Insomnia

Psychophysiological insomnia; Learned insomnia; Chronic insomnia; Primary insomnia

Insomnia is difficulty getting to sleep or staying asleep, or having nonrefreshing sleep for at least 1 month.

Causes, incidence, and risk factors

Primary insomnia refers to insomnia that is not caused by any known physical or mental condition.

Insomnia is caused by many different things. The most common causes of insomnia are:

• Alcohol
• Anxiety
• Coffee
• Stress

Secondary insomnia is caused by a medical condition. Depression is a very common cause of secondary insomnia. Often, insomnia is the symptom that causes people with depression to seek medical help.

Symptoms

• Difficulty falling asleep on most nights
• Feeling tired during the day or falling asleep during the day
• Not feeling refreshed when you wake up
• Waking up several times during sleep

People who have primary insomnia tend to keep thinking about getting enough sleep. The more they try to sleep, the greater their sense of frustration and distress, and the more difficult sleep becomes.

Signs and tests

Your health care provider will do a physical exam and ask you questions about your current medications, drug use, and medical history. Usually, these are the only methods needed to diagnose insomnia.

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Treatment

The following tips can help improve sleep. This is called sleep hygiene.

• Avoid caffeine, alcohol, or nicotine before bed.
• Don't take daytime naps.
• Eat at regular times each day (avoid large meals near bedtime).
• Exercise at least 2 hours before going to bed.
• Go to bed at the same time every night.
• Keep comfortable sleeping conditions.
• Remove the anxiety that comes with trying to sleep by reassuring yourself that you will sleep or by distracting yourself.
• Use the bed only for sleep and sex.

Do something relaxing just before bedtime (such as reading or taking a bath) so that you don't dwell on worrisome issues. Watching TV or using a computer may be stimulating to some people and interfere with their ability to fall asleep.

If you can't fall asleep within 30 minutes, get up and move to another room. Engage in a quiet activity until you feel sleepy.

One method of preventing worries from keeping you awake is to keep a journal before going to bed. List all issues that worry you. By this method, you transfer your worries from your thoughts to paper. This leaves your mind quieter and more ready to sleep.

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What People are using to Stop INSOMNIA

Alcohol

Alcohol is often used as a form of self-treatment of insomnia to induce sleep. However, alcohol use to induce sleep can be a cause of insomnia. Long-term use of alcohol is associated with a decrease in NREM stage 3 and 4 sleep as well as suppression of REM sleep and REM sleep fragmentation. Frequent moving between sleep stages occurs, with awakenings due to headaches, polyuria, dehydration, anddiaphoresis. Glutamine rebound also plays a role as when someone is drinking; alcohol inhibits glutamine, one of the body's natural stimulants. When the person stops drinking, the body tries to make up for lost time by producing more glutamine than it needs. The increase in glutamine levels stimulates the brain while the drinker is trying to sleep, keeping him/her from reaching the deepest levels of sleep.^[51]Stopping chronic alcohol use can also lead to severe insomnia with vivid dreams. During withdrawal REM sleep is typically exaggerated as part of a rebound effect.^[52]

[edit]Opioids

Opioid medications such as hydrocodone, oxycodone, and morphine are used for insomnia that is associated with pain due to their analgesicproperties and hypnotic effects. Opioids can fragment sleep and decrease REM and stage 2 sleep. By producing analgesia and sedation, opioids may be appropriate in carefully selected patients with pain-associated insomnia.^[13]

[edit]Antidepressants

Some antidepressants such as amitriptyline, doxepin, mirtazapine, and trazodone can often have a very strong sedative effect, and are prescribed off label to treat insomnia.^[53] The major drawback of these drugs is that they have properties that can lead to many side-effects; for example, amitriptyline and doxepin both have antihistaminergic, anticholinergic, and antiadrenergic properties, which contribute to their side-effect profile, while mirtazapines side-effects are primarily antihistaminergic, and trazadones side-effects are primarily antiadrenergic. Some also alter sleep architecture. As with benzodiazepines, the use of antidepressants in the treatment of insomnia can lead to withdrawaleffects; withdrawal may induce rebound insomnia.

Mirtazapine is known to decrease sleep latency, promoting sleep efficiency and increasing the total amount of sleeping time in patients suffering from both depression and insomnia.^[54][55]

[edit]Melatonin and melatonin agonists

The hormone melatonin, sold as a "dietary supplement" in some countries, is effective in several types of insomnia. Melatonin has demonstrated effectiveness equivalent to the prescription sleeping tablet zopiclone in inducing sleep and regulating the sleep/waking cycle.^[56] One particular benefit of melatonin is that it can treat insomnia without altering the sleep pattern, which is altered by many prescription sleeping tablets. Another benefit is it does not impair performance related skills.^[57][58]

Melatonin agonists, including ramelteon (Rozerem) and tasimelteon, seem to lack the potential for misuse and dependence. This class of drugs has a relatively mild side-effect profile and low likelihood of causing morning sedation. While these drugs show good effect for the treatment of insomnia due to jet lag^[59] and the chronic circadian rhythm disorders, the results for other forms of insomnia are less promising.^[60]

Natural substances such as 5-HTP and L-Tryptophan have been said to fortify the serotonin-melatonin pathway.^[61]

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Melatonin Notes

Use as medication

A bottle of melatonin tablets

The hormone melatonin is used to treat circadian rhythm sleep disorders and some types of insomnia.

Studies have found that the use of melatonin can help entrain the circadian clock to environmental cycles and have beneficial effects for the treatment of certain forms of insomnia (2004).^[105] Prolonged release melatonin has shown good results in treating insomnia in older adults (2007).^[106]

A 2004 review found that melatonin significantly increased total sleep time in people suffering from sleep restriction.^[17]

Other studies have found that for certain types of sleep disorders, melatonin is not effective. A 2006 review found that although it is safe for short term use (of three months or less), there is "no evidence that melatonin is effective in treating secondary sleep disorders or sleep disorders accompanying sleep restriction, such asjet lag and shiftwork disorder."^[58]

In a 2005 study, researchers concluded that while "there is some evidence to suggest that melatonin is effective in treating delayed sleep phase syndrome, ...there is evidence to suggest that melatonin is not effective in treating most primary sleep disorders with short-term use (4 weeks or less)."^[59]

[edit]Dosage

Melatonin tablets/capsules often contain three to ten times the amount needed to produce physiologic nocturnal blood melatonin levels for a more rapid sleep onset. Studies suggest that smaller doses (for example 0.3 mg as opposed to 3 mg) are just as effective.^[61]

Large doses of melatonin can even be counterproductive: Lewy et al.^[107] provide support to the "idea that too much melatonin may spill over onto the wrong zone of the melatonin phase-response curve" (PRC). In one of their blind subjects, 0.5 mg of melatonin was effective while 20 mg was not. Solomon Labs tested initial doses of 30 and 60 milligrams and found very little efficacy even at those levels.^[107][108]

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