Insomnia

The symptoms of insomnia include:

• Difficulty getting to sleep (taking more than 45 minutes to get to sleep)
• Difficulty staying asleep (frequent awakenings and difficulty getting back to sleep)
• Early morning waking
• Feeling tired and unrefreshed in the morning.

Some people notice that the irritability that results from their insomnia has an effect on partners, families and work colleagues. 

Accident statistics have shown that daytime sleepiness can double the chance of experiencing an accident while operating machinery or driving a car.  There's also a link with physical illness. Statistical studies indicate that people suffering from insomnia had a higher than average chance of dying from cancer, heart disease or stroke. People with stress, anxiety and depression have a high level of insomnia.

Typically, there is no single cause for insomnia but a number of factors are known to contribute:

• Lifestyle – eating late at night, jet lag, hunger, alcohol, caffeine, stimulant drugs, including nicotine
• Environment – noise (e.g. partner snoring), uncomfortable bed or bedroom
• Physical health problems – sleep apnoea, asthma, tinnitus, pain, prostate problems, indigestion
• Psychological – stress, grief
• Pyschiatric – depression, anxiety, ania
• Medication – e.g. certain tablets for asthma and treatments for nasal congestion, vertigo and depression

Rarely, insomnia occurs even when none of the above are present. This is known as 'primary' insomnia.

Self-help tips
There is a number of things that people affeced by insomnia can do to help themselves. These are known as sleep hygiene measures:

• Avoid taking cat-naps during the day
• Reduce the number of cups of coffee, tea or cola drinks  you drink, especially later on in the day
• Only drink alcohol in moderation. It may make you feel sleepy but will tend to make you wake up after a short time
• Stop smoking – it can make breathing difficulties while asleep more likely
• Take regular exercise but avoid strenuous activity immediately before going to bed
• Try to get into a daily routine. Go to bed the same time each night and get up the same time each morning
• Avoid heavy or rich meals, especially in the few hours before bedtime
• Work out how many hours sleep you can manage with before daytime sleepiness becomes a problem. Becoming unnecessarily stressed over insomnia can lead to a vicious cycle
• If you can't sleep, get up and read in a dim light until you feel sleepy. Don't watch television or lie in bed thinking about how much sleep you are missing.
• Other activities that can create a relaxed mood include taking a warm bath, having a milky drink, or listening to soothing music.
• Mentally dealing with the day's unfinished business is also helpful. Writing down any worries to deal with the next day may help to clear them from the mind and prevent them re-surfacing in the early hours.

Pyschological therapies

Psychologists can teach simple relaxation techniques. They can also provide “talking therapy” (psychotherapy) which can help people come to terms with various life events  – e.g. bereavement, marital problems etc. that may be triggers of insomnia. Psychological “tricks” can also be taught – e.g. telling you to try and keep awake, which often has the opposite effect.

Specific sleep therapy includes cognitive behaviour therapy (CBT) which deals with misconceptions about sleep such as believing that frequent short naps during the day are good for you.

Medication

There are a number of over-the-counter treatments that might help for occasional insomnia in conjunction with the sleep hygiene tips mentioned above:

Sedative antihistamines – e.g diphenhydramine (Nytol) and promethazine (Phenergan). These are effective but stay in the body for a long time and can cause a hangover effect in the morning.

Herbal – there is some scientific evidence that valerian is effective. Passiflora and wild lettuce extract are also used, but their benefits have not been tested in medical trials and, like other unlicensed remedies, their safety may not have been rigorously tested. If you are taking any other medication, you should consult your doctor or pharmacist first.

Getting help

If work or leisure activities are disturbed by daytime sleepiness, or if you wake up feeling unrefreshed and irritable, you should consult your GP. Some doctors feel that prescription-only medication –known as hypnotics – should be started as soon as these problems start, while others believe that sleep hygiene methods should be tried first. In all cases, drugs should be used for as short a period as possible, and certainly no longer than two weeks. Beyond this, there’s a danger that dependency (addiction) to sleeping tablets, will develop.

A GP will also be able to detect any underlying cause of insomnia that also needs treatment. Depression, for example, may need treatment with antidepressants as well as sleeping medication.

The GP may prescribe the following drugs:
Benzodiazepines

• Nitrazepam   useful and effective but can be habit forming in long term. It continues to work for several hours (medium-acting) which means it has the potential to cause hangover drowsiness the following morning.
• Temazepam and lormetazepam are shorter acting, and less likely to cause daytime drowsiness.

All benzodiazepines can affect hand-eye co-ordination, which can impair driving ability and operating machinery the next day. Because of their potential for causing dependence, doctors are now discouraged from prescribing benzodiazepines for insomnia except for very short term use in specific situations, such as in people who are very distressed.

Newer drugs – zopiclone (Zimovane), zolpidem (Stilnoct), zaleplon (Sonata)– are very short acting. In theory they should cause less daytime drowsiness than the benzodiazepines and have less potential for causing dependence, but there are few scientific studies comparing the two groups. Zopiclone can cause a metallic taste in the mouth. Other side-effects affecting these drugs include indigestion and headache.

Antidepressants – if a person with insomnia has depression, some ‘tricyclic’ antidepressant medicines –such as dothiepin and trazodone  – also have a sedative effect. These drugs do not cause dependence.

The British Sleep Foundation
www.britishsleepfoundation.org.uk

American Academy of Sleep Medicine 
http://www.aasmnet.org

National Sleep Foundation 
http://www.sleepfoundation.org

National Womens Health Information Center 
http://www.4woman.gov/faq/insomnia.htm

National Heart, Lung, and Blood Institute 
http://www.nhlbi.nih.gov