View source for Insomnia

{{Short description|Disorder causing trouble with sleeping}}
{{About|the sleeping disorder|other uses}}
{{Redirect|Trouble sleeping}}
{{cs1 config|name-list-style=vanc|display-authors=6}}
{{Infobox medical condition (new)
| name            = Insomnia
| synonyms        = Sleeplessness, trouble sleeping
| image           = 53-aspetti di vita quotidiana, insonnia, Taccuino Sanitatis,.jpg
| caption         = Depiction of insomnia from the 14th century medical manuscript ''[[Tacuinum Sanitatis]]''
| field           = [[Psychiatry]], [[sleep medicine]]
| pronounce       = {{IPAc-en|ɪ|n|ˈ|s|ɒ|m|n|i|ə}}<ref name=NIH2011Ov/>
| symptoms        = Trouble [[sleeping]], daytime sleepiness, low energy, irritability, [[depression (mood)|depressed mood]]<ref name=NIH2011Ov/>
| complications   = [[Motor vehicle collisions]]<ref name=NIH2011Ov/>
| onset           =
| duration        =
| causes          = Unknown, [[psychological stress]], [[chronic pain]], [[heart failure]], [[hyperthyroidism]], [[heartburn]], [[restless leg syndrome]], others<ref name=NIH2011Ca/>
| risks           =
| diagnosis       = Based on symptoms, [[sleep study]]<ref name=NIH2011Diag/>
| differential    = [[Delayed sleep phase disorder]], [[restless leg syndrome]], [[sleep apnea]], [[psychiatric disorder]]<ref>{{cite book| vauthors = Watson NF, Vaughn BV |title=Clinician's Guide to Sleep Disorders|date=2006|publisher=CRC Press|isbn=978-0-8493-7449-4 |page=10|url=https://books.google.com/books?id=M9zKBQAAQBAJ&pg=PA10|language=en}}</ref>
| prevention      =
| treatment       = [[Sleep hygiene]], [[Cognitive behavioral therapy for insomnia|cognitive behavioral therapy]], [[sleeping pills]]<ref name=NIH2011Tx/><ref name=AC2016/><ref name=Wil2008/>
| medication      =
| prognosis       =
| frequency       = ~20%<ref name=WHO2009/><ref name=Th2007/><ref name=Tas2015/>
| deaths          =
}}
<!-- Definition and symptoms -->
'''Insomnia''', also known as '''sleeplessness''', is a [[sleep disorder]] where people have trouble [[sleeping]].<ref name="NIH2011Ov">{{cite web |date=24 March 2022 |title=What Is Insomnia? |url=https://www.nhlbi.nih.gov/health/health-topics/topics/inso |url-status=live |archive-url=https://web.archive.org/web/20160728012148/http://www.nhlbi.nih.gov/health/health-topics/topics/inso |archive-date=28 July 2016 |access-date=26 November 2023 |website=Health Topics |publisher=[[NHLBI]]}}</ref><ref>{{Cite web |date=2020-07-16 |title=Insomnia: Causes, symptoms, and treatments |url=https://www.medicalnewstoday.com/articles/9155 |access-date=2024-07-25 |website=www.medicalnewstoday.com |language=en}}</ref> They may have difficulty falling asleep, or staying asleep for as long as desired.<ref name="NIH2011Ov" /><ref name="Th2007">{{cite journal |vauthors=Roth T |date=August 2007 |title=Insomnia: definition, prevalence, etiology, and consequences |journal=[[Journal of Clinical Sleep Medicine]] |type=Supplement |volume=3 |issue=5 Suppl |pages=S7–10 |doi=10.5664/jcsm.26929 |pmc=1978319 |pmid=17824495 |doi-access=free}}</ref><ref name="Pun2012">{{cite journal |vauthors=Punnoose AR, Golub RM, Burke AE |date=June 2012 |title=Insomnia |journal=[[JAMA]] |type=JAMA patient page |volume=307 |issue=24 |pages=2653 |doi=10.1001/jama.2012.6219 |pmid=22735439 |doi-access=free}}</ref> Insomnia is typically followed by daytime [[sleepiness]], low energy, [[irritability]], and a [[depression (mood)|depressed mood]].<ref name="NIH2011Ov" /> It may result in an increased risk of accidents of all kinds as well as problems focusing and learning.<ref name="Th2007" /> Insomnia can be short term, lasting for days or weeks, or long term, lasting more than a month.<ref name="NIH2011Ov" /> The concept of the word ''insomnia'' has two distinct possibilities: insomnia disorder (ID) or insomnia symptoms, and many abstracts of randomized controlled trials and systematic reviews often underreport on which of these two possibilities the word refers to.<ref name="Banno2022">{{cite journal | vauthors = Banno M, Tsujimoto Y, Kohmura K, Dohi E, Taito S, Someko H, Kataoka Y | title = Unclear Insomnia Concept in Randomized Controlled Trials and Systematic Reviews: A Meta-Epidemiological Study | journal = International Journal of Environmental Research and Public Health | volume = 19 | issue = 19 | pages = 12261 | date = September 2022 | pmid = 36231555 | doi = 10.3390/ijerph191912261 | pmc = 9566752 | doi-access = free }}</ref>
<!-- Cause and diagnosis -->
Insomnia can occur independently or as a result of another problem.<ref name=NIH2011Ca>{{cite web |title=What Causes Insomnia? |url=https://www.nhlbi.nih.gov/health/health-topics/topics/inso/causes |website=NHLBI |access-date=9 August 2016 |date=13 December 2011 |url-status=live |archive-url=https://web.archive.org/web/20160728012201/http://www.nhlbi.nih.gov/health/health-topics/topics/inso/causes |archive-date=28 July 2016 }}</ref> Conditions that can result in insomnia include [[psychological stress]], [[chronic pain]], [[heart failure]], [[hyperthyroidism]], [[heartburn]], [[restless leg syndrome]], [[menopause]], certain [[medication]]s, and drugs such as [[caffeine]], [[nicotine]], and [[Alcohol (drug)|alcohol]].<ref name=NIH2011Ca/><ref name=WHO2009>{{cite web |url=https://www.who.int/selection_medicines/committees/expert/17/application/Section24_GAD.pdf |title=Dyssomnias |access-date=25 January 2009 |publisher=WHO |pages=7–11 |url-status=dead |archive-url=https://web.archive.org/web/20090318104517/http://www.who.int/selection_medicines/committees/expert/17/application/Section24_GAD.pdf |archive-date=18 March 2009 }}</ref> Insomnia is also common in people with [[Attention deficit hyperactivity disorder|ADHD]],<ref>{{Cite journal |last1=Wynchank |first1=Dora |last2=Ten Have |first2=Margreet |last3=Bijlenga |first3=Denise |last4=Penninx |first4=Brenda W. |last5=Beekman |first5=Aartjan T. |last6=Lamers |first6=Femke |last7=de Graaf |first7=Ron |last8=Kooij |first8=J. J. Sandra |date=2018-03-15 |title=The Association Between Insomnia and Sleep Duration in Adults With Attention-Deficit Hyperactivity Disorder: Results From a General Population Study |journal=Journal of Clinical Sleep Medicine |volume=14 |issue=3 |pages=349–357 |doi=10.5664/jcsm.6976 |issn=1550-9397 |pmc=5837836 |pmid=29458702}}</ref> and children with [[autism]].<ref>{{Cite journal |last1=Cortesi |first1=Flavia |last2=Giannotti |first2=Flavia |last3=Ivanenko |first3=Anna |last4=Johnson |first4=Kyle |date=July–August 2010 |title=Sleep in children with autistic spectrum disorder |url=https://linkinghub.elsevier.com/retrieve/pii/S1389945710001759 |journal=Sleep Medicine |language=en |volume=11 |issue=7 |pages=659–664 |doi=10.1016/j.sleep.2010.01.010|pmid=20605110 }}</ref> Other risk factors include working [[night shifts]] and [[sleep apnea]].<ref name=Th2007/> Diagnosis is based on sleep habits and an examination to look for underlying causes.<ref name=NIH2011Diag/> A [[sleep study]] may be done to look for underlying sleep disorders.<ref name=NIH2011Diag>{{cite web |title=How Is Insomnia Diagnosed? |url=https://www.nhlbi.nih.gov/health/health-topics/topics/inso/diagnosis |website=NHLBI |access-date=9 August 2016 |date=13 December 2011 |url-status=dead |archive-url=https://web.archive.org/web/20160811091424/http://www.nhlbi.nih.gov/health/health-topics/topics/inso/diagnosis |archive-date=11 August 2016 }}</ref> Screening may be done with questions like "Do you experience difficulty sleeping?" or "Do you have difficulty falling or staying asleep?"<ref name=Th2007/>
<!-- Treatment -->
Although their efficacy as first line treatments is not unequivocally established,<ref name="Behavioral and psychological treatm">{{cite journal | vauthors = Edinger JD, Arnedt JT, Bertisch SM, Carney CE, Harrington JJ, Lichstein KL, Sateia MJ, Troxel WM, Zhou ES, Kazmi U, Heald JL, Martin JL | title = Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment | journal = Journal of Clinical Sleep Medicine | volume = 17 | issue = 2 | pages = 263–298 | date = February 2021 | pmid = 33164741 | pmc = 7853211 | doi = 10.5664/jcsm.8988 }}</ref> [[sleep hygiene]] and lifestyle changes are typically the first treatment for insomnia.<ref name=NIH2011Tx>{{cite web |title=How Is Insomnia Treated? |url=https://www.nhlbi.nih.gov/health/health-topics/topics/inso/treatment |website=NHLBI |access-date=9 August 2016 |date=13 December 2011 |url-status=dead |archive-url=https://web.archive.org/web/20160728012302/http://www.nhlbi.nih.gov/health/health-topics/topics/inso/treatment |archive-date=28 July 2016 }}</ref><ref name=Wil2008>{{cite journal | vauthors = Wilson JF | title = In the clinic. Insomnia | journal = Annals of Internal Medicine | volume = 148 | issue = 1 | pages = ITC13–1–ITC13–16 | date = January 2008 | pmid = 18166757 | doi = 10.7326/0003-4819-148-1-200801010-01001 | s2cid = 42686046 }}</ref> Sleep hygiene includes a consistent bedtime, a quiet and dark room, exposure to sunlight during the day and regular [[exercise]].<ref name=Wil2008/> [[Cognitive behavioral therapy for insomnia|Cognitive behavioral therapy]] may be added to this.<ref name=AC2016>{{cite journal | vauthors = Qaseem A, Kansagara D, Forciea MA, Cooke M, Denberg TD | title = Management of Chronic Insomnia Disorder in Adults: A Clinical Practice Guideline From the American College of Physicians | journal = Annals of Internal Medicine | volume = 165 | issue = 2 | pages = 125–133 | date = July 2016 | pmid = 27136449 | doi = 10.7326/M15-2175 | doi-access = free }}</ref><ref name=Tra2015>{{cite journal | vauthors = Trauer JM, Qian MY, Doyle JS, Rajaratnam SM, Cunnington D | title = Cognitive Behavioral Therapy for Chronic Insomnia: A Systematic Review and Meta-analysis | journal = Annals of Internal Medicine | volume = 163 | issue = 3 | pages = 191–204 | date = August 2015 | pmid = 26054060 | doi = 10.7326/M14-2841 | s2cid = 21617330 }}</ref> While [[sleeping pill]]s may help, they are sometimes associated with [[injuries]], [[dementia]], and [[addiction]].<ref name=NIH2011Tx/><ref name=AC2016/> These medications are not recommended for more than four or five weeks.<ref name=AC2016/> The effectiveness and safety of [[#Alternative medicine|alternative medicine]] is unclear.<ref name=NIH2011Tx/><ref name=AC2016/>
<!-- Epidemiology and history -->
Between 10% and 30% of adults have insomnia at any given point in time and up to half of people have insomnia in a given year.<ref name=WHO2009/><ref name=Th2007/><ref name=Tas2015>{{cite book |vauthors=Tasman A, Kay J, Lieberman JA, First MB, Riba M |title=Psychiatry, 2 Volume Set |date=2015 |publisher=John Wiley & Sons |isbn=978-1-118-75336-1 |page=4253 |edition=4 |url=https://books.google.com/books?id=l2KRBgAAQBAJ&pg=PT4253 |access-date=2017-09-01 |archive-date=2023-01-12 |archive-url=https://web.archive.org/web/20230112211935/https://books.google.com/books?id=l2KRBgAAQBAJ&pg=PT4253 |url-status=live }}</ref> About 6% of people have insomnia that is not due to another problem and lasts for more than a month.<ref name=Th2007/> People over the age of 65 are affected more often than younger people.<ref name=Wil2008/> Women are more often affected than men.<ref name=WHO2009/> Descriptions of insomnia occur at least as far back as [[ancient Greece]].<ref>{{cite book | vauthors = Attarian HP |title=Clinical Handbook of Insomnia |date=2003 |publisher=Springer Science & Business Media |isbn=978-1-59259-662-1 |chapter = chapter 1 |chapter-url=https://books.google.com/books?id=Fx-sBAAAQBAJ&pg=PT20 |language=en }}</ref>
{{TOC limit|3}}
== Signs and symptoms ==
[[File:Complications of insomnia.svg|thumb|upright=1.4|Potential complications of insomnia<ref>{{cite web | url = http://www.mayoclinic.com/health/insomnia/ds00187/dsection=complications | title = Insomnia > Complications | archive-url = https://web.archive.org/web/20090208085332/http://mayoclinic.com/health/insomnia/DS00187/DSECTION%3Dcomplications |archive-date=8 February 2009 | work = Mayo Clinic | access-date = 5 May 2009 }}</ref>]]
Symptoms of insomnia:<ref name="BBDinsomnia">{{Cite journal |author1=Consumer Reports |author1-link=Consumer Reports |author2=Drug Effectiveness Review Project |author2-link=Drug Effectiveness Review Project |date=January 2012 |title=Evaluating New Sleeping Pills Used to Treat: Insomnia Comparing Effectiveness, Safety, and Price |journal=Best Buy Drugs Consumer Reports |page=4 |url=http://www.consumerreports.org/health/resources/pdf/best-buy-drugs/InsomniaUpdate-FINAL-July2008.pdf |access-date=4 June 2013 |url-status=live |archive-url=https://web.archive.org/web/20131209122641/http://www.consumerreports.org/health/resources/pdf/best-buy-drugs/InsomniaUpdate-FINAL-July2008.pdf |archive-date=9 December 2013}}</ref>
*Difficulty falling asleep, including difficulty finding a comfortable [[sleeping position]]
*Waking during the night, being unable to return to sleep<ref>{{Cite journal|title=Caffeine consumption, insomnia, and sleep duration: Results from a nationally representative sample|first1=Ninad S.|last1=Chaudhary|first2=Michael A.|last2=Grandner|first3=Nicholas J.|last3=Jackson|first4=Subhajit|last4=Chakravorty|date=October 9, 2016|journal=Nutrition (Burbank, Los Angeles County, Calif.)|volume=32|issue=11–12|pages=1193–1199|doi=10.1016/j.nut.2016.04.005|pmid=27377580|pmc=6230475}}</ref> and waking up early
*Not able to focus on daily tasks, difficulty in remembering
*[[Excessive daytime sleepiness|Daytime sleepiness]], [[irritability]], [[Depression (mood)|depression]] or [[anxiety]]
*Feeling tired or having low energy during the day<ref>{{Cite news|url=https://www.sleepfoundation.org/insomnia/symptoms|title=Symptoms|access-date=15 April 2019|language=en|archive-date=15 April 2019|archive-url=https://web.archive.org/web/20190415172923/https://www.sleepfoundation.org/insomnia/symptoms|url-status=live}}</ref>
*Trouble concentrating
*Being irritable, acting aggressive or impulsive
[[Sleep onset]] insomnia is difficulty falling asleep at the beginning of the night, often a symptom of [[anxiety disorder]]s. [[Delayed sleep phase disorder]] can be misdiagnosed as insomnia, as sleep onset is delayed to much later than normal while awakening spills over into daylight hours.<ref>{{cite journal | vauthors = Kertesz RS, Cote KA | s2cid = 30439961 | title = Event-related potentials during the transition to sleep for individuals with sleep-onset insomnia | journal = Behavioral Sleep Medicine|volume=9|issue = 2|pages=68–85|year=2011| pmid = 21491230 |doi=10.1080/15402002.2011.557989}}</ref>
It is common for patients who have difficulty falling asleep to also have nocturnal awakenings with difficulty returning to sleep.<ref>{{Citation |last=Cormier |first=René E. |title=Sleep Disturbances |date=1990 |work=Clinical Methods: The History, Physical, and Laboratory Examinations |editor-last=Walker |editor-first=H. Kenneth |url=https://www.ncbi.nlm.nih.gov/books/NBK401/ |access-date=2024-11-15 |edition=3rd |place=Boston |publisher=Butterworths |isbn=978-0-409-90077-4 |pmid=21250242 |editor2-last=Hall |editor2-first=W. Dallas |editor3-last=Hurst |editor3-first=J. Willis}}</ref> Two-thirds of these patients wake up in the middle of the night, with more than half having trouble falling back to sleep after a [[middle-of-the-night insomnia|middle-of-the-night awakening]].<ref>{{cite book | vauthors = Doghramji K |title=Clinical Management of Insomnia |year=2007 |publisher=Professional Communications, Inc. |location=Caddo, OK |isbn=978-1-932610-14-7 |page=[https://archive.org/details/clinicalmanageme0000dogh/page/28 28] |url-access=registration |url=https://archive.org/details/clinicalmanageme0000dogh }}</ref>
Early morning awakening is an awakening occurring earlier (more than 30 minutes) than desired with an inability to go back to sleep, and before total sleep time reaches 6.5 hours. Early morning awakening is often a characteristic of [[major depressive disorder|depression]].<ref>{{cite book | vauthors = Morin C |title=Insomnia: A Clinician's Guide to Assessment and Treatment |year=2003 |publisher=Kluwer Academic/Plenum Publishers |location=New York |isbn=978-0-306-47750-8 |page=16}}</ref> Anxiety symptoms may well lead to insomnia. Some of these symptoms include [[tension (psychological)|tension]], compulsive worrying about the future, feeling overstimulated, and overanalyzing past events.<ref>{{Cite news|url=https://www.sleepfoundation.org/insomnia/what-causes-insomnia|title=What Causes Insomnia?|access-date=24 April 2019|language=en|archive-date=15 April 2019|archive-url=https://web.archive.org/web/20190415173039/https://www.sleepfoundation.org/insomnia/what-causes-insomnia|url-status=live}}</ref>
=== Poor sleep quality ===
Poor sleep quality can occur as a result of, for example, [[restless legs]], [[sleep apnea]] or [[major depression]]. Poor sleep quality is defined as the individual not reaching [[Slow-wave sleep|stage 3]] or delta sleep which has restorative properties.<ref>{{Cite web |url=https://sleepfoundation.org/how-sleep-works/what-happens-when-you-sleep |title=What Happens When You Sleep? |date=22 December 2009 |access-date=24 February 2017 |url-status=live |archive-url=https://web.archive.org/web/20170305005723/https://sleepfoundation.org/how-sleep-works/what-happens-when-you-sleep |archive-date=5 March 2017 }}</ref>
Major depression leads to alterations in the function of the [[hypothalamic–pituitary–adrenal axis]], causing excessive release of [[cortisol]] which can lead to poor sleep quality.
Nocturnal [[polyuria]], excessive night-time urination, can also result in a poor quality of sleep.<ref>{{cite journal | vauthors = Adler CH, Thorpy MJ | s2cid = 24024570 | title = Sleep issues in Parkinson's disease | journal = Neurology | volume = 64 | issue = 12 Suppl 3 | pages = S12–20 | date = June 2005 | pmid = 15994219 | doi = 10.1212/WNL.64.12_suppl_3.S12 }}</ref>
=== Subjectivity ===
{{Main|Sleep state misperception}}
Some cases of insomnia are not really insomnia in the traditional sense because people experiencing [[sleep state misperception]] often sleep for a normal amount of time.<ref name="Harvey_2012" /> The problem is that, despite sleeping for multiple hours each night and typically not experiencing significant daytime sleepiness or other symptoms of sleep loss, they do not feel like they have slept very much, if at all.<ref name="Harvey_2012" /> Because their perception of their sleep is incomplete, they incorrectly believe it takes them an abnormally long [[Sleep onset latency|time to fall asleep]], and they underestimate how long they stay asleep.<ref name="Harvey_2012">{{cite journal | vauthors = Harvey AG, Tang NK | title = (Mis)perception of sleep in insomnia: a puzzle and a resolution | journal = Psychological Bulletin | volume = 138 | issue = 1 | pages = 77–101 | date = January 2012 | pmid = 21967449 | pmc = 3277880 | doi = 10.1037/a0025730 }}</ref>
=== Problematic digital media use ===
{{See also|Screen time|Binge-watching|Internet addiction disorder|Nomophobia|Problematic smartphone use|Problematic social media use|Television addiction|Video game addiction}}
{{Excerpt|Digital media use and mental health|Insomnia}}
== Causes ==
While insomnia can be caused by a number of conditions, it can also occur without any identifiable cause. This is known as Primary Insomnia.<ref>{{cite web | vauthors = Moawad H | date = 2020 | title = Primary insomnia: A lifelong problem | work = Psychiatric Times | url = https://www.psychiatrictimes.com/view/primary-insomnia-lifelong-problem | archive-url = https://web.archive.org/web/20221229175034/https://www.psychiatrictimes.com/view/primary-insomnia-lifelong-problem | archive-date=29 December 2022 | access-date = 29 December 2022 }}</ref> Primary Insomnia may also have an initial identifiable cause but continues after the cause is no longer present. For example, a bout of insomnia may be triggered by a stressful work or life event. However, the condition may continue after the stressful event has been resolved. In such cases, the insomnia is usually perpetuated by the anxiety or fear caused by the sleeplessness itself, rather than any external factors.<ref>{{cite book | vauthors = Meadows G | date = 2015 | title = The sleep book: How to sleep well every night. | location = London, UK | publisher = Orion Publishing Group | page = 21 }}</ref>
Symptoms of insomnia can be caused by or be associated with:
*Sleep breathing disorders, such as [[sleep apnea]] or [[upper airway resistance syndrome]]<ref>{{cite book |vauthors=Edinger JD |title=Insomnia, An Issue of Sleep Medicine Clinics |date=2013 |publisher=Elsevier Health Sciences |isbn=978-0-323-18872-2 |page=389 |url=https://books.google.com/books?id=O_cxAgAAQBAJ&pg=PA389 |language=en |access-date=2023-03-19 |archive-date=2023-03-26 |archive-url=https://web.archive.org/web/20230326164814/https://books.google.com/books?id=O_cxAgAAQBAJ&pg=PA389 |url-status=live }}</ref>
*Use of [[psychoactive drug]]s (such as [[stimulant]]s), including certain [[medication]]s, [[herb]]s, [[caffeine]], [[nicotine]], [[cocaine]], [[amphetamine]]s, [[methylphenidate]], [[aripiprazole]], [[MDMA]], [[modafinil]], or excessive alcohol intake<ref name=umm_causes>{{cite web |title=Insomnia |url=http://umm.edu/health/medical/reports/articles/insomnia |publisher=University of Maryland Medical Center |access-date=11 July 2013 |url-status=live |archive-url=https://web.archive.org/web/20130703135611/http://umm.edu/health/medical/reports/articles/insomnia |archive-date=3 July 2013 }}</ref>
*Use of or withdrawal from alcohol and other [[sedative]]s, such as anti-anxiety and sleep drugs like [[benzodiazepine withdrawal|benzodiazepines]]<ref name=umm_causes/>
*Use of or withdrawal from pain-relievers such as [[opioid withdrawal|opioids]]<ref name="umm_causes" />
*[[Heart disease]]<ref name=comorbidity>{{cite journal | vauthors = Taylor DJ, Mallory LJ, Lichstein KL, Durrence HH, Riedel BW, Bush AJ | title = Comorbidity of chronic insomnia with medical problems | journal = Sleep | volume = 30 | issue = 2 | pages = 213–18 | date = February 2007 | pmid = 17326547 | doi = 10.1093/sleep/30.2.213 | doi-access = free }}</ref>
*[[Restless legs syndrome]], which can cause sleep onset insomnia due to the discomforting sensations felt and the need to move the legs or other body parts to relieve these sensations<ref name=mayo_insomnia_causes>{{cite web |title=Insomnia Causes |url=http://www.mayoclinic.com/health/insomnia/DS00187/DSECTION=causes |publisher=Mayo Clinic |access-date=11 July 2013 |url-status=live |archive-url=https://web.archive.org/web/20131021183326/http://www.mayoclinic.com/health/insomnia/DS00187/DSECTION%3Dcauses |archive-date=21 October 2013 }}</ref>
*[[Periodic limb movement disorder]] (PLMD), which occurs during sleep and can cause arousals of which the sleeper is unaware<ref>{{cite web |title=Restless Legs Syndrome/Periodic Limb Movement Disorder |url=http://www.nhlbi.nih.gov/health/prof/sleep/res_plan/section5/section5d.html |publisher=National Heart Lung and Blood Institute |access-date=11 July 2013 |url-status=dead |archive-url=https://web.archive.org/web/20130803020537/http://www.nhlbi.nih.gov/health/prof/sleep/res_plan/section5/section5d.html |archive-date=3 August 2013 }}</ref>
*[[Pain]]:<ref name="Ramakrishnan-2007">{{cite journal | vauthors = Ramakrishnan K, Scheid DC | title = Treatment options for insomnia | journal = American Family Physician | volume = 76 | issue = 4 | pages = 517–26 | date = August 2007 | pmid = 17853625 }}</ref> an injury or condition that causes pain can preclude an individual from finding a comfortable position in which to fall asleep, and can also cause awakening.
*[[Hormone]] shifts such as those that precede [[menstruation]] and those during [[menopause]]<ref name=Santoro2015rev>{{cite journal | vauthors = Santoro N, Epperson CN, Mathews SB | title = Menopausal Symptoms and Their Management | journal = Endocrinology and Metabolism Clinics of North America | volume = 44 | issue = 3 | pages = 497–515 | date = September 2015 | pmid = 26316239 | pmc = 4890704 | doi = 10.1016/j.ecl.2015.05.001 }}</ref>
*Life events such as [[fear]], [[stress (psychology)|stress]], [[anxiety]], emotional or mental tension, work problems, financial stress, birth of a child, and bereavement<ref name=mayo_insomnia_causes />
*Gastrointestinal issues such as heartburn or constipation<ref name=nhlbi_causes>{{cite web |title=What causes insomnia? |url=http://www.nhlbi.nih.gov/health/health-topics/topics/inso/causes.html |publisher=National Heart, Lung, and Blood Institute |access-date=11 July 2013 |url-status=live |archive-url=https://web.archive.org/web/20130703143347/http://www.nhlbi.nih.gov/health/health-topics/topics/inso/causes.html |archive-date=3 July 2013 }}</ref>
*[[Mental disorder|Mental]], [[Learning Disability|neurobehavioral]], or [[Neurodevelopmental disorder|neurodevelopmental]] disorders such as [[bipolar disorder]], [[clinical depression]], [[generalized anxiety disorder]], [[post traumatic stress disorder]], [[schizophrenia]], [[obsessive compulsive disorder]], [[autism]], [[dementia]],<ref name=Psych4th/>{{rp|326}} [[ADHD]],<ref>{{cite journal | vauthors = Bendz LM, Scates AC | s2cid = 207263711 | title = Melatonin treatment for insomnia in pediatric patients with attention-deficit/hyperactivity disorder | journal = The Annals of Pharmacotherapy | volume = 44 | issue = 1 | pages = 185–91 | date = January 2010 | pmid = 20028959 | doi = 10.1345/aph.1M365 }}</ref> and [[Fetal Alcohol Spectrum Disorder|FASD]]
*Disturbances of the [[circadian rhythm]], such as [[shift work]] and [[jet lag]], can cause an inability to sleep at some times of the day and excessive sleepiness at other times of the day. Chronic [[Circadian rhythm sleep disorder|circadian rhythm disorders]] are characterized by similar symptoms.<ref name=umm_causes/>
* Certain [[Neurology|neurological]] disorders such as [[brain damage|brain lesions]], or a [[Medical history|history]] of [[traumatic brain injury]]<ref>{{cite journal | vauthors = Ouellet MC, Beaulieu-Bonneau S, Morin CM | title = Insomnia in patients with traumatic brain injury: frequency, characteristics, and risk factors | journal = The Journal of Head Trauma Rehabilitation | volume = 21 | issue = 3 | pages = 199–212 | year = 2006 | pmid = 16717498 | doi = 10.1097/00001199-200605000-00001 | s2cid = 28255648 }}</ref>
*[[Disease|Medical conditions]] such as [[hyperthyroidism]]<ref name=NIH2011Ca/>
*Abuse of over-the-counter or prescription sleep aids ([[sedative]] or [[depressant]] drugs) can produce [[rebound insomnia]]<ref name=umm_causes />
*Poor [[sleep hygiene]], e.g., [[Noise health effects|noise]] or over-consumption of caffeine<ref name=umm_causes />
*A rare genetic condition can cause a [[prion]]-based, permanent and eventually fatal form of insomnia called [[fatal familial insomnia]]<ref name="pmid17406188">{{cite journal | vauthors = Schenkein J, Montagna P | title = Self management of fatal familial insomnia. Part 1: what is FFI? | journal = MedGenMed | volume = 8 | issue = 3 | pages = 65 | date = September 2006 | pmid = 17406188 | pmc = 1781306 }}</ref>
*[[Physical exercise]]: exercise-induced insomnia is common in athletes in the form of prolonged [[sleep onset latency]]<ref>{{cite web | url = http://cev.org.br/biblioteca/the-epidemiological-survey-of-exercise-induced-insomnia-in-chinese-athletes | title = The epidemiological survey of exercise-induced insomnia in chinese athletes | archive-url = https://web.archive.org/web/20090909095412/http://cev.org.br/biblioteca/the-epidemiological-survey-of-exercise-induced-insomnia-in-chinese-athletes | archive-date = 9 September 2009 | vauthors = Shi Y, Zhou Z, Ning K, Liu J | location = Athens | date = 2004 | work = Pre-Olympic Congress }}</ref>
*Increased exposure to the blue light from artificial sources, such as phones or computers<ref>{{Cite news|url=https://www.scientificamerican.com/article/q-a-why-is-blue-light-before-bedtime-bad-for-sleep/|title=Q&A: Why Is Blue Light before Bedtime Bad for Sleep?|vauthors=Schmerler J|work=Scientific American|access-date=19 October 2018|language=en|archive-date=16 February 2021|archive-url=https://web.archive.org/web/20210216123401/https://www.scientificamerican.com/article/q-a-why-is-blue-light-before-bedtime-bad-for-sleep/|url-status=live}}</ref>
*Chronic pain<ref>{{cite journal | vauthors = Roth T | title = Insomnia: definition, prevalence, etiology, and consequences | journal = Journal of Clinical Sleep Medicine | volume = 3 | issue = 5 Suppl | pages = S7-10 | date = August 2007 | pmid = 17824495 | pmc = 1978319 | doi = 10.5664/jcsm.26929 }}</ref><ref name="nsf">{{Cite web|date=2021|title=What Causes Insomnia?|url=https://www.sleepfoundation.org/insomnia/what-causes-insomnia|access-date=26 February 2021|website=Sleep Foundation|archive-date=15 April 2019|archive-url=https://web.archive.org/web/20190415173039/https://www.sleepfoundation.org/insomnia/what-causes-insomnia|url-status=live}}</ref>
*[[Lower back pain]]<ref name=nsf/>
*[[Asthma]]<ref name=nsf/>
Sleep studies using [[polysomnography]] have suggested that people who have sleep disruption have elevated night-time levels of circulating [[cortisol]] and [[adrenocorticotropic hormone]].<ref>{{cite journal | vauthors = Hirotsu C, Tufik S, Andersen ML | title = Interactions between sleep, stress, and metabolism: From physiological to pathological conditions | journal = Sleep Science | volume = 8 | issue = 3 | pages = 143–152 | date = November 2015 | pmid = 26779321 | pmc = 4688585 | doi = 10.1016/j.slsci.2015.09.002 }}</ref> They also have an elevated metabolic rate, which does not occur in people who do not have insomnia but whose sleep is intentionally disrupted during a sleep study. Studies of brain metabolism using [[positron emission tomography|positron emission tomography (PET) scans]] indicate that people with insomnia have higher metabolic rates by night and by day. The question remains whether these changes are the causes or consequences of long-term insomnia.<ref name=Mendelson>{{Cite journal | vauthors = Mendelson WB |title=New Research on Insomnia: Sleep Disorders May Precede or Exacerbate Psychiatric Conditions |journal=Psychiatric Times |volume=25 |issue=7 |year=2008 |url=http://www.psychiatrictimes.com/insomnia/article/10168/1163082 |url-status=live |archive-url=https://web.archive.org/web/20091019054800/http://www.psychiatrictimes.com/insomnia/article/10168/1163082 |archive-date=19 October 2009 }}</ref>
=== Genetics ===
[[Heritability]] estimates of insomnia vary between 38% in males to 59% in females.<ref name=Lind>{{cite journal | vauthors = Lind MJ, Aggen SH, Kirkpatrick RM, Kendler KS, Amstadter AB | title = A Longitudinal Twin Study of Insomnia Symptoms in Adults | journal = Sleep | volume = 38 | issue = 9 | pages = 1423–30 | date = September 2015 | pmid = 26132482 | pmc = 4531410 | doi = 10.5665/sleep.4982 }}</ref> A [[genome-wide association study]] (GWAS) identified 3 genomic loci and 7 [[genes]] that influence the risk of insomnia, and showed that insomnia is highly polygenic.<ref name=Hammerschlag>{{cite journal | vauthors = Hammerschlag AR, Stringer S, de Leeuw CA, Sniekers S, Taskesen E, Watanabe K, Blanken TF, Dekker K, Te Lindert BH, Wassing R, Jonsdottir I, Thorleifsson G, Stefansson H, Gislason T, Berger K, Schormair B, Wellmann J, Winkelmann J, Stefansson K, Oexle K, Van Someren EJ, Posthuma D | title = Genome-wide association analysis of insomnia complaints identifies risk genes and genetic overlap with psychiatric and metabolic traits | journal = Nature Genetics | volume = 49 | issue = 11 | pages = 1584–92 | date = November 2017 | pmid = 28604731 | pmc = 5600256 | doi = 10.1038/ng.3888 }}</ref> In particular, a strong positive association was observed for the [[MEIS1]] gene in both males and females. This study showed that the genetic architecture of insomnia strongly overlaps with psychiatric disorders and metabolic traits.
It has been hypothesized that epigenetics might also influence insomnia through a controlling process of both sleep regulation and brain-stress response having an impact as well on the brain plasticity.<ref name="palagini">{{cite journal | vauthors = Palagini L, Biber K, Riemann D | title = The genetics of insomnia – evidence for epigenetic mechanisms? | journal = Sleep Medicine Reviews | volume = 18 | issue = 3 | pages = 225–35 | date = June 2014 | pmid = 23932332 | doi = 10.1016/j.smrv.2013.05.002 }}</ref>
=== Substance-induced ===
==== Alcohol-induced ====
{{Main|Alcohol use and sleep}}
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|the need to urinate]], [[dehydration]], and [[diaphoresis|excessive sweating]]. [[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 them from reaching the deepest levels of sleep.<ref>{{cite web | vauthors = Perry L | date = 12 October 2004 | url = http://health.howstuffworks.com/hangover5.htm | work = HowStuffWorks | title = How Hangovers Work | archive-url = https://web.archive.org/web/20100315050850/http://health.howstuffworks.com/hangover5.htm | archive-date = 15 March 2010 | access-date = 20 November 2011 }}</ref> 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]].<ref name="sleep_medicine_a04">{{Cite book | vauthors = Lee-chiong T |title=Sleep Medicine: Essentials and Review |date=24 April 2008 |publisher=Oxford University Press|url=https://books.google.com/books?id=s1F_DEbRNMcC&pg=PT105 |isbn=978-0-19-530659-0 |page=105 }}</ref>
====Caffeine====
Some people experience sleep disruption or anxiety if they consume caffeine.<ref>{{cite journal | vauthors = O'Callaghan F, Muurlink O, Reid N | title = Effects of caffeine on sleep quality and daytime functioning | journal = Risk Management and Healthcare Policy | volume = 11 | pages = 263–271 | date = 7 December 2018 | pmid = 30573997 | pmc = 6292246 | doi = 10.2147/RMHP.S156404 | doi-access = free | title-link = doi }}</ref> Doses as low as 100&nbsp;mg/day, such as a {{cvt|6|oz|g}} cup of coffee or two to three {{cvt|12|oz|g}} servings of caffeinated soft-drink, may continue to cause sleep disruption, among other intolerances. Non-regular caffeine users have the least caffeine tolerance for sleep disruption.<ref name="Caffeinedependence JohnHopkins">{{cite web|url=http://www.caffeinedependence.org/caffeine_dependence.html|title=Information about caffeine dependence|date=9 July 2003|website=Caffeinedependence.org|publisher=Johns Hopkins Medicine|archive-url=https://web.archive.org/web/20120523135807/http://www.caffeinedependence.org/caffeine_dependence.html|archive-date=23 May 2012|access-date=25 May 2012}}</ref> Some coffee drinkers develop tolerance to its undesired sleep-disrupting effects, but others apparently do not.<ref name="Fredholm">{{cite journal | vauthors = Fredholm BB, Bättig K, Holmén J, Nehlig A, Zvartau EE | title = Actions of caffeine in the brain with special reference to factors that contribute to its widespread use | journal = Pharmacological Reviews | volume = 51 | issue = 1 | pages = 83–133 | date = March 1999 | pmid = 10049999 }}</ref>
==== Benzodiazepine-induced ====
Like alcohol, [[benzodiazepine]]s, such as [[alprazolam]], [[clonazepam]], [[lorazepam]], and [[diazepam]], are commonly used to treat insomnia in the short-term (both prescribed and self-medicated), but worsen sleep in the long-term. While benzodiazepines can put people to sleep (i.e., inhibit NREM stage 1 and 2 sleep), while asleep, the drugs disrupt [[sleep architecture]]: decreasing sleep time, delaying time to REM sleep, and decreasing deep [[slow-wave sleep]] (the most restorative part of sleep for both energy and mood).<ref>{{cite journal | vauthors = Ashton H | s2cid = 1709063 | title = The diagnosis and management of benzodiazepine dependence | journal = Current Opinion in Psychiatry | volume = 18 | issue = 3 | pages = 249–55 | date = May 2005 | pmid = 16639148 | doi = 10.1097/01.yco.0000165594.60434.84 }}</ref><ref>{{cite journal | vauthors = Morin CM, Bélanger L, Bastien C, Vallières A | title = Long-term outcome after discontinuation of benzodiazepines for insomnia: a survival analysis of relapse | journal = Behaviour Research and Therapy | volume = 43 | issue = 1 | pages = 1–14 | date = January 2005 | pmid = 15531349 | doi = 10.1016/j.brat.2003.12.002 }}</ref><ref>{{cite journal | vauthors = Poyares D, Guilleminault C, Ohayon MM, Tufik S | title = Chronic benzodiazepine usage and withdrawal in insomnia patients | journal = Journal of Psychiatric Research | volume = 38 | issue = 3 | pages = 327–34 | date = 1 June 2004 | pmid = 15003439 | doi = 10.1016/j.jpsychires.2003.10.003 }}</ref>
==== Opioid-induced ====
[[Opioid]] medications such as [[hydrocodone]], [[oxycodone]], and [[morphine]] are used for insomnia that is associated with [[pain]] due to their [[analgesic]] properties and [[hypnotic]] effects. Opioids can fragment sleep and decrease [[Rapid eye movement sleep|REM]] and [[Non-rapid eye movement sleep|stage 2]] sleep. By producing [[analgesia]] and [[sedation]], opioids may be appropriate in carefully selected patients with pain-associated insomnia.<ref name="Ramakrishnan-2007" /> However, dependence on opioids can lead to long-term sleep disturbances.<ref>{{Cite journal | vauthors = Asaad TA, Ghanem MH, Samee AM, El-Habiby MM |s2cid=76376646 |title=Sleep Profile in Patients with Chronic Opioid Abuse |doi=10.1097/ADT.0b013e3181fb2847 |journal=Addictive Disorders & Their Treatment |volume=10 |pages=21–28 |year=2011 }}</ref>
=== Risk factors ===
Insomnia affects people of all age groups, but people in the following groups have a higher chance of acquiring insomnia:<ref>{{Cite news|url=https://www.mayoclinic.org/diseases-conditions/insomnia/symptoms-causes/syc-20355167|title=Insomnia – Symptoms and causes|work=Mayo Clinic|access-date=5 February 2018|language=en|archive-date=24 January 2018|archive-url=https://web.archive.org/web/20180124135326/https://www.mayoclinic.org/diseases-conditions/insomnia/symptoms-causes/syc-20355167|url-status=live}}</ref>
*Individuals older than 60
*History of mental health disorder including depression, etc.
*Emotional stress
*Working late night shifts
*Traveling through different time zones<ref name=Pun2012/>
*Having chronic diseases such as [[diabetes]], kidney disease, lung disease, [[Alzheimer's]], or heart disease<ref>{{Cite news|url=http://www.winchesterhospital.org/health-library/article?id=19705|title=Risk Factors For Insomnia|access-date=14 April 2019|language=en|archive-date=19 February 2020|archive-url=https://web.archive.org/web/20200219030647/https://www.winchesterhospital.org/health-library/article?id=19705|url-status=dead}}</ref>
*[[Alcohol (drug)|Alcohol]] or drug use disorders
*Gastrointestinal reflux disease
*Heavy smoking
*Work stress<ref>{{cite book | vauthors = Lichstein KL, Taylor DJ, McCrae CS, Ruiter ME | chapter = Insomnia: epidemiology and risk factors. | title = Principles and Practice of Sleep Medicine | edition = Fifth | date = November 2010 | pages = 827–837 | publisher = Elsevier Inc. | doi = 10.1016/B978-1-4160-6645-3.00076-1 }}</ref>
*Individuals of low socioeconomic status<ref name="Billings_2021">{{cite journal | vauthors = Billings ME, Cohen RT, Baldwin CM, Johnson DA, Palen BN, Parthasarathy S, Patel SR, Russell M, Tapia IE, Williamson AA, Sharma S | title = Disparities in Sleep Health and Potential Intervention Models: A Focused Review | journal = Chest | volume = 159 | issue = 3 | pages = 1232–1240 | date = March 2021 | pmid = 33007324 | pmc = 7525655 | doi = 10.1016/j.chest.2020.09.249 }}</ref>
*Urban Neighborhoods <ref name="Billings_2021" />
*Household stress<ref name="Billings_2021" />
== Mechanism ==
Two main models exist as to the mechanism of insomnia, cognitive and physiological. The cognitive model suggests rumination and hyperarousal contribute to preventing a person from falling asleep and might lead to an episode of insomnia.
The physiological model is based upon three major findings in people with insomnia; firstly, increased urinary [[cortisol]] and [[catecholamines]] have been found suggesting increased activity of the HPA axis and arousal; second, increased global cerebral glucose utilization during wakefulness and NREM sleep in people with insomnia; and lastly, increased full body metabolism and heart rate in those with insomnia. All these findings taken together suggest a deregulation of the arousal system, cognitive system, and [[HPA axis]] all contributing to insomnia.<ref name="Th2007"/><ref>{{cite journal | vauthors = Bonnet MH | title = Evidence for the pathophysiology of insomnia | journal = Sleep | volume = 32 | issue = 4 | pages = 441–42 | date = April 2009 | pmid = 19413138 | pmc = 2663857 | doi = 10.1093/sleep/32.4.441 }}</ref> However, it is unknown if the hyperarousal is a result of, or cause of insomnia. Altered levels of the inhibitory [[neurotransmitter]] [[GABA]] have been found, but the results have been inconsistent, and the implications of altered levels of such a ubiquitous neurotransmitter are unknown. Studies on whether insomnia is driven by circadian control over sleep or a wake dependent process have shown inconsistent results, but some literature suggests a deregulation of the circadian rhythm based on core temperature.<ref>{{cite journal | vauthors = Levenson JC, Kay DB, Buysse DJ | title = The pathophysiology of insomnia | journal = Chest | volume = 147 | issue = 4 | pages = 1179–92 | date = April 2015 | pmid = 25846534 | pmc = 4388122 | doi = 10.1378/chest.14-1617 }}</ref> Increased beta activity and decreased delta wave activity has been observed on [[electroencephalogram]]s; however, the implication of this is unknown.<ref>{{cite journal | vauthors = Mai E, Buysse DJ | title = Insomnia: Prevalence, Impact, Pathogenesis, Differential Diagnosis, and Evaluation | journal = Sleep Medicine Clinics | volume = 3 | issue = 2 | pages = 167–74 | date = 1 January 2008 | pmid = 19122760 | pmc = 2504337 | doi = 10.1016/j.jsmc.2008.02.001 }}</ref>
Around half of post-menopausal women experience sleep disturbances, and generally sleep disturbance is about twice as common in women as men; this appears to be due in part, but not completely, to changes in hormone levels, especially in and post-menopause.<ref name=Santoro2015rev/><ref>{{cite journal | vauthors = Shaver JL, Woods NF | s2cid = 23937236 | title = Sleep and menopause: a narrative review | journal = Menopause | volume = 22 | issue = 8 | pages = 899–915 | date = August 2015 | pmid = 26154276 | doi = 10.1097/GME.0000000000000499 }}</ref>
Changes in [[sex hormone]]s in both men and women as they age may account in part for increased prevalence of [[sleep disorder]]s in older people.<ref>{{cite journal | vauthors = Lord C, Sekerovic Z, Carrier J | title = Sleep regulation and sex hormones exposure in men and women across adulthood | journal = Pathologie-Biologie | volume = 62 | issue = 5 | pages = 302–10 | date = October 2014 | pmid = 25218407 | doi = 10.1016/j.patbio.2014.07.005 }}</ref>
== Diagnosis ==
{{Further|Ford Insomnia Response to Stress Test}}
In medicine, insomnia is widely measured using the [[Athens Insomnia Scale|Athens insomnia scale]].<ref>{{cite journal | vauthors = Soldatos CR, Dikeos DG, Paparrigopoulos TJ | title = Athens Insomnia Scale: validation of an instrument based on ICD-10 criteria | journal = Journal of Psychosomatic Research | volume = 48 | issue = 6 | pages = 555–60 | date = June 2000 | pmid = 11033374 | doi = 10.1016/S0022-3999(00)00095-7 }}</ref> It is measured using eight different parameters related to sleep, finally represented as an overall scale which assesses an individual's sleep pattern.
A qualified sleep specialist should be consulted for the diagnosis of any sleep disorder, so the appropriate measures can be taken. Past medical history and a physical examination need to be done to eliminate other conditions that could be the cause of insomnia. After all other conditions are ruled out, a comprehensive sleep history should be taken. The sleep history should include sleep habits, medications (prescription and non-prescription), alcohol consumption, nicotine and caffeine intake, co-morbid illnesses, and sleep environment.<ref name="Passarella, S 2008">Passarella, S, Duong, M. "Diagnosis and treatment of insomnia." 2008.</ref> A [[sleep diary]] can be used to keep track of the individual's sleep patterns. The diary should include time to bed, total sleep time, time to sleep onset, number of awakenings, use of medications, time of awakening, and subjective feelings in the morning.<ref name="Passarella, S 2008"/> The sleep diary can be replaced or validated by the use of out-patient [[actigraphy]] for a week or more, using a non-invasive device that measures movement.<ref name=Schutte-Rodin>{{cite journal | vauthors = Schutte-Rodin S, Broch L, Buysse D, Dorsey C, Sateia M | title = Clinical guideline for the evaluation and management of chronic insomnia in adults | journal = Journal of Clinical Sleep Medicine | volume = 4 | issue = 5 | pages = 487–504 | date = October 2008 | pmid = 18853708 | pmc = 2576317 | url = http://www.aasmnet.org/Resources/clinicalguidelines/040515.pdf | quote = Actigraphy is indicated as a method to characterize circadian patterns or sleep disturbances in individuals with insomnia, ... | access-date = 30 July 2015 | url-status = live | archive-url = https://web.archive.org/web/20150209031235/http://www.aasmnet.org/Resources/clinicalguidelines/040515.pdf | archive-date = 9 February 2015 | doi = 10.5664/jcsm.27286 }}</ref>
Workers who complain of insomnia should not routinely have [[polysomnography]] to screen for sleep disorders.<ref name="ACOEMfive">{{Citation |author1=American College of Occupational and Environmental Medicine |author1-link=American College of Occupational and Environmental Medicine |date=February 2014 |title=Five Things Physicians and Patients Should Question |publisher=American College of Occupational and Environmental Medicine |work=[[Choosing Wisely]]: an initiative of the [[ABIM Foundation]] |url=http://www.choosingwisely.org/doctor-patient-lists/american-college-of-occupational-and-environmental-medicine/ |access-date=24 February 2014 |url-status=live |archive-url=https://web.archive.org/web/20140911001813/http://www.choosingwisely.org/doctor-patient-lists/american-college-of-occupational-and-environmental-medicine/ |archive-date=11 September 2014 }}</ref> This test may be indicated for patients with symptoms in addition to insomnia, including [[sleep apnea]], obesity, a thick neck diameter, or high-risk fullness of the flesh in the [[oropharynx]].<ref name="ACOEMfive"/> Usually, the test is not needed to make a diagnosis, and insomnia especially for working people can often be treated by changing a job schedule to make time for sufficient sleep and by improving [[sleep hygiene]].<ref name="ACOEMfive"/>
Some patients may need to do an overnight sleep study to determine if insomnia is present. Such a study will commonly involve assessment tools including a polysomnogram and the [[multiple sleep latency test]]. Specialists in [[sleep medicine]] are qualified to diagnose disorders within the, according to the [[International Classification of Sleep Disorders|ICSD]], 81 major sleep disorder diagnostic categories.<ref>{{cite journal | vauthors = Thorpy MJ | title = Classification of sleep disorders | journal = Neurotherapeutics | volume = 9 | issue = 4 | pages = 687–701 | date = October 2012 | pmid = 22976557 | pmc = 3480567 | doi = 10.1007/s13311-012-0145-6 }}</ref> Patients with some disorders, including [[delayed sleep phase disorder]], are often mis-diagnosed with primary insomnia; when a person has trouble getting to sleep and awakening at desired times, but has a normal sleep pattern once asleep, a circadian rhythm disorder is a likely cause.
In many cases, insomnia is co-morbid with another disease, side-effects from medications, or a psychological problem. Approximately half of all diagnosed insomnia is related to psychiatric disorders.<ref name="Wilson" /> For those who have depression, "insomnia should be regarded as a co-morbid condition, rather than as a secondary one;" insomnia typically predates psychiatric symptoms.<ref name="Wilson" /> "In fact, it is possible that insomnia represents a significant risk for the development of a subsequent psychiatric disorder."<ref name=Th2007 /> Insomnia occurs in between 60% and 80% of people with depression.<ref name=Luca2013/> This may partly be due to treatment used for depression.<ref name=Luca2013>{{cite journal | vauthors = Luca A, Luca M, Calandra C | title = Sleep disorders and depression: brief review of the literature, case report, and nonpharmacologic interventions for depression | journal = Clinical Interventions in Aging | volume = 8 | pages = 1033–39 | date = 2013 | pmid = 24019746 | pmc = 3760296 | doi = 10.2147/CIA.S47230 | doi-access = free }}</ref>
Determination of causation is not necessary for a diagnosis.<ref name="Wilson">{{cite journal | vauthors = Wilson SJ, Nutt DJ, Alford C, Argyropoulos SV, Baldwin DS, Bateson AN, Britton TC, Crowe C, Dijk DJ, Espie CA, Gringras P, Hajak G, Idzikowski C, Krystal AD, Nash JR, Selsick H, Sharpley AL, Wade AG | title = British Association for Psychopharmacology consensus statement on evidence-based treatment of insomnia, parasomnias and circadian rhythm disorders | journal = Journal of Psychopharmacology | volume = 24 | issue = 11 | pages = 1577–1601 | date = November 2010 | pmid = 20813762 | doi = 10.1177/0269881110379307 | s2cid = 16823040 }}</ref>
=== DSM-5 criteria ===
The [[DSM-5]] criteria for insomnia include the following:<ref>{{cite book | chapter = Sleep Wake Disorders | title = Diagnostic and statistical manual of mental disorders: DSM-5 | location = Washington, D.C. | publisher = American Psychiatric Association | date = 2013 }}</ref>
Predominant complaint of dissatisfaction with sleep quantity or quality, associated with one (or more) of the following symptoms:
*Difficulty initiating sleep. (In children, this may manifest as difficulty initiating sleep without caregiver intervention.)
*Difficulty maintaining sleep, characterized by frequent awakenings or problems returning to sleep after awakenings. (In children, this may manifest as difficulty returning to sleep without caregiver intervention.)
*Early-morning awakening with inability to return to sleep.
In addition:
*The sleep disturbance causes clinically significant distress or impairment in social, occupational, educational, academic, behavioral, or other important areas of functioning.
*The sleep difficulty occurs at least three nights per week.
*The sleep difficulty is present for at least three months.
*The sleep difficulty occurs despite adequate opportunity for sleep.
*The insomnia is not better explained by and does not occur exclusively during the course of another sleep-wake disorder (e.g., narcolepsy, a breathing-related sleep disorder, a circadian rhythm sleep-wake disorder, a parasomnia).
*The insomnia is not attributable to the physiological effects of a substance (e.g., a [[drug of abuse]], a medication).
The [[DSM-IV TR]] includes insomnia but does not fully elaborate on the symptoms compared to the DSM-5. Instead of early-morning waking as a symptom, the DSM-IV-TR listed “nonrestorative sleep” as a primary symptom. The duration of the experience was also vague in the DSM-IV-TR. The DSM-IV-TR stated that symptoms had to be present for a month, whereas in the DSM-5, it stated symptoms had to be present for three months and occur at least 3 nights a week (Gillette).
=== Types ===
Insomnia can be classified as transient, acute, or chronic.
*''Transient insomnia'' lasts for less than a week. It can be caused by another disorder, by changes in the sleep environment, by the timing of sleep, severe [[Major depressive disorder|depression]], or by [[stress (biology)|stress]]. Its consequences&nbsp;– sleepiness and impaired psychomotor performance&nbsp;– are similar to those of [[sleep deprivation]].<ref name="Roth">{{cite journal | vauthors = Roth T, Roehrs T | title = Insomnia: epidemiology, characteristics, and consequences | journal = Clinical Cornerstone | volume = 5 | issue = 3 | pages = 5–15 | year = 2003 | pmid = 14626537 | doi = 10.1016/S1098-3597(03)90031-7 }}</ref>
*''[[Acute (medicine)|Acute]] insomnia'' is the inability to consistently sleep well for a period of less than a month. Insomnia is present when there is difficulty initiating or maintaining sleep or when the sleep that is obtained is non-refreshing or of poor quality. These problems occur despite adequate opportunity and circumstances for sleep and they must result in problems with daytime function.<ref>{{cite web |url=http://articles.directorym.com/Insomnia-a352.html |title=Insomnia&nbsp;– sleeplessness, chronic insomnia, acute insomnia, mental ... |access-date=29 April 2008 |archive-url=https://web.archive.org/web/20080329155902/http://articles.directorym.com/Insomnia-a352.html |archive-date=29 March 2008}}</ref> Hyperarousal can be linked to acute insomnia since it activates the body's fight-or-flight response. When we encounter stress or danger, our bodies naturally become more alert, which can interfere with our capacity to both fall asleep and remain asleep. This heightened state of arousal can be useful in the short term during threatening situations, but if it continues over an extended period, it can result in acute insomnia.<ref name="Acute and Chronic Insomnia: What Ha">{{cite journal | vauthors = Vargas I, Nguyen AM, Muench A, Bastien CH, Ellis JG, Perlis ML | title = Acute and Chronic Insomnia: What Has Time and/or Hyperarousal Got to Do with It? | journal = Brain Sciences | volume = 10 | issue = 2 | pages = 71 | date = January 2020 | pmid = 32013124 | pmc = 7071368 | doi = 10.3390/brainsci10020071 | doi-access = free }}</ref> Acute insomnia is also known as ''short term insomnia'' or ''stress related insomnia''.<ref name=r1>{{cite web |url=http://sleepdisorders.about.com/od/commonsleepdisorders/a/Acute_Insomnia.htm |title=Acute Insomnia – What is Acute Insomnia |publisher=Sleepdisorders.about.com |access-date=10 March 2013 |url-status=live |archive-url=https://web.archive.org/web/20130329185735/http://sleepdisorders.about.com/od/commonsleepdisorders/a/Acute_Insomnia.htm |archive-date=29 March 2013 }}</ref>
*''[[chronic (medical)|Chronic]] insomnia'' lasts for longer than a month. It can be caused by another disorder, or it can be a primary disorder. Common causes of chronic insomnia include persistent stress, trauma, work schedules, poor sleep habits, medications, and other mental health disorders.<ref>{{Cite web |date=2020-08-31 |title=Types of Insomnia |url=https://www.sleepfoundation.org/insomnia/types-of-insomnia |access-date=2022-07-15 |website=Sleep Foundation |language=en |archive-date=2022-07-14 |archive-url=https://web.archive.org/web/20220714180512/https://www.sleepfoundation.org/insomnia/types-of-insomnia |url-status=live }}</ref> When an individual consistently engages in behaviors that disrupt their sleep, such as irregular sleep schedules, spending excessive time awake in bed, or engaging in stimulating activities close to bedtime, it can lead to conditioned wakefulness contributing to chronic insomnia.<ref name="Acute and Chronic Insomnia: What Ha"/> People with high levels of stress hormones or shifts in the levels of [[cytokine]]s are more likely than others to have chronic insomnia.<ref>{{cite news | vauthors = Simon H |title=In-Depth Report: Causes of Chronic Insomnia |url=http://health.nytimes.com/health/guides/symptoms/sleeping-difficulty/causes-of-chronic-insomnia.html |newspaper=The New York Times |access-date=4 November 2011 |url-status=live |archive-url=https://web.archive.org/web/20111108185210/http://health.nytimes.com/health/guides/symptoms/sleeping-difficulty/causes-of-chronic-insomnia.html |archive-date=8 November 2011 }}</ref> Its effects can vary according to its causes. They might include muscular weariness, [[hallucination]]s, and/or [[mental fatigue]].<ref name="Roth"/>
==Prevention==
Prevention and treatment of insomnia may require a combination of [[cognitive behavioral therapy]],<ref name=Tra2015/> medications,<ref name="abad">{{cite journal | vauthors = Abad VC, Guilleminault C | s2cid = 51866276 | title = Insomnia in Elderly Patients: Recommendations for Pharmacological Management | journal = Drugs & Aging | volume = 35 | issue = 9 | pages = 791–817 | date = September 2018 | pmid = 30058034 | doi = 10.1007/s40266-018-0569-8 }}</ref> and lifestyle changes.<ref name="mayo">{{cite web |title=Insomnia: Diagnosis and treatment |url=https://www.mayoclinic.org/diseases-conditions/insomnia/diagnosis-treatment/drc-20355173 |publisher=Mayo Clinic |access-date=11 October 2018 |date=15 October 2016 |archive-date=4 October 2017 |archive-url=https://web.archive.org/web/20171004131534/https://www.mayoclinic.org/diseases-conditions/insomnia/diagnosis-treatment/drc-20355173 |url-status=live }}</ref>
Among lifestyle practices, going to sleep and waking up at the same time each day can create a steady pattern which may help to prevent insomnia.<ref name=Pun2012/> Avoidance of vigorous [[Physical exercise|exercise]] and [[Caffeine|caffeinated drinks]] a few hours before going to sleep is recommended, while exercise earlier in the day may be beneficial.<ref name=mayo/> Other practices to improve [[sleep hygiene]] may include:<ref name=mayo/><ref>{{cite web|url=https://www.webmd.com/sleep-disorders/guide/insomnia-symptoms-and-causes#2-8|title=Insomnia (Acute & Chronic): Symptoms, Causes, and Treatment|vauthors=Pathak N|date=17 January 2017|website=WebMD|access-date=11 October 2018|archive-date=11 October 2018|archive-url=https://web.archive.org/web/20181011022132/https://www.webmd.com/sleep-disorders/guide/insomnia-symptoms-and-causes#2-8|url-status=live}}</ref>
* Avoiding or limiting [[nap]]s
* Treating pain at bedtime
* Avoiding large meals, beverages, [[Alcohol (drug)|alcohol]], and [[nicotine]] before bedtime
* Finding soothing ways to relax into sleep, including use of [[white noise]]
* Making the bedroom suitable for sleep by keeping it dark, cool, and free of devices, such as clocks, cell phones, or televisions
* Maintain regular exercise
* Try relaxing activities before sleeping
== Management ==
It is recommended to rule out medical and psychological causes before deciding on the treatment for insomnia.<ref>{{cite journal | vauthors = Wortelboer U, Cohrs S, Rodenbeck A, Rüther E | s2cid = 38910586 | title = Tolerability of hypnosedatives in older patients | journal = Drugs & Aging | volume = 19 | issue = 7 | pages = 529–39 | year = 2002 | pmid = 12182689 | doi = 10.2165/00002512-200219070-00006 }}</ref> [[Cognitive behavioral therapy]] is generally the first line treatment once this has been done.<ref>{{cite journal | vauthors = van Straten A, van der Zweerde T, Kleiboer A, Cuijpers P, Morin CM, Lancee J | title = Cognitive and behavioral therapies in the treatment of insomnia: A meta-analysis | journal = Sleep Medicine Reviews | volume = 38 | pages = 3–16 | date = April 2018 | pmid = 28392168 | doi = 10.1016/j.smrv.2017.02.001 | url = https://research.vu.nl/ws/files/104498588/Cognitive_and_behavioral_therapies_in_the_treatment_of_insomnia.pdf | hdl = 1871.1/6fbbd685-d526-41ec-9961-437833035f53 | s2cid = 3359815 | hdl-access = free | access-date = 2020-09-18 | archive-date = 2020-11-05 | archive-url = https://web.archive.org/web/20201105000321/https://research.vu.nl/ws/files/104498588/Cognitive_and_behavioral_therapies_in_the_treatment_of_insomnia.pdf | url-status = live }}</ref> It has been found to be effective for chronic insomnia.<ref name=Tra2015/> The beneficial effects, in contrast to those produced by medications, may last well beyond the stopping of therapy.<ref>{{cite journal | title = NIH State-of-the-Science Conference Statement on manifestations and management of chronic insomnia in adults | journal = NIH Consensus and State-Of-The-Science Statements | volume = 22 | issue = 2 | pages = 1–30 | year = 2005 | pmid = 17308547 }}</ref>
Medications have been used mainly to reduce symptoms in insomnia of short duration; their role in the management of chronic insomnia remains unclear.<ref name=WHO2009/> Several different types of medications may be used.<ref>{{cite journal | vauthors = Sateia MJ, Buysse DJ, Krystal AD, Neubauer DN, Heald JL | title = Clinical Practice Guideline for the Pharmacologic Treatment of Chronic Insomnia in Adults: An American Academy of Sleep Medicine Clinical Practice Guideline | journal = Journal of Clinical Sleep Medicine | volume = 13 | issue = 2 | pages = 307–349 | date = February 2017 | pmid = 27998379 | pmc = 5263087 | doi = 10.5664/jcsm.6470 }}</ref><ref>{{cite journal | vauthors = Riemann D, Perlis ML | title = The treatments of chronic insomnia: a review of benzodiazepine receptor agonists and psychological and behavioral therapies | journal = Sleep Medicine Reviews | volume = 13 | issue = 3 | pages = 205–14 | date = June 2009 | pmid = 19201632 | doi = 10.1016/j.smrv.2008.06.001 }}</ref><ref name=abad/> Many doctors do not recommend relying on prescription sleeping pills for long-term use.<ref name=mayo/> It is also important to identify and treat other medical conditions that may be contributing to insomnia, such as depression, breathing problems, and chronic pain.<ref name=mayo/><ref name="insomnia JAMA">{{cite journal | vauthors = Merrigan JM, Buysse DJ, Bird JC, Livingston EH | title = JAMA patient page. Insomnia | journal = JAMA | volume = 309 | issue = 7 | pages = 733 | date = February 2013 | pmid = 23423421 | doi = 10.1001/jama.2013.524 | doi-access = free }}</ref> As of 2022, many people with insomnia were reported as not receiving overall sufficient sleep or treatment for insomnia.<ref>{{Cite web |date=2021-10-25 |title=Sleep Statistics - Facts and Data About Sleep 2022 |url=https://www.sleepfoundation.org/how-sleep-works/sleep-facts-statistics |access-date=2022-07-15 |website=Sleep Foundation |language=en |archive-date=2022-07-15 |archive-url=https://web.archive.org/web/20220715223335/https://www.sleepfoundation.org/how-sleep-works/sleep-facts-statistics |url-status=live }}</ref><ref>{{cite journal | vauthors = Drake CL, Roehrs T, Roth T | title = Insomnia causes, consequences, and therapeutics: an overview | journal = Depression and Anxiety | volume = 18 | issue = 4 | pages = 163–76 | date = December 2003 | pmid = 14661186 | doi = 10.1002/da.10151 | s2cid = 19203612 | doi-access = free }}</ref>
=== Non-medication based ===
Non-medication based strategies have comparable efficacy to [[hypnotic]] medication for insomnia and they may have longer lasting effects. Hypnotic medication is only recommended for short-term use because [[substance dependence|dependence]] with [[rebound withdrawal effects]] upon discontinuation or [[drug tolerance|tolerance]] can develop.<ref>{{cite journal | author = National Prescribing Service | date = 1 February 2010 | url = http://www.nps.org.au/publications/health-professional/nps-news/2010/nps-news-67 | title = Addressing hypnotic medicines use in primary care | archive-url = https://web.archive.org/web/20131101224851/http://www.nps.org.au/publications/health-professional/nps-news/2010/nps-news-67 |archive-date=1 November 2013 | journal = NPS News | volume = 67 }}</ref>
Non medication based strategies provide long lasting improvements to insomnia and are recommended as a first line and long-term strategy of management. Behavioral sleep medicine (BSM) tries to address insomnia with non-pharmacological treatments. The BSM strategies used to address chronic insomnia include attention to [[sleep hygiene]], [[stimulus control]], behavioral interventions, [[Cognitive behavioral therapy for insomnia#Sleep restriction therapy|sleep-restriction therapy]], [[paradoxical intention]], patient education, and [[relaxation technique|relaxation therapy]].<ref>{{cite journal | vauthors = Kirkwood CK | title = Management of insomnia | journal = Journal of the American Pharmaceutical Association | volume = 39 | issue = 5 | pages = 688–96; quiz 713–14 | year = 1999 | pmid = 10533351 | doi = 10.1016/s1086-5802(15)30354-5 }}</ref> Some examples are keeping a journal, restricting the time spent awake in bed, practicing [[relaxation technique]]s, and maintaining a regular sleep schedule and a wake-up time. Behavioral therapy can assist a patient in developing new sleep behaviors to improve sleep quality and consolidation. Behavioral therapy may include, learning healthy sleep habits to promote sleep relaxation, undergoing light therapy to help with worry-reduction strategies and regulating the circadian clock.<ref name="insomnia JAMA"/>
Music may improve insomnia in adults (see [[music and sleep]]).<ref>{{cite journal | vauthors = Jespersen KV, Pando-Naude V, Koenig J, Jennum P, Vuust P | title = Listening to music for insomnia in adults | journal = The Cochrane Database of Systematic Reviews | volume = 2022 | issue = 8 | pages = CD010459 | date = August 2022 | pmid = 36000763 | pmc = 9400393 | doi = 10.1002/14651858.CD010459.pub3 }}</ref> [[EEG biofeedback]] has demonstrated effectiveness in the treatment of insomnia with improvements in duration as well as quality of sleep.<ref>{{Cite book | vauthors = Lake JA |title=Textbook of Integrative Mental Health Care |url=https://books.google.com/books?id=Bt5euqMwbpYC&pg=PA313 |date= 2006 |publisher=Thieme Medical Publishers |isbn=978-1-58890-299-3 |page=313 }}</ref> Self-help therapy (defined as a psychological therapy that can be worked through on one's own) may improve sleep quality for adults with insomnia to a small or moderate degree.<ref>{{cite journal | vauthors = van Straten A, Cuijpers P | title = Self-help therapy for insomnia: a meta-analysis | journal = Sleep Medicine Reviews | volume = 13 | issue = 1 | pages = 61–71 | date = February 2009 | pmid = 18952469 | doi = 10.1016/j.smrv.2008.04.006 }}</ref>
Stimulus control therapy is a treatment for patients who have conditioned themselves to associate the bed, or sleep in general, with a negative response. As stimulus control therapy involves taking steps to control the sleep environment, it is sometimes referred interchangeably with the concept of [[sleep hygiene]]. Examples of such environmental modifications include using the bed for sleep and sex only, not for activities such as reading or watching television; waking up at the same time every morning, including on weekends; going to bed only when sleepy and when there is a high likelihood that sleep will occur; leaving the bed and beginning an activity in another location if sleep does not occur in a reasonably brief period of time after getting into bed (commonly ~20 min); reducing the subjective effort and energy expended trying to fall asleep; avoiding exposure to bright light during night-time hours, and eliminating daytime naps.<ref>{{cite journal | vauthors = Lande RG, Gragnani C | title = Nonpharmacologic approaches to the management of insomnia | journal = The Journal of the American Osteopathic Association | volume = 110 | issue = 12 | pages = 695–701 | date = December 2010 | pmid = 21178150 }}</ref>
A component of stimulus control therapy is sleep restriction, a technique that aims to match the time spent in bed with actual time spent asleep. This technique involves maintaining a strict sleep-wake schedule, sleeping only at certain times of the day and for specific amounts of time to induce mild sleep deprivation. Complete treatment usually lasts up to 3 weeks and involves making oneself sleep for only a minimum amount of time that they are actually capable of on average, and then, if capable (i.e. when [[Polysomnography#Interpretation|sleep efficiency]] improves), slowly increasing this amount (~15 min) by going to bed earlier as the body attempts to reset its internal sleep clock. [[Bright light therapy]] may be effective for insomnia.<ref>{{cite journal |vauthors=van Maanen A, Meijer AM, van der Heijden KB, Oort FJ |title=The effects of light therapy on sleep problems: A systematic review and meta-analysis |journal=Sleep Med Rev |volume=29 |pages=52–62 |date=October 2016 |pmid=26606319 |doi=10.1016/j.smrv.2015.08.009 |s2cid=3410636 |url=https://dare.uva.nl/personal/pure/en/publications/the-effects-of-light-therapy-on-sleep-problems(723b9aaa-7eed-4f5c-a69e-39056a2c95c4).html |access-date=2020-06-30 |archive-date=2021-08-28 |archive-url=https://web.archive.org/web/20210828125128/https://dare.uva.nl/search?identifier=723b9aaa-7eed-4f5c-a69e-39056a2c95c4 |url-status=live }}</ref>
Paradoxical intention is a cognitive reframing technique where the insomniac, instead of attempting to fall asleep at night, makes every effort to stay awake (i.e. essentially stops trying to fall asleep). One theory that may explain the effectiveness of this method is that by not voluntarily making oneself go to sleep, it relieves the performance anxiety that arises from the need or requirement to fall asleep, which is meant to be a passive act. This technique has been shown to reduce sleep effort and performance anxiety and also lower subjective assessment of sleep-onset latency and overestimation of the sleep deficit (a quality found in many insomniacs).<ref>{{cite journal | vauthors = Kierlin L | s2cid = 22141056 | title = Sleeping without a pill: nonpharmacologic treatments for insomnia | journal = Journal of Psychiatric Practice | volume = 14 | issue = 6 | pages = 403–07 | date = November 2008 | pmid = 19057243 | doi = 10.1097/01.pra.0000341896.73926.6c }}</ref>
==== Sleep hygiene ====
[[Sleep hygiene]] is a common term for all of the behaviors which relate to the promotion of good sleep. They include habits which provide a good foundation for sleep and help to prevent insomnia. However, sleep hygiene alone may not be adequate to address chronic insomnia. Sleep hygiene recommendations are typically included as one component of [[cognitive behavioral therapy for insomnia]] (CBT-I).<ref name="Schutte-Rodin" /><ref name="AC2016" /> Recommendations include reducing caffeine, nicotine, and alcohol consumption, maximizing the regularity and efficiency of sleep episodes, minimizing medication usage and daytime napping, the promotion of regular exercise, and the facilitation of a positive sleep environment.<ref name="Ellis_2002">{{cite journal | vauthors = Ellis J, Hampson SE, Cropley M |title=Sleep hygiene or compensatory sleep practices: An examination of behaviours affecting sleep in older adults |journal=Psychology, Health & Medicine |date=May 2002 |volume=7 |issue=2 |pages=156–161 |doi=10.1080/13548500120116094 |s2cid=143141307 }}</ref> The creation of a positive sleep environment may also be helpful in reducing the symptoms of insomnia.<ref name="Insomnia">{{cite web |url= https://www.lecturio.com/concepts/insomnia/ |title= Insomnia |website= The Lecturio Medical Concept Library |access-date= 2021-06-24 |archive-date= 2021-06-24 |archive-url= https://web.archive.org/web/20210624220727/https://www.lecturio.com/concepts/insomnia/ |url-status= live }}</ref>
On the other hand, a systematic review by the AASM concluded that clinicians should not prescribe sleep hygiene for insomnia due to the evidence of absence of its efficacy and potential delaying of adequate treatment, recommending instead that effective therapies such as CBT-i should be preferred.<ref name="Behavioral and psychological treatm"/>
==== Cognitive behavioral therapy ====
{{main|Cognitive behavioral therapy for insomnia}}
There is some evidence that cognitive behavioral therapy for insomnia (CBT-I) is superior in the long-term to [[benzodiazepine]]s and the [[nonbenzodiazepine]]s in the treatment and management of insomnia.<ref name="Mitchell-2012">{{cite journal | vauthors = Mitchell MD, Gehrman P, Perlis M, Umscheid CA | title = Comparative effectiveness of cognitive behavioral therapy for insomnia: a systematic review | journal = BMC Family Practice | volume = 13 | pages = 40 | date = May 2012 | pmid = 22631616 | pmc = 3481424 | doi = 10.1186/1471-2296-13-40 | doi-access = free }}</ref> In this therapy, patients are taught improved sleep habits and relieved of counter-productive assumptions about sleep. Common misconceptions and expectations that can be modified include:{{Cn|date=November 2024}}
* Unrealistic sleep expectations.
* Misconceptions about insomnia causes.
* Amplifying the consequences of insomnia.
* Performance anxiety after trying for so long to have a good night's sleep by controlling the sleep process.
Numerous studies have reported positive outcomes of combining cognitive behavioral therapy for insomnia treatment with treatments such as stimulus control and the relaxation therapies. [[Hypnotic]] medications are equally effective in the short-term treatment of insomnia, but their effects wear off over time due to [[drug tolerance|tolerance]]. The effects of [[CBT-I]] have sustained and lasting effects on treating insomnia long after therapy has been discontinued.<ref name="JacobsG2004Cognitive">{{cite journal | vauthors = Jacobs GD, Pace-Schott EF, Stickgold R, Otto MW | title = Cognitive behavior therapy and pharmacotherapy for insomnia: a randomized controlled trial and direct comparison | journal = Archives of Internal Medicine | volume = 164 | issue = 17 | pages = 1888–96 | date = September 2004 | pmid = 15451764 | doi = 10.1001/archinte.164.17.1888 | doi-access = free }}</ref><ref>{{cite journal | vauthors = Morin CM, Colecchi C, Stone J, Sood R, Brink D | title = Behavioral and pharmacological therapies for late-life insomnia: a randomized controlled trial | journal = JAMA | volume = 281 | issue = 11 | pages = 991–99 | date = March 1999 | pmid = 10086433 | doi = 10.1001/jama.281.11.991 | doi-access = free }}</ref> The addition of hypnotic medications with CBT-I adds no benefit in insomnia. The long lasting benefits of a course of CBT-I shows superiority over pharmacological hypnotic drugs. Even in the short term when compared to short-term hypnotic medication such as zolpidem, CBT-I still shows significant superiority. Thus CBT-I is recommended as a first line treatment for insomnia.<ref>{{Cite journal | vauthors = Miller KE |title=Cognitive Behavior Therapy vs. Pharmacotherapy for Insomnia |journal=American Family Physician |volume=72 |issue=2 |pages=330 |year=2005 |url=http://www.aafp.org/afp/2005/0715/p330.html |archive-url=https://web.archive.org/web/20110606060237/http://www.aafp.org/afp/2005/0715/p330.html |archive-date=6 June 2011}}</ref>
Common forms of CBT-I treatments include stimulus control therapy, sleep restriction, sleep hygiene, improved sleeping environments, relaxation training, paradoxical intention, and biofeedback.<ref>{{cite journal | vauthors = Ramakrishnan K, Scheid DC | title = Treatment options for insomnia | language = en-US | journal = American Family Physician | volume = 76 | issue = 4 | pages = 517–526 | date = August 2007 | pmid = 17853625 | url = https://www.aafp.org/pubs/afp/issues/2007/0815/p517.html | access-date = 2022-07-15 | archive-date = 2022-07-27 | archive-url = https://web.archive.org/web/20220727045819/https://www.aafp.org/pubs/afp/issues/2007/0815/p517.html | url-status = live }}</ref>
CBT is the well-accepted form of therapy for insomnia since it has no known adverse effects, whereas taking medications to alleviate insomnia symptoms have been shown to have adverse side effects.<ref>{{cite journal | vauthors = Krystal AD | title = A compendium of placebo-controlled trials of the risks/benefits of pharmacological treatments for insomnia: the empirical basis for U.S. clinical practice | journal = Sleep Medicine Reviews | volume = 13 | issue = 4 | pages = 265–74 | date = August 2009 | pmid = 19153052 | doi = 10.1016/j.smrv.2008.08.001 }}</ref> Nevertheless, the downside of CBT is that it may take a lot of time and motivation.<ref>{{cite journal | vauthors = Matthews EE, Arnedt JT, McCarthy MS, Cuddihy LJ, Aloia MS | title = Adherence to cognitive behavioral therapy for insomnia: a systematic review | journal = Sleep Medicine Reviews | volume = 17 | issue = 6 | pages = 453–64 | date = December 2013 | pmid = 23602124 | pmc = 3720832 | doi = 10.1016/j.smrv.2013.01.001 }}</ref>
==== Acceptance and commitment therapy ====
Treatments based on the principles of [[acceptance and commitment therapy]] (ACT) and [[metacognition]] have emerged as alternative approaches to treating insomnia.<ref>{{cite journal | vauthors = Ong JC, Ulmer CS, Manber R | title = Improving sleep with mindfulness and acceptance: a metacognitive model of insomnia | journal = Behaviour Research and Therapy | volume = 50 | issue = 11 | pages = 651–60 | date = November 2012 | pmid = 22975073 | pmc = 3466342 | doi = 10.1016/j.brat.2012.08.001 }}</ref> ACT rejects the idea that behavioral changes can help insomniacs achieve better sleep, since they require "sleep efforts" - actions which create more "struggle" and arouse the nervous system, leading to [[hyperarousal]].<ref name="meadows">Meadows, G. (2015) The sleep book: How to sleep well every night. London, UK: Orion Publishing Group, p.2-7</ref> The ACT approach posits that acceptance of the negative feelings associated with insomnia can, in time, create the right conditions for sleep. [[Mindfulness]] practice is a key feature of this approach, although mindfulness is not practised to induce sleep (this in itself is a ''sleep effort'' to be avoided) but rather as a longer-term activity to help calm the nervous system and create the internal conditions from which sleep can emerge.
A key distinction between CBT-i and ACT lies in the divergent approaches to time spent awake in bed. Proponents of CBT-i advocate minimizing time spent awake in bed, on the basis that this creates cognitive association between being in bed and wakefulness. The ACT approach proposes that avoiding time in bed may increase the pressure to sleep and arouse the nervous system further.<ref name=meadows/>
Research has shown that "ACT has a significant effect on primary and comorbid insomnia and sleep quality, and ... can be used as an appropriate treatment method to control and improve insomnia".<ref name="Salari_2020">{{cite journal | vauthors = Salari N, Khazaie H, Hosseinian-Far A, Khaledi-Paveh B, Ghasemi H, Mohammadi M, Shohaimi S | title = The effect of acceptance and commitment therapy on insomnia and sleep quality: A systematic review | journal = BMC Neurology | volume = 20 | issue = 1 | pages = 300 | date = August 2020 | pmid = 32791960 | pmc = 7425538 | doi = 10.1186/s12883-020-01883-1 | doi-access = free }}</ref>
==== Internet interventions ====
Despite the therapeutic effectiveness and proven success of CBT, treatment availability is significantly limited by a lack of trained clinicians, poor geographical distribution of knowledgeable professionals, and expense.<ref>{{cite journal | vauthors = Edinger JD, Means MK | title = Cognitive-behavioral therapy for primary insomnia | journal = Clinical Psychology Review | volume = 25 | issue = 5 | pages = 539–58 | date = July 2005 | pmid = 15951083 | doi = 10.1016/j.cpr.2005.04.003 }}</ref> One way to potentially overcome these barriers is to use the Internet to deliver treatment, making this effective intervention more accessible and less costly. The Internet has already become a critical source of health-care and medical information.<ref name="pewinternet.org">{{cite web | vauthors = Fox S, Fallows D | date = 5 October 2005 | title = Digital Divisions | url = http://www.pewinternet.org/PPF/r/165/report_display.asp | work = Internet health resources | location = Washington, DC | publisher = Pew Internet & American Life Project | archive-url = https://web.archive.org/web/20051021001805/http://www.pewinternet.org/PPF/r/165/report_display.asp | archive-date = 21 October 2005 }}</ref> Although the vast majority of health websites provide general information,<ref name="pewinternet.org"/><ref>{{cite journal | vauthors = Rabasca L |title=Taking telehealth to the next step |url=http://www.apa.org/monitor/apr00/telehealth.aspx |journal=Monitor on Psychology |year=2000 |volume=31 |pages=36–37 |doi=10.1037/e378852004-017 |url-status=live |archive-url=https://web.archive.org/web/20121230005926/http://www.apa.org/monitor/apr00/telehealth.aspx |archive-date=30 December 2012 }}</ref> there is growing research literature on the development and evaluation of Internet interventions.<ref>{{cite book | vauthors = Marks IM, Cavanagh K, Gega L | date = 2007 | title = Hands-on Help: Computer-Aided Psychotherapy | location = Hove, England and New York | publisher = Psychology Press | isbn = 978-1-84169-679-9 }}</ref><ref name=ritter>{{Cite journal | vauthors = Ritterband LM, Gonder-Frederick LA, Cox DJ, Clifton AD, West RW, Borowitz SM |s2cid=161666 |doi=10.1037/0735-7028.34.5.527 |title=Internet interventions: In review, in use, and into the future |journal=Professional Psychology: Research and Practice |volume=34 |issue=5 |pages=527–34 |year=2003 }}</ref>
These online programs are typically behaviorally-based treatments that have been operationalized and transformed for delivery via the Internet. They are usually highly structured; automated or human supported; based on effective face-to-face treatment; personalized to the user; interactive; enhanced by graphics, animations, audio, and possibly video; and tailored to provide follow-up and feedback.<ref name=ritter/>
There is good evidence for the use of computer based CBT for insomnia.<ref>{{cite journal | vauthors = Cheng SK, Dizon J | s2cid = 10527276 | title = Computerised cognitive behavioural therapy for insomnia: a systematic review and meta-analysis | journal = Psychotherapy and Psychosomatics | volume = 81 | issue = 4 | pages = 206–16 | date = 2012 | pmid = 22585048 | doi = 10.1159/000335379 }}</ref>
=== Medications ===
{{See also|Somnifacient}}
<!--"Sleep aid", "Sleep aids", and "Sleep Aids" redirect to this section. If the section name (Medications) is changed, please change the redirects as well.-->
Many people with insomnia use [[sleeping tablet]]s and other [[sedative]]s. In some places medications are prescribed in over 95% of cases.<ref>{{cite journal | vauthors = Charles J, Harrison C, Britt H | title = Insomnia | journal = Australian Family Physician | volume = 38 | issue = 5 | pages = 283 | date = May 2009 | pmid = 19458795 | url = http://www.racgp.org.au/afp/200905/200905beach.pdf | archive-url = https://web.archive.org/web/20110312061834/http://www.racgp.org.au/afp/200905/200905beach.pdf | archive-date = 12 March 2011 }}</ref> They, however, are a second line treatment.<ref>{{cite journal | vauthors = Qaseem A, Kansagara D, Forciea MA, Cooke M, Denberg TD | title = Management of Chronic Insomnia Disorder in Adults: A Clinical Practice Guideline From the American College of Physicians | journal = Annals of Internal Medicine | volume = 165 | issue = 2 | pages = 125–133 | date = July 2016 | pmid = 27136449 | doi = 10.7326/m15-2175 | doi-access = free }}</ref> In 2019, the US [[Food and Drug Administration]] stated it is going to require warnings for [[eszopiclone]], [[zaleplon]], and [[zolpidem]], due to concerns about serious injuries resulting from abnormal sleep behaviors, including [[sleepwalking]] or driving a vehicle while asleep.<ref>{{cite web |title=FDA adds Boxed Warning for risk of serious injuries caused by sleepwalking with certain prescription insomnia medicines |url=https://www.fda.gov/drugs/drug-safety-and-availability/fda-adds-boxed-warning-risk-serious-injuries-caused-sleepwalking-certain-prescription-insomnia |publisher=US Food and Drug Administration |access-date=2 May 2019 |date=30 April 2019 |archive-date=2 May 2019 |archive-url=https://web.archive.org/web/20190502051204/https://www.fda.gov/drugs/drug-safety-and-availability/fda-adds-boxed-warning-risk-serious-injuries-caused-sleepwalking-certain-prescription-insomnia |url-status=live }}</ref>
The percentage of adults using a prescription sleep aid increases with age. During 2005–2010, about 4% of U.S. adults aged 20 and over reported that they took prescription sleep aids in the past 30 days. Rates of use were lowest among the youngest age group (those aged 20–39) at about 2%, increased to 6% among those aged 50–59, and reached 7% among those aged 80 and over. More adult women (5%) reported using prescription sleep aids than adult men (3%). Non-Hispanic white adults reported higher use of sleep aids (5%) than non-Hispanic black (3%) and Mexican-American (2%) adults. No difference was shown between non-Hispanic black adults and Mexican-American adults in use of prescription sleep aids.<ref name="pmid24152538">{{cite journal | vauthors = Chong Y, Fryer CD, Gu Q | title = Prescription sleep aid use among adults: United States, 2005-2010 | journal = NCHS Data Brief | volume = | issue = 127 | pages = 1–8 | date = August 2013 | pmid = 24152538 | doi = | url = https://purl.fdlp.gov/GPO/gpo41892 | archive-url = https://web.archive.org/web/20210828125123/https://permanent.fdlp.gov/gpo41892/db127.pdf | archive-date=2021-08-28 | location = Hyattsville, Md. | publisher = [[United States Department of Health and Human Services|U.S. Department of Health and Human Services]], [[Centers for Disease Control and Prevention]], [[National Center for Health Statistics]]}}</ref>
==== Antihistamines ====
As an alternative to taking prescription drugs, some evidence shows that an average person seeking short-term help may find relief by taking [[over-the-counter]] [[antihistamines]] such as [[diphenhydramine]] or [[doxylamine]].<ref name="BBDinsomnia-2">{{Cite journal |author1=Consumer Reports |author1-link=Consumer Reports |author2=Drug Effectiveness Review Project |author2-link=Drug Effectiveness Review Project |date=January 2012 |title=Evaluating Newer Sleeping Pills Used to Treat: Insomnia. Comparing Effectiveness, Safety, and Price |journal=Best Buy Drugs |pages=3, 8, 11 |url=http://www.consumerreports.org/health/resources/pdf/best-buy-drugs/InsomniaUpdate-FINAL-July2008.pdf |access-date=4 June 2013 |url-status=live |archive-url=https://web.archive.org/web/20131209122641/http://www.consumerreports.org/health/resources/pdf/best-buy-drugs/InsomniaUpdate-FINAL-July2008.pdf |archive-date=9 December 2013 }}</ref> Diphenhydramine and doxylamine are widely used in nonprescription sleep aids. They are the most effective over-the-counter sedatives currently available, at least in much of Europe, Canada, Australia, and the United States, and are more sedating than some prescription [[hypnotic]]s.<ref name="drugbankDB00366">{{cite web | url = http://www.drugbank.ca/cgi-bin/getCard.cgi?CARD=DB00366.txt | work = DrugBank | id = DB00366 | title = Doxylamine | archive-url = https://web.archive.org/web/20091203012047/http://www.drugbank.ca/cgi-bin/getCard.cgi?CARD=DB00366.txt | archive-date=3 December 2009 }}</ref> Antihistamine effectiveness for sleep may decrease over time, and [[anticholinergic]] side-effects (such as dry mouth) may also be a drawback with these particular drugs. While addiction does not seem to be an issue with this class of drugs, they can induce dependence and rebound effects upon abrupt cessation of use.<ref>{{cite journal | vauthors = Lie JD, Tu KN, Shen DD, Wong BM | title = Pharmacological Treatment of Insomnia | journal = P & T | volume = 40 | issue = 11 | pages = 759–771 | date = November 2015 | pmid = 26609210 | pmc = 4634348 | doi =  }}</ref> However, people whose insomnia is caused by restless legs syndrome may have worsened symptoms with antihistamines.<ref>{{cite web|title=Restless Legs Syndrome Fact Sheet {{!}} National Institute of Neurological Disorders and Stroke|url=https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Restless-Legs-Syndrome-Fact-Sheet|website=www.ninds.nih.gov|access-date=29 August 2017|url-status=live|archive-url=https://web.archive.org/web/20170728021833/https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Restless-Legs-Syndrome-Fact-Sheet|archive-date=28 July 2017}}</ref>
==== Antidepressants ====
While insomnia is a common symptom of depression, [[antidepressant]]s are effective for treating sleep problems whether or not they are associated with depression. While all antidepressants help regulate sleep, some antidepressants, such as [[amitriptyline]], [[doxepin]], [[mirtazapine]], [[trazodone]], and [[trimipramine]], can have an immediate sedative effect, and are prescribed to treat insomnia.<ref>{{cite journal | vauthors = Bertschy G, Ragama-Pardos E, Muscionico M, Aït-Ameur A, Roth L, Osiek C, Ferrero F | title = Trazodone addition for insomnia in venlafaxine-treated, depressed inpatients: a semi-naturalistic study | journal = Pharmacological Research | volume = 51 | issue = 1 | pages = 79–84 | date = January 2005 | pmid = 15519538 | doi = 10.1016/j.phrs.2004.06.007 }}</ref> Trazodone was at the beginning of the 2020s the biggest prescribed drug for sleep in the United States despite not being indicated for sleep.<ref name="Dunleavy">{{Cite web | vauthors = Dunleavy K |date=2023-04-07 |title=Idorsia petitions DEA to de-schedule its insomnia drug—plus Merck and Eisai rivals |url=https://www.fiercepharma.com/pharma/idorsia-petitions-dea-get-its-insomnia-drug-quviviq-and-others-dora-class-controlled |access-date=2023-08-31 |website=Fierce Pharma |archive-date=2023-08-31 |archive-url=https://web.archive.org/web/20230831190635/https://www.fiercepharma.com/pharma/idorsia-petitions-dea-get-its-insomnia-drug-quviviq-and-others-dora-class-controlled |url-status=live }}</ref>
Amitriptyline, doxepin, and trimipramine all have [[antihistaminergic]], [[anticholinergic]], [[antiadrenergic]], and [[antiserotonergic]] properties, which contribute to both their therapeutic effects and side effect profiles, while mirtazapine's actions are primarily antihistaminergic and antiserotonergic and trazodone's effects are primarily antiadrenergic and antiserotonergic. Mirtazapine is known to decrease sleep latency (i.e., the time it takes to fall asleep), promoting sleep efficiency and increasing the total amount of sleeping time in people with both depression and insomnia.<ref>{{cite journal | vauthors = Winokur A, DeMartinis NA, McNally DP, Gary EM, Cormier JL, Gary KA | title = Comparative effects of mirtazapine and fluoxetine on sleep physiology measures in patients with major depression and insomnia | journal = The Journal of Clinical Psychiatry | volume = 64 | issue = 10 | pages = 1224–29 | date = October 2003 | pmid = 14658972 | doi = 10.4088/JCP.v64n1013 }}</ref><ref>{{cite journal | vauthors = Schittecatte M, Dumont F, Machowski R, Cornil C, Lavergne F, Wilmotte J | s2cid = 25351993 | title = Effects of mirtazapine on sleep polygraphic variables in major depression | journal = Neuropsychobiology | volume = 46 | issue = 4 | pages = 197–201 | year = 2002 | pmid = 12566938 | doi = 10.1159/000067812 }}</ref>
[[Agomelatine]], a melatonergic antidepressant with claimed sleep-improving qualities that does not cause daytime drowsiness,<ref>{{cite journal | vauthors = Le Strat Y, Gorwood P | s2cid = 29745284 | title = Agomelatine, an innovative pharmacological response to unmet needs | journal = Journal of Psychopharmacology | volume = 22 | issue = 7 Suppl | pages = 4–8 | date = September 2008 | pmid = 18753276 | doi = 10.1177/0269881108092593 }}</ref> is approved for the treatment of depression though not sleep conditions in the European Union<ref name="emea">{{cite web |url=http://www.ema.europa.eu/docs/en_GB/document_library/EPAR_-_Product_Information/human/000915/WC500046227.pdf |title=Summary of Product Characteristics |publisher=European Medicine Agency |access-date=14 October 2013 |url-status=live |archive-url=https://web.archive.org/web/20141029015615/http://www.ema.europa.eu/docs/en_GB/document_library/EPAR_-_Product_Information/human/000915/WC500046227.pdf |archive-date=29 October 2014 }}</ref> and [[Australia]].<ref name="PI">{{cite web |title=VALDOXAN® Product Information |url=https://www.ebs.tga.gov.au/ebs/picmi/picmirepository.nsf/pdf?OpenAgent&id=CP-2010-PI-07273-3 |work=TGA eBusiness Services |publisher=Servier Laboratories Pty Ltd |access-date=14 October 2013 |format=PDF |date=23 September 2013 |url-status=live |archive-url=https://web.archive.org/web/20170324132859/https://www.ebs.tga.gov.au/ebs/picmi/picmirepository.nsf/pdf?OpenAgent&id=CP-2010-PI-07273-3 |archive-date=24 March 2017 }}</ref> After trials in the United States, its development for use there was discontinued in October 2011<ref>{{cite web | url = http://www.scripintelligence.com/home/Novartis-drops-future-blockbuster-agomelatine-322880 | title = Novartis drops future blockbuster agomelatine. | archive-url = https://web.archive.org/web/20111111121308/http://www.scripintelligence.com/home/Novartis-drops-future-blockbuster-agomelatine-322880 | archive-date=11 November 2011 | work = Scrip Intelligence | date = 25 October 2011 | access-date = 30 October 2011 }}</ref> by [[Novartis]], who had bought the rights to market it there from the European pharmaceutical company [[Servier]].<ref name="Bentham">{{cite news |url=http://www.servier.co.uk/news/news-details.asp?StoryID=76 |title=Servier and Novartis sign licensing agreement for agomelatine, a novel treatment for depression | vauthors = Bentham C |date=29 March 2006 |publisher=Servier UK |access-date=15 May 2009 |archive-url=https://web.archive.org/web/20090416210513/http://www.servier.co.uk/news/news-details.asp?StoryID=76 |archive-date=16 April 2009 |url-status=dead }}</ref>
A 2018 [[Cochrane review]] found the safety of taking antidepressants for insomnia to be uncertain with no evidence supporting long term use.<ref>{{cite journal | vauthors = Everitt H, Baldwin DS, Stuart B, Lipinska G, Mayers A, Malizia AL, Manson CC, Wilson S | title = Antidepressants for insomnia in adults | journal = The Cochrane Database of Systematic Reviews | volume = 2018 | pages = CD010753 | date = May 2018 | issue = 5 | pmid = 29761479 | pmc = 6494576 | doi = 10.1002/14651858.CD010753.pub2 }}</ref>
==== Melatonin agonists ====
[[Melatonin receptor agonist]]s such as [[melatonin (medication)|melatonin]] and [[ramelteon]] are used in the treatment of insomnia. The evidence for melatonin in treating insomnia is generally poor.<ref name=Bra2015/> There is low-quality evidence that it may speed the onset of sleep by 6{{nbsp}}minutes.<ref name=Bra2015/> Ramelteon does not appear to speed the onset of sleep or the amount of sleep a person gets.<ref name="Bra2015">{{cite book | vauthors = Brasure M, MacDonald R, Fuchs E, Olson CM, Carlyle M, Diem S, Koffel E, Khawaja IS, Ouellette J, Butler M, Kane RL, Wilt TJ | chapter = Management of Insomnia Disorder | title = AHRQ Comparative Effectiveness Reviews | location = Rockville (MD) | publisher = Agency for Healthcare Research and Quality (US) | date = December 2015 | pmid = 26844312 }}</ref>
Usage of melatonin as a treatment for insomnia in adults has increased from 0.4% between 1999 and 2000 to nearly 2.1% between 2017 and 2018.<ref>{{Cite web |date=2022-02-28 |title=Use of melatonin supplements rising among adults |url=https://www.nih.gov/news-events/nih-research-matters/use-melatonin-supplements-rising-among-adults |access-date=2022-06-29 |website=National Institutes of Health (NIH) |language=EN |archive-date=2022-06-29 |archive-url=https://web.archive.org/web/20220629045236/https://www.nih.gov/news-events/nih-research-matters/use-melatonin-supplements-rising-among-adults |url-status=live }}</ref>
While the use of melatonin in the short-term has been proven to be generally safe and it is shown to not be a dependent medication, side effects can still occur.<ref name="Pros and cons of melatonin">{{Cite web |title=Pros and cons of melatonin |url=https://www.mayoclinic.org/healthy-lifestyle/adult-health/expert-answers/melatonin-side-effects/faq-20057874 |access-date=2024-05-01 |website=Mayo Clinic |language=en}}</ref>
Most common side effects of melatonin include:<ref name="Pros and cons of melatonin"/>
* Headache
* Dizziness
* Nausea
* Daytime drowsiness
[[Prolonged-release melatonin]] may improve quality of sleep in older people with minimal side effects.<ref>{{cite journal | vauthors = Lyseng-Williamson KA | s2cid = 1403262 | title = Melatonin prolonged release: in the treatment of insomnia in patients aged ≥55 years | journal = Drugs & Aging | volume = 29 | issue = 11 | pages = 911–23 | date = November 2012 | pmid = 23044640 | doi = 10.1007/s40266-012-0018-z }}</ref><ref>{{cite journal | vauthors = Lemoine P, Zisapel N | s2cid = 23291045 | title = Prolonged-release formulation of melatonin (Circadin) for the treatment of insomnia | journal = Expert Opinion on Pharmacotherapy | volume = 13 | issue = 6 | pages = 895–905 | date = April 2012 | pmid = 22429105 | doi = 10.1517/14656566.2012.667076 }}</ref>
Studies have also shown that children who are on the [[autism spectrum]] or have learning disabilities, [[attention-deficit hyperactivity disorder]] (ADHD) or related [[neurological]] diseases can benefit from the use of melatonin. This is because they often have trouble sleeping due to their disorders. For example, children with ADHD tend to have trouble falling asleep because of their [[hyperactivity]] and, as a result, tend to be tired during most of the day. Another cause of insomnia in children with ADHD is the use of stimulants used to treat their disorder. Children who have ADHD then, as well as the other disorders mentioned, may be given melatonin before bedtime in order to help them sleep.<ref>{{cite journal | vauthors = Sánchez-Barceló EJ, Mediavilla MD, Reiter RJ | title = Clinical uses of melatonin in pediatrics | journal = International Journal of Pediatrics | volume = 2011 | pages = 892624 | year = 2011 | pmid = 21760817 | pmc = 3133850 | doi = 10.1155/2011/892624 | doi-access = free }}</ref>
==== Benzodiazepines ====
[[File:Normison.jpg|thumb|Normison ([[temazepam]]) is a [[benzodiazepine]] commonly prescribed for insomnia and other [[sleep disorders]].<ref>{{cite web | url = http://www.websters-online-dictionary.org/definitions/Temazepam | title = Temazepam | archive-url = https://web.archive.org/web/20130530212815/http://www.websters-online-dictionary.org/definitions/Temazepam | archive-date=30 May 2013 | work = Websters-online-dictionary.org. | access-date = 20 November 2011 }}</ref>]]
The most commonly used class of hypnotics for insomnia are the [[benzodiazepine]]s.<ref name=Psych4th>{{cite book | vauthors = Geddes J, Price J, McKnight R, Gelder M, Mayou R |title=Psychiatry |date=2012 |publisher=Oxford University Press |location=Oxford |isbn=978-0-19-923396-0 |edition=4th}}</ref>{{rp|363}} Benzodiazepines are [[statistical significance|not significantly]] better for insomnia than [[antidepressant]]s.<ref name="pmid17619935">{{cite journal | vauthors = Buscemi N, Vandermeer B, Friesen C, Bialy L, Tubman M, Ospina M, Klassen TP, Witmans M | title = The efficacy and safety of drug treatments for chronic insomnia in adults: a meta-analysis of RCTs | journal = Journal of General Internal Medicine | volume = 22 | issue = 9 | pages = 1335–50 | date = September 2007 | pmid = 17619935 | pmc = 2219774 | doi = 10.1007/s11606-007-0251-z }}</ref> Chronic users of [[hypnotic]] medications for insomnia do not have better sleep than chronic insomniacs not taking medications. In fact, chronic users of hypnotic medications have more regular night-time awakenings than insomniacs not taking hypnotic medications.<ref>{{cite journal | vauthors = Ohayon MM, Caulet M | s2cid = 20655328 | title = Insomnia and psychotropic drug consumption | journal = Progress in Neuro-Psychopharmacology & Biological Psychiatry | volume = 19 | issue = 3 | pages = 421–31 | date = May 1995 | pmid = 7624493 | doi = 10.1016/0278-5846(94)00023-B }}</ref> Many have concluded that these drugs cause an unjustifiable risk to the individual and to [[public health]] and lack evidence of long-term effectiveness. It is preferred that hypnotics be prescribed for only a few days at the lowest effective dose and avoided altogether wherever possible, especially in the elderly.<ref>{{cite journal | s2cid = 40188442 | title = What's wrong with prescribing hypnotics? | journal = Drug and Therapeutics Bulletin | volume = 42 | issue = 12 | pages = 89–93 | date = December 2004 | pmid = 15587763 | doi = 10.1136/dtb.2004.421289 }}</ref> Between 1993 and 2010, the prescribing of benzodiazepines to individuals with sleep disorders has decreased from 24% to 11% in the US, coinciding with the first release of [[nonbenzodiazepine]]s.<ref name="Kaufmann">{{cite journal | vauthors = Kaufmann CN, Spira AP, Alexander GC, Rutkow L, Mojtabai R | title = Trends in prescribing of sedative-hypnotic medications in the USA: 1993–2010 | journal = Pharmacoepidemiology and Drug Safety | volume = 25 | issue = 6 | pages = 637–45 | date = June 2016 | pmid = 26711081 | pmc = 4889508 | doi = 10.1002/pds.3951 }}</ref>
The [[benzodiazepine]] and [[nonbenzodiazepine]] [[hypnotic]] medications also have a number of side-effects such as day time fatigue, motor vehicle crashes and other accidents, cognitive impairments, and falls and fractures. Elderly people are more sensitive to these side-effects.<ref>{{cite journal | vauthors = Glass J, Lanctôt KL, Herrmann N, Sproule BA, Busto UE | title = Sedative hypnotics in older people with insomnia: meta-analysis of risks and benefits | journal = BMJ | volume = 331 | issue = 7526 | pages = 1169 | date = November 2005 | pmid = 16284208 | pmc = 1285093 | doi = 10.1136/bmj.38623.768588.47 }}</ref> Some benzodiazepines have demonstrated effectiveness in sleep maintenance in the short term but in the longer term benzodiazepines can lead to [[drug tolerance|tolerance]], [[physical dependence]], [[benzodiazepine withdrawal syndrome]] upon discontinuation, and long-term worsening of sleep, especially after consistent usage over long periods of time. Benzodiazepines, while inducing unconsciousness, actually worsen sleep as – like alcohol – they promote light sleep while decreasing time spent in deep sleep.<ref>{{cite journal | vauthors = Tsoi WF | title = Insomnia: drug treatment | journal = Annals of the Academy of Medicine, Singapore | volume = 20 | issue = 2 | pages = 269–72 | date = March 1991 | pmid = 1679317 }}</ref> A further problem is, with regular use of short-acting sleep aids for insomnia, daytime [[rebound anxiety]] can emerge.<ref>{{cite journal | vauthors = Montplaisir J | title = Treatment of primary insomnia | journal = CMAJ | volume = 163 | issue = 4 | pages = 389–91 | date = August 2000 | pmid = 10976252 | pmc = 80369 }}</ref> Although there is little evidence for benefit of benzodiazepines in insomnia compared to other treatments and evidence of major harm, prescriptions have continued to increase.<ref name="handbook_of_integrative">{{Cite book |vauthors=Carlstedt RA |title=Handbook of Integrative Clinical Psychology, Psychiatry, and Behavioral Medicine: Perspectives, Practices, and Research |date=2009 |publisher=Springer |url=https://books.google.com/books?id=4Tkdm1vRFbUC |isbn=978-0-8261-1094-7 |pages=128–30 |access-date=2020-05-12 |archive-date=2020-06-04 |archive-url=https://web.archive.org/web/20200604135538/https://books.google.com/books?id=4Tkdm1vRFbUC%2F |url-status=live }}</ref> This is likely due to their addictive nature, both due to misuse and because – through their rapid action, tolerance and withdrawal they can "trick" insomniacs into thinking they are helping with sleep. There is a general awareness that long-term use of benzodiazepines for insomnia in most people is inappropriate and that a gradual withdrawal is usually beneficial due to the adverse effects associated with the [[long-term use of benzodiazepines]] and is recommended whenever possible.<ref>{{cite book | vauthors =  Lader M, Cardinali DP, Pandi-Perumal SR |title=Sleep and sleep disorders: a neuropsychopharmacological approach |date=2006 |publisher=Landes Bioscience/Eurekah.com |location=Georgetown, Tex. |isbn=978-0-387-27681-6 |page=127 }}</ref><ref name="Authier-">{{cite journal | vauthors = Authier N, Boucher A, Lamaison D, Llorca PM, Descotes J, Eschalier A | title = Second meeting of the French CEIP (Centres d'Evaluation et d'Information sur la Pharmacodépendance). Part II: benzodiazepine withdrawal | journal = Therapie | volume = 64 | issue = 6 | pages = 365–70 | year = 2009 | pmid = 20025839 | doi = 10.2515/therapie/2009051 }}</ref>
Benzodiazepines all bind unselectively to the [[GABAA receptor|GABA<sub>A</sub> receptor]].<ref name="pmid17619935" /> Some theorize that certain benzodiazepines (hypnotic benzodiazepines) have significantly higher activity at the α<sub>1</sub> subunit of the GABA<sub>A</sub> receptor compared to other benzodiazepines (for example, triazolam and temazepam have significantly higher activity at the α<sub>1</sub> subunit compared to alprazolam and diazepam, making them superior sedative-hypnotics&nbsp;– alprazolam and diazepam, in turn, have higher activity at the α<sub>2</sub> subunit compared to triazolam and temazepam, making them superior anxiolytic agents). Modulation of the α<sub>1</sub> subunit is associated with sedation, motor impairment, respiratory depression, amnesia, ataxia, and reinforcing behavior (drug-seeking behavior). Modulation of the α<sub>2</sub> subunit is associated with anxiolytic activity and disinhibition. For this reason, certain benzodiazepines may be better suited to treat insomnia than others.<ref name="Insomnia"/>
==== Z-Drugs ====
[[Nonbenzodiazepine]] or [[Z-drug]] sedative–hypnotic drugs, such as [[zolpidem]], [[zaleplon]], [[zopiclone]], and [[eszopiclone]], are a class of hypnotic medications that are similar to benzodiazepines in their mechanism of action, and indicated for mild to moderate insomnia. Their effectiveness at improving time to sleeping is slight, and they have similar—though potentially less severe—side effect profiles compared to benzodiazepines.<ref>{{cite journal | vauthors = Huedo-Medina TB, Kirsch I, Middlemass J, Klonizakis M, Siriwardena AN | title = Effectiveness of non-benzodiazepine hypnotics in treatment of adult insomnia: meta-analysis of data submitted to the Food and Drug Administration | journal = BMJ | volume = 345 | pages = e8343 | date = December 2012 | pmid = 23248080 | pmc = 3544552 | doi = 10.1136/bmj.e8343 }}</ref> Prescribing of nonbenzodiazepines has seen a general increase since their initial release on the US market in 1992, from 2.3% in 1993 among individuals with sleep disorders to 13.7% in 2010.<ref name="Kaufmann" />
==== Orexin antagonists ====
[[Orexin receptor antagonist]]s are a more recently introduced class of sleep medications and include [[suvorexant]], [[lemborexant]], and [[daridorexant]], all of which are FDA-approved for treatment of insomnia characterized by difficulties with [[sleep onset]] and/or sleep maintenance.<ref name="pmid35043499">{{cite journal | vauthors = Jacobson LH, Hoyer D, de Lecea L | title = Hypocretins (orexins): The ultimate translational neuropeptides | journal = J Intern Med | volume = 291| issue = 5| pages = 533–556| date = January 2022 | pmid = 35043499 | doi = 10.1111/joim.13406 | s2cid = 248119793 | url = }}</ref><ref name="prescribing info">{{cite web |url=http://www.merck.com/product/usa/pi_circulars/b/belsomra/belsomra_pi.pdf |title=Highlights of prescribing information |url-status=live |archive-url=https://web.archive.org/web/20140912065432/http://www.merck.com/product/usa/pi_circulars/b/belsomra/belsomra_pi.pdf |archive-date=12 September 2014 }}</ref> They are oriented towards blocking signals in the brain that stimulate wakefulness, therefore claiming to address insomnia without creating dependence. There are three [[Orexin antagonist|dual orexin receptor (DORA)]] drugs on the market: [[Suvorexant|Belsomra]] ([[Merck & Co.|Merck]]), [[Lemborexant|Dayvigo]] ([[Eisai (company)|Eisai]]) and [[Daridorexant|Quviviq]] ([[Idorsia]]).<ref name="Dunleavy"/>
==== Antipsychotics ====
Certain [[atypical antipsychotic]]s, particularly [[quetiapine]], [[olanzapine]], and [[risperidone]], are used in the treatment of insomnia.<ref name="pmid27544830">{{cite journal | vauthors = Thompson W, Quay TA, Rojas-Fernandez C, Farrell B, Bjerre LM | title = Atypical antipsychotics for insomnia: a systematic review | journal = Sleep Med | volume = 22 | issue = | pages = 13–17 | date = June 2016 | pmid = 27544830 | doi = 10.1016/j.sleep.2016.04.003 | url = }}</ref><ref name="Morin2014">{{cite journal | vauthors = Morin AK | title = Off-label use of atypical antipsychotic agents for treatment of insomnia | journal = Mental Health Clinician | date = 1 March 2014 | volume = 4 | issue = 2 | pages = 65–72 | eissn = 2168-9709 | doi = 10.9740/mhc.n190091 | pmid = | url = | doi-access = free }}</ref> However, while common, use of antipsychotics for this indication is not recommended as the evidence does not demonstrate a benefit, and the risk of adverse effects are significant.<ref name="pmid27544830" /><ref>{{Citation |author1=American Psychiatric Association |author1-link=American Psychiatric Association |date=September 2013 |title=Five Things Physicians and Patients Should Question |publisher=[[American Psychiatric Association]] |work=[[Choosing Wisely]]: an initiative of the [[ABIM Foundation]] |url=http://www.choosingwisely.org/doctor-patient-lists/american-psychiatric-association/ |access-date=30 December 2013 |url-status=live |archive-url=https://web.archive.org/web/20131203174206/http://www.choosingwisely.org/doctor-patient-lists/american-psychiatric-association/ |archive-date=3 December 2013 }}, which cites
* {{cite journal | title = Consensus development conference on antipsychotic drugs and obesity and diabetes | journal = Diabetes Care | volume = 27 | issue = 2 | pages = 596–601 | date = February 2004 | pmid = 14747245 | doi = 10.2337/diacare.27.2.596 | author1 = American Association of Clinical Endocrinologists | author2 = North American Association for the Study of Obesity | doi-access = free }}
* {{cite book | vauthors = Maglione M, Maher AR, Hu J, Wang Z, Shanman R, Shekelle PG, Roth B, Hilton L, Suttorp MJ, Ewing BA, Motala A, Perry T | chapter = Off-Label Use of Atypical Antipsychotics: An Update | title = AHRQ Comparative Effectiveness Reviews | location = Rockville (MD) | publisher = Agency for Healthcare Research and Quality (US)| date = Sep 2011 | pmid = 22132426 }}
* {{cite journal | vauthors = Nasrallah HA | title = Atypical antipsychotic-induced metabolic side effects: insights from receptor-binding profiles | journal = Molecular Psychiatry | volume = 13 | issue = 1 | pages = 27–35 | date = January 2008 | pmid = 17848919 | doi = 10.1038/sj.mp.4002066 | s2cid = 205678886 }}</ref><ref>{{cite journal | vauthors = Coe HV, Hong IS | title = Safety of low doses of quetiapine when used for insomnia | journal = The Annals of Pharmacotherapy | volume = 46 | issue = 5 | pages = 718–722 | date = May 2012 | pmid = 22510671 | doi = 10.1345/aph.1Q697 | s2cid = 9888209 }}</ref><ref name="Off-Label Use">{{cite book |title=Off-Label Use of Atypical Antipsychotics: An Update |vauthors=Maglione M, Maher AR, Hu J, Wang Z, Shanman R, Shekelle PG, Roth B, Hilton L, Suttorp MJ |publisher=Agency for Healthcare Research and Quality |year=2011 |series=Comparative Effectiveness Reviews, No. 43 |location=Rockville |pmid=22973576}}</ref> A major 2022 systematic review and network meta-analysis of medications for insomnia in adults found that quetiapine did not demonstrate any short-term benefits for insomnia.<ref name="pmid35843245">{{cite journal |vauthors=De Crescenzo F, D'Alò GL, Ostinelli EG, Ciabattini M, Di Franco V, Watanabe N, Kurtulmus A, Tomlinson A, Mitrova Z, Foti F, Del Giovane C, Quested DJ, Cowen PJ, Barbui C, Amato L, Efthimiou O, Cipriani A |date=July 2022 |title=Comparative effects of pharmacological interventions for the acute and long-term management of insomnia disorder in adults: a systematic review and network meta-analysis |url= |journal=Lancet |volume=400 |issue=10347 |pages=170–184 |doi=10.1016/S0140-6736(22)00878-9 |pmid=35843245 |s2cid=250536370|doi-access=free |hdl=11380/1288245 |hdl-access=free }}</ref> Some of the more serious adverse effects may also occur at the low doses used, such as [[dyslipidemia]] and [[neutropenia]].<ref>{{cite journal | vauthors = Pillinger T, McCutcheon RA, Vano L, Mizuno Y, Arumuham A, Hindley G, Beck K, Natesan S, Efthimiou O, Cipriani A, Howes OD | title = Comparative effects of 18 antipsychotics on metabolic function in patients with schizophrenia, predictors of metabolic dysregulation, and association with psychopathology: a systematic review and network meta-analysis | journal = The Lancet. Psychiatry | volume = 7 | issue = 1 | pages = 64–77 | date = January 2020 | pmid = 31860457 | pmc = 7029416 | doi = 10.1016/s2215-0366(19)30416-x }}</ref><ref>{{cite journal | vauthors = Yoshida K, Takeuchi H | title = Dose-dependent effects of antipsychotics on efficacy and adverse effects in schizophrenia | journal = Behavioural Brain Research | volume = 402 | pages = 113098 | date = March 2021 | pmid = 33417992 | doi = 10.1016/j.bbr.2020.113098 | s2cid = 230507941 | doi-access = free }}</ref> Such concerns of risks at low doses are supported by Danish observational studies that showed an association of use of low-dose quetiapine (excluding prescriptions filled for tablet strengths >50&nbsp;mg) with an increased risk of major cardiovascular events as compared to use of [[Z-drugs]], with most of the risk being driven by cardiovascular death.<ref>{{cite journal | vauthors = Højlund M, Andersen K, Ernst MT, Correll CU, Hallas J | title = Use of low-dose quetiapine increases the risk of major adverse cardiovascular events: results from a nationwide active comparator-controlled cohort study | journal = World Psychiatry | volume = 21 | issue = 3 | pages = 444–451 | date = October 2022 | pmid = 36073694 | pmc = 9453914 | doi = 10.1002/wps.21010 }}</ref> Laboratory data from an unpublished analysis of the same cohort also support the lack of dose-dependency of metabolic side effects, as new use of low-dose quetiapine was associated with a risk of increased fasting triglycerides at one-year follow-up.<ref>{{Cite thesis |date=2022-09-12 |title=Low-dose Quetiapine: Utilization and Cardiometabolic Risk |url=https://portal.findresearcher.sdu.dk/en/publications/low-dose-quetiapine-utilization-and-cardiometabolic-risk |language=English |doi=10.21996/mr3m-1783 |vauthors=Højlund M |publisher=Syddansk Universitet. Det Sundhedsvidenskabelige Fakultet |access-date=2022-10-18 |archive-date=2022-10-18 |archive-url=https://web.archive.org/web/20221018082542/https://portal.findresearcher.sdu.dk/en/publications/low-dose-quetiapine-utilization-and-cardiometabolic-risk |url-status=live }}</ref> Concerns regarding side effects are greater in the elderly.<ref name="Conn 271–287">{{cite journal |vauthors=Conn DK, Madan R |year=2006 |title=Use of sleep-promoting medications in nursing home residents: risks versus benefits |journal=Drugs & Aging |volume=23 |issue=4 |pages=271–87 |doi=10.2165/00002512-200623040-00001 |pmid=16732687 |s2cid=38394552}}</ref>
==== Other sedatives ====
[[Gabapentinoid]]s like [[gabapentin]] and [[pregabalin]] have sleep-promoting effects but are not commonly used for treatment of insomnia.<ref name="pmid29487083">{{cite journal|author3-link=Gabriella Gobbi | vauthors = Atkin T, Comai S, Gobbi G | title = Drugs for Insomnia beyond Benzodiazepines: Pharmacology, Clinical Applications, and Discovery | journal = Pharmacol Rev | volume = 70 | issue = 2 | pages = 197–245 | date = April 2018 | pmid = 29487083 | doi = 10.1124/pr.117.014381 | s2cid = 3578916 | url = | doi-access = free }}</ref> Gabapentin is not effective in helping alcohol related insomnia.<ref name="NIHR Evidence_2022">{{Cite journal |date=17 October 2022 |title=Review finds little evidence to support gabapentinoid use in bipolar disorder or insomnia |url=https://evidence.nihr.ac.uk/alert/review-finds-little-evidence-support-gabapentinoid-use-bipolar-disorder-or-insomnia/ |journal=NIHR Evidence |type=Plain English summary |language=en |publisher=National Institute for Health and Care Research |doi=10.3310/nihrevidence_54173 |s2cid=252983016 |access-date=21 November 2022 |archive-date=27 November 2022 |archive-url=https://web.archive.org/web/20221127080508/https://evidence.nihr.ac.uk/alert/review-finds-little-evidence-support-gabapentinoid-use-bipolar-disorder-or-insomnia/ |url-status=live }}</ref><ref name="Hong_2022">{{cite journal |vauthors=Hong JS, Atkinson LZ, Al-Juffali N, Awad A, Geddes JR, Tunbridge EM, Harrison PJ, Cipriani A |date=March 2022 |title=Gabapentin and pregabalin in bipolar disorder, anxiety states, and insomnia: Systematic review, meta-analysis, and rationale |journal=Molecular Psychiatry |volume=27 |issue=3 |pages=1339–1349 |doi=10.1038/s41380-021-01386-6 |pmc=9095464 |pmid=34819636}}</ref>
[[Barbiturate]]s, while once used, are no longer recommended for insomnia due to the risk of addiction and other side effects.<ref>{{cite book| vauthors = Aschenbrenner DS, Venable SJ |title=Drug Therapy in Nursing |date=2009 |publisher=Lippincott Williams & Wilkins |isbn=978-0-7817-6587-9 |page=[https://archive.org/details/studyguidetoacco0000asch/page/277 277]|url=https://archive.org/details/studyguidetoacco0000asch|url-access=registration|language=en}}</ref>
====Comparative effectiveness====
Medications for the treatment of insomnia have a wide range of [[effect size]]s.<ref name="pmid35843245" /> When comparing drugs such as [[benzodiazepine]]s, [[Z-drug]]s, sedative [[antidepressant]]s and [[antihistamine]]s, [[quetiapine]], [[orexin receptor antagonist]]s, and [[melatonin receptor agonist]]s, the orexin antagonist [[lemborexant]] and the Z-drug [[eszopiclone]] had the best profiles overall in terms of [[efficacy]], [[tolerability]], and [[acceptability]].<ref name="pmid35843245" />
===Alternative medicine===
[[Herbal product]]s, such as [[valerian (herb)|valerian]], [[kava]], [[chamomile]], and [[lavender]], have been used to treat insomnia.<ref name="pmid25644982">{{cite journal | vauthors = Leach MJ, Page AT | title = Herbal medicine for insomnia: A systematic review and meta-analysis | journal = Sleep Med Rev | volume = 24 | issue = | pages = 1–12 | date = December 2015 | pmid = 25644982 | doi = 10.1016/j.smrv.2014.12.003 | url = }}</ref><ref name="pmid29356580">{{cite journal | vauthors = Kim J, Lee SL, Kang I, Song YA, Ma J, Hong YS, Park S, Moon SI, Kim S, Jeong S, Kim JE | title = Natural Products from Single Plants as Sleep Aids: A Systematic Review | journal = J Med Food | volume = 21 | issue = 5 | pages = 433–444 | date = May 2018 | pmid = 29356580 | doi = 10.1089/jmf.2017.4064 | url = }}</ref><ref name="pmid17561634">{{cite journal | vauthors = Meolie AL, Rosen C, Kristo D, Kohrman M, Gooneratne N, Aguillard RN, Fayle R, Troell R, Townsend D, Claman D, Hoban T, Mahowald M | title = Oral nonprescription treatment for insomnia: an evaluation of products with limited evidence | journal = J Clin Sleep Med | volume = 1 | issue = 2 | pages = 173–87 | date = April 2005 | pmid = 17561634 | doi = 10.5664/jcsm.26314| url = | doi-access = free }}</ref><ref name="pmid15982998">{{cite journal | vauthors = Wheatley D | title = Medicinal plants for insomnia: a review of their pharmacology, efficacy and tolerability | journal = J Psychopharmacol | volume = 19 | issue = 4 | pages = 414–21 | date = July 2005 | pmid = 15982998 | doi = 10.1177/0269881105053309 | s2cid = 34484538 | url = }}</ref> However, there is no [[quality evidence]] that they are effective and safe.<ref name="pmid25644982" /><ref name="pmid29356580" /><ref name="pmid17561634" /><ref name="pmid15982998" /> The same is true for [[cannabis (drug)|cannabis]] and [[cannabinoid]]s.<ref name="pmid33244728">{{cite journal | vauthors = Bhagavan C, Kung S, Doppen M, John M, Vakalalabure I, Oldfield K, Braithwaite I, Newton-Howes G | title = Cannabinoids in the Treatment of Insomnia Disorder: A Systematic Review and Meta-Analysis | journal = CNS Drugs | volume = 34 | issue = 12 | pages = 1217–1228 | date = December 2020 | pmid = 33244728 | doi = 10.1007/s40263-020-00773-x | s2cid = 227174084 | url = }}</ref><ref name="pmid32603954">{{cite journal | vauthors = Suraev AS, Marshall NS, Vandrey R, McCartney D, Benson MJ, McGregor IS, Grunstein RR, Hoyos CM | title = Cannabinoid therapies in the management of sleep disorders: A systematic review of preclinical and clinical studies | journal = Sleep Med Rev | volume = 53 | issue = | pages = 101339 | date = October 2020 | pmid = 32603954 | doi = 10.1016/j.smrv.2020.101339 | s2cid = 219452622 | url = }}</ref><ref name="pmid24726015">{{cite journal | vauthors = Gates PJ, Albertella L, Copeland J | title = The effects of cannabinoid administration on sleep: a systematic review of human studies | journal = Sleep Med Rev | volume = 18 | issue = 6 | pages = 477–87 | date = December 2014 | pmid = 24726015 | doi = 10.1016/j.smrv.2014.02.005 | url = }}</ref> It is likewise unclear whether [[acupuncture]] is useful in the treatment of insomnia.<ref>{{cite journal | vauthors = Cheuk DK, Yeung WF, Chung KF, Wong V | title = Acupuncture for insomnia | journal = The Cochrane Database of Systematic Reviews | volume = 2012 | issue = 9 | pages = CD005472 | date = September 2012 | pmid = 22972087 | doi = 10.1002/14651858.CD005472.pub3 | hdl = 10722/198790 | pmc = 11262418 }}</ref>
== Prognosis ==
[[File:Insomnia world map - DALY - WHO2004.svg|thumb|upright=1.3|[[Disability-adjusted life year]] for insomnia per 100,000&nbsp;inhabitants in 2004:{{Div col|small=yes|colwidth=10em}}
{{legend|#b3b3b3|no data}}
{{legend|#ffff65|less than 25}}
{{legend|#fff200|25–30.25}}
{{legend|#ffdc00|30.25–36}}
{{legend|#ffc600|36–41.5}}
{{legend|#ffb000|41.5–47}}
{{legend|#ff9a00|47–52.5}}
{{legend|#ff8400|52.5–58}}
{{legend|#ff6e00|58–63.5}}
{{legend|#ff5800|63.5–69}}
{{legend|#ff4200|69–74.5}}
{{legend|#ff2c00|74.5–80}}
{{legend|#cb0000|more than 80}}
{{div col end}}]]
A survey of 1.1 million residents in the United States found that those that reported sleeping about 7 hours per night had the lowest rates of mortality, whereas those that slept for fewer than 6 hours or more than 8 hours had higher mortality rates. Severe insomnia&nbsp;– sleeping less than 3.5 hours in women and 4.5 hours in men&nbsp;– is associated with a 15% increase in mortality, while getting 8.5 or more hours of sleep per night was associated with a 15% higher mortality rate.<ref name="Kripke-2002"/>
With this technique, it is difficult to distinguish lack of sleep caused by a disorder which is also a cause of premature death, versus a disorder which causes a lack of sleep, and the lack of sleep causing premature death. Most of the increase in mortality from severe insomnia was discounted after controlling for [[comorbidity|associated disorder]]s. After controlling for sleep duration and insomnia, use of sleeping pills was also found to be associated with an increased [[mortality rate]].<ref name="Kripke-2002"/>
The lowest mortality was seen in individuals who slept between six and a half and seven and a half hours per night. Even sleeping only 4.5 hours per night is associated with very little increase in mortality. Thus, mild to moderate insomnia for most people is associated with increased [[longevity]] and severe insomnia is associated only with a very small effect on mortality.<ref name="Kripke-2002"/> It is unclear why sleeping longer than 7.5 hours is associated with excess mortality.<ref name="Kripke-2002">{{cite journal | vauthors = Kripke DF, Garfinkel L, Wingard DL, Klauber MR, Marler MR | title = Mortality associated with sleep duration and insomnia | journal = Archives of General Psychiatry | volume = 59 | issue = 2 | pages = 131–36 | date = February 2002 | pmid = 11825133 | doi = 10.1001/archpsyc.59.2.131 | doi-access = free }}</ref>
==Epidemiology==
Between 10% and 30% of adults have insomnia at any given point in time and up to half of people have insomnia in a given year, making it the most common sleep disorder.<ref name=Th2007/><ref name=WHO2009/><ref name=Tas2015/><ref>{{cite web |title=What are Sleep Disorders? |url=https://psychiatry.org/patients-families/sleep-disorders/what-are-sleep-disorders |website=Psychiatry.org |access-date=2022-10-27 |archive-date=2022-10-27 |archive-url=https://web.archive.org/web/20221027112656/https://psychiatry.org/patients-families/sleep-disorders/what-are-sleep-disorders |url-status=live }}</ref> About 6% of people have insomnia that is not due to another problem and lasts for more than a month.<ref name=Th2007/> People over the age of 65 are affected more often than younger people.<ref name=Wil2008/> Females are more often affected than males.<ref name=WHO2009/> Insomnia is 40% more common in women than in men.<ref>{{cite journal |title=Several Sleep Disorders Reflect Gender Differences |journal=Psychiatric News |year=2007 |volume=42 |issue=8 |page=40|doi=10.1176/pn.42.10.0040 | vauthors = Lamberg L }}</ref>
There are higher rates of insomnia reported [[Sleep deprivation in higher education|among university students]] compared to the general population.<ref>{{cite journal | vauthors = Jiang XL, Zheng XY, Yang J, Ye CP, Chen YY, Zhang ZG, Xiao ZJ | title = A systematic review of studies on the prevalence of insomnia in university students | journal = Public Health | volume = 129 | issue = 12 | pages = 1579–84 | date = December 2015 | pmid = 26298588 | doi = 10.1016/j.puhe.2015.07.030 }}</ref>
==Society and culture==
The word insomnia is from {{langx|la|in |italic=yes}} + {{lang|la|[[wiktionary:somnus#Latin|somnus]] |italic=yes}} "without sleep" and ''-ia'' as a [[nominalization|nominalizing]] [[suffix]].
The [[popular press]] have published stories about people who supposedly never sleep, such as that of Thái Ngọc and [[Al Herpin]].<ref>{{cite book |vauthors=Horne J |title=Sleeplessness Assessing Sleep Need in Society Today |date=2016 |isbn=978-3-319-30572-1 |page=114 |publisher=Springer |url=https://books.google.com/books?id=A5TlDAAAQBAJ&pg=PA114 |quote=Everyone sleeps and needs to do so |access-date=2017-09-01 |archive-date=2023-01-12 |archive-url=https://web.archive.org/web/20230112211952/https://books.google.com/books?id=A5TlDAAAQBAJ&pg=PA114 |url-status=live }}</ref> Horne writes "everybody sleeps and needs to do so", and generally this appears true. However, he also relates from contemporary accounts the case of Paul Kern, who was shot in 1915 fighting in [[World War I]] and then "never slept again" until his death in 1955.<ref>{{cite book |vauthors=Horne J |title=Sleeplessness Assessing Sleep Need in Society Today |date=2016 |isbn=978-3-319-30572-1 |page=116 |publisher=Springer |url=https://books.google.com/books?id=A5TlDAAAQBAJ&pg=PA114 |access-date=2017-09-01 |archive-date=2023-01-12 |archive-url=https://web.archive.org/web/20230112211952/https://books.google.com/books?id=A5TlDAAAQBAJ&pg=PA114 |url-status=live }}</ref> Kern appears to be a completely isolated, unique case.
== References ==
{{Reflist}}
== External links ==
<!-- place any external links ABOVE the medical resources template -->
{{Medical resources
| DiseasesDB      = 26877
| ICD11           = {{ICD11|7A00}}, {{ICD11|7A01}}, {{ICD11|7A0Z}}, {{ICD11|8E02.2}}, {{ICD11|SD84}}
| ICD10           = {{ICD10|F51}}, {{ICD10|G47.0}}
| ICD9            = {{ICD9|307.42}}, {{ICD9|307.41}}, {{ICD9|327.0}}, {{ICD9|780.51}}, {{ICD9|780.52}}
| ICDO            =
| OMIM            =
| MedlinePlus     = 000805
| eMedicineSubj   = med
| eMedicineTopic  = 2698
| MeshID          = D007319
| SNOMED CT       = 193462001
}}
{{Sleep}}
{{Hypnotics}}
{{Insomnia pharmacotherapies}}
{{Digital media use and mental health}}
{{authority control}}
[[Category:Insomnia| ]]
[[Category:Sleep disorders]]
[[Category:Sleeplessness and sleep deprivation]]
[[Category:Wikipedia medicine articles ready to translate]]
[[Category:Wikipedia neurology articles ready to translate]]