Insomnia is very common. Approximately 20% of US adults can have an occasional night or two of difficulty falling or staying asleep, waking feeling dissatisfied, run down, and even out of sorts the next day.¹ According to the American Academy of Sleep Medicine’s (AASM) International Classification of Sleep Disorders, 3rd edition, text revised (ICSD-3-TR),² the diagnosis of insomnia is based on these symptoms being present at least 3 nights per week. About 10% of adults have chronic insomnia,¹ which the ICSD 3-TR² defines as an insomnia disorder that lasts 3 months or longer; short-term insomnia lasts for less than 3 months. 

In general, insomnia refers to difficulty falling asleep, staying asleep, or waking up too early. However, insomnia is a 24-hour problem, not just a nighttime sleep problem. The multiple daytime challenges include fatigue (which pertains more to physical exhaustion and is different from sleepiness per se³), difficulty concentrating, problems with attention, and memory dysfunction, in addition to irritability or low mood. 

Insomnia Disorder Diagnostic Criteria³

A. The patient reports, or the patient’s parent or caregiver observes, one or more of the following:

1. Difficulty initiating sleep
2. Difficulty maintaining sleep
3. Final awakening earlier than desired
4. Resistance to going to bed on an appropriate schedule
5. Difficulty sleeping without parent or caregiver presence or intervention

B. The patient reports, or the patient’s parent or caregiver observes, one or more of the following related to the nighttime sleep difficulty

1. Fatigue/malaise
2. Impaired attention, concentration, or memory
3. Impaired social, family, occupational, or academic performance
4. Mood disturbance/irritability
5. Subjective daytime sleepiness
6. Behavioral problems (eg, hyperactivity, impulsivity, aggression)
7. Reduced motivation/energy/initiative
8. Proneness for errors/accidents
9. Concerns about or dissatisfaction with sleep

C. The reported sleep/wake complaints cannot be explained purely by inadequate opportunity (ie, enough time is allotted for sleep) or inadequate circumstances (ie, the environment is safe, dark, and comfortable for sleep).

D. The sleep disturbance and associated daytime symptoms occur at least three times per week.

E. The sleep disturbance and associated daytime symptoms have been present for at least three months for chronic insomnia and less than 3 months for short-term insomnia.

F. The sleep disturbance and associated daytime symptoms are not solely due to another current sleep disorder, medical disorder, mental disorder, or medication/substance use.

The Treatment of Insomnia 

If you are experiencing the occasional sleepless night and want to avoid making it a habit, consider evaluating and optimizing your sleep hygiene. If the sleepless problems continue, consider keeping a symptom diary to better understand your day and night factors contributing to and being affected by your sleep challenges. Being prepared can make your visit with a primary care provider more productive and likely to help identify the cause. Stress, certain medications, other sleep disorders, and some medical and mental health conditions can increase the likelihood of having insomnia, so tuning into your particular patterns is critical.

The first-line treatment for insomnia is cognitive behavior therapy for insomnia (CBT-I), which seeks to change thought and behavior patterns to improve sleep.⁴ CBT-I aims to have you become more in-tune with what is causing you to have sleep difficulties and also how you’re responding to those difficulties so that you can replace them with thoughts and behaviors that are more likely to support sleep. This technique puts you in control, rather than feeling like you are controlled by your insomnia. Insomnia related to another medical or mental health condition involves addressing those disorders to reduce their impact on sleep. The effects of many over-the-counter sleep aids might last well into the next day, impairing daytime functioning. 

Pharmacotherapy, treatment with medication, may be helpful in treating chronic insomnia. A common way to explain a treatment approach is using a driving analogy. If you are driving and you want to slow down, you have a choice of two ways to do so: you can take your foot off the gas or you can press down on the brake.

Taking Your Foot off the Gas: The wake-suppressing approach to negotiating those sleepless nights is typically done through limiting the impact of the major waking-promoting neurotransmitter orexin with orexin receptor antagonists. Three dual orexin receptor antagonists (DORAs) are currently approved by the US Food and Drug Administration (FDA): suvorexant, lemborexant, and daridorexant. However, the availability of these may vary internationally. Seltorexant, a selective orexin 2 receptor antagonist, has been studied in phase 3 clinical trials for the treatment of adults and older adults with major depressive disorder depression and insomnia and has promising results. If FDA-approved, seltorexant will be a first-in-class medication as a selective orexin 2 receptor antagonist, as well as having a unique position as having data to support a positive impact in depression and insomnia.

Pressing Down on the Brake: The sleep-promoting medications that have been used historically act upon the GABA (gamma-aminobutyric acid) system and include the benzodiazepines, benzodiazepine receptor agonists, and barbiturate family of medications. The melatonin receptor agonist ramelteon has FDA approval for the treatment of insomnia. The antidepressants doxepin and amitriptyline can also be used as treatments for insomnia. 

In general, sleep and neurology professional organizations recommend avoiding antipsychotic use for the primary indication of insomnia. In addition, the AASM guidelines include recommendations against the use of trazodone, tiagabine, diphenhydramine (found in many over-the-counter sleep aids), melatonin, tryptophan, or valerian to treat sleep-onset or sleep-maintenance insomnia.⁵ With this stated, it is important to outline that there may be specific patient populations, such as those who have autism, for instance, for whom melatonin is a very commonly used and effective treatment. 

Understanding that your journey is not anyone else’s is the reason we established and are growing WSCN. Although there is specific guidance for treating insomnia on its own, these recommendations may or may not fully apply to individuals with coexisting conditions. Our goal is to bridge the gap between day and night for you to unlock your full potential. 

References

1. Morin CM, Jarrin DC. Epidemiology of insomnia: prevalence, course, risk factors, and public health burden. Sleep Med Clin. 2022;17(2):173-191.
2. American Academy of Sleep Medicine. International Classification of Sleep Disorders, 3rd ed, Text Revision. American Academy of Sleep Medicine; 2023.
3. Shen J, Barbera J, Shapiro CM. Distinguishing sleepiness and fatigue: focus on definition and measurement. Sleep Med Rev. 2006;10(1):63-76.
4. Edinger JD, Arnedt JT, Bertisch SM, et al. Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2021;17(2):255-262.5. Sateia MJ, Buysse DJ, Krystal AD, Neubauer DN, Heald JL. Clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2017;13(2):307-349.
5. Sateia MJ, Buysse DJ, Krystal AD, Neubauer DN, Heald JL. Clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2017;13(2):307-349.