What are the common causes and treatments of insomnia in adults?

From the Guidelines

Insomnia in adults is commonly caused by stress, anxiety, depression, poor sleep habits, certain medications, medical conditions, caffeine, alcohol, and irregular sleep schedules, and should be treated with cognitive behavioral therapy for insomnia (CBT-I) as the first-line treatment. The most recent and highest quality study, published in 2021 by the American Academy of Sleep Medicine, supports the use of CBT-I as the primary treatment for chronic insomnia disorder in adults 1. This study found that CBT-I improved sleep outcomes, including reduced sleep onset latency and wake after sleep onset, and improved sleep efficiency and sleep quality.

Some of the common causes of insomnia in adults include:

• Stress and anxiety
• Depression and other psychiatric disorders
• Poor sleep habits, such as irregular sleep schedules and consuming caffeine and alcohol before bedtime
• Certain medications, such as those used to treat depression, anxiety, and hypertension
• Medical conditions, such as sleep apnea, restless leg syndrome, and chronic pain
• Irregular sleep schedules, such as those experienced by shift workers or travelers

Treatment options for insomnia in adults include:

• Cognitive behavioral therapy for insomnia (CBT-I), which includes sleep hygiene improvements, such as maintaining a consistent sleep schedule, creating a comfortable sleep environment, avoiding screens before bed, limiting caffeine and alcohol, and exercising regularly but not close to bedtime 1
• Over-the-counter options, such as melatonin (0.5-5mg taken 1-2 hours before bedtime) and antihistamines like diphenhydramine (25-50mg)
• Prescription medications, such as benzodiazepines (like temazepam 15-30mg), non-benzodiazepine hypnotics (like zolpidem 5-10mg, eszopiclone 1-3mg), orexin receptor antagonists (like suvorexant 10-20mg), and certain antidepressants (like trazodone 25-100mg) 1

It is essential to address underlying conditions that may be contributing to insomnia, such as sleep apnea, restless leg syndrome, or psychiatric disorders. CBT-I is preferred as a first-line treatment because it addresses the root causes of insomnia and provides long-lasting benefits without the side effects associated with medications 1.

From the FDA Drug Label

14.2 Chronic Insomnia Zolpidem was evaluated in two controlled studies for the treatment of patients with chronic insomnia (most closely resembling primary insomnia, as defined in the APA Diagnostic and Statistical Manual of Mental Disorders, DSM-IV™)

The FDA drug label does not answer the question of common causes of insomnia in adults, but it does discuss the treatment of chronic insomnia.

• Common causes of insomnia are not directly addressed in the provided drug labels.
• The labels discuss treatment options for insomnia, including zolpidem and ramelteon, but do not provide information on the underlying causes of the condition 2, 3.

From the Research

Common Causes of Insomnia in Adults

• Insomnia is a significant public health problem due to its high prevalence and management challenges 4
• It is often associated with various medical and psychiatric comorbidities, such as mood, anxiety, and psychotic disorders 5
• The symptom of insomnia can be acute, intermittent, or chronic and may be the presenting symptom for several common sleep disorders 6
• Insomnia can also occur comorbidly with mental and physical health conditions, making evaluation and treatment more complex 6

Treatment of Insomnia in Adults

• Cognitive behavioral therapy for insomnia (CBT-I) is the mainstay of treatment and is a safe and effective approach 4, 7, 5
• CBT-I is the preferred treatment approach due to its efficacy, safety, and durability of benefit 6
• Pharmaceutical treatments, such as nonbenzodiazepines (e.g., zolpidem, zaleplon) and melatonin agonists (e.g., ramelteon), are also used to treat insomnia 4, 7, 8
• Newer therapeutic options, such as those acting on orexinergic systems, may represent interesting pathways for intervention in insomnia treatment in mental disorders 5
• Treatment of insomnia may not only foster normal sleep processes but also the stress system, neuroinflammation, and brain plasticity, playing a preventive and neuroprotective role 5