Insomnia

What is insomnia?

Insomnia is a difficulty to get to sleep, get enough sleep, stay asleep, or sleep well.^1,3 This occurs despite having the opportunity to get enough sleep and impairs your ability to function during the day.³ However, if an inability to sleep does not impair your daytime functioning, it is not considered to be insomnia.³

If your symptoms occur for less than three months (a few days or weeks), you have short-term (acute) insomnia.^1,3,4 If you have insomnia for at least three nights per week for three months or more, you have chronic insomnia.^1,3,4

Insomnia can manifest as:¹

• Difficulty falling asleep (sleep onset insomnia)
• Waking up in the middle of the night (maintenance insomnia)
• Waking up too early and not falling back to sleep (early waking insomnia)

Maintenance insomnia is the most common form of the condition.¹  

Insomnia affects around a third of adults in Western countries.⁵ 6–10% of these fulfil the criteria for chronic insomnia.⁵ Anyone can experience insomnia, but it occurs 1.5–2 times more frequently in females than males and is reported by 25% of women in perimenopause.⁵ It increases with age and occurs most often in older adults.⁵

How many hours of sleep do I need?

You may have heard that you need eight hours of sleep a night, but the amount of sleep each person needs is highly individual.²

The idea of eight hours a night is prevalent because most adults need between seven and eight hours to function well.^2,4 But some people can function well on four to five hours of sleep and others may need more like nine hours.^2,4 However, children tend to need between nine and 13 hours of sleep and toddlers and babies need between 12 and 17 hours.⁴ The amount of sleep we each need tends to reduce as we age.²

What matters overall, however, is whether you feel you’re getting enough sleep and whether the sleep you’re getting is high quality.^2,6

Insomnia symptoms

You have insomnia if you regularly:^1,4

• Have difficulty falling asleep
• Struggle to stay asleep
• Wake up early and cannot go back to sleep
• Feel tired during the day
• Experience delayed reactions
• Have trouble remembering things
• Have trouble concentrating
• Feel irritable, anxious or depressed
• Find it hard to nap during the day, even though you're tired

Your insomnia shouldn’t be caused by medications or other sleep disorders, medical or mental health conditions.

Complications of insomnia

Severe insomnia or chronic insomnia can cause sleep deprivation.¹ Sleep deprivation can make you extremely sleepy during the day, which can be dangerous if you’re doing tasks that require high levels of concentration, such as driving.¹ Additionally, it can cause you to take more days off work than other people.⁷

Sleep deprivation can also increase your risk of:^1,7

• Depression
• Anxiety
• Substance misuse
• High blood pressure (hypertension)
• Heart attack
• Stroke
• Obstructive sleep apnoea
• Type 2 diabetes
• Obesity
• Psychosis

Causes of insomnia

People with insomnia may have more active brains or brain chemistry differences that affect their ability to sleep.¹

However, a number of other factors can contribute to insomnia, such as:^1,4,6

• Having a family history of insomnia
• Medical conditions, like acid reflux or parkinson’s disease
• Mental health conditions, like anxiety and depression
• Going through stressful circumstances
• Doing shift work
• Having poor sleep hygiene (e.g. Drinking caffeine late into the evening, taking naps during the day and going to sleep at different times each night)
• Sleeping in a room that’s too hot or too cold
• Noises that keep you awake
• Using drugs like caffeine, nicotine, cocaine or ecstasy
• Having an uncomfortable bed

How to treat insomnia

You may be able to treat your insomnia yourself by improving your sleep hygiene and with over the counter (OTC) sleep drugs.^4,6,8 However, if these approaches don’t work, you should make an appointment with your GP.⁴

Depending on the cause of your insomnia and how severe it is, your GP may prescribe medication, or a course of cognitive behavioural therapy specifically designed for insomnia (CBTi).^4,6,8

How to improve your sleep hygiene

Changing your sleep habits can improve your insomnia:^4,6

• Go to bed at the same time every day
• Get up at the same time every day, even if you don’t feel like you’ve had enough sleep
• Do not nap during the day
• Make sure your bedroom is dark and quiet – use thick blinds or curtains and an eye mask or ear plugs
• Keep your bedroom slightly cooler than the rest of your living area
• Get regular exercise, but don’t exercise for at least four hours before going to bed
• Make sure your mattress, covers and pillow are comfortable
• Relax for at least an hour before bed (e.g., take a bath, read a book or listen to gentle music)
• Write any worries and ideas down before going to bed, so that you can mentally put them to the side until morning
• Avoid caffeine, alcohol and smoking for a few hours before bed
• Don’t eat a big meal just before bedtime
• Avoid watching television or using a smartphone right before bed, as the blue light can make you feel more awake
• Don’t eat a big meal just before bedtime
• Try not to use your bedroom for anything other than sleeping or sex

Medicine for sleep over the counter

OTC tablets or liquids from a pharmacy may help you to overcome an acute bout of insomnia.^4,6,9 The best sleeping tablets contain ingredients, such as:^1,4,6,9–11

• Antihistamines – drowsy antihistamines, such as doxylamine, diphenhydramine and promethazine, can help you fall asleep. However, you should only use medications that contain drowsy antihistamines for short periods, as you can develop a tolerance to their sedative effects
• Lavender – some research has identified the beneficial effects of lavender on both the quality and duration of sleep
• Valerian – limited research has demonstrated that valerian may reduce the amount of time it takes to get to sleep and improve sleep quality
• Melatonin – melatonin is a hormone that helps to regulate your sleep-wake cycle. Supplementing with melatonin tablets has been found to help treat jet lag and reduce the amount of time it takes to fall asleep

Cognitive behavioural therapy

If changing your sleep habits and using OTC sleep drugs doesn’t improve your insomnia, you may be offered CBTi.^4,6,8 This includes behavioural interventions (e.g. stimulus control and sleep restriction), cognitive therapy, and relaxation training.⁸ The aim is to change the unhelpful thoughts and behaviours that contribute to your insomnia.⁶

CBTi has been found to be an effective treatment for many people and the results can be long term.⁶

Prescription sleeping pills

You will only be prescribed sleeping pills in very severe cases, and only for short term use (preferably less than one week).^4,8 This is because they can have serious side effects and you can become dependent on them.⁴

Prescription sleeping pills in the UK include:^1,8,12–15

• Benzodiazepines – a group of depressant medication that slow down the central nervous system. Benzodiazepines prescribed in the uk include diazepam (valium)
• Zopiclone and temazepam –sleeping pills that increase the calming chemical in your brain (gaba) to help you fall asleep and prevent you from waking up during the night
• Prolonged release melatonin – you can get slow-release melatonin tablets on prescription, which release melatonin gradually into your body overnight to help you sleep

How to fall asleep when you’re struggling

According to the NHS, if you can’t fall asleep and this is making you anxious, you should:

• Get up
• Move to a different room
• Do something relaxing, like reading or listening to music
• Try going to sleep again in around 20 minutes, or whenever you feel tired again

Sources

1. https://my.clevelandclinic.org/health/diseases/12119-insomnia
2. https://royalpapworth.nhs.uk/application/files/5316/4640/2088/PI_215_How_to_tackle_insomnia_V2_online.pdf
3. https://cks.nice.org.uk/topics/insomnia/background-information/definition/
4. https://www.nhs.uk/conditions/insomnia/
5. https://cks.nice.org.uk/topics/insomnia/background-information/prevalence/
6. https://www.nhsinform.scot/illnesses-and-conditions/mental-health/insomnia/
7. https://cks.nice.org.uk/topics/insomnia/background-information/complications/
8. https://cks.nice.org.uk/topics/insomnia/management/managing-insomnia/
9. https://www.mayoclinic.org/healthy-lifestyle/adult-health/in-depth/sleep-aids/art-20047860
10. https://pmc.ncbi.nlm.nih.gov/articles/PMC3612440/
11. https://www.mayoclinic.org/diseases-conditions/insomnia/expert-answers/valerian/faq-20057875
12. https://www.nhsinform.scot/healthy-living/drugs-and-drug-use/common-drugs/benzodiazepines-benzos-diazepam-valium/
13. https://www.nhs.uk/medicines/zopiclone/about-zopiclone/
14. https://www.nhs.uk/medicines/temazepam/about-temazepam/
15. https://www.nhs.uk/medicines/melatonin/how-and-when-to-take-melatonin/