Over the last 20 years, scientists have advanced understanding of chronic sleep deprivation.
Insomnia is one of the most reported psychological problems in Britain, with about a third of the adult population in England reporting frequent insomnia symptoms.
Shift from 'Secondary Insomnia' to 'Insomnia Disorder'
Historically, insomnia co-occurring with another illness was termed 'secondary insomnia' and considered a consequence of the underlying condition, so it was often not treated separately. However, evidence from early 2000s indicated that insomnia could precede or persist independently of comorbid conditions. This led to abandoning the primary/secondary distinction, acknowledging insomnia as an independent disorder requiring its own treatment.
Relationship with Other Health Conditions
Research shows that treating insomnia can improve other health conditions such as chronic pain, chronic heart failure, depression, psychosis, alcohol dependency, bipolar disorder, and PTSD.
Prevalence and Risk Groups
Insomnia affects almost everyone, but women, older people, and those of lower socio-economic status are more vulnerable due to biological, psychological, and social risk factors (e.g., hormone fluctuations, pregnancy, caregiving roles, higher prevalence of depression/anxiety).
Current Research Issues
- Understanding different insomnia symptom types and their health risks: difficulty initiating sleep is associated with increased risk of depression.
- Investigating changes in brain activity, heart rate, and stress hormones accompanying insomnia.
- Biomarkers for insomnia remain unidentified.
Prevention: Behavioral Recommendations
When insomnia symptoms occur more nights than not for over three months, chronic insomnia can be diagnosed. To prevent progression:
If you can't sleep, get up. Avoid lying in bed awake, as it trains the brain to disconnect bed from sleep.
- If unable to sleep, get up and do something absorbing but calming (reading, listening to music, breathing exercises). Return to bed when sleepy.
- Short naps (max 20 minutes) in the afternoon may help, but daytime sleeping can reduce nighttime sleepiness.
Treatment: Cognitive Behavioral Therapy for Insomnia (CBTI)
CBTI is a package of techniques to maximize sleepiness at bedtime. Predictors of success: shorter duration of insomnia (years vs decades), less depression/pain, positive expectations. CBTI is broadly effective across all groups.
Access to Treatment
Only a tiny proportion of people with insomnia seek medical help, possibly because symptoms are seen as trivial, unawareness of options, or unavailability of treatments. CBTI remains largely unavailable in clinical practice due to clinician unfamiliarity and limited funding. This pushes patients toward sleeping tablets.
Sleeping Tablets
Traditional sleeping tablets are associated with cognitive and motor impairment, increased fall risk, dependence, tolerance, withdrawal symptoms, daytime lethargy, dizziness, and headaches. A newer class, dual orexin receptor antagonists (DORAs), approved in the UK in 2022, show better safety profile regarding dependence, but long-term data are lacking.
Alternative: Online Self-Delivered CBTI
Platforms such as Sleepful offer free online CBTI as a decent alternative.
Conclusion
Significant progress has been made in sleep medicine for insomnia over the past 20 years, but there is a need to provide the right help to those suffering from it.