What is insomnia?
Insomnia is a common sleep disorder comprising low-quality sleep or not enough sleep due to trouble initiating sleep and/or maintaining sleep. Insomnia can be short term (lasting days or weeks) or chronic (lasting 3 months or longer).[1] Insomnia occurs in 10-15% of the general population, with a greater prevalence in women during and after menopause, as well as older adults. In fact, up to 50% of older adults report insomnia or sleep disturbances.[2][3]
What are the main signs and symptoms of insomnia?
Some symptoms of insomnia include:[1]
- Lying awake for a long time before being able to fall asleep
- Only sleeping for short periods of time
- Staying awake throughout most of the night
- Feeling unrested or unrefreshed after sleep
- Involuntarily waking up too early
How is insomnia diagnosed?
A healthcare provider will diagnose insomnia by taking a detailed medical history, including many questions about sleep habits. A physical exam is done to rule out other medical or mental conditions that can cause difficulty sleeping. Sometimes sleep studies can be performed to arrive at an accurate diagnosis. Insomnia is characterized as “chronic” when sleep problems occur at least 3 nights per week for at least 3 months.[2]
What are some of the main medical treatments for insomnia?
Medication treatments for insomnia are indicated for improving sleep onset, sleep maintenance, or both. Examples of medications with evidence of benefit for insomnia include orexin receptor antagonists (suvorexant), nonbenzodiazepine hypnotics (eszopiclone Lunesta, zolpidem Ambien, zaleplon Sonata), certain benzodiazepines (triazolam, temazepam), melatonin agonists (ramelteon Rozerem), and certain antidepressants (doxepin Silenor). Although medications such as trazodone, tiagabine, and diphenhydramine are commonly used, experts do not recommend them for chronic insomnia due to potential harms and inadequate evidence of benefit.[4]
Have any supplements been studied for insomnia?
Supplements studied for insomnia include melatonin, valerian root, kava-kava, chamomile, lavender, and many others. These supplements have sedating effects and can increase relaxation and induce sleep in some people with short-term insomnia.[3] There is much less research on supplements for chronic insomnia.[4]
How could diet affect insomnia?
A common therapeutic approach for alleviating insomnia is maintaining sleep hygiene, a part of which involves diet. Sleep hygiene techniques include not eating too much at night and not eating too late into the night. It also includes avoiding or limiting the intake of alcohol, caffeine, and caffeine-containing foods and drinks (e.g., coffee, tea, and chocolate), especially when it is close to bedtime. Following a healthy, nutrient-rich diet (e.g., high in fruits and vegetables, low in refined sugar) is also considered a part of maintaining good sleep hygiene.[3][2][5]
Are there any other treatments for insomnia?
For short-term insomnia, sleep hygiene techniques which involve adjusting lifestyle factors (e.g., diet, exercise) and environmental factors (e.g., light, noise, temperature) is commonly recommended, however, sleep hygiene is not recommended as a solo treatment for chronic insomnia. For chronic insomnia, cognitive behavioral therapy (CBT) has good evidence of benefit, especially when used in combination with other therapies. Sleep hygiene and CBT are usually recommended in combination with other behavioral treatments such as sleep restriction, relaxation therapy, and stimulus control.[6]
What causes insomnia?
Common causes of insomnia include work stress, relationship issues, or traumatic events. Often times, insomnia occurs in response to certain medical conditions, medicines, and other sleep disorders (e.g., obstructive sleep apnea). Caffeine, tobacco, alcohol, and other substances can also trigger insomnia. However, in some cases, insomnia is considered to be a primary problem because it does not have an identifiable cause, although risk factors include long-lasting emotional upset, stress, travel, and shift work.[1]
Research FeedRead all studies
In this meta-analysis of randomized controlled trials, melatonin supplementation reduced the amount of time it took participants to fall asleep and increased their total sleep time. Subgroup analyses suggested that these benefits were greatest when participants took 3 to 4 mg of melatonin approximately 3 hours before bedtime.
Frequently asked questions
Insomnia is a common sleep disorder comprising low-quality sleep or not enough sleep due to trouble initiating sleep and/or maintaining sleep. Insomnia can be short term (lasting days or weeks) or chronic (lasting 3 months or longer).[1] Insomnia occurs in 10-15% of the general population, with a greater prevalence in women during and after menopause, as well as older adults. In fact, up to 50% of older adults report insomnia or sleep disturbances.[2][3]
How much sleep you need may take some trial-and-error testing to see what works best. But if you’re looking for some general guidelines, check out the recommendations from the National Sleep Foundation below.[18]
| AGE | RECOMMENDED | MAY BE APPROPRIATE | NOT RECOMMENDED |
|---|---|---|---|
| 0–3 months | 14–17 | 11–19 | < 11 or > 19 |
| 4–11 months | 12–15 | 10–18 | < 10 or > 18 |
| 1–2 years | 11–14 | 9–16 | < 9 or > 16 |
| 3–5 years | 10–13 | 8–14 | < 8 or > 14 |
| 6–13 years | 9–11 | 7–12 | < 7 or > 12 |
| 14–17 years | 8–10 | 7–11 | < 7 or > 11 |
| 18–25 years | 7–9 | 6–11 | < 6 or > 11 |
| 26–64 years | 7–9 | 6–10 | < 6 or > 10 |
| ≥65 years | 7–8 | 5– 9 | < 5 or > 9 |
Adapted from Hirshkowitz et al. Sleep Health. 2015.[18]
Some symptoms of insomnia include:[1]
- Lying awake for a long time before being able to fall asleep
- Only sleeping for short periods of time
- Staying awake throughout most of the night
- Feeling unrested or unrefreshed after sleep
- Involuntarily waking up too early
A healthcare provider will diagnose insomnia by taking a detailed medical history, including many questions about sleep habits. A physical exam is done to rule out other medical or mental conditions that can cause difficulty sleeping. Sometimes sleep studies can be performed to arrive at an accurate diagnosis. Insomnia is characterized as “chronic” when sleep problems occur at least 3 nights per week for at least 3 months.[2]
The Pittsburgh Sleep Quality Index (PSQI) is a short self-report questionnaire and the most widely used subjective measure of sleep quality.[36] The PSQI consists of 24 questions or items measuring seven dimensions from 0 (best) to 3 (worst). These seven factors can be broadly categorized into sleep efficiency factors (sleep quality, sleep latency, sleep duration, and habitual sleep efficiency) and sleep disturbance factors (sleep disturbance, use of sleep medications, and daytime disturbance).
For example, sleep duration of more than 7 hours scores 0, while sleeping less than 5 hours is a score of 3. Adding up the average scores of the seven factors gives a global PSQI score from 0 to 21, with 0–4 indicating “good” sleep and 5–21 indicating “poor” sleep. This subjective and straightforward measure of sleep quality may seem oversimplified. However, a review found that, besides being short and practical for clinical and non-clinical research, the PSQI has high reliability and validity in measuring sleep quality.[37] The PSQI has also been proposed as the primary method to measure sleep quality by expert consensus recommendations.[38]
In summary, the PSQI is a practical measure of sleep quality. Numerous independent studies have repeatedly validated the reliability and validity. Thus, the PSQI is one of the most widely used subjective measures of sleep quality — and rightly so.
Medication treatments for insomnia are indicated for improving sleep onset, sleep maintenance, or both. Examples of medications with evidence of benefit for insomnia include orexin receptor antagonists (suvorexant), nonbenzodiazepine hypnotics (eszopiclone Lunesta, zolpidem Ambien, zaleplon Sonata), certain benzodiazepines (triazolam, temazepam), melatonin agonists (ramelteon Rozerem), and certain antidepressants (doxepin Silenor). Although medications such as trazodone, tiagabine, and diphenhydramine are commonly used, experts do not recommend them for chronic insomnia due to potential harms and inadequate evidence of benefit.[4]
Supplements studied for insomnia include melatonin, valerian root, kava-kava, chamomile, lavender, and many others. These supplements have sedating effects and can increase relaxation and induce sleep in some people with short-term insomnia.[3] There is much less research on supplements for chronic insomnia.[4]
Overall, melatonin supplementation is relatively safe. First, melatonin toxicity is very low. Studies testing up to 240 mg[9] and 500 mg[10] taken orally do not report any toxic effects. Second, tolerance does not seem to be an issue. A study examining the continued administration of melatonin over 6–12 months did not find any evidence of tolerance.[11] Third, there is currently no evidence to support addiction or withdrawal symptoms. However, doses higher than 2 mg have not been sufficiently studied over the long term. Lastly, if you’re worried about the potential testosterone-lowering effect of melatonin, rest assured, there is currently no conclusive evidence to support this claim.
A common therapeutic approach for alleviating insomnia is maintaining sleep hygiene, a part of which involves diet. Sleep hygiene techniques include not eating too much at night and not eating too late into the night. It also includes avoiding or limiting the intake of alcohol, caffeine, and caffeine-containing foods and drinks (e.g., coffee, tea, and chocolate), especially when it is close to bedtime. Following a healthy, nutrient-rich diet (e.g., high in fruits and vegetables, low in refined sugar) is also considered a part of maintaining good sleep hygiene.[3][2][5]
The circadian clock in humans is controlled primarily by the suprachiasmatic nucleus (SCN) within the brain. The SCN is a group of cells that sit by the optic nerve and respond to light and other stimuli that come in from the eye. Hypothetically, caffeine could affect the SCN (and other tissues throughout the body) in various ways, depicted below.
Possible ways caffeine could affect circadian rhythm
One way is through increasing a cell’s levels of cyclic AMP (cAMP), which is often created inside a cell in response to a signal. This occurs for two reasons. First, caffeine blocks adenosine receptors that normally reduce cAMP levels. Second, caffeine binds phosphodiesterase enzymes that act to degrade cAMP.[19] When these enzymes are blocked, cAMP levels are raised.
It's also been shown that circadian rhythms within the SCN are regulated in part by the release of calcium ions during the stimulation of ryanodine receptors,[20] which caffeine also binds.[21]
At first, alcohol can help you fall asleep, but this effect fades off after a few days if you keep drinking close to bedtime.[33] And right from the start, it will impair the quality of your sleep.[34][35] Ironically, alcohol-use disorders have even been linked to insomnia, though their being cause or consequence is uncertain.[33]
In short, don’t use alcohol as a sleep aid — it might help you relax, but it will impair the quality of your sleep. You may find it beneficial to avoid alcohol after dinner.
For short-term insomnia, sleep hygiene techniques which involve adjusting lifestyle factors (e.g., diet, exercise) and environmental factors (e.g., light, noise, temperature) is commonly recommended, however, sleep hygiene is not recommended as a solo treatment for chronic insomnia. For chronic insomnia, cognitive behavioral therapy (CBT) has good evidence of benefit, especially when used in combination with other therapies. Sleep hygiene and CBT are usually recommended in combination with other behavioral treatments such as sleep restriction, relaxation therapy, and stimulus control.[6]
If you ask people what they’d like to do before bed, you might hear answers such as meditate or read a book. But in reality, texting, playing games, or working is becoming more prevalent by the year, to the probable detriment of sleep quality.[27]
Aside from fiendishly typing and checking social media, are there any other activities you should avoid in order to get a sound night’s sleep?
Eating right before bed is often targeted as a sleep killer. But the evidence is more nuanced; in some people, consuming small amounts of food, such as a glass of milk or a small snack, can benefit sleep.[28] Nighttime exercise is another frowned-upon activity, yet a recent trial[29] and survey[30] evidence has shown a potential benefit on sleep.
As it stands, excess light exposure is more likely to hurt your sleep than your choice of pre-bed activities. The bright lights of a gym will have this effect, as will using a tablet or any other blue light-emitting device.[31][32]
Common causes of insomnia include work stress, relationship issues, or traumatic events. Often times, insomnia occurs in response to certain medical conditions, medicines, and other sleep disorders (e.g., obstructive sleep apnea). Caffeine, tobacco, alcohol, and other substances can also trigger insomnia. However, in some cases, insomnia is considered to be a primary problem because it does not have an identifiable cause, although risk factors include long-lasting emotional upset, stress, travel, and shift work.[1]
Sunlight exposure does not just result in vitamin D production in our skin. It can also directly influence sleep quality through its effects on our circadian rhythms.[22] Increased exposure to sunlight in elderly nursing home residents can improve sleep quality scores.[23] Similarly, workers in windowless offices suffered from poorer sleep quality than those working by windows.[24] For workers in Antarctica in the winter,[25] the benefits of light can be produced using bright sun lamps, which make up for the negative effects of under-exposure of sunlight on sleep.[26] So, it seems that increased sun exposure could benefit sleep quality both through improved circadian rhythms and also increased vitamin D levels. Therefore, sun exposure is a confounding factor when studying the relationship between vitamin D levels and sleep.
References
Examine Database References
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