Insomnia

What Causes Insomnia?

Insomnia can be caused by numerous medical problems, stressors, mental health-related issues, medication side effects, and lifestyle habits. Common causes include:

• Stress
• Schedule disruptions (due to work, travel, etc.)
• Poor sleep habits
• Anxiety or depression
• Mental health issues such as post-traumatic stress disorder (PTSD)
• Medications, including antidepressants, high blood pressure medications, asthma medications, and over-the-counter stimulants
• Chronic pain
• Digestive disorders
• Degenerative neurological disorders such as Alzheimer’s or Parkinson’s disease
• Sleep apnea
• Substance use (e.g., nicotine, caffeine, alcohol)
• Hormonal changes (e.g., menopause, thyroid disease, menstruation)

Is Insomnia Hereditary?

Most of the time, insomnia is caused by external factors, medical disorders, or other underlying conditions other than genetics. However, studies have suggested that some people have a genetic predisposition to sleep disorders such as insomnia, and that predisposition may be inherited. In addition, the genetic risk for insomnia also seems to be associated with other conditions, including major depression and type 2 diabetes.

Researchers have identified some possible genetic variations that may be behind insomnia risk, but further research is necessary to confirm a definite genetic connection.

How Is Insomnia Detected?

More than half of adults experience occasional trouble sleeping, but sleep difficulties that cause you anxiety, leave you feeling tired and unwell during the day, or last for a prolonged period could be a reason to consult a doctor. Insomnia that lasts for a long time and does not respond to lifestyle changes can be a cause for concern.

How Is Insomnia Diagnosed?

Doctors may take several different diagnostic steps when a patient is experiencing chronic sleep difficulties.

• Physical exam. A basic physical exam will screen for indications of medical conditions that could be causing the sleep problems.
• Blood tests. The doctor may order laboratory blood tests to rule out conditions, such as thyroid dysfunction, that may be causing insomnia.
• Sleep diary. Your doctor may ask you to keep a log of your sleep over two weeks or so to look for patterns in your sleep behavior. You may also be asked to track other habits that could impact your sleep, such as your caffeine use.
• Sleep study. A study of your sleep patterns, which may be conducted at a sleep center, may be recommended if your doctor suspects that a condition such as sleep apnea could be the cause of your insomnia.

The Diagnostic and Statistical Manual of Mental Disorders (DSM) includes diagnostic criteria providers can use to diagnose insomnia disorder. The criteria include:

• The patient has trouble falling asleep or staying asleep.
• The symptoms have lasted at least three months.
• The symptoms occur at least three times a week.
• The symptoms cause significant impairment or distress.
• The patient has adequate opportunities for sleep.
• The symptoms are not caused by another sleep disorder, a mental disorder, a medical condition, medications, or substance use.

PLEASE CONSULT A PHYSICIAN FOR MORE INFORMATION.

How Is Insomnia Treated?

Treatment for insomnia varies according to its underlying cause. In many cases, insomnia resolves with the treatment of an underlying medical condition or the removal of a stressor causing the sleep difficulty.

Common treatment approaches include:

• Cognitive-behavioral therapy. A specialized psychotherapy technique called cognitive-behavioral therapy for insomnia (CBT-I) helps identify the thoughts and behaviors associated with sleep difficulties and replace them with strategies that support good sleep habits.
• Medications. Prescription medications such as eszopiclone, ramelteon, zaleplon, and zolpidem may help control short-term or occasional insomnia. Still, in general, doctors do not recommend their long-term use for chronic insomnia.

Over-the-counter sleep aids can have side effects that make them unsuitable for regular use. The supplement melatonin, which is often promoted as a sleep aid, has not been shown by scientific studies to consistently improve insomnia symptoms.

You should always follow your doctor’s guidance for any treatment program and consult your doctor before using any over-the-counter sleep aid.

How Does Insomnia Progress?

Untreated chronic insomnia can lead to a wide variety of medical problems, quality-of-life complications, and mental health-related issues, including:

• Problems at work or school
• Relationship difficulties
• Accidents caused by fatigue or mental fogginess
• Anxiety or depression
• Substance abuse
• Weight gain
• Diabetes
• High blood pressure
• Heart disease

How Is Insomnia Prevented?

Good sleep habits and a healthy lifestyle can help prevent insomnia. Steps you can take to ensure better sleep include:

• Stick to a regular sleep schedule (even on weekends)
• Don’t eat or drink close to bedtime
• Avoid stimulating activities (e.g., watching TV, using electronics) 30 minutes before bedtime
• Use your bedroom only for sleep
• Keep your bedroom dark and cool
• Get plenty of exercise
• Limit consumption of caffeine and alcohol
• Quit smoking
• Don’t take naps
• Try meditation or relaxation techniques

Insomnia Caregiver Tips

Some people with insomnia also suffer from other brain and mental health-related issues, a condition called co-morbidity. Here are a few of the disorders commonly associated with insomnia:

• Depression can cause insomnia symptoms, and chronic insomnia can have depression as a complication.
• Anxiety disorders are common underlying causes of insomnia.
• Stress-related conditions such as post-traumatic stress disorder (PTSD) can cause insomnia.
• Insomnia is common in people with psychotic disorders such as schizophrenia.
• Children with attention-deficit/hyperactivity disorder (ADHD) are at increased risk of insomnia.
• Alcoholism and substance abuse are commonly associated with insomnia.
• People with degenerative diseases such as Alzheimer’s, Parkinson’s, and dementia often suffer from insomnia.

Insomnia Brain Science

Studies have shown many differences between the brains of people with insomnia and the brains of people who are not having sleep problems. Some of those differences include:

• While working on memory-related tasks, people with insomnia showed lower than expected activity in the dorsolateral prefrontal cortex. This part of the brain helps to support memory during intensive tasks. The insomniacs also were less able to turn off other parts of their brains to aid in their focus on the task.
• Some people with chronic insomnia have smaller than usual frontal lobes, a part of the brain that helps with decision-making, memory, and cognitive functions.
• People with insomnia showed unusual activity in their motor cortex, the part of the brain responsible for the planning and execution of voluntary movement. The unusual activity included a high degree of “plasticity” (the brain’s ability to rewire its neurons in response to stimuli) and “excitability” (the tendency of neurons to remain active at all times).

Insomnia Research

Title: Reducing Use of Sleep Medications Assisted by a Digital Insomnia Intervention (SEDATIVE)

Stage: Not Yet Recruiting

Principal investigator: Adam D. Bramoweth, PhD

VA Pittsburgh Healthcare System University Drive Division

Pittsburgh, PA

Chronic insomnia is one of the most common health problems among Veterans and significantly impacts their health, function, and quality of life. Sedative-hypnotic medications are the most common treatment despite mixed effectiveness and are associated with numerous risks that can further impact Veteran function. An intervention combining evidence-based interventions for deprescribing sedative-hypnotics and behavioral interventions for insomnia can help to optimize sleep and functional outcomes for Veterans with a desire to reduce or stop using these medications. Furthermore, delivering these interventions through an easy-to-use and highly accessible digital platform can provide additional benefits to Veterans, especially those with limited time and access to traditional in-person interventions. The Clinician Operated Assistive Sleep Technology (COAST) is an efficient, scalable, and adaptable platform that can help providers reach more Veterans and provide evidence-based care that translates to improved health and function.

Aim 1: To assess the feasibility of recruiting Veterans with chronic sedative-hypnotic use to participate in a 12-week combined deprescribing and CBT-I intervention delivered through the COAST digital platform.

Aim 2: To assess Veteran acceptability and usability of the COAST platform.

Aim 3: To assess change in Veteran sleep, sedative-hypnotic use, and function pre- to post-intervention.

Title: Improving Negative Stressful Perseverations in Insomnia to Revitalize Expectant Moms (INSPIRE)

Stage: Recruiting

Principal investigator: David Kalmbach, PhD

Henry Ford Health System

Novi, MI

This randomized controlled trial aims to determine the efficacy of cognitive-behavioral therapy for insomnia (CBTI) and mindfulness-based treatment for insomnia (MBTI) for perinatal insomnia relative to sleep education and hygiene, which is a minimal intervention control. The long-term goal is to maximize the effectiveness of insomnia treatment for perinatal women by adapting safe and efficacious therapies to meet the evolving needs of women through pregnancy and postpartum. Over half of pregnant women develop insomnia, which is associated with high rates of depression during pregnancy and postpartum. By successfully treating insomnia during pregnancy and improving cognitive-emotion regulation, the mental health of pregnant and postpartum women may be substantially improved. In a previous clinical trial, Dr. Kalmbach (PI) showed that digital CBTI (i.e., a fully automated online program) improved sleep during pregnancy and offered some protection against sleep problems after childbirth. Women in this previous trial were highly satisfied with CBTI and the ability to participate in treatment remotely. However, the investigators identified important shortcomings of CBTI in this population. Namely, standard CBTI was ineffective at reducing cognitive arousal and depression. Preliminary data suggest that MBTI may effectively reduce cognitive arousal in insomnia patients, which has immense potential to enhance sleep and mental health outcomes in perinatal insomnia. Thus, the investigators will conduct a randomized controlled trial to determine the efficacy of MBTI and CBTI for perinatal insomnia relative to a minimal intervention control.

The current study is a 3-arm RCT comparing CBTI and MBTI to sleep education and hygiene utilizing minimal intervention control for treating perinatal insomnia. One hundred twenty women with insomnia symptoms will be treated beginning in pregnancy and into early postpartum. CBTI and MBTI will address changes in sleep symptoms and challenges that emerge after childbirth. The investigators will collect outcome data on insomnia symptoms and related health outcomes (e.g., cognitive arousal, depression) after prenatal treatment and monthly across the first postpartum year. The investigators will determine the efficacy of the investigator’s CBTI and MBTI protocols for perinatal insomnia relative to minimal intervention control. The investigators will then compare the effects of CBTI and MBTI on short- and long-term outcomes.

Title: Partial Reinforcement II: Three Approaches to Maintenance Therapy for Chronic Insomnia (R01)

Stage: Recruiting

Principal investigator: Michael L Perlis, PhD

University of Pennsylvania

Philadelphia, PA

The study is a three-phase sequential study of the medical treatment of insomnia with Zolpidem. All participating subjects will receive one month of standard nightly treatment. If the subject has a positive treatment response, they continue in the study. They are randomized to one of four conditions: intermittent dosing (3-5 pills a week, full dose) or one of three variable dose conditions (nightly pill use where any given tablet is a variable dose). Standard treatment will last for four weeks. The experimental phase will extend over two periods. The first period will last for 12 weeks. The second period will last for 36 weeks. Both periods include:

• Taking a pill 30 minutes before bedtime.
• In one case, this will involve taking 3-5 pills per week. In the remaining condition, pills will be taken on every night. Depending on the specific group that the subject is assigned to, they will either receive 10mg or 5mg of zolpidem (variable by age and sex) or a variable dose of zolpidem on a nightly basis (range from 0 mg to 10 mg per night).
• Completing a sleep diary each day.
• Completing 6 to 7 questionnaires each week.
• A monthly visit to Penn to return medication foil packs and to receive a new foil pack with the next month of medication.

During Phases 3 and 4, the subject will be asked to undergo quarter annual physicals so that we can optimally track their health and wellbeing. The physicals will involve standard vitals measures (e.g., temperature, blood pressure, height, weight, etc.) and, based on the judgment of the research clinician, may involve an EKG and blood and urine chemistries.

If the subject does not experience a treatment response or (following a treatment response) experiences a relapse of insomnia, they will not continue in the study but will be given the opportunity to be treated with Cognitive Behavioral Therapy for Insomnia (CBT-I) at no cost. Assessments of the subjects’ clinical status will be based on daily sleep diaries and weekly questionnaires.