What doctors wish patients knew about insomnia

Even for those who have never acquired SARS-CoV-2, the COVID-19 pandemic has still exacted its toll on health. But it’s not just COVID-19 itself. It’s the anxiety and stress surrounding the pandemic that have contributed to insomnia—the inability to fall asleep or stay asleep. While insomnia was a problem before COVID-19, more people have been fighting a loss of sleep and are unsure of what to do.

Nearly 60% of Americans have struggled with sleep during the pandemic, according to the American Academy of Sleep Medicine. This lack of sleep has led to insomnia, which is a common sleep complaint. 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.

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

In this installment, two AMA members who are sleep medicine physicians shared what doctors wish patients knew about insomnia. They are:

• Alejandro D. Chediak, MD, associate professor of medicine and associate chief of clinical affairs in the Division of Pulmonary, Critical Care and Sleep Medicine at the University of Miami Miller School of Medicine. Dr. Chediak serves as an AMA delegate for the American Academy of Sleep Medicine.
• Ilene Rosen, MD, MSCE, associate professor of medicine in the Division of Sleep Medicine and assistant dean for Graduate Medical Education at the Perelman School of Medicine at the University of Pennsylvania. 

“About 25 to 30 million Americans have insomnia at any given time—whether it’s acute or chronic,” said Dr. Rosen. “In the setting of what’s going on in the world—the pandemic, the unrest, the uncertainty now about the world—insomnia is a big player, maybe even more so, now.

“A lot of that in the beginning was the coronasomnia that everyone was talking about,” she said. “But more people are working from home. Pre-pandemic they were just tired because they were getting up for work and doing things at night—i.e., they were sleep deprived.”

Now they don’t have that commute to and from work, and the whole day is in the house—maybe even in the bedroom—so they are finding that they “just can’t sleep,” Dr. Rosen said.

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.” 

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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.

“There are many things that can do that such as sleep apnea or restless leg syndrome, which can wake you up throughout the night,” she said.

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 pandemic 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.”

“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.”

“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.

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.