Insomnia is one of the most common complaints in medicine and is often associated with anxiety or depression, which it may precede, accompany or follow.
What it is
Insomnia is defined as difficulty falling asleep, staying asleep or waking early without being able to get back to sleep, despite adequate opportunity to sleep, with daytime consequences: tiredness, difficulty concentrating, irritability or poorer performance. It is considered chronic when it occurs at least three nights a week for three months or more.
Causes and associated factors
- anxiety, depression and other psychiatric disorders;
- chronic pain, respiratory or heart disease, reflux, needing to urinate at night;
- other sleep disorders, such as obstructive sleep apnoea or restless legs syndrome;
- medicines, caffeine, alcohol and other substances;
- irregular schedules, shift work and screen use late at night.
Over time, worry about sleep itself and the habits adopted to compensate (staying longer in bed, long naps) tend to maintain insomnia, even when the original cause has gone.
When to seek an assessment
When insomnia has lasted more than a month, affects daytime functioning, comes with low mood or anxiety, or when sleeping medication is taken regularly. Loud snoring, breathing pauses observed by someone else or severe daytime sleepiness warrant assessment for sleep apnoea.
What the assessment involves
The assessment is based on the sleep history and on looking for associated disorders. A sleep diary kept for one to two weeks is a simple and very useful tool. When sleep apnoea or another primary sleep disorder is suspected, a sleep study may be requested.
Treatment
Cognitive behavioural therapy for insomnia (CBT-I) is the recommended first-line treatment in European and North American guidelines. It combines stimulus control, sleep restriction, restructuring of beliefs about sleep and relaxation techniques; its benefits often persist after treatment ends.
Sleeping medication has a limited and usually temporary role. Benzodiazepine and related hypnotics should be used at the lowest effective dose and for a short time, because of the risk of tolerance, dependence, falls and memory problems. When insomnia is part of depression or an anxiety disorder, treating that condition is essential.
Frequently asked questions
Is sleep hygiene enough?
Rules such as regular schedules and avoiding caffeine in the afternoon help, but on their own they rarely resolve chronic insomnia. They are one component of cognitive behavioural therapy, not a substitute for it.
Does melatonin help?
It has a modest effect in some situations, especially in older people and in circadian rhythm disorders. It is not a first-line treatment for chronic insomnia, and its use is best discussed with your doctor.
Can I take a sleeping pill every night?
Daily, long-term use of hypnotics is not recommended in most cases. If you have been taking them for a long time, reducing them should be planned and gradual, with support.
References
- Riemann D, et al. The European Insomnia Guideline: an update on the diagnosis and treatment of insomnia 2023. J Sleep Res. 2023;32(6):e14035.
- Edinger JD, 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.
- American Psychiatric Association. DSM-5-TR. 2022.
This page is for information only and does not replace an individual medical assessment. Clinical review: Pedro Zuzarte, psychiatrist · Published and reviewed: .