What doctors wish patients knew about insomnia

At nighttime when it’s time for bed and the lights are turned off, most people drift into their dreams. But for millions in the U.S., the night is anything but restful. It’s a long, restless stress of tossing, turning and checking the clock—on repeat. Whether it is due to constant connectivity, economic stress or digital overload, more people are finding themselves wide awake when they should be sound asleep. This lack of sleep has led to insomnia, which is the inability to fall asleep or stay asleep.

About one-third of adults experience acute insomnia, which means they have bouts of sleep loss that last a few days at a time. But one in 10 suffer from chronic insomnia, which lasts for more than three nights a week for three or more months. Chronic insomnia can lead to increased risk of depression, anxiety, substance abuse and motor vehicle accidents. Over time, this lack of sleep can contribute to health problems such as type 2 diabetes and hypertension.

Insomnia is also more common in older adults, women, people under stress and people with certain medical and mental health problems such as depression, according to the American Academy of Sleep Medicine. 

The AMA’s What Doctors Wish Patients Knew™ series gives physicians a platform to share what they want patients to understand about today’s health care headlines.

In this installment, three AMA members shared what doctors wish patients knew about insomnia. They are:

• Khaled Almadhoun, DO, a sleep medicine physician in Detroit at Henry Ford Health, which is a member of the AMA Health System Program that provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.
• Alejandro D. Chediak, MD, a sleep medicine physician in Miami who serves as an AMA delegate for the American Academy of Sleep Medicine.
• Ilene Rosen, MD, MSCE, a sleep medicine physician in Philadelphia and associate professor of medicine in the division of sleep medicine. 

“Insomnia is the inability to fall or stay asleep, typically. It's not a one or two month or one- or two-week type of thing,” said Dr. Almadhoun. “It's over a few months where you're having persistent difficulty falling or staying asleep multiple times a week for multiple months.”

“About 25 to 30 million Americans have insomnia at any given time—whether it’s acute or chronic,” said Dr. Rosen.

“What’s also important for insomnia is it causes disruption in your daytime activity, meaning you're tired, you're fatigued, you're sleepy,” Dr. Almadhoun said, noting “if you have difficulty falling and staying asleep, but you wake up feeling refreshed, no issues, that's not insomnia.” 

“Sometimes you can have poor night's rest where you'll have an evening shift or something like that,” he said. “There may be other factors, but insomnia is multiple nights a week for multiple months having difficulty falling and staying asleep.”

Patients will often tell their doctor, “I can’t fall asleep, I can’t stay asleep, or I wake up too early,” said Dr. Chediak. “What I try to ascertain from my patients and teach them is that ... the amount of sleep and how long it takes you to fall asleep is not the relevant point.

The question, he said, “is how does that affect you the next day? What can’t you do the next day because you slept badly the day before? I look at it in terms of function—what are the functional outcomes of bad sleep or short sleep? What are the emotional outcomes of bad sleep?

“And then what are the behavioral compensations that might not be conducive to good sleep the next night that subjects adhere to?” Dr. Chediak added. “That tells me a lot about how to fix their problem.”

“When you work up someone who does have insomnia, there's something called the three Ps of insomnia,” said Dr. Almadhoun. “There's the predisposing, the precipitating and perpetuating factors for insomnia.”

“Predisposing factors for someone who may have insomnia may be that they have been a naturally short sleeper their entire life. They've only slept four to five hours and felt refreshed,” he said. “Then some precipitating factor happens such as a death of a family member. Well, now that four to five hours that they’ve once always used to be fine with now is a little bit less at three to four hours. But now they start to feel symptoms of tiredness, fatigue and daytime sleepiness.

“And then the last P is perpetuating—what are they doing to keep continuing with their insomnia habits? So, staying up at night watching TV or trying to drown away their sorrows by drinking at night,” Dr. Almadhoun added. “All those are perpetuating symptoms that then put you across the insomnia thresholds that makes you continue to have insomnia moving forward.”

An important thing to keep in mind is that “insomnia can also be a symptom” of another condition, said Dr. Rosen. That means, “I can get into bed, and I feel like I don’t sleep straight through the night” because there is an underlying condition involved.

“People may have restless leg syndrome at night that may contribute to insomnia. They may have sleep apnea that can contribute to insomnia. They may have a nightmare disorder. They may have anxiety or depression,” Dr. Almadhoun said, noting that “people who do have depression typically have about a two to three times more likelihood of insomnia.”

Additionally, “people who have insomnia also have an elevated risk for depression as well,” he said. “They go hand in hand, but there are multiple factors—mental and physical health—that can negatively affect sleep.”

“For most people who come to me, let’s say they say that they can’t stay asleep, but then they’re also snoring and they’re tired and their sleep is broken. Well, the first thing I’m going to do is rule out sleep apnea for them,” Dr. Almadhoun said. “Or let’s stay they have restless legs. I’ll look to diagnose restless leg syndrome and treat it.

“We work closely with behavioral health because if someone has generalized anxiety disorder and they go to bed and their can’t shut off, no matter what I do they’re still going to be anxious,” he added. “You want to make sure that their mental health is well treated so that it does help their sleep at night so they’re able to fall asleep.”

There are “two big buckets of insomnia as a primary disorder, based on how long the symptoms have been around,” said Dr. Rosen. “You can have acute insomnia in the setting of a stressor” such as the COVID-19 public health emergency or a death in the family.

“Acute insomnia is something that causes the brain to be hyperaroused or hyperalert … and it occurs over a couple of weeks to months, but the strict definition is less than three months,” she said. “You don’t get into deep sleep, and you notice that you’re having trouble falling asleep, or even just going to sleep for four hours and then you’re wide awake.”

“The second bucket of insomnia is chronic insomnia, which has lasted more than three days a week for more than three months,” said Dr. Rosen. “Many individuals are able to say, ‘I used to be a good sleeper until a specific stressor happened.’”

“They may have had an acute episode of insomnia and then now the stressor has either gone away or maybe the stressor is still there, but it’s not new,” she said. “And yet the sleep patterns are maintained, meaning the fragmented sleep and the having trouble falling asleep or waking up.”

“Sometimes we have what we call primary insomnia, so there's no identifiable cause. It's just someone is unable to fall asleep at a specific time,” Dr. Almadhoun said, noting that “insomnia is different from delayed sleep phase, which sometimes people link together.” 

“Delayed sleep phase is when you go to bed later than normal and wake up later than normal, but you're feeling refreshed,” he said. “Those are teenagers in summer. They're going to bed at 2 a.m. and they're waking up at 10 a.m. They're getting eight hours of sleep, they're waking up feeling fine.

“But because they're going to bed at 2 a.m. that doesn't mean they have insomnia. That just means that they're having a delayed sleep phase,” Dr. Almadhoun added. “Insomnia is you're going to bed at 2 a.m. unable to maintain sleep, unable to fall asleep, your sleep is broken and then you still wake up feeling tired, fatigued not having a good night's rest.”

“People have genetic predispositions to insomnia,” said Dr. Rosen, adding “there’s a concept called an insomnia threshold. People who are genetically predisposed live a little bit closer to that threshold so that when they experience a stressor, the brain tips over into the insomnia.

“Some people eat when they’re stressed. Some people cry when they’re stressed. Some people get into bed and sleep more,” she added. “And a certain group of people have trouble sleeping.”

“Women tend to have more insomnia than men, especially women of postmenopausal age or who are going through menopause,” Dr. Almadhoun said. This is because during menopause, “hot flashes, disturbed sleep, decreased estrogen all can negatively affect their sleep quality overall.”

“So, women who are going through menopause or the perimenopause stage, it can be a bad time for their sleep given those instances,” he said.

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“You diagnose insomnia clinically, which means you don’t need a sleep study for it,” said Dr. Almadhoun, noting that “someone who does have multiple awakenings per week for multiple months and does have tiredness in the daytime meets clinical criteria for insomnia.”

“There are also different levels of insomnia. We use the ISI, which is the insomnia severity index,” he said. “We determine how severe someone’s insomnia is, but those used together we can diagnose primary insomnia if we ruled everything out.”

“Acute insomnia, whether you are given a medication for it—that is, a sedative to help you sleep—or not, does go away in weeks to months, usually less than three months,” said Dr. Rosen, even if you do nothing.”

That’s why it is important to not “stress about it and keep your routines like you always have, and the insomnia is likely to resolve,” she said. “Certainly, some people find this distressing. If it’s a reactive insomnia—for example, if someone died or there’s a major life stressor—some people find it a lot better to cope during the day if they have gotten some sleep at night, but either way, the brain corrects itself.” 

The term “orthosomnia” came out of people watching their Fitbit or Apple Watch, said Dr. Chediak. “They’re obsessed that—I’m not getting eight hours of sleep. My Fitbit or whatever it is that I’m wearing tells me that my sleep is insufficient, light and not refreshing, although one may feel great.”

“This phenomenon, orthosomnia, is a new term based on our ability to technologically monitor something that people think actually is sleep when it doesn’t necessarily mean you’re sleeping,” he said. “The commercially available sleep trackers offer some insight into our patterns of sleep, but they should not be taken literally, particularly when they’re trying to separate deep sleep from light sleep.

“They have absolutely no clue what is deep and what is light sleep,” Dr. Chediak added. “I personally like to look at them when patients bring them up in clinic. They will get better with time, but right now they’re most useful to tell you your pattern when you’re going to bed, when you’re waking up, what are those hours and not to focus on light versus deep.”

“Insomnia has a really good response rate to behavioral intervention,” said Dr. Chediak. “About 70–80% of those individuals with chronic insomnia who complete a structured cognitive behavioral therapy for insomnia (CBTi) program will respond favorably, and they can actually exit insomnia altogether.”

“There are several aspects to CBTi—a lot of it involves not obsessing about the insomnia and dialing down the sympathetic tone,” said Dr. Rosen. Instead, “keep the same bedtime and wake time that are about seven or eight hours apart, do not lay in bed awake for more than 15–30 minutes, and engage in activities, such as deep breathing or progressive muscle relaxation.”

“If someone doesn’t have access to a CBTi program, they can consider an online program or even try an app-based program as a first step,” she said. 

“Then there are two big things that are important and those are called stimulus control and sleep restriction therapy,” Dr. Almadhoun said. “Stimulus control means that you’re only in bed to sleep. So, you’re not reading in bed even though reading is a great nighttime activity to unwind.

“You’re not in bed watching TV, you’re not in bed eating, you’re not in bed talking … you’re doing all that outside the bedroom,” he added. “Once you’re tired and ready to go to bed, that’s when you go to bed and try to fall asleep.”

“Alcohol is notorious for breaking up your sleep,” said Dr. Almadhoun. Yet “people use it to fall asleep, which actually shortens sleep latency.”

“It is terrible for maintaining sleep including deeper stages of sleep such as REM sleep, which is rapid eye movement,” he said. That is why it is important to not rely on alcohol to help because what it is really doing is “draining sleep. You will fall asleep, but you will not maintain sleep.”

While melatonin can help with jet lag, taking it “randomly doesn’t help because melatonin is not a good sleep drug,” Dr. Chediak explained. “What melatonin does is it tell your brain when you should be shutting down your alertness centers.”

“You need to know in what direction you want to shift, and you need to know what time your brain is at to know when to take melatonin,” he said, adding that “taking melatonin for insomnia is not very effective and may lead to bad dreams, particularly at higher doses.”

“But melatonin is a good drug for circadian changes—changing the intrinsic clock time,” said Dr. Chediak. “All you need is 0.3 milligrams to achieve the change in your circadian clock. Not five, not one, not 10 and not 20. The more you take, the more likely you are to have nightmares or disturbing dreams.”

“The message here is that we don’t use medicines once insomnia has become chronic,” Dr. Rosen said.

“A lot of people nowadays think success equals less sleep and that’s not true,” Dr. Almadhoun. “It is recommended for adults to get seven to nine hours of sleep. Anything less than that and you wake up feeling tired, that’s your body telling you it needs more sleep.”

That is why “it is important that we do get that mark and not listen to this fad that sleep is just wasteful,” he said. “It’s not. Sleep is how your body regenerates, grows and sharpens up for the next day.”