smoke before bed or if you wake in the middle of the night
• Do not drink alcohol to try to get to sleep. It may cause you to wake at night
• Avoid heavy meals before bedtime
• Avoid naps during the day
• Avoid exercise up to four hours before bedtime. This can cause over stimulation
• If you can't fall asleep get up and do something else and go back to bed once you feel sleepy
• Make sure the bedroom is dark, silent, and a comfortable temperature

Getting help

If you are experiencing persisting sleep problems, discuss the problem with your doctor.