1. What is Insomnia?

Insomnia exist in various forms: many suffers experience difficulty in getting to sleep, others have interrupted sleep, some wake up too early in the morning and a few simply have poor quality sleep and do not feel rested. If insomnia lasts for more than 3-4 weeks, it is termed chronic.

2. What are the problems associated with insomnia?

Individuals vary in their need for sleep: we all know of individuals who can ordinarily function well with less sleep than others. However, for people with insomnia, it causes distress and affects their everyday lives. Poor sleep result in daytime drowsiness and can impair attention and motor coordination when driving or operating machinery. This can be dangerous. Poor attention and memory also affect studies and work productivity. A person deprived of sleep will tend to be irritable and this can impair his relationship with others. Hence an individual with a sleep problem may have an impaired quality of life. It is also important to note that in many cases, insomnia can be a symptom of a psychological disorder such as an anxiety disorder or depression, and these disorders should be treated. Some individuals with chronic insomnia attempt to treat themselves by consuming cough syrup or alcohol. Unfortunately, such an abusive pattern of drug use will not only compound the sleep problem but also cause damage to physical health and create addiction problems.

3. What are the causes of insomnia?

Insomnia is a very common condition, and most people would have experienced it a few times in their lives. Sleep disturbances can happen in normal people simply due to situational influences. For example, excessive noise or an unfamiliar environment can affect sleep. It occurs in jet-lag, when the person travels across different time zones, and also when a person engages in shift work. Correction of these situational influences will usually improve sleep. Certain physical symptoms such as pain and shortness of breath in patients with medical problems can disrupt sleep.

Transient insomnia also occurs in response to stress or worry. It is common to have poor sleep when one is undergoing stress in studies, workplace or relationship. When the stress is overcome, sleep will usually improve.

However many individuals also suffer from chronic insomnia, where sleep problems persist for more than a few weeks, because the stressors are persistent or overwhelming. Insomnia occurs commonly in adjustment disorders, where one’s coping strategies to stress are overwhelmed. Others may have a psychological disorder such as depression, which needs prompt medical treatment.

Insomnia, especially early awakening, occurs commonly in depression. Other accompanying symptoms of depression that one should look out for include depressed mood, loss of appetite, loss of drive or interest, frequent negative thinking, feelings of worthlessness and even suicidal thoughts. Depression is a disorder that can severely affect an individual’s life but effective treatments are abailable. Another group of disorders commonly associated with insomnia are the anxiety disorders. These disorders are characterized by persistent and excessive anxiety and worry. Some may also have panic attacks, whereas others have persistent bodily complaints. Yet others have compulsive cleaning or checking rituals, which are symptoms of an obsessive-compulsive disorder. Finally, insomnia is also experienced by an individual developing a major mental disorder like schizophrenia. In this disorder, one experience hallucinatory "voices" and has strange behaviours and beliefs.

It is unfortunate that the psychological disorders mentioned above are frequently under-diagnosed and under-treated, as effective treatments are currently available for these conditions.

4. How do I know if I need assessment and treatment?

If you have poor sleep for more than 2 weeks and it has been affecting your activities and function, a consult with a doctor will be appropriate. This is especially so if you have other symptoms suggestive of a medical or psychiatric disorder such as depression – these will need to be addressed too and remember, they respond well to treatment. The doctor will talk to you to obtain a thorough medical history, followed by a physical examination. This is to identify any medical or psychological factors that might contribute to your insomnia. Physical investigations such as blood tests may or may not be required. The doctor then makes the diagnosis and decides on the treatment.

5. How is insomnia treated?

This is achieved using both non-pharmacologic (non-medical) and pharmacologic (medical) approaches.

i) Non-Pharmacologic

Firstly anyone who is a light sleeper or has sleep problems should adopt proper sleep hygiene. Hence one should avoid coffee, tea and drinks containing caffeine from late afternoon onwards, avoid prolonged afternoon naps and ensure that the bedroom is quiet (ear plugs can help) and comfortable. Alcohol should be reduced: although it appears to help induce sleep, it actually disrupt sleep later on. Only go to bed when very sleepy and get out of bed to do some quiet reading if still not asleep after 15 minutes. Relaxing activities such as meditation or practicing muscle relaxation before sleep also helps.

ii) Pharmacologic

For individuals who need it, the doctor may prescribe sleeping pills. Sleeping pills generally belong to a group of sedatives called benzodiazepines. Certain sedatives such as zolpidem and zopiclone have benzodiazepine-like actions. Different sedatives are effective in promoting sleep in various ways, for example the shorter-acting ones (such as lorazepam) promote initiation of sleep without causing much daytime sedation, whereas the longer-acting ones (such as diazepam) helps one to maintain a longer period of uninterrupted sleep. Despite its proven effectiveness, in a small proportion of users, benzodiazepines are associated with dependence (difficulty stopping its use and need for larger doses over time): this risk is much reduced if the users take the pills for short periods, in moderate doses and under medical supervision. As the patient’s condition improves, the doctor will instruct the tapering down of sedative doses. It is important to note that most users of sleeping pills successfully stop its use when their conditions are treated.

Some individuals taking longer acting benzodiazepine sedatives might experience daytime sleepiness and this is of concern when driving or operating machinery. Sometimes, a person with concerns about the addictive potential of benzodiazepine sedatives may instead be prescribed antihistamines (such as certain flu medicines) or antidepressants with sedating properties. These can work equally well.

It is also important to note that in individuals with depression or anxiety, sleeping pills are adjuncts to antidepressants and anti-anxiety medicines, which are main medical treatment. As the individual’s depression lifts, his sleep will also improve.

There are guidelines set by the Singapore Medical Council regulating the prescription of sedatives by general practitioners, and patients must understand that if the insomnia persists and more sedatives are required, a referral to a psychiatrist may be needed.