Insomnia

Insomnia is the most common sleep disorder, with estimates of the prevalence varying from 1-10% and up to 25% in the elderly. Insomnia can be a symptom, meaning that it is secondary to another physical or mental disorder, e.g., depression. It can also be primary if no other cause is found.

Many factors may contribute to insomnia such as environmental factors (e.g., uncomfortable, noisy, or hot/cold surroundings; stressful life events), medical treatment, alcohol, or dietary stimulants such as caffeine. Behavioural processes, (e.g., conditioning, where patients convince themselves that they will not be able to sleep) may lead to or sustain insomnia caused by other factors. Increasing age is also a contributing factor to insomnia.

Therefore, the underlying cause(s) of insomnia can be complex, as multiple contributing factors may act singly or in combination.

Key elements for the definition of primary insomnia include difficulties to initiate or maintain sleep. Non-restorative sleep (or inadequate sleep quality) is the feeling of being unrefreshed upon wakening even after adequate hours spent sleeping, and is a less well known independent symptom of primary insomnia.  In addition to these key elements, the insomnia must have negative effects on subsequent daytime functioning. [i]

Effect of insomnia on daily life
In practical terms, insomnia that affects daily functioning can be detrimental to a person’s life, with poor alertness and efficiency raising the risk of vehicle or occupational accidents through a lack of concentration. Also absenteeism from work is high in sufferers of insomnia, up to twice as large as for good sleepers[ii]. Insomnia is a risk factor for other diseases, such as depression and anxiety[iii]. Self-perceived quality of life is affected to a degree corresponding to other chronic diseases[iv]. Furthermore, directly or indirectly, disrupted sleep can have a negative effect on family life and relationships, by affecting a person’s mood and the way in which they are able to perform daily activities and interact socially[v].

Despite the negative impact on the ability to function well during the day, insomnia is underdiagnosed and undertreated. Very few of the people suffering from insomnia actually go to see a physician. In a consumer survey conducted in France, Germany, Italy and the UK, it was found that 37% of respondents with insomnia took no action to resolve it at all, while 10% used over- the-counter remedies and 13% adopted non-pharmacological measures[vi].

Treatment of insomnia has indeed been difficult due to lack of medication with both a good efficacy and a good safety profile. Traditional sleep drugs such as benzodiazepines were tested and approved based on their ability to increase quantity of sleep. However, they were not necessarily evaluated as regards improvement on quality of sleep and daytime functioning. As discussed above, persons complaining of insomnia suffer because of the implications insomnia has on their daily life. Paradoxically, many of these traditional sleep drugs actually impair the patients’ daytime functioning, with feeling ‘hungover’, being unable to concentrate, and having memory problems, in addition to carrying risks of dependency. This leaves both patients and physicians in a dilemma: treatment of insomnia may leave the patient even worse off than before treatment.

Newer treatment regimes focus both on sleep hygiene, cognitive-behavioural therapy and sleep drugs with a new mechanism of action, which have a benign safety profile and are non-addictive.

For patients and relatives
As described in the above sections, insomnia is either a symptom or a disease in itself. It may severely affect daily life due to daytime sleepiness and concentration problems both at work and at home. Insomnia may affect a person’s ability to cope with daily challenges, and directly or indirectly cause difficulties in relationships with family or friends. It is important to see a physician and possibly even a sleep therapist. Insomnia can be treated safely!

[i]Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition text revision (DSM-IV-TR)

[ii]Léger D, Guilleminault C, Bader G, et al. Medical and socioprofessional impact of insomnia. Sleep 2002;25:625-9

[iii]Taylor DJ, Lichstein KL, Durrence HH. Insomnia as a health risk factor. Behav Sleep Med 2003;1:227-47

[iv]Zammit GK, Weiner J, Damato N, et al. Quality of life in  people with insomnia. Sleep 1999;22(Suppl 2):S379-85

[v]Kandel ER, Schwartz JH, Jessell TM. Principles of neural science. © The McGraw-Hill Companies Inc, 2000.

[vi] Estivill E. Behaviour of insomniacs and implication for their management.

Sleep Med Rev 2002;6(Suppl 1):

S3-6