From Restless to Restful: Exploring the Causes and Treatment of Insomnia

• What is insomnia?
• What are the Causes of Insomnia?
• Why Should I Be Concerned if I Have Insomnia?
• What Treatments Are Available for Insomnia?
  • Sleep Habits
  • Counseling
  • Medications
• How Long Can I Take Sleeping Medications?
• How Do I Know if I am Dependent or Addicted to Benzodiazepines (Or Other Sleeping Pills)?

Key Takeaways

• Various factors can contribute to a single diagnosis of insomnia. Your doctor must determine all contributing factors to treat it successfully.
• Chronic insomnia is defined as having trouble sleeping at least three nights per week for three or more months. When this occurs, your quality of life can be affected.
• Chronic insomnia can lead to more severe health problems like cardiovascular diseases and diabetes.
• Insomnia treatment is most effective when your doctor can minimize as many factors interfering with your sleep as possible.
• After your doctor has minimized all contributing factors and you’re still experiencing insomnia, then further treatments can include changes in sleep habits, counseling, and medications.

What is Insomnia?

If your doctor has diagnosed you with insomnia, it means you have trouble sleeping, and it is affecting your daytime function. You may find falling or staying asleep challenging or need better sleep quality. But it’s also important to recognize that insomnia is only one of the many different types of sleep disorders.

What are the Causes of Insomnia?

Various factors can contribute to a single diagnosis of insomnia. To have the most successful treatment, your doctor must determine all the factors that may be involved in your unique situation.

Listed below are some significant factors that can lead to an insomnia diagnosis:

1. Mental Health Disorders. Depression and anxiety are commonly associated with insomnia. Insomnia is one of the most common symptoms of depression and anxiety mood disorders.
   Insomnia often happens before depression or anxiety develops. If you are receiving treatment for anxiety or depression, your treatment can improve insomnia. If it does not, then the insomnia needs to be treated directly.
2. Substance Abuse Disorders. Insomnia is very common in many different substance use disorders, including alcoholism. For alcoholics in remission, insomnia is a risk factor for relapse.
3. Medical Conditions. There are many chronic medical problems associated with insomnia. The most common comorbidities include chronic lung disease, high blood pressure, diabetes, cancer, chronic pain, neurological disorders such as Parkinson’s disease, and heart failure. However, many other conditions are also associated with insomnia.
4. Medications. The list of medications that can cause or aggravate insomnia is long and includes the following:
   • Stimulants. Most people use caffeine to stay awake. However, overusing it can lead to insomnia. Other over-the-counter stimulants can also cause insomnia, including energy drinks (for example, ginseng, guarana, and ephedrine), decongestants, and tobacco.
     Prescription stimulants for ADHD and narcolepsy can also cause insomnia. Illegal stimulants, including cocaine and methamphetamines, can do so as well.
   • Appetite Suppressants. Many prescription and over-the-counter appetite suppressants can cause insomnia due to their stimulant effect.
   • Antidepressants. The group of antidepressant medications most prone to causing insomnia are monoamine oxidase (MAO) inhibitors. Thankfully, these meds are no longer commonly used. Other more common antidepressants that can sometimes cause insomnia include fluoxetine (Prozac), bupropion (Wellbutrin), venlafaxine (Effexor), and protriptyline(Vivactil).
   • Beta-blockers. This family of medications lowers heart rate and blood pressure. However, doctors sometimes prescribe them for other disorders, including migraine and performance anxiety.
   • Glucocorticoids. The adrenal glands make glucocorticoids, usually as a response to stress. Medications in this family include prednisone, methylprednisolone, and dexamethasone. All of these affect sleep, particularly when taking high dosages.
   • Alcohol. Alcohol can make you drowsy and initially makes it easier to fall asleep. However, it can disrupt your sleep patterns, causing disturbances in the later stages of sleep, especially after a few nights of use.
   • Opioids. While opioid medications make you drowsy, when used regularly, they can cause you to wake up in the middle of the night. They can also disrupt standard sleep patterns.
   • Medication Withdrawal. Many medications can cause insomnia as part of a withdrawal reaction, including sleeping pills, alcohol, and sedatives such as benzodiazepines and glucocorticoids.
5. Sleep Disorders. Sleep disorders are addressed in more detail in a separate article, Sleep Disorders: Symptoms, Diagnosis and Treatment. Sleep disorders that can affect your ability to sleep well include:
   • Sleep apnea
   • Restless legs syndrome
   • Periodic limb movement disorder
   • Circadian rhythm (sleep-wake) disorders

Why Should I Be Concerned If I Have Insomnia?

Most people have experienced a sleepless night here or there, which is normal. And if you have, you probably noticed that the next day, you felt tired or couldn’t get as much done as you usually would. However, if you have persistent or chronic insomnia, you should be aware of the significant health risks.

Chronic insomnia is defined as having trouble sleeping at least three nights per week for three or more months. When this occurs, your quality of life can be affected.

Reduced quality of life can lead to difficulties at work, such as poor work performance and absences. While studies show that insomnia has a small effect on memory and problem-solving, the good news is that your brain’s ability to process information (cognitive function) is not affected.

Chronic insomnia can cause cardiovascular problems such as high blood pressure and heart attacks. People with insomnia have higher blood pressure at night. When this occurs, treating your insomnia will also reduce your blood pressure.

Chronic insomnia can also increase the risk of another serious medical condition –  diabetes. Again, treatment of insomnia not only helps sleep but also improves diabetes. Scientists believe the constant activation of the “fight or flight” response may be why insomnia increases cardiovascular risk.

Cardiovascular diseases and diabetes can increase the risk of death. But there’s another reason for an increased risk of death related to insomnia, and that’s people taking their own lives (suicide).

How do I Get Help if I am Suicidal?

If you are feeling suicidal now or at any other time, call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255). There is someone available 24/7 to provide you with emotional support and help you if you are feeling suicidal or having severe emotional distress. This is free, confidential, and available throughout the United States.

If a friend or family member is talking about suicide, encourage them to call the Lifeline above at 1-800-273-TALK (8255). Even if they aren’t in immediate danger, the trained counselor can help them and point them in the right direction.

If you, or someone you know, is in immediate danger of suicide or has attempted suicide, call 911.

What Treatments Are Available for Insomnia?

Insomnia treatment is most effective when your doctor can minimize as many factors interfering with your sleep as possible.

You may need behavioral and medication treatments in addition. Still, they may not work as well if your doctor does not address the contributing factors.

If you are waking up at night and having trouble falling back asleep, it is essential to address the reason you are waking up in the first place. Reasons may include pain, shortness of breath, or frequent urination. All contributing factors should be addressed before medication for insomnia is introduced.

Sleep disorders, such as restless legs syndrome or sleep apnea, should be treated initially. This may be all that is needed to treat your insomnia. It is always best to start with the big picture and determine other factors that may be causing your sleep pattern to be off-balanced.

With the sleep apnea example, you are waking up because your oxygen levels have dropped too low, and your body is waking you up to breathe. Taking a sleeping pill can lead to more prolonged and severe low oxygen levels because your body can’t wake you up to breathe. Testing for sleep apnea is an important aspect of your insomnia evaluation.

If you are taking medications that can affect sleep, you should ask your doctor whether you need to stop or switch to something else. Also, avoid any stimulant substances or medications, including caffeine, after midday, as they can affect your sleep long after the stimulant effect has waned.

If you are still experiencing insomnia after addressing all the possible contributing factors, your doctor will consider further treatments, including changes in sleep habits, counseling, and medications.

1. Changes in Sleep Habits. The more you can work on changing your sleep habits, the better. If you see a counselor, they will discuss these with you.
   • Go to bed and get up at the same time every day, seven days a week.
   • Avoid daytime naps.
   • Wait until you feel sleepy to go to bed.
   • Make sure your room is dark, quiet, and has a comfortable temperature to sleep.
   • Exercise regularly, but avoid exercise within 4 hours of sleep.
   • Avoid alcohol near bedtime.
   • Avoid smoking, particularly in the evening.
   • Avoid large meals and limit fluids right before bed.
   • Do not go to bed hungry.
   • Minimize screen time before bed.
   • Address your worries before you go to bed.
   • If you cannot sleep after 20 minutes, get out of bed and do something else until you feel sleepy again, then return to bed. Do not read, sew, watch television, etc. in the bed. The bed should be for sleeping and intimacy only.
2. Counseling. If you have insomnia lasting more than one month, your therapist may recommend cognitive behavioral therapy (CBT).
   

   CBT alone, or in combination with medication, is more effective than medication alone. It also has fewer risks, such as potential medication side effects.

   Cognitive behavioral therapy addresses common thought and behavioral patterns that adversely affect sleep. This can be done through one-on-one or group counseling. Sessions may be in person or virtual.

   While you and your therapist should decide together on how to proceed, the different items that may be addressed include:

   • Anxious thoughts that are affecting sleep
   • Expectations about the amount of sleep needed
   • Understanding of the effects of inadequate sleep
   • Relaxation exercises, including progressive muscle relaxation and mindfulness

   Relaxation exercises help you relax enough to fall asleep. They include progressive muscle relaxation and guided imagery or visualization.

   Progressive muscle relaxation is a technique where you contract and relax the muscles in your body, one at a time, moving from one end to the other.

   Visualization or guided imagery involves creating an image in your mind of a relaxing or peaceful setting, such as lying in a hammock on the beach.

   Mindfulness usually involves meditation, which focuses your awareness about the present moment and, over time, trains your mind to be calmer. Mindfulness can help you learn not to get caught up in anxious thinking.

   Most of these techniques are often easier to learn with the help of a therapist, but you can also find books and apps to teach you.

   Many medical and mental health professionals offer therapy. They include psychiatrists, psychologists, licensed professional counselors, licensed social workers, licensed marriage and family therapists, or psychiatric nurses.

   Psychiatrists and primary care physicians are all medical doctors, so they can prescribe medications. Mental health nurse practitioners also have prescription writing privileges. Other therapists will not be able to prescribe medications.

   “Psychotherapist” is a general term and not a title. Before you see a therapist, it’s a good idea to check their background to be sure they meet their state certification and licensing requirements. This ensures you see someone with the training and skills to help you. Your primary care doctor can also provide a referral, which may be the best first step.

   Therapy is confidential. Your therapist will never discuss your care with anyone outside of the medical team without your permission. Exceptions to confidentiality are cases where there is an immediate concern of self-harm or threats to others. By law, your counselor is required to report these cases. Ask your therapist if you have any questions about confidentiality.

3. Medications.Some common prescription medications for sleep include:
   • older benzodiazepine sleeping medications (such as temazepam and flurazepam)
   • newer benzodiazepine receptor agonists (zolpidem, eszopiclone, zaleplon)
   • a newer class of drugs called DORAs-dual orexin receptor agonists (lemborexant, suvorexant)
   • sedating antidepressants in low doses (doxepin, trazadone)
   • melatonin receptor agonists (ramelteon)

   Medications can help improve your sleep. However, medication works best when used in conjunction with lifestyle changes and counseling.

   Benzodiazepines have the highest potential for misuse as they are habit-forming and can be addictive. The DORAs also have some potential for misuse.

   If you choose to take an over-the-counter or herbal supplement for sleep, speak to your doctor to see which is right for you. It is important to review any potential side effects and drug interactions before starting any meds, whether prescription or non-prescription drugs. For example, one supplement for sleep and anxiety, Kava, is no longer recommended as research showed that some people who took this supplement had severe liver problems.

   Common over-the-counter or herbal medications for sleep include:

   • Melatonin. This is a hormone made by the pineal gland at the base of the brain. It is useful in helping you fall asleep but doesn’t help you stay asleep.
   • Valerian root. This is more closely related to benzodiazepines, but it is not habit-forming. It may be effective for sleep but isn’t proven to be effective.
   • Magnesium. This may have fewer risks than other medications if you are over age 65.
   • Antihistamines such as diphenhydramine or doxylamine. While these can be effective, doctors don’t recommend them if you are over 65 due to increased risks of falls and fractures, cognitive problems, and adversely affecting safe driving.
   • Medical marijuana. Scientists need to do further research on the effectiveness and safety of marijuana before doctors can recommend it for insomnia treatment.

   The US Food & Drug Administration (FDA) does not regulate herbal supplements, so many unknowns exist. Side effects, drug interactions,  potency, and purity vary among the different brands.

   While most supplements are considered safe, it is wise to speak to your doctor about what to take for your insomnia, as they can have side effects and drug interactions just like other medications.

Special Considerations. Here are some situations that need additional attention when considering medications for sleep.

• Age Over 65. There are many reasons why drug treatment is more complicated when you are older. Medications don’t break down as readily due to changes in your liver. This can lead to higher blood concentrations of the drugs, which can cause increased side effects. Older people are also at an increased risk for drowsiness, cognitive problems, balance problems, and falls. All of these are potential risks associated with sleep medications.As a result, doctors don’t recommend benzodiazepines or benzodiazepine-like drugs in older adults. If a benzo is absolutely necessary, your doctor will recommend the lowest dose. You should take care not to exceed that low dose.
  

  If the low dose of one medication doesn’t work, it is better to try a low dose of a different medication than try a higher dose of the first medication.

  In addition, over-the-counter antihistamines have higher risks, including confusion in older individuals. Trazadone, a sedating antidepressant used for sleep, can cause low blood pressure in seniors, leading to an increased fall risk. Therefore, you must talk to your doctor before you start any over-the-counter medications for sleep if you are over 65.

  While you can take low doses of some medications if you are over 65, it is more important to focus on non-medication therapies for insomnia, such as good sleep habits and counseling.

• Liver and Kidney Problems. It is not safe to take certain medications for insomnia if you have liver or kidney problems. In some cases, your doctor needs to adjust the dose. Tell your doctor if you have liver or kidney problems whenever they are prescribing medications so they can make these adjustments for you.
• Sleep Apnea. People with untreated sleep apnea should be very cautious about taking insomnia medications. For example, benzodiazepines cause respiratory depression, meaning it makes it difficult to breathe. In sleep apnea, the main reason you have trouble sleeping is because you are having apnea spells where you stop breathing. Taking a sleeping pill like a benzodiazepine can make apnea worse. This can lead to lower oxygen levels with damage to the heart or even stop your breathing altogether,  which can lead to death.
• Opioid Use. The use of opioids (narcotic pain medication) and benzodiazepines should not be combined.  Taken together, opioids and benzos can cause you to stop breathing, causing a respiratory arrest.
• Substance Use Disorders. Many sleep medications have the potential to be habit-forming (addictive) or misused. This makes prescribing more complicated if you have a current or past history of substance abuse. Tell your doctor if you have a history of any substance use problems, including alcohol, so that they can make the safest prescribing decisions with you.
• Pregnancy. Sleep problems are common during pregnancy, with the risk increasing as the pregnancy progresses. Causes specific to pregnancy include nausea, frequent urination, back pain, fetal movements, acid reflux, leg cramps, and restless legs syndrome. Improving sleep habits through counseling and cognitive behavioral therapy are the preferred treatments. If you need sleep medications, your doctor will most likely recommend doxylamine or diphenhydramine. These are both over-the-counter, but when you are pregnant, you should always discuss taking any over-the-counter medications with your doctor beforehand to be sure they are safe for you and your baby.

Cautions. All medications for sleep share some potential side effects, including the following:

• Drowsiness. Of course, you want the medication to make you drowsy so you can sleep better. However, the problem is that some medications will make you drowsy the next day. You should always be sure you have at least 8 hours after you take a sleeping pill before you are up and driving. Even if 8 hours have passed, if you feel drowsy, you should not drive. You should also not mix any sleeping medication with alcohol, opioids, or other sedating medications without discussing it with your doctor. The drowsiness, when combined this way, can be much more extreme, even to the point of respiratory depression. This means your breathing can become too slow, which can even lead to death.
• Abnormal Thinking and Behavior. This includes hallucinations, amnesia, sleepwalking, and sleep-driving.
• Depression and even suicidal thoughts.

You should tell your doctor if you have any of these side effects.

How do I Get Help if I am Suicidal?

If you are feeling suicidal now or at any other time, call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255). There is someone available 24/7 to provide you with emotional support and help you if you are feeling suicidal or having severe emotional distress. This is free, confidential, and available throughout the United States.

If you, or someone you know, is in immediate danger of suicide or has attempted suicide, call 911.

How Long Can I Take Sleeping Medications?

This is an excellent question to ask your doctor. Some people have to take them daily for the long term. However, it is best to take them only briefly or intermittently. This helps you to avoid tolerance and dependence.

While dependence is mainly an issue with habit-forming medications, tolerance can occur with any medication. Tolerance happens when you need to take more medication over time to have the same effect.

If you have been taking sleeping medications for a long time, it is best to taper down on your dose rather than stop it suddenly to avoid rebound insomnia.

How do I Know if I am Dependent or Addicted to Benzodiazepines (or other sleeping pills)?

Some of the symptoms you might have if you have developed a benzodiazepine use disorder include the following:

• Difficulty in cutting back or stopping the medication
• Cravings
• Spending a lot of time trying to get benzodiazepines
• Social problems develop from your use of the medication. This could include problems at work, home, or relationships.
• Continuing to take these medications when it isn’t safe, such as when driving or operating heavy or dangerous machinery or mixing them with alcohol.
• Having to take more of the medication for it to work.
• Withdrawal symptoms if you try to cut back quickly or abruptly stop the medication. Symptoms of withdrawal include anxiety and insomnia in the first few days after you stop it. In addition to anxiety and insomnia, over the next two weeks, you might also experience the following symptoms:
  • Irritability
  • Tremor
  • Sweating
  • Difficulty concentrating
  • Nausea and vomiting
  • Palpitations
  • Headache or muscle aches.

The most severe symptoms of withdrawal, which can be life-threatening in severe benzodiazepine withdrawal, include seizures and psychosis (severe confusion where you lose your sense of reality). This is not likely if you are taking a benzodiazepine that is specifically for sleep and taking FDA-approved doses. However, other benzodiazepines, or higher-than-recommended dosages of sleeping medications, can make you more prone to severe withdrawal symptoms.

Therefore, it is always important to wean off of benzodiazepines rather than stop them suddenly. Talk to your doctor about the best way to stop these if you take them regularly. Let your doctor know if you are taking more than the prescribed amount. It may mean that you are developing dependency or addiction related to the medications, or it may simply mean that your medication isn’t the right one for you and needs to be changed.

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Written by: myObMD physician writing team | Editor: Jennifer Abayowa and Dr. Dayna Smith, MD | Reviewed: February 29, 2024 | Copyright myObMD, Inc. 2024.

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