Chronic insomnia: diagnosis and non-pharmacological management
BMJ 2016; 355 doi: https://doi.org/10.1136/bmj.i5819 (Published 16 November 2016) Cite this as: BMJ 2016;355:i5819
What you need to know
Establish whether insomnia is acute or chronic as management differs
Chronic insomnia persists even when lifestyle factors adversely affecting sleep are addressed
Cognitive behavioural therapy for insomnia (CBT-I) is the recommended first line treatment for chronic insomnia
Medications may be used as an adjunct to CBT-I, but their long term effectiveness and safety have not been well assessed
Surveys of adults show that 13-33% of the adult population have regular difficulty either getting to sleep or staying asleep.1 2 3 Insomnia is dissatisfaction with sleep quantity or quality with one of more of difficulty initiating sleep, difficulty maintaining sleep, and early morning awakening. The sleep disturbance causes significant distress or impairment of functioning. There may be a feeling of having been awake all night even when getting some sleep.
People with comorbid disorders of physical or mental health, such as depression, have higher rates of insomnia. Depression and sleep disturbance are the first and third most common psychological reasons for patient encounters in general practice.4 Untreated, insomnia increases the risk of development or exacerbation of anxiety, depression, hypertension, and diabetes.5 6 This article outlines current concepts in insomnia and provides up to date information on treatment.
When does acute insomnia become chronic insomnia?
Most people will experience sleep disturbance or acute insomnia at some point in any given year. This often occurs around predictable times of stress or when sleep patterns are disrupted, such as with travel, busy periods at work, illness, or emotional upset. While people may be distressed about sleep loss during acute insomnia, once the trigger factors are removed, sleep usually returns to normal.
Insomnia becomes chronic when someone has difficulty either getting to sleep or staying asleep for at least three nights a week (not necessarily every night) for at least three months and is distressed by their sleep symptoms.7 There may be preoccupation and fear associated with sleep. Pre-sleep arousal is also common, manifesting as feeling sleepy before retiring to bed but then becoming more alert once in bed and faced with the task of sleeping.
Figure 1⇓ shows the evolution of acute insomnia into chronic insomnia. Some groups are more prone to insomnia (see box 1). Once a cycle of worry about sleep or a conditioned arousal response to sleep has developed, it can become self perpetuating. This can result in persistent hyperarousal, resulting in people feeling paradoxically alert or “wired” during both waking and sleeping hours despite a lack of sleep.
Fig 1 Stages in the development of insomnia. In the development of chronic insomnia and with treatment people move from the left to the right of this diagram. People commonly have episodes of acute insomnia, which settle spontaneously with the passage of intercurrent precipitating circumstances (column 2). With repeated or prolonged episodes of acute anxiety, people introduce coping behaviours such as going to bed earlier or staying in bed later trying to create more opportunity for sleep (column 3). When these perpetuating factors don’t settle insomnia symptoms, people develop a conditioned arousal response to sleep, or hyperarousal (column 4). With treatment, changed thinking and behaviours are addressed, and, as they improve, people’s insomnia symptoms settle (columns 5 and 6). The threshold line indicates when contributing factors reach sufficient intensity to result in insomnia symptoms
Box 1: Risk factors for insomnia
Physical health problems
Persistent pain
Cardiac or respiratory failure
Chronic inflammatory conditions—such as arthritis, connective tissue disorders, inflammatory bowel disease
Chronic infection—such as hepatitis, HIV infection
Mental health problems
Depression
Anxiety
Bipolar disorder
Personality disorders—such as narcissistic and borderline
Medications that can disturb sleep
Antidepressants—such as selective serotonin reuptake inhibitors and serotonin–norepinephrine reuptake inhibitors
Adrenergic agonists—such as salbutamol, terbutaline, dexamphetamine, methylphenidate
Corticosteroids
Opioids
Personal factors
Family history of insomnia from a young age
Tendency to anxiety or perfectionism
Lifestyle factors
Shift work or long working hours with little recovery time between shifts
Excess stimulant use—such as caffeine, energy drinks, nicotine
A small, well conducted longitudinal study of 388 people with insomnia disorder and insomnia symptoms at baseline found that 46% had ongoing symptoms or met the diagnostic criteria for insomnia disorder after three years’ follow-up, while 27% had spontaneous resolution, and 27% experienced remission and relapse.8
How to assess people with sleep disturbance
Ask about common symptoms of insomnia and establish the frequency and duration (box 2). When assessing people with sleep disturbance or insomnia, it is important to ask about the impact the sleep disturbance is having. If this is minimal, treatment may not be required, and reassurance about the variation in sleep pattern might be all that is needed.
Box 2: Questions to ask when taking a sleep history
Sleep itself
Behaviour around bed and sleep—time in to bed, time taken to get to sleep, how long spent awake during the night, time out of bed in the morning, any napping during the day. A sleep diary can help to collect this information
Anything happening during sleep—snoring, restless legs symptoms, nightmares, sleep walking or sleep talking
What is the patient’s relationship with sleep? Is there emotion? Does the patient attribute other problems to sleep problems?
Impact of any sleep problems
Waking function—subjective alertness throughout the day. A validated scale such as the Epworth Sleepiness Scale can be used
Safety—sleepiness while driving or operating equipment
Risk factors that may contribute to sleep problems (see box 1)
Insomnia is one of many causes of sleep disturbance, so if sleep disturbance is considered a problem, identify other physical or mental illnesses that might be contributing to the symptoms (see box 1).
What are the principles of insomnia treatment?
It is important to distinguish between acute and chronic insomnia as they have different management pathways (box 3). Management should be tailored according to expected duration of symptoms and factors contributing to insomnia.
Box 3: Diagnosis and management of acute and chronic insomnia
Acute insomnia
Diagnosis—Sleep disturbance with distress about sleep and impact on waking function that has been triggered by short term circumstances (such as ill health, stress, medication, or change in time zone), lasting <3 months and usually settling once short term circumstances have resolved
Management:
Address short term circumstances that have resulted in insomnia
Review sleep hygiene measures
Provide support and reassurance that symptoms are usually self limiting and an expected reaction to short term circumstances
Consider short term use of hypnotic medication to reduce distress about lack of sleep if symptoms are sufficiently intense
Chronic insomnia:
Diagnosis—Persistent sleep disturbance (>3 nights per week for >3 months) resulting in significant impact on waking function and distress about sleep despite adequate opportunity for sleep, does not co-occur with another sleep disorder, and is not explained by coexisting mental disorders or medical conditions7
Management:
Address changed thinking and behaviour around sleep using cognitive behavioural therapy as first line treatment9
Review physical and mental health and medications to reduce factors that may be contributing to insomnia
If there is significant distress and impact on waking function from disturbed sleep, consider use of hypnotic medication, but always use in parallel with non-drug treatments and review need for medication regularly
People with chronic insomnia may be offered advice more appropriate for acute insomnia, such as modifying lifestyle factors or waiting for symptoms to pass. Hypnotics are often prescribed for a limited time that is out of keeping with the expected duration of symptoms.10 Our personal experience and feedback from patients via a Facebook group surveyed in preparing this article show this is one of the most frustrating aspects of dealing with their insomnia.
The key principles for assessing and managing chronic insomnia require healthcare professionals to:
Address anxiety about sleep
Address maladaptive behaviours around sleep
Address fear of further disruption of sleep
Consider predisposing dispositions
Consider comorbidities
Consider pharmacological options, but consider hypnotics only as a short term measure
Refer to a specialist (where available) if there are ongoing symptoms despite the above measures.
Non-drug treatments
There is good evidence from randomised controlled trials (RCTs) for cognitive behavioural therapy for insomnia (CBT-I).11 This is a package of treatments incorporating sleep restriction, stimulus control, relaxation strategies, cognitive therapy, and sleep hygiene measures (table 1⇓). It commonly consists of between two and eight sessions conducted over two to eight weeks with a psychologist or healthcare professional such as a trained practice nurse.
Components of cognitive behavioural therapy for insomnia
A recent meta-analysis of studies of cognitive behavioural therapy for chronic insomnia showed that multi-component CBT-I reduced the time to sleep onset by 19 minutes and the amount of wakefulness after sleep onset by 26 minutes and that effects were sustained to 12 months after treatment.11 It is difficult to assess the relevance of this change because baseline levels of sleep reported in individual trials are so variable. These effect sizes are similar to those seen in trials of modern hypnotics for chronic insomnia, but the effect of hypnotics wears off once treatment is stopped, whereas cognitive behavioural therapy has ongoing effects. Similar results have been shown in a meta-analysis of insomnia occurring comorbid with other conditions.12 The American College of Physicians recommends CBT-I as first line treatment for chronic insomnia in adults.9
CBT-I can be delivered by healthcare providers trained in the delivery of treatment for insomnia. However, there are limited numbers of qualified behavioural sleep medicine practitioners. A stepped-care approach has been proposed, starting with self administered CBT-I, followed by CBT-I delivered by trained therapists such as nurses, and finally stepping up to CBT-I delivered by a psychologist if more expert care is needed.13 There is little evidence to guide which step to start a patient on, how long to keep the patient at that level, and when to progress to the next level.
Online CBT-I programmes have shown their effectiveness in randomised controlled trials.14 15 A recent meta-analysis of internet-delivered CBT-I for chronic insomnia reduced the time to sleep onset by 11 minutes and the amount of wakefulness after sleep onset by 20 minutes.16 The availability and type of CBT-I programmes varies with different practice settings, so decisions about how CBT-I is accessed will depend on local circumstances as well as the patient’s needs and preferences.
While some clinical trials show positive effects from individual components of CBT-I, combining these components provides the best results. There is insufficient evidence to support the use of sleep hygiene as a single therapy for chronic insomnia.17 18 Ensuring patients have exposure to all components of CBT-I for the appropriate duration is important to optimise outcomes. Failure to ensure CBT-I is delivered appropriately might give the impression that the therapy is unsuccessful.
There is ongoing research into alternative non-drug strategies for non responders to CBT-I. A small randomised control trial of mindfulness based therapy (combining mindfulness with CBT-I) showed improvement in sleep related symptoms.19 Small studies have shown a small benefit of Tai Chi in reducing symptoms of insomnia.20 21 Although current evidence for managing circadian factors, such as light exposure in the evening before bed, is limited, measuring circadian rhythm phase and optimising circadian function may play a role in the treatment of insomnia in future.22
What is the role of pharmacological treatment?
Drugs are not recommended as the sole treatment for chronic insomnia. The most commonly used agents are hypnotics (benzodiazepines and benzodiazepine receptor agonists), sedating antidepressants, antipsychotics, antihistamines, melatonin or melatonin receptor agonists, and dual orexin receptor antagonists (DORAs). All medications are associated with side effects and some with longer term dependence. Those most at risk of side effects include elderly people and those taking other drugs that may interact with medication used for insomnia. No drug used for chronic insomnia has the perfect pharmacological profile, and the choice of drug used should be tailored to individuals based on their symptoms, comorbidities, and concurrent medication.
Overall, the risks of medication should be balanced against the risks of ongoing chronic insomnia, such as increased risk of depression and hypertension.5 6 Use of drugs should be cautious, at the minimum dose required and for the minimum duration possible.
Sources and selection criteria
In preparing this review, we obtained articles on insomnia and its treatment from personal archives, as well as searches of the Cochrane Collaboration and Clinical Evidence databases for relevant reviews from 1993 to 2016 using the term “insomnia”. We consulted other experts in the specialty for advice on articles suitable for inclusion and important themes and points to include in the review.
Questions for future research
Does treating insomnia reduce the risk the future development of depression or anxiety?
What is the role of circadian rhythm in the development and the treatment of chronic insomnia?
What other treatments can be added to or combined with cognitive behavioural therapy for insomnia to increase its effectiveness?
Additional educational resources
Resources for healthcare professionals
Sleep Health Foundation (www.sleephealthfoundation.org.au/)—Resources for practitioners, information on various sleep disorders
Sleep Education (www.sleepeducation.org/healthysleep/resources-for-health-care-professionals/)
SleepHub. Sleep Talk podcast (http://sleephub.com.au/podcast/)—Monthly podcast on sleep
Information resources for patients
Harvard Healthy Sleep (http://healthysleep.med.harvard.edu/healthy/)—Free information on sleep
National Sleep Foundation’s Sleep.org (http://sleep.org)—Free information on sleep and health
SleepHub. Sleep Talk podcast (http://sleephub.com.au/podcast/)—Monthly podcast on sleep
How patients were involved in the creation of this article
Over 5000 Facebook users with an interest in insomnia were asked to provide answers to the question: “What do you wish your doctor or health professional knew about insomnia?” In writing the paper, we aimed to address the points raised by responders by ensuring the common themes were included in the manuscript. The main themes that came out in responses were:
Emphasising the chronic nature of insomnia, and differentiating acute from chronic insomnia
Recognising the impact insomnia can have
Understanding that insomnia can occur commonly in other chronic medical conditions such as chronic kidney disease, pain, narcolepsy, multiple sclerosis, rheumatoid arthritis, cancer, and heart failure
Footnotes
Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; externally peer reviewed.