What Is Insomnia?

Insomnia is frequent difficulty sleeping resulting in daytime impairment and occurring despite adequate opportunity for sleep.

Insomnia is common, with 19% to 50% of adults reporting symptoms of insomnia in some published surveys.

Short-term insomnia typically lasts for several days to weeks and is often triggered by a recent episode of stress (physical, psychological, or interpersonal). Short-term insomnia usually disappears with improvement or resolution of the stressor, but it may progress to chronic insomnia.

Chronic insomnia is difficulty falling asleep, staying asleep, or waking up in the early morning unable to go back to sleep for at least 3 nights per week over at least 3 months. Chronic insomnia is often worsened by certain behaviors. For example, spending too much time in bed trying to get more sleep may lead to periods of wakefulness at night and less restorative sleep. This can also result in feelings of frustration, anxiety, and distress, which create negative associations with sleep. Insomnia is also worsened by daytime napping, which reduces the need for sleep at night, and by use of alcohol, which negatively affects sleep quality.

Insomnia is more common in older adults; women; and people with anxiety, depression, substance use disorders, and certain medical conditions (such as pulmonary disease, heart failure, cancer, or chronic pain); and with use of some medications (such as blood pressure drugs, corticosteroids, and antidepressants).

A sleep study is not generally needed but may be considered if sleep apnea is suspected (such as for people with loud snoring or witnessed pauses in breathing during sleep).

For short-term insomnia, discussion with a clinician about the stressor causing sleep difficulty may be helpful. Patients with severe acute insomnia may also benefit from short-term use of medications to decrease the physical and psychological effects of sleepiness and to reduce the likelihood of developing dysfunctional behavioral responses to insomnia.

For chronic insomnia, first-line treatment is cognitive behavior therapy for insomnia (CBTI), which aims to reduce fear and anxiety about sleeping and provide bedtime relaxation strategies. CBTI also gives behavioral recommendations, including establishing a wake-up time, restricting time in bed, reserving the bed for sleep and sex, avoiding naps, and recommending against caffeine, alcohol, use of electronic screens, and exercise close to bedtime. CBTI can be done in person or via telehealth, web-based, or app-based tools.

If chronic insomnia does not improve with CBTI, adults may benefit from medication. US Food and Drug Administration (FDA)–approved drugs for insomnia include nonbenzodiazepine hypnotics (zolpidem, zaleplon, eszopiclone), benzodiazepines (triazolam, temazepam), selective histamine antagonists (doxepin), melatonin receptor agonists (ramelteon), and hypocretin/orexin receptor antagonists (suvorexant, lemborexant). Some drugs without FDA approval for treatment of insomnia are also commonly used, including trazadone, quetiapine, gabapentin, melatonin, and over-the-counter sleep aids. Medications should be chosen so that the timing of their effect matches the time of night affected by the insomnia (trouble falling asleep, trouble staying asleep, or early morning awakening). Side effects (confusion and falls) and habit-forming potential should be considered.

There are no FDA-approved drugs to treat insomnia in children, although some evidence supports use of melatonin for sleep-onset problems in children with neurodevelopmental disorders.

Conflict of Interest Disclosures: Dr Krystal reported receiving personal fees and/or grants from Janssen, NeuraWell, Sage, Axsome, Reveal, Big Health, Evecxia, Eisai, Idorsia, Neurocrine, Takeda, Jazz, Harmony, Adare, Millennium, Angelini, Otsuka, and Merck. Dr Ashbrook reported receiving grants from Itamar Medical and Jazz Pharmaceuticals. Dr Prather reported receiving personal fees from Big Health and Fitbit and grants from Eisai, the National Institutes of Health, and Headspace and having stock options in NeuroGeneCES.

Source: Sutton EL. Insomnia. Ann Intern Med. 2021;174(3):ITC33-ITC48. doi:10.7326/AITC202103160