"The best cure for Insomnia is to get a lot of sleep" W.C. Fields.
What is Insomnia?
Insomnia, literally without sleep, is defined as having difficulty falling asleep, or maintaining sleep, or having non-restorative (light or poor quality of) sleep. For a diagnosis of clinical insomnia, it must be associated with impaired function when you are awake, and have been present for at least one month.
Approximately 13% of all New Zealanders aged 18-59 are thought to be affected by insomnia. The prevalence in Maori (19%) is significantly higher than in Non-Maori. Increasing age, loss of or lack of employment, and socioeconomic deprivation have been shown in studies to be associated with an increased risk for insomnia.
A common misconception about sleep is that everyone needs to sleep for eight hours a night. A teenager might require eight hours of sleep a night, but as we get older, and with reduced activity, many people might need only six hours or less a night. The key marker of insomnia is how you are able to function during the day, and whether a lack of sleep is impairing ones performance during the daytime.
Is Insomnia bad for you?
Apart from feeling tired or sleep deprived, it is now well recognised that insomnia can have other effects upon your health. Insomnia has been linked with an increased risk for obesity, high blood pressure and type 2 diabetes. There is also an increased risk to your mental health, with anxiety and depression particularly associated with insomnia. Insomnia can increase your risk of accidents, such as road crashes, with sleep deprivation being found to be comparable to milder degrees of intoxication with alcohol.
What causes Insomnia?
Insomnia is frequently due to other (secondary) causes, such as chronic medical conditions, illnesses or environmental reasons. We have all suffered from an acute, short term episode of insomnia in response to significant stress, grief or loss, however mental health conditions such as depression or anxiety can cause ongoing or chronic insomnia. Other causes of so-called secondary insomnia include certain drugs, or alcohol or drug withdrawal - either prescribed or illicit, or excessive caffeine. Alcohol, perhaps the most commonly self-prescribed insomnia therapy, may improve getting to off to sleep initially, but often results in early wakening and a much poorer quality of sleep. Medical conditions include breathing problems like uncontrolled asthma, chronic obstructive pulmonary disease (COPD) or sleep obstructive apnoea (OSA), acid reflux indigestion, chronic pain conditions such as arthritis or fibromyalgia, sleep disorders such as restless leg syndrome or prostate or bladder conditions. The pet cat or dog is a common environmental cause of non-restorative sleep. Likewise getting too hot or cold, noise or movements from your partner or spouse can also contribute to poor sleep quality.
It is estimated that in up to 20% of people their insomnia is not due to another cause. This is Primary Insomnia. To understand why you have insomnia, it is important to rule out possible secondary causes of insomnia. Typically this might require use of a sleep diary, blood or urine tests to exclude certain medical conditions, and in some cases even a referral to a specialist sleep laboratory.
Can Insomnia be treated?
Where insomnia is caused by an illness, then the therapy should be aimed at treating or minimising that condition, e.g. treatment of an underlying depression or chronic pain condition. Irrespective of the cause of insomnia, sleep hygiene is about optimising your body and the environment for you to sleep.
You can use the acronym ASLEEP to remember sleep hygiene advice.
A Avoid alcohol, caffeine and nicotine
S Sleep and intimacy should be the only things done in your bed
L Leave electronics (TV, smart phones, iPads, etc) and work out of the bedroom
E Exercise (is there anything that exercise isn't good for?)
E Early rising. Avoid lying in or daytime naps
P Plan for bedtime by getting into a routine such as a shower, bath or warm drink
Other non-drug treatments for insomnia include Stimulus Control, similar to sleep hygiene, where the bedroom is used almost exclusively for sleeping, avoiding bright light, noise, temperature extremes, eating large evening meals and drinking (alcohol, caffeine as well as other fluids) in the evening. Relaxation therapy and cognitive therapy may require a referral to a psychologist.
Many people treat their insomnia with over the counter and/or prescription only medications. The most commonly prescribed medications are sleeping tablets such as zopiclone or temazepam. These are short acting sedative medications that can decrease the time to go to sleep, and increase the duration of sleep. Both of these drugs can have similar hangover effects and are associated with dependency, particularly in those people who are more at risk of this, such as those taking higher doses, a longer duration of treatment or those who have a prior history of substance abuse. As such, these therapies should be used at the lowest possible dose, and for the shortest duration, ideally for no more than 5-10 days.
Antidepressants can be particularly helpful in treating insomnia when there is an underlying mood disorder. Low doses of some antidepressants, although less helpful in getting off to sleep, do seem to reduce waking, improve quality of sleep and total length of sleep, with only a small risk of side effects. It is important to be aware that several of the most commonly prescribed antidepressants, such as SSRIs and venlafaxine, can worsen insomnia. Anti-allergy medications such as sedating antihistamines are not recommended for insomnia due to the risk of daytime sleepiness, and the risk of other side effects. There is limited evidence that melatonin may have a weak effect upon the time required to go to sleep (sleep latency), whilst the total duration of sleep may also be improved. Melatonin is not funded in New Zealand, and only the 2mg modified release formulation is approved by Medsafe for the treatment of primary insomnia in adults over the age of 55.
New Treatments and Insomnia Research
Traditional sedatives used to treat Insomnia work by inhibiting activity across a wide range of pathways in the brain. A new class of insomnia treatment, the orexin inhibitors, specifically block the signal that stimulate the brains awake centre. The Wellington P3 Research unit is currently undertaking a study of an orexin inhibitor for people with difficulty getting off to sleep, or those who cannot stay asleep. To find out more about this contact the Wellington Unit of P3 Research at 0800 P3 STUDY (0800 737 883) or e-mail us at email@example.com.
Written by Dr Dean Quinn
Manager and Investigator
P3 Research Wellington Unit