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What is Insomnia?

Insomnia is said to be defined as difficulty falling asleep or staying asleep, even when the person has the chance to do so.  People with insomnia can feel dissatisfied with their length and/or quality of sleep and it can end up affecting them throughout the rest of the day.  Insomnia has several patterns in the way that it can affect patients.  You may have trouble getting to sleep initially (Initial Insomnia/delayed sleep latency).  Even if you can fall asleep easily, you may not be able to stay asleep as long as desired (Terminal Insomnia).  Lastly, you may be waking throughout the night and not be able to get back to sleep as soon as you would like (Middle Insomnia/Sleep Maintenance Insomnia). 

While only one type of symptom is necessary to cause issues many patients will present with multiple symptoms patterns at the same time.  Diagnosis of insomnia must include some of these symptoms but condition must also affect the person throughout the day.  Having a sleep experience that does not meet our expectation, but we have good daytime functioning, does not constitute insomnia.

Insomnia is classified into acute and chronic conditions.  Acute insomnia will meet the above criteria but with symptoms lasting for less than 4 weeks.  Generally, acute insomnia is triggered by a specific event and treatment is geared towards withdrawal of the precipitating factor.

Chronic insomnia presents once the symptoms have been present for more than 4 weeks.  This can evolve in patients with recurrent cases of acute insomnia or in patients with co-morbidities that contribute to the condition.  Chronic insomnia treatment protocols are geared more towards a chronic disease management model of relapse and remission rather than resolution.

How sleep works

The ability to sleep is primarily linked to two processes within the body, one called homeostatic sleep drive and the other being the circadian rhythm. 

The Homeostatic Sleep Drive

The homeostatic sleep drive is the gradual desire a person feels to sleep that builds the longer that person stays awake.   It relates to the gradual accumulation of a chemical within the brain called adenosine, otherwise known as a neurotransmitter.   This neurotransmitter eventually helps to initiate sleep; during sleep, it's cleared away so that midway through the night, the desire for sleep is reduced or depleted. By morning, the desire (and a decent proportion of adenosine) should be gone. 

The Circadian Rhythm

The circadian rhythm is any biological process that displays an endogenous, trainable oscillation of approximately 24 hours.  This may not sound too important however it starts by being behind the sleeping and feeding patterns of all animals, including humans.  There are also clear patterns for core body temperature, brain wave activity, hormone production, cell regeneration, and other biological activities.  Our circadian rhythm is produced from a small cluster of cell within the hypothalamus, and while it is largely self-regulating, its location allows it to respond to several types of external cues to keep it set at 24 hours. 

Light is the most influential cue to our circadian rhythm, the effect of which can be seen by anyone travelling across the globe? 

Time itself may not be the best influencer of our circadian rhythm however time cues are.  Reading the time, leaving work, eating dinner all produce cognitive pressures on our internal clock to keep moving. 

Lastly, certain cell in the brain contain receptors for the hormone melatonin.  Melatonin forms part of the system that regulates the sleep-wake cycle by chemically causing drowsiness and lowering body temperature.  Production and release of melatonin is inhibited by light hitting the retina and hence permitted once light is removed.  This aligns with the fact that levels of melatonin begin to climb after dark and peak just before dawn.

Prevalence of Insomnia

When non-restrictive definitions of insomnia are used, a study found insomnia in 33 per cent of the general population.  A later European study found 37 percent of the population reported sleep difficulties, including short sleep (20%), light sleep (17%) and global sleep dissatisfaction (8%).  Chronic insomnia was also reported at 9% in another general population prospective study after a 7.5 year follow up. 

In Australia, insomnia is also estimated to affect up to 33 per cent of the population.  This statistic however may be higher due to significant under-diagnosis due to patients not seeking treatment for the condition.  Most people at some point during their life will experience insomnia conditions and at any given point approximately 10% of the population have at least mild insomnia.

Who is most likely to have insomnia?

Individuals that are most likely to be affected by insomnia symptoms include:

• People over the age of 45
• Females (twice as prevalent as men)
• People who are overweight or obese
• People affected by medical conditions that interfere with normal sleep (see Causes)
• Shift workers or frequent travellers
• People who consume large amount of caffeinated products, alcohol or recreational drugs.

What causes insomnia?

The aetiology of insomnia is complex and usually multi-factorial. The Spielman Model is useful and proposes three main factors (predisposing, precipitating and perpetuating – the ‘3 Ps’) which potentially trigger, establish and maintain insomnia.

• Predisposing Factors include demographic (aging, female gender, living alone), Hereditary (Family history), Physiological (mental disorders, personality traits), and lifestyle factors (medications, food, caffeine, smoking and alcohol intake).
• Precipitating factors include acute stress (grief, relationship, financial, work) as well as medical issues (Pain, cardiovascular disease, airway disease, mental health problems).
• Perpetuating factors include maladaptive sleep habits, staying in bed awake, stress about the lack of sleep, and bad sleep hygiene.  These factors can be due to lack of education and incorrect cognitive practices and will usually turn into self-fulfilling prophecies over time.

Insomnia Classification

Insomnia can be broadly classified into two types, primary and secondary.

Primary Insomnia

Primary insomnia is sleeplessness or the perception of poor quality sleep that cannot be attributed to a medical, psychiatric, or environmental cause (such as drug abuse or medications).  Primary insomnia can be linked to 2 main causes, Psychophysiological and idiopathic insomnia. 

Psychophysiological insomnia is when a person with previously adequate sleep, sleeplessness begins because of a prolonged period of stress.  This then results in tension and anxiety that causes awakening, and this sleep trouble then reinforces the anxiety which in turn worsens the insomnia in a self-perpetuating cycle. 

Idiopathic insomnia is attributed to an abnormality in the neurologic control of the sleep-wake cycle involving areas of the brain responsible for wakefulness and sleep. It may begin in childhood and can continue throughout life. 

Secondary Insomnia

Secondary insomnia can be brought on by many different causes.  These include psychiatric and medical conditions, unhealthy sleep habits, specific medications and substances, and other lifestyle factors.

Medical causes

There are many medical conditions that can lead to insomnia. In some cases, a medical condition itself causes insomnia, while in other cases, symptoms of the condition cause discomfort that can make it difficult for a person to sleep.

Some examples of the conditions that can cause insomnia include:

• Mental conditions (see below)
• Allergies (including nasal/sinus and dermatological conditions)
• Gastrointestinal conditions (e.g. Reflux)
• Metabolic conditions (E.g. Hyperthyroidism)
• Asthma
• Neurological conditions (E.g. Restless less syndrome, Parkinson's disease)
• Sleep Apnoea
• Pain (E.g. Chronic, Arthritis, Lower back, Fibromyalgia)

Many medical conditions that can cause insomnia do so not directly but indirectly due to one or more symptom/s of the condition.  This is especially true for any condition causing pain or other discomfort.

Depression

Insomnia can be caused by psychiatric conditions such as depression. While insomnia itself can bring on changes in mood, psychological struggles can also make it hard to sleep.  This can also lead to shifts in hormones and physiology that can lead to both psychiatric issues and insomnia at the same time.

Anxiety

While most adults have had some trouble sleeping because they feel worried or nervous, for some it's a pattern that interferes with sleep on a regular basis.  It’s not hard to understand why anxiety can affect sleep however when this happens for many nights, you might start to feel anxiousness or panic at just the prospect of not sleeping. This is how anxiety and insomnia can feed each other and become a cycle that can best be interrupted through treatment of some kind.

Medications

While medications can be used to treat insomnia, certain medications can cause it as a side effect.  Over the counter cold and flu medications, nasal decongestants, medications for hypothyroidism, cardiovascular drugs, some anti-depressants and any medication to treatments containing hormones can cause insomnia.

Some drug classes that can contribute to insomnia include:

Heart medications

• Alpha-blockers (Reduce blood pressure and treatment for benighn prostatic hypertrophy)

Eg. alfuzosin (Uroxatral), doxazosin (Cardura), prazosin (Minipress), silodosin (Rapaflo), terazosin (Hytrin) and tamsulosin (Flomax).

• Beta-blockers (reduce blood pressure

Eg. atenolol (Tenormin), carvedilol (Coreg), metoprolol (Lopressor, Toprol), propranolol (Inderal), sotalol (Betapace), timolol (Timoptic) and some other drugs whose chemical names end with "-olol."

• HMG Co Reductase inhibitors (“Statins” - reduce cholesterol)

Eg. Atorvastatin (Lipitor), Rosovastatin (Crestor), Simvastatin (Zocor), Pravastatin (Pravachol)

Asthma Medications

• Corticosteroids

E.g cortisone, methylprednisolone (Medrol), prednisone (sold under many brand names, such as Deltasone and Sterapred) and triamcinolone.

• Theophylline

Antidepressants

• Selective Serotonin Reuptake Inhibitors (SSRI)

Eg. citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac, Sarafem), fluvoxamine (Luvox), paroxetine (Paxil, Pexeva) and sertraline (Zoloft).

• Selective Serotonin and Noradrenaline Reuptake Inhibitors

Eg. Venlafaxine (Efexor), Desvenlafaxine (Pristiq)

Smoking Cessation Medications

• Nicotine Receptor Agonists

Eg. Champix

• Nicotine replacement therapy

Central Nervous System Stimulants

• ADHD medications

Eg. Methylphenidate (Ritalin), Dexamphetamine

• Medications for Hypothyroidism

Eg Thyroxine (Oroxine)

Lifestyle effects on insomnia

Insomnia can be triggered or perpetuated by certain behaviours and sleep patterns. Unhealthy lifestyles and sleep habits can create insomnia on their own (without any underlying medical problem), or they can make insomnia from another cause worse.  Some lifestyle habits that can affect insomnia include working at home in the evenings which can make it hard to unwind.  Taking naps in the afternoon can be helpful for some people in some respects however in others is can lead to trouble falling asleep, and this also applies to trying to sleep in later to make up for lost sleep.  Lastly, shift work is notorious for interrupting the normal functioning of our body clock, which can make normal sleeping patterns very difficult to keep.

Sleep Hygiene

Sleep hygiene is a group of best practise ideas to optimise the chance of sleep and reduce the risk of insomnia.

Some sleep hygiene habits include:

• Getting up and going to bed at the same time every day
• Go to bed if you are tired, and don't if you are not.
• Get early morning sunshine to resent the body clock
• Invest in a comfortable bed
• Sleep in a comfortable temperature
• Sleep in a room with enough darkness
• Reduce noise while sleeping (use earplugs if necessary
• Use the bedroom for sleep and intimacy
• Avoid drugs (cigarettes, Alcohol, sleeping pills)
• Relax the mind before trying to sleep
• Exercise every day, but away from bedtime
• Avoid caffeine close to bedtime

Food and Dietary effects on insomnia

Most things we do can affect our sleeping habits and this is also true for food stuffs the activities, including eating patterns that accompany them.

Alcohol is a sedative. It can make you fall asleep initially, but may disrupt your sleep later in the night.

Caffeine is a stimulant. Most people understand the alerting power of caffeine and use it in the morning to help them start the day and feel productive. Caffeine in moderation is fine for most people, however excessive amounts of caffeine or having it too close to bedtime can cause insomnia.

Nicotine is also a stimulant and can cause insomnia. Smoking cigarettes or tobacco products close to bedtime can make it hard to fall asleep and to sleep well through the night.

Heavy meals close to bedtime can disrupt your sleep.  This can also be compounded by the type of food you eat, such as spicy foods which can lead to indigestion and heartburn.  Best practice is to eat a light meal before bedtime which will reduce the risk of gastrointestinal discomfort and allow your body to settle and relax.

What are the symptoms and health effects of Insomnia?

Insomnia can only be diagnosed once its effects are affecting your daytime activities.  Some symptoms of insomnia include:

• Excessive daytime tiredness
• Physical weariness
• Fatigue
• Muscle aches
• Loss of concentration
• Determination of memory
• Irritability and mood changes
• Anxiety and depression

Aside from the immediate effects that insomnia has on a person’s day to day functioning, it also eventually effects many other areas of your health in a negative way.  These include:

• Increased risk of hypertension (high blood pressure)
• Increased Risk of diabetes
• Increased risk of obesity
• Increased risk of depression
• Increased risk of heart attack
• Increase risk of stroke
• Decrease in sex drive
• Increased risk of falls and accidents
• Decrease in cognitive ability

All of these really build a very strong case to aim for a healthy amount of sleep every night.

Treatments

Insomnia treatment is based firstly on the length of the condition, acute or chronic.  For acute insomnia (less than approximately 2 weeks), which will often follows a life-changing event, medication over a short period is the normal method of treatment.  The main reason for this is the effectiveness of the medication is only challenged over time due to the rise in tolerance levels when given as long term therapy.  Treatment options for chronic insomnia are generally divided into two major categories, pharmacological and non-pharmacological interventions.

Pharmacological Treatments

Benzodiazepine Hypnotics

Benzodiazepines are a group of drugs called minor tranquillisers and are used to treat several conditions including insomnia.   There are about 30 different types (generic names) of benzodiazepines, and while they all work in the same way, their strength and duration of action differ widely.

The list below shows some of the different generic and brand names of benzodiazepines.

• diazepam - Valium, Ducene, Antenex
• oxazepam - Serepax, Murelax, Alepam
• nitrazepam - Mogadon, Alodorm
• temazepam - Normison, Temaze
• lorazepam - Ativan
• flunitrazepam - Hypnodorm
• bromazepam - Lexotan
• clonazepam - Rivotril

Benzodiazepines work by enhancing the effect of the neurotransmitter gamma-aminobutyric acid (GABA) - which is responsible for reducing the activity of neurons that cause stress and anxiety.  In insomnia, benzodiazepines increase sleep time and improve sleep duration and the ones with shorter half-lives are preferred to minimise drowsiness in the morning. While inducing unconsciousness, benzodiazepines actually worsen sleep quality as they promote light sleep and decrease time spent in deep REM sleep.  As stated previously,. Tolerance and dependence can also occur with prolonged use; thus, benzodiazepines are most useful for alleviating insomnia in the short term while also addressing the cognitive aspects of the condition.

Nonbenzodiazepine hypnotics

Nonbenzodiazepine hypnotics are a class of drug that is in every way similar to Benzodiazepines except in their chemical structure.  Nonbenzodiazepine pharmacodynamics are almost entirely the same and so therefore employ extremely similar benefits, side effects and risks.

The list below shows some of the different generic and brand names of benzodiazepines.

• Zolpidem (Stilnox) – Available in Australia
• Alpidem
• Necopidem
• Saripidem
• Eszopiclone 
• Zopiclone (Imovane) – Available in Australia
• Zaleplon

Nonbenzodiazepines were introduced into the market to treat mild insomnia.  The biggest advantage of this class of drug was that tolerance was developed much slower and withdrawal was also less severe.  In practice however these benefits have been reported to be less than originally hoped.  While some Nonbenzodiazepine drugs do seem to provide a slower road to tolerance, long term use is still associated with this side effect.

More recently, media reports have sensationalised an uncommon side effect of these medicines.  On rare occasions, these drugs can produce a fugue state, wherein the patient sleepwalks and may perform relatively complex actions, including cooking meals or driving cars, while effectively unconscious and with no recollection of the events upon awakening.

Barbiturates

Barbiturates function to decrease time to sleep onset and reduce REM sleep.  Extended use is associated with tolerance and psychological and physical dependence.  Also, Barbiturates were superseded by benzodiazepines because in overdose barbiturates would sedate the brain through all functions including the heart and respiratory centres.  This made barbiturates a potentially dangerous and deadly class of medications.

Antihistamines

Nearly 25% of individuals who experience insomnia use over-the-counter medication to aid sleep.  However the use of antihistamines is not ideal as they are only minimally effective at inducing sleep, they also reduces the quality of sleep and the ones available over the counter in Australia tend to cause morning drowsiness as well.

Natural Treatments for Insomnia

There are several herbal and natural treatments for insomnia, and with over 40% of the population currently taking a supplement of some kind, these treatments are big business.

The main problem with natural medications is proof that they actually work.  This is because often they have multiple active ingredients, a natural product cannot be patented and so they studies of their effectiveness and underfunded and often of poor quality.  That being said, there have been some studies done and there is evidence to support the use of some herbs to treat insomnia.

Below is a list of the most commonly used natural treatments;

• Valerian – Low level of evidence in human trails
• Passionflower – Low level of evidence in human trails
• Chamomile – Little evidence to support use but generally considered a mild sedative
• Kava – Human trials conducted but more research needed
• Hops – Human trials conducted but more research needed

These treatments are considered safe however they can still cause side effects and interact with other medications so should be discussed with a health professional before use.

Melatonin

Melatonin, while being a naturally produced chemical in the human body, falls into the pharmacological treatment category as a drug.   Melatonin is a neurotransmitter and hormone secreted by the pineal gland in the brain.    In the biosynthesis of melatonin, tryptophan is converted to 5-hydroxytryptophan, which is then decarboxylated to serotonin.   Serotonin is then catalysed by two enzymes to form melatonin.  As already discussed, melatonin is well known for causing and regulating sleep.  However melatonin also has a huge number of other effects throughout the body, mainly due to its role as a potent antioxidant.  These effects include general neuroprotective effects, several anti-cancer properties and it can even potentially stop your body from gaining more fat.  Melatonin supplementation also benefits eye health, can help reduces tinnitus, and improve mood (by helping you get better sleep).

Melatonin Function

Melatonin’s main role within the body is to help regulate certain hormones and maintain the body’s circadian rhythm. The circadian rhythm is an internal 24-hour “clock” that plays a critical role in when we fall asleep and when we wake up.  When light stops hitting our eyes, our body is triggered to start producing melatonin, and this process is reversed when the light begins to increase again.  Studies have shown that the light required to instigate melatonin suppression is within the blue spectrum, which is why screens that produce light such as computers, tv’s and phones are especially bad for maintaining our circadian rhythm.  Also, simply being exposed to bright lights in the evening or too little light during the day can disrupt the body’s normal melatonin cycles.  This is why sleep cycle abnormalities form in people undertaking international travel, shift work or even simply having bad eye sight.

Some researchers also believe that melatonin levels may be related to aging. As an example, young children have the highest levels of night time melatonin. Research has proven that these levels drop as we age, and these lower levels of melatonin may explain why some older adults have sleep problems and tend to go to bed and wake up earlier than when they were younger. However, newer research calls this theory into question.

Sleep

Insomnia is an exceptionally hard to treat condition.  The psychological, medical, pharmacological and lifestyle components of the condition all add their own layer of complexity which ultimately makes it very difficult to treat.  Melatonin supplementation offers a safe and clinically proven treatment that be used in conjunction with other treatment options to provide the best outcomes.  Research has shown that many patients with insomnia have decreased nocturnal melatonin secretion. This is especially the case in the over 55 age group which have only half the amount of melatonin released compared to that of young adults. There have been multiple well designed studies that have proven that insomnia may be effectively treated by supplementing melatonin. 

Specifically, melatonin has been shown to be effective in treating conditions such as;

Delayed sleep phases syndrome, a condition that results in delayed sleep onset despite normal sleep patterns and duration.  Studies report that melatonin helps improve the amount of time it takes to fall asleep.

Jet Lag, Several human trials suggest that melatonin taken by mouth, started on the day of travel and continued for several days, reduces the number of days needed to begin a normal sleep pattern, shortens the time it takes to fall asleep, improves alertness, and reduces daytime fatigue. 

Sleep disorders (behavioural, developmental, mental), Studies have looked at the use of melatonin in children with mental and nervous system disorders, including mental retardation, autism, vision loss, or epilepsy (seizure disorder). More research is needed before further conclusions can be made.

Insomnia (elderly and children), melatonin may benefit children with insomnia. Melatonin has been studied for sleep-wake disorders in children and adolescents.  Several human studies also report that supplementing with melatonin will improve insomnia in the elderly.

Sleep enhancement in healthy people, most human studies have been small and short in duration. However, evidence does support that melatonin decreases the time it takes to fall asleep, as well as increases sleepiness and sleep duration. 

Melatonin has also been shown to affect may other areas of the body.  Some of these include:

Age-related macular degeneration

Research suggests that melatonin may play a role in protecting the retina to delay macular degeneration.

Aging (body temperature regulation)

Melatonin may help regulate age-dependent changes in body temperature rhythm. 

Alzheimer's disease/ cognitive decline

Limited research has looked at the effects of melatonin on cognitive disorders. Some studies suggest a possible benefit. In elderly people with mild cognitive impairment, a combination treatment containing melatonin improved cognitive function scores and sense of smell, as well as speech fluency.

Benzodiazepine withdrawal

A small amount of research has looked at the use of melatonin to assist with withdrawal from benzodiazepines (antianxiety drugs) such as diazepam (Valium®) or lorazepam (Ativan®). Melatonin has been studied for this purpose in people with schizophrenia. Although early results are promising, further research is needed before a firm conclusion can be reached.

Cancer treatment

Early human studies have looked at melatonin use in people with different types of late-stage cancer, including cancer of the brain, breast, colon, rectum, stomach, liver, lung, pancreas, testicles, immune system, skin, kidney, and soft tissues. Melatonin has been used together with many other agents and therapies. Some promising results have been found in non-small cell lung cancer and breast cancer.

Breast Cancer

Several studies suggest that low melatonin levels may be associated with breast cancer risk. For example, women with breast cancer tend to have lower levels of melatonin than those without the disease. Laboratory experiments have found that low levels of melatonin stimulate the growth of certain types of breast cancer cells, while adding melatonin to these cells slows their growth. Preliminary evidence also suggests that melatonin may strengthen the effects of some chemotherapy drugs used to treat breast cancer. In a study that included a small number of women with breast cancer, melatonin (given 7 days before beginning chemotherapy) prevented the lowering of platelets in the blood. This is a common complication of chemotherapy that can lead to bleeding.

In another small study of women who were taking tamoxifen for breast cancer but seeing no improvement, adding melatonin caused tumours to modestly shrink in more than 28% of the women. Women with breast cancer should ask their doctors before taking

Prostate cancer

Studies show that men with prostate cancer have lower melatonin levels than men without the disease. In test tube studies, melatonin blocks the growth of prostate cancer cells. In one small-scale study, melatonin -- combined with conventional medical treatment -- improved survival rates in 9 out of 14 men with metastatic prostate cancer. Interestingly, since meditation may cause melatonin levels to rise it appears to be a valuable addition to the treatment of prostate cancer. More research is needed before doctors can make recommendations in this area. Men with prostate cancer should talk to their doctor before taking medication.

Chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a chronic lung disease that makes it difficult to breathe. Early research showed that melatonin reduced oxidative stress and shortness of breath. Changes in lung function were lacking. 

Depression

Melatonin has been suggested as a possible treatment for depression. However, human research remains inconclusive. More evidence is needed before a conclusion can be made.

Fibromyalgia

Early studies suggest that melatonin may improve symptoms of fibromyalgia (chronic body-wide pain). A randomized, placebo-controlled study found that people with fibromyalgia experienced a significant reduction in their symptoms when they took a melatonin supplement either alone or in conjunction with fluoxetine (Prozac).

Other

Melatonin has been investigated for many more issues and conditions than the ones listed above.  Some examples include glaucoma, headache, heart disease, high cholesterol, liver inflammation, memory improvement, menopause symptoms relief, parkinsons disease, restless legs syndrome, tinnitus, sarcoidosis and schizophrenia.  This is by no means an exhaustive list however a little research will uncover the many and varied applications currently being investigated for melatonin. 

Dosage

There is currently no recommended dose for melatonin supplements and different people will respond differently to its effects.  While some people may be especially sensitive to the medication others will require larger doses.  The best approach to most treatment regimens are to start low and go slow, which means beginning at a low dose and slowly working the way up.  Melatonin dosing also should be fitted to this methodology however due to its safely, often the dose initially prescribed will be moderate to then the dosing regime will change according to response. 

The dose range usually prescribed varies between 1-10mg however doses above 5mg are uncommon.  For insomnia, the dose is usually given 2 hours before retiring to sleep to allow sufficient time for the medication to work.

Melatonin safety has been studied extensively when taken orally for up to 3 months.  It has been shown to be safe when taken within normal ranges, typically between 1 – 20 mgs.  It has also been shown to be safe in children for long term use at the recommended doses.  This safety is reassuring however it can still produce side effects from time to time.  The most common of these is simply drowsiness which can uncommonly hang over into the morning.  It is not recommended to drive or operate machinery if it affects you in this way. 

When you should not take melatonin

Melatonin is not recommended for pregnant or breastfeeding women as there is no clinical evidence to prove safety.

Melatonin should be avoided in people with severe liver or kidney problems.

Melatonin is not recommended when consuming alcohol or other illicit substances.

Non pharmacological treatments

Insomnia treatment is based firstly on the length of the condition, acute or chronic.  For acute insomnia (less than approximately 2 weeks), which will often follows a life-changing event, medication over a short period is the normal method of treatment.  The main reason for this is the effectiveness of the medication is only challenged over time due to the rise in tolerance levels when given as long term therapy.  Treatment options for chronic insomnia are generally divided into two major categories, pharmacological and non-pharmacological interventions.

While medications are used in the majority of cases to treat insomnia, these are only effective in the short term and can have serious side effects associated with them.  Psychological treatments for insomnia target maladaptive sleep behaviours and thoughts.  Cognitive behavioural therapy is the most effective objectively measured treatment for insomnia and has been shown to be more efficacious when compared to hypnotic drugs used alone.  A key message in the psychological treatment of insomnia is that current sleep behaviours have not been working and for any improvement to occur the individual needs to do something different.  Treatment usually starts with education to provide a good understanding of sleep, sleep staging, circadian rhythm and healthy sleep practices. Behavioural interventions such as stimulus control, sleep/bed restriction and relaxation techniques are then introduced as the first change required for effective treatment.

Circadian rhythm and sleep hygiene education

The most important component of education in relation to insomnia is to provide information about the circadian rhythm and to encourage rising at the same time each day regardless of the previous night’s sleep.  People should ensure that they are exposed to light after a short period of in order to suppress the sleep hormone levels (melatonin) and reset the body clock.  This is also important in reverse as the person should also reduce exposure to bright light in the evening to again, help raise the levels of melatonin.

Some sleep hygiene habits include reducing light and noise while sleeping and avoiding alcohol, caffeine or heavy meals just before bed.  For a more comprehensive list on sleep hygiene see here.

Relaxation Techniques

Progressive relaxation, imagery training, biofeedback, meditation, hypnosis and autogenic training, can all be used.  However they tend to be less effective as a stand-alone treatment for insomnia but can be useful techniques when used in combination with other treatment interventions.

Sleep stimulus control

Stimulus control involves strategies that enable a person to learn to differentiate between the daytime and night time sleep environment. The aim of this therapy is to promote a positive association between the bedroom and sleepiness, however in today’s society the bedroom has become a cue for being awake and engaged. Treatment involves removing all stimuli from the bedroom that are potentially sleep-incompatible (e.g., computers, books, television, iPads, mobile phones), and not sleeping in living areas. The person is usually told to get out of bed if not asleep within 15-20 minutes, when wakeful during the night, or when experiencing anxiety in relation to the insomnia.  They should then do a non-stimulating activity until feeling ready to try to sleep again.

Paradoxical intention

This is otherwise known simply as trying to stay awake.  By putting the effort into remaining wakeful rather than ‘trying’ to fall asleep a person can strengthen the sleep drive and mitigate the anxiety failing while trying to fall asleep. 

Biofeedback

This method allows the person to observe their biological signs such as heart rate and muscle tension and shows you how to adjust them. Using a computer, special software, and sensors placed on the body, stress levels are recorded and the patient can learn to control normally involuntary Processes.  By using the information recorded during this process, a person can identify patterns that contribute to insomnia and learn how to change those patterns.