The Facts

Insomnia can refer to difficulty getting to sleep, difficulty staying asleep, waking up early without being able to return to sleep, or a combination of the three. In order to be diagnosed with insomnia, sleep difficulty must occur at least 3 nights per week even though the opportunity for adequate sleep is available. It must also interfere with your life and functioning – for example, if you wake feeling unrefreshed or find yourself dozing during the day.

Insomnia is not defined based on how many hours you've slept, since the amount people need can vary from person to person. It is also normal to sleep less as you age. If you're sleeping less than you did when you were younger, it doesn't necessarily mean you have insomnia.

Insomnia is a very common medical complaint. About 10% of adults in Canada experience persistent insomnia, and an additional 20% to 25% report occasional insomnia. It is more common among women, older adults, shift workers, and people with medical conditions and mental health issues.

Causes

Insomnia usually has an underlying cause. Common causes of insomnia include:

• air travel, especially when travelling from west to east (jet lag)
• environmental disturbances such as noise, light and temperature
• exercise just before going to bed
• illegal drug use
• medical conditions such as gastroesophageal reflux, prostate enlargement, Parkinson's disease, Alzheimer's disease, and stroke
• medications such as decongestants, stimulants (e.g., methylphenidate*) and some antidepressants
• mental health conditions such as anxiety or depression
• nicotine, caffeine, and alcohol
• not being active enough during the day
• other sleep disorders such as sleep apnea and restless leg syndrome
• pain from arthritis or other medical conditions
• poor sleep habits
• shift work
• stress caused by work, family life, death or illness of a family member or friend, or financial difficulties
• watching TV or other screens late at night

Short-term insomnia (insomnia that lasts less than 3 months) is usually caused by temporary stressors such as changes in sleep environment (e.g. noise, light, and temperature), a stressful event (e.g. death or illness of a family member, job loss, surgery, divorce), travelling, and shift work. The insomnia often goes away when the stressor is resolved. Persistent insomnia, which lasts at least 3 months, is usually caused by factors such as medical illness, medication and mental health issues. Insomnia can also occur on its own.

Symptoms and Complications

Symptoms of insomnia can include:

• trouble falling asleep
• trouble staying asleep
• waking up too early in the morning and being unable to get back to sleep
• not feeling rested or refreshed when you wake up despite getting enough hours of sleep
• feeling tired and sleepy during the day
• feeling irritable or anxious
• headaches
• difficulty focusing or concentrating during the day

Staying up for several days in a row can produce symptoms like hallucinations, but few people with insomnia reach that stage. However, insomnia can often cause poor concentration, forgetfulness, and fatigue that negatively affects personal relationships as well as job and school performance. It can also result in a higher risk of accidents. People with insomnia are also more likely to suffer from depression and anxiety.

Worrying about not being able to get adequate sleep can often worsen the insomnia. It is important to get help in order to not get caught in this cycle.

Making the Diagnosis

To diagnose insomnia, your doctor will want to know what your sleep pattern is and how tightly you stick to the same schedule. Your doctor may ask you to keep a sleep diary for a week or two to get more information about your sleep pattern. You'll also be asked about any medications you may be taking (including herbal products and non-prescription medications), as well as nicotine use and your intake of coffee and alcohol. Your doctor will also ask you if you have any stresses in your life that might be affecting your sleep.

A general medical examination and history may provide clues about other conditions, such as depression, anxiety, or arthritis, which may be contributing to or causing insomnia. In addition, blood tests might be ordered to check for underlying medical conditions.

Some patients may be referred to a specialized sleep disorder clinic that offers diagnostic tests for insomnia such as overnight polysomnography. In this test, you sleep the night at the clinic, wired to electrodes that measure the various stages of sleep from light (stage I) to deep sleep (stage IV) as well as REM ("dream") sleep. The polysomnograph can also detect sleep apnea.

Treatment and Prevention

A treatment plan for insomnia can include treating an underlying medical problem, learning about and practicing good sleep hygiene, learning about and making behaviour changes, and taking sleep medications. If insomnia is caused by an underlying medical condition such as arthritis or depression, the condition should be treated first, as this will likely alleviate the insomnia.

Sleep hygiene includes basic things you can do to increase your chances of having a good night's sleep. Changing certain behaviours can also help improve sleep. As part of a treatment plan, your doctor might recommend any of the following sleep hygiene or behaviour changes:

• Develop a regular bedtime routine.
• Avoid sleeping in, extensive periods of horizontal rest or daytime napping; these activities usually worsen the subsequent night's sleep.
• Don't use the bedroom for daytime activities – just for intimacy and sleep.
• Don't consume caffeinated beverages (e.g. coffee, tea) after lunch.
• Don't go to bed thinking about work or other stressful matters – read a book for a while if this helps reduce stress.
• Learn to replace worrying thoughts about sleep with more positive ones.
• Go to bed and wake up at the same times every day, even on weekends.
• If you have a back disorder, try lying on your back with a pillow under your knees.
• Keep the bedroom dark, quiet, and not too warm – white noise devices can help drown out traffic sounds or a partner's snoring.
• Drink warm milk or have a warm bath before bed.
• Avoid heavy, spicy, or sugary foods 4 to 6 hours before bedtime; try a light carbohydrate snack (e.g. crackers and warm milk) instead
• Exercise during the day – if exercising before bed keeps you up, then exercise earlier.
• Try to cut down on smoking and alcohol, especially in the evening.
• Avoid watching the clock – just set the alarm and turn the clock around so you can't see the time.
• If you can't fall asleep within 20 minutes of lying in bed, get up and do something relaxing. Try again once you feel sleepy.
• Stash the phone away at bedtime.
• Try relaxation techniques

Cognitive behaviour therapy for insomnia is also available and incorporates many of the suggestions above. Your doctor may also prescribe a sleep medication, especially if your insomnia is caused by acute stress (e.g., loss of a loved one), or if non-medication approaches haven't helped. These medications can help in the short term (e.g., for a few weeks) when used on an as-needed basis as opposed to every night. However, they are not a cure and may even worsen insomnia if used for long periods of time. This happens when sleeping medications are stopped and the insomnia comes back even worse than before.

Benzodiazepines (e.g., temazepam*, triazolam, lorazepam, diazepam) are commonly used medications for insomnia. There are several benzodiazepines that can be used, although some have been studied more than others. Your doctor will consider your age, other medical conditions, and side effects of the benzodiazepine when selecting the one that is best for you. Some people can become physically dependent on benzodiazepines and experience withdrawal symptoms when they stop using them.

Many sleep medicines can also lead to tolerance (a reduced effect over time). For this reason, doctors don't like to prescribe them for long periods unless other treatments fail or it is clear that tolerance is not developing. These sleep medicines should never be combined with alcohol. Other medications used to treat insomnia include zopiclone and zolpidem, which are not benzodiazepines.

If you are prescribed a medication to help with sleep, it's important to continue to use non-medication approaches as well.

If odd working hours disturb your sleep rhythm, the best way to get back on track is to expose yourself to bright light in the morning. The evidence shows that this resets the body clock more effectively than the much-hyped supplement melatonin. Natural light causes the brain to later produce melatonin in darkness anyway.

Non-prescription medications that contain diphenhydramine are available. However, they should not be used without discussing with a health care professional first. If you find that you have sleep problems, it is best to see your doctor for a proper assessment.