What is the relationship between elevated Dehydroepiandrosterone (DHEA) levels and insomnia?

Elevated DHEA and Insomnia: A Complex Relationship

The relationship between elevated DHEA levels and insomnia is paradoxical—while low DHEA-S is associated with insomnia in frail elderly populations, elevated DHEA may reflect physiological hyperarousal states that perpetuate sleep disturbance.

The Evidence on DHEA and Sleep

The most direct evidence comes from a nursing home study showing that low DHEA-S levels were associated with high degrees of insomnia in elderly patients 1. This suggests that DHEA deficiency, rather than elevation, is typically linked to sleep problems in aging populations 1.

However, this finding must be interpreted within the broader context of insomnia pathophysiology. The American Academy of Sleep Medicine identifies that physiological hyperarousal is a significant factor in chronic insomnia, characterized by increased 24-hour metabolic rate and elevated cortisol levels particularly in the presleep period 2. Since DHEA is an adrenal hormone that rises with stress and arousal states, elevated DHEA may be a marker of the same hyperarousal mechanisms driving insomnia 3.

DHEA in Chronic Fatigue and Sleep Disorders

A key study in chronic fatigue syndrome (CFS) found that basal DHEA levels were significantly higher in patients compared to controls (14.1 vs 9.0 ng/ml), and these higher levels correlated with greater disability scores 3. This demonstrates that elevated DHEA can occur in conditions characterized by sleep disturbance and fatigue 3.

Importantly, when these CFS patients were treated with low-dose hydrocortisone, DHEA levels decreased toward normal and patients experienced reduced fatigue, suggesting that elevated DHEA may represent a maladaptive stress response rather than a protective mechanism 3.

Interpreting Your Patient's Elevated DHEA

When you encounter elevated DHEA in a patient with insomnia, consider the following algorithm:

Step 1: Assess for physiological hyperarousal

• Evaluate for elevated cortisol, particularly evening levels 2
• Screen for anxiety, performance anxiety about sleep, and worry about sleep consequences 2
• Document 24-hour activity patterns and metabolic indicators 2

Step 2: Rule out secondary causes

• Review all medications, as stimulants, decongestants (pseudoephedrine), SSRIs, SNRIs, bronchodilators, and corticosteroids can disrupt sleep and may affect adrenal hormone production 2
• Assess for comorbid psychiatric conditions, particularly depression and anxiety, which show bidirectional relationships with insomnia 2, 4
• Evaluate for medical conditions including cardiovascular disease, pulmonary disease, pain syndromes, and endocrine disorders 2

Step 3: Determine if DHEA elevation is primary or reactive

• If DHEA is elevated with normal or low cortisol, consider exogenous DHEA supplementation (often taken as an "anti-aging" supplement) 5, 6
• If both DHEA and cortisol are elevated, this suggests an activated HPA axis and stress response 3
• If insomnia preceded DHEA elevation, the hormone change is likely reactive to chronic sleep disruption 3

Treatment Approach

Regardless of DHEA levels, cognitive behavioral therapy for insomnia (CBT-I) is the first-line treatment and should be initiated immediately 2, 7. The American College of Physicians provides a strong recommendation for CBT-I as initial treatment for chronic insomnia disorder 2.

CBT-I components should include 7:

• Stimulus control: Go to bed only when sleepy, maintain regular schedule, avoid naps, use bed only for sleep, leave bed after 20 minutes if unable to sleep 7
• Sleep restriction: Track total sleep time for 1-2 weeks, then limit time in bed to match actual sleep time 7
• Cognitive therapy: Address distorted beliefs about sleep 7
• Relaxation training: Progressive muscle relaxation to reduce physiological arousal 7

If CBT-I alone is insufficient after 2-4 weeks, add pharmacological therapy while continuing CBT-I 7. First-line options include short-intermediate acting benzodiazepine receptor agonists (zolpidem, eszopiclone, zaleplon, temazepam) or ramelteon for patients with substance use history 7.

Critical Pitfalls to Avoid

• Do not assume elevated DHEA requires supplementation or specific hormonal treatment—the elevation is likely a marker of underlying pathophysiology rather than the cause 3, 1
• Avoid over-the-counter antihistamines or herbal supplements, as these lack efficacy and safety data in chronic insomnia 7
• Do not overlook medication-induced insomnia, particularly from SSRIs, SNRIs, stimulants, and decongestants that patients may be taking 2
• Screen for bipolar disorder if insomnia is accompanied by decreased need for sleep (not just difficulty sleeping), racing thoughts, or mood lability, as insomnia can precipitate manic episodes 4

The Gender Consideration

DHEA's effects may differ by gender and hormonal milieu 8. In premenopausal women with high estrogen, DHEA acts more androgenically, while in postmenopausal women or men, it may have more estrogenic effects 8. However, these hormonal nuances do not change the fundamental approach to treating insomnia, which remains CBT-I first 2, 7.

Monitoring Strategy

Reassess every few weeks initially to evaluate treatment effectiveness 7. Focus on sleep diary metrics (sleep latency, wake after sleep onset, total sleep time, sleep efficiency) rather than repeat DHEA measurements 2. If DHEA was markedly elevated initially, consider rechecking after successful insomnia treatment to determine if levels normalize with improved sleep 3.