August, 2006

What is Insomnia?

Insomnia is defined as taking more than 30 minutes to get to sleep, waking for a period of more than 30 minutes, or waking earlier than desired, with feelings of fatigue and drowsiness during the day, recurring over at least a 30 day period (Lacks, 1987).

Dimensions of the Problem

About 10 million people visit physicians a year complaining of insomnia. The average time it takes people to seek professional help for insomnia is 14 years, but some people wait as long as 30 years (Lacks, 1987). Around one-third of Americans are experiencing insomnia at any given time. In a typical survey, 32% of respondents in Los Angeles complained of insomnia at time of survey, while another 10% said they had insomnia in the previous month (Bixler, Kales, et al, 1976).

The National Commission on Sleep Disorders Research reported $15.9 billion as direct cost of sleep disorders and sleep deprivation, with an estimated $50 to $100 billion in indirect costs, mostly from accidents (1998). In European studies, drowsiness was found to be a greater traffic hazard than drinking alcohol (Haraldsson and Akerstedt, 2001).

Americans spent $1.1 billion on sleep products in 1999, split about 50/50 between prescription medicines and herbal sleep aids, according to the National Sleep Foundation.

A 1991 survey on 1308 workers found that insomnia was the most predictable factor of absenteeism at work. Insomniacs had an average monthly sick absence rate 2.8 times that of the total group (Leigh, 1991). The estimated annual loss of productivity due to insomnia in the U.S. was $41.1 billion in 1988 (Stoller, 1994).

Causes of Chronic Insomnia

Although a number of medical conditions can cause insomnia chronic insomnia is most commonly a behavioral or psychophysiological problem (Lacks, 1987). Temporary sleeplessness during stressful times can lead people to leads to form a link between bed and worrying. Insomniacs tend to have higher than normal levels of anxiety and depression, expect too much from themselves, and low self-efficacy -- all of which can be either cause or effect of sleeplessness. Hormonal changes and drug use, including prescription drugs, cigarettes, and alcohol, can also cause insomnia (Lacks).

Medical Treatment

Until recently, sleeping pills have had as many risks as benefits. With the older pills people can build up a tolerance to them in about 2 weeks. With the new ones, it can take about 4 weeks. In elderly patients, sleep medications cause falls or breathing complications. Sleep aids can interact with other medications or alcohol, and can disrupt natural sleep/awake cycles (circadian rhythms).

There is a rebound effect after people stop taking them (Hauri, 1982). The next-day, the after-effects of sleep medications can make people feel as bad as not sleeping does (Lacks, 1987).

Recently introduced medications like zalpidem (Ambien) and zaleplon (Sonata) have less dangerous side effects. Although they’re often effective for short-term (7-10 days) episodes, they’re not recommended for chronic insomnia. Escopiclone (Lunesta), a newer hypnotic, is approved for long-term use, as is ramelteon (Rozerem). All but ramelteon are controlled substances.

Non-medication Treatment Including Guided Imagery

"CBT [cognitive behavioral therapy] has emerged as 'the treatment of choice'" for managing the sleep/wake aspects of primary insomnia, according to one research team (Edinger & Means, 2005). Behavioral therapy has been repeatedly demonstrated the most effective long-term approach to chronic insomnia (Backhaous, Hohagen, et al., 2001; Dashevsky and Kramer, 1998; Jansson & Linton, 2005; McClusky, Milby et al, 1991; Morin, Mimeault and Gagne, 1999; Smith, Huang & Manber, 2005).

CBT proved superior to zopiclone in both short- and long-term outcome (Sivertsen, Omvik, et al, 2006). Cognitive Behavioral Therapy (CBT) alone or in combination with medication has been shown effective many times, and across different age populations (Irwin, Cole & Nicassio, 2006) including those with comorbid conditions (Ediger, Wohlgemuth, et al, 2001b; Espie, Inglis & Harvey, 2001; Perlis, Sharpe, et al, 2001; Montgomery & Pennis, 2003; Morin, Blais & Savard, 2002; Savard, Simard, et al, 2006).

The main categories of behavior therapy for insomnia are stimulus control – using bed only for sleep – a sleep hygiene program, keeping a sleep log, cognitive control, and progressive relaxation. These methods are often combined.

The use of relaxation has been found to reduce sleep-onset insomnia, with or without stimulus control measures (Cannici, Malcolm & Peek, 1983; Viens, DeKonick, et al, 2003). Effects are better when the two are combined (Jacobs, Rosenberg, et al, 1993).

Patients using CBT and relaxation therapy had improvement in how long they were able to stay asleep (Edinger, Wohlgemuth, et al, 2001). Similar results were reported in a 2002 study of older patients, with 54% of patients who received classroom CBT, and 35% of patients who used home-based audio relaxation treatment achieving clinically significant changes (Rybarczyk, Lopez, et al 2002). In older adults, both sleep hygiene combined with stimulus control was as effective as sleep hygiene combined with relaxation tapes (Pallesen, Nordhus, 2003).

Since CBT and relaxation (including audio tapes) are both effective, evidence suggests that combining the two would yield greater benefits. One study demonstrated that progressive relaxation and learning new sleep habits helped patients become less depressed. Subjects achieved a greater sense of control, fell asleep quicker, and slept better, even two years later (Engle-Friedman, Bootzin, et al, 1992).

Subjects in one study who used hypnosis slept better (Younes, Simpson, et al, 2003); subjects in another study who used imagery fell asleep faster and had less intrusive “mind-racing” prior to sleep (Harvey and Payne, 2002). Cognitive distraction – a major component of guided imagery, hypnosis, and similar techniques, can be instrumental in avoiding worry and anxiety (Harvey & Payne, 2002; Ree, Harvey, et al, 2005).

Progressive relaxation and autogenic training improved insomnia in cancer patients; subjects had moderate or large improvements in sleep latency, duration, efficiency, quality, use of medication, and daytime dysfunction (Simeit, Deck, et al, 2004). CBT was effective in significantly improving Sickness Impact Profile, Sleep Evaluation Form, and Dysfunctional Beliefs and Attitudes About Sleep in both groups and individuals.

Hypnosis improved sleep onset in 90% of children; a cessation in awakenings from nightmares in 52% of children and improvement in an additional 38%; improvement in somatic complaints in 41% (Anbar and Slothower, 2006). Mindfulness meditation improved sleep in post-transplant patients (Gross, Kreitzer, et al, 2004).

Authors of three reviews of the literature of mind-body techniques (including techniques such as relaxation, meditation, biofeedback) concluded that there is, respectively, either “considerable,” “sufficient,” or “moderate” evidence of their effectiveness in insomnia (Astin, Shapiro, et al, 2003; Barrows & Jacobs, 2002; Mamtani & Cimino, 2002). A 2003 study found that at-home use of relaxation tapes was just as effective as massage in improving subjects’ sleep (Hanley, Stirling & Brown, 2003).


A low-cost guided imagery program can help patients cope with chronic insomnia, and may save resources spent on prescription sleep medications, especially when behavioral recommendations are also followed.


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