What conditions are associated with insomnia?

Conditions Associated with Insomnia

Insomnia is most commonly associated with psychiatric disorders, medical conditions, medications/substances, and other primary sleep disorders, all of which require careful evaluation and targeted treatment to improve morbidity, mortality, and quality of life. 1

Medical Conditions Associated with Insomnia

• Cardiopulmonary disorders, including heart disease, chronic obstructive pulmonary disease, and sleep-related breathing disorders (e.g., obstructive sleep apnea) 1
• Neurological disorders, including Parkinson's disease, Alzheimer's disease, and other neurodegenerative conditions 1
• Chronic pain syndromes, including arthritis, fibromyalgia, and neuropathic pain 1
• Gastrointestinal disorders, particularly those causing nocturnal symptoms 1
• Endocrine disorders, including hyperthyroidism and diabetes 1
• Movement disorders during sleep, including restless legs syndrome and periodic limb movement disorder 1

Psychiatric Conditions Associated with Insomnia

• Depression - patients with depression are 2.5 times more likely to report insomnia, with a bidirectional relationship where insomnia can both precede and result from depression 1
• Anxiety disorders, including generalized anxiety disorder, panic disorder, and post-traumatic stress disorder 1
• Bipolar disorder - sleep disturbances are common and may be both a symptom and trigger for mood episodes 2
• Substance use disorders, including alcohol dependence 1

Medications and Substances Associated with Insomnia

• Antidepressants, particularly SSRIs (fluoxetine, paroxetine, sertraline, citalopram, escitalopram, fluvoxamine), venlafaxine, duloxetine, and monoamine oxidase inhibitors 1
• Stimulants, including caffeine, methylphenidate, amphetamine derivatives, ephedrine, and cocaine 1
• Decongestants, such as pseudoephedrine, phenylephrine, and phenylpropanolamine 1
• Narcotic analgesics, including oxycodone, codeine, and propoxyphene 1
• Cardiovascular medications, including β-blockers, α-receptor agonists and antagonists, diuretics, and lipid-lowering agents 1
• Pulmonary medications, such as theophylline and albuterol 1
• Alcohol - while initially sedating, it disrupts sleep architecture and causes sleep fragmentation 1

Other Sleep Disorders Associated with Insomnia

• Circadian rhythm sleep disorders, including delayed sleep phase syndrome and shift work disorder 1
• Sleep-related breathing disorders, particularly obstructive sleep apnea 1
• Movement disorders during sleep, including restless legs syndrome and periodic limb movement disorder 1

Consequences of Untreated Insomnia

• Increased mortality risk - particularly in older adults who take more than 30 minutes to fall asleep and have sleep efficiency less than 80% 1
• Cognitive impairment - difficulty with memory, attention, and complex mental tasks 1
• Mood disturbances - irritability, loss of interest, anxiety, and worsening depression 1
• Increased risk of falls - especially in older adults who nap during the day and sleep less than 7 hours at night 1
• Impaired quality of life and interpersonal relationships 1
• Higher healthcare utilization and costs 1, 3
• Increased risk of accidents, including motor vehicle accidents 1, 4

Important Clinical Considerations

• When evaluating insomnia, it's crucial to determine whether comorbid conditions are causing insomnia or simply coexisting with it 5
• Multiple insomnia diagnoses may coexist and require separate identification and treatment 1
• The failure of insomnia to remit after 7-10 days of treatment may indicate an underlying psychiatric or medical illness that requires evaluation 4, 6
• Daytime sleepiness is not typically a primary symptom of insomnia and should prompt investigation for other sleep disorders 1
• Medications used to treat insomnia may themselves cause complex sleep behaviors and cognitive impairment that can impact quality of life 4, 6

Clinical Pitfalls to Avoid

• Treating insomnia solely as a symptom rather than as a potential independent disorder requiring specific treatment 5
• Failing to recognize the bidirectional relationship between insomnia and comorbid conditions (particularly depression), where each can exacerbate the other 1
• Overlooking medication side effects or substance use as potential causes of insomnia 1
• Missing underlying sleep disorders such as sleep apnea or restless legs syndrome that may present with insomnia symptoms 1
• Neglecting to assess for daytime consequences of insomnia, which are essential for diagnosis and treatment planning 1