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Insomnia


Patient Information Brochure


 

What is insomnia?

Insomnia is a condition that involves dissatisfaction with sleep quality or duration, along with problems falling asleep at bedtime, waking up in the middle of the night, or awakening too early in the morning. Insomnia becomes a clinical problem when a person experiences trouble falling or staying asleep several nights per week and these difficulties cause distress or impairments of daytime functioning such as fatigue, decreased energy, mood disturbances, or concentration problems.

How prevalent is insomnia?

About 10% of the adult population in Canada experience persistent insomnia and an additional 20% to 25% reports occasional insomnia symptoms. Insomnia can be a problem in children, adolescents and adults. It is more common among women, older adults, shift workers, and people with medical or psychological problems.

What are the main causes?

Psychological factors such as stress, anxiety, and depression are the most common causes of insomnia. Chronic insomnia may, on the other hand, increase the risk of depression, even among individuals without any prior history of depression. Medical illnesses can also disrupt sleep due to underlying symptoms (such as pain), the treatment used to alleviate those symptoms, or emotional distress about the illness. Prescribed and over-the counter medications can cause insomnia as a side effect. Insomnia can also be induced by alcohol or by excessive use of stimulants such as caffeine (contained in coffee, chocolate, energy drinks). Insomnia may be caused by another sleep disorder. Restless legs syndrome is a condition that produces an uncomfortable sensation in the calves and an irresistible urge to move the legs during wakefulness, particularly in the evening, and may cause difficulties initiating sleep. It is often associated with periodic limb movements, a condition characterized by frequent movements of the legs or arms during sleep. Sleep apnea (a breathing disorder during sleep) can also cause insomnia, although it is more frequently associated with excessive daytime sleepiness.

Insomnia is often triggered by a significant life event (e.g., a separation, death of a loved one). Most people will return to a normal sleep pattern once they have adjusted to this life event but, for others, perhaps those who are more vulnerable to insomnia, sleep disturbances persist over time. A vicious cycle often develops in which insomnia produces anxiety about one’s ability to sleep, more sleeplessness, more worries about not sleeping, and the vicious cycle goes on and on.

What are the treatment options?

There are several treatments for insomnia including medications (both prescribed and over-the-counter drugs), insomnia-specific cognitive behavioural therapy (CBT), and numerous complementary and alternative therapies (e.g., herbal and dietary products, acupuncture). Only CBT and selected prescribed medications have adequate scientific evidence to support their use in the management of insomnia. The first step in managing insomnia is to identify and remove the underlying cause (e.g., stress, pain), but even then sleep difficulties may persist and treatment must involve CBT, medications, or both.

Drug Therapy

Hypnotic medications (e.g., zolpidem, zopiclone, temazepam) are helpful to alleviate sleep disturbances resulting from situational stress (e.g., illness, hospitalization), from changes in sleep schedules due to jet lag, and for sleep disturbances associated with some medical or psychiatric conditions. These medications should be used only for a short period of time (ideally no more than a few nights or weeks) because they lose their efficacy and may produce dependency when used on a nightly basis over a prolonged period of time. They may remain effective for a longer period of time when used on an occasional schedule. Some sleep medications may produce residual effects the next day (e.g., drowsiness) and interfere with daytime functioning (e.g., driving). Despite their widespread availability, over-the-counter sleep aids (e.g., Sominex, Nytol) and herbal/dietary supplements (e.g., valerian) are of limited benefits for insomnia. Also, Natural health products are not regulated by Health Canada to the same extent as are prescribed sleep medications, and there is always a risk that they do not contain exactly what is on the product labels. Melatonin is also available without prescription in Canada and, although it may be helpful for some forms of acute insomnia associated with shift-work or jet lag, such medication does not work as rapidly as does a prescribed hypnotic drug melatonin is generally not helpful for chronic insomnia. Also, there is much less information about its risks and benefits relative to prescribed medications.

Cognitive Behavioural Therapy (CBT)

CBT for insomnia involves a set of psychological and behavioural interventions designed to alleviate stress or tension, change poor sleep habits and scheduling factors, alter misconceptions about sleep, and teach coping strategies to manage the effects of insomnia. Some of the basic CBT procedures involve simple steps:

 

Learn to relax. Relaxation is helpful when stress or anxiety is part of an insomnia problem. Some relaxation exercises are designed to reduce physical tension, whereas others seek to eliminate intrusive thoughts and worries at bedtime.
Give yourself at least one hour to unwind before bedtime. Use this transitional period to read, watch television, listen to music, or simply relax. Do not ruminate about events of the day. Rather, write down your worries and set aside another time to manage them.
Restrict the amount of time you spend in bed to the actual sleep time. People with insomnia often spend excessive amounts of time in bed in an attempt to get enough sleep. Spending too much time in bed may actually lead to poorer sleep quality.
Go to bed only when sleepy. Individuals with insomnia often go to bed too early. Such practice is counterproductive because the bed becomes a cue associated with wakefulness rather than with sleep. Postpone your bedtime until you are sleepy.
Get out of bed if you can’t sleep. Whenever you are awake for more than 15-20 minutes in bed, get up and go to another room, and engage in some quiet activity. Return to bed only when you feel that sleep is imminent.
Arise at the same time every morning. Set the alarm clock and get out of bed at the same time, weekdays and weekends, regardless of the amount of sleep obtained on the previous night. Sticking to a schedule will help regulate your internal biological clock and synchronize your sleep/wake rhythm.
Reserve your bed and bedroom for sleep only. Do not read, watch television, or use cell phones or other electronic devices in bed. When you engage in these practices, the bedroom becomes associated with wakefulness rather than with sleepiness.
Avoid daytime napping. Among insomnia sufferers, napping is generally counterproductive. A nap disrupts the natural sleep/wake rhythm and interferes with nighttime sleep.
Maintain good sleep hygiene. Avoid stimulants (e.g., caffeine) several hours before bedtime. Do not drink alcohol too close to bedtime as it can lead to poor quality sleep. Regular exercise in the late afternoon or early evening may deepen sleep. Keep the bedroom environment quiet, dark, and comfortable.

 

When and where should you seek professional treatment?

If you experience significant difficulties falling or staying asleep several nights per week, and these difficulties cause distress or interfere with your daytime functioning, it is time to seek professional help. You should speak to your family doctor or to another healthcare provider who is knowledgeable about sleep (e.g., a psychologist or a pharmacist). The first step is to make an appropriate diagnosis and make sure insomnia is the main problem to address. The first line of treatment may depend on whether you have an acute or chronic sleep problem, whether there is a co-existing medical or psychological condition and whether or not you have already been using sleep medications. As a general rule of thumb, medication is indicated for situational insomnia resulting from acute stress or life events whereas CBT is the treatment of choice for chronic insomnia. If you have been using sleep medications for a prolonged period and still have sleep problems, the first step may be to discontinue very gradually such medication following a tapering schedule from your physician or pharmacist.

What results can you expect?

Medication can be helpful when used on an occasional basis or for a limited period of time. It is likely to make you fall asleep faster and sleep more continuously with overall gain of 45 to 60 minutes of sleep. CBT will take a bit more time and effort but sleep improvements with CBT are more durable over time. CBT and medication can complement each other. Sleep medication is particularly useful in the initial phase of treatment to break the vicious cycle of insomnia, while CBT is essential in long-term insomnia for directly addressing psychological and behavioural factors that perpetuate sleep disturbances. The success of CBT depends largely on how well you carry out the recommended changes in sleep scheduling and behavioural practices. Don’t give up too quickly if this approach does not work immediately as it may take a few weeks. Guidance from a behavioral sleep medicine specialist or a psychologist knowledgeable about insomnia treatment is often necessary for optimal results. Please check on the CSS website for a listing of clinicians in your area with expertise in treating insomnia.

 

Insomnia can be a debilitating condition that greatly impairs quality of life; fortunately, there is hope because effective therapies are available.

 

 

Authored by:
Charles M. Morin, PhD
Professor of Psychology
Director, Sleep Research Center
Canada Research Chair
(Behavioural Sleep Medicine)
Université Laval, Québec