Take On Insomnia Head-on

Dr. WONG Chak Tong

Resident Medical Officer

Specialist in Family Medicine

Insomnia is common in people of all ages. A recent survey by the HKU’s Department of Psychiatry shows that, in the 15-24 age group, over 23.5% of respondents are present with symptoms of insomnia. In another survey conducted by Caritas Youth and Community Service with Caritas Institute of Higher Education, 1 out of 8 people aged 15 to 60 reports difficulty to stay concentrated in at least a day per week. A quarter of them, mostly youths, say they use alcohol to help them sleep.

Criteria for Insomnia

According to the 5^th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the criteria for the diagnosis of insomnia include predominant complaint of dissatisfaction with sleep quantity or quality, associated with difficulty initiating sleep, maintaining sleep, and/or early-morning awakening with inability to return to sleep. The sleep difficulty must occur at least 3 days per week and present for at least 3 months despite adequate opportunity for sleep.  

Adverse Impacts of Insomnia

You may feel tired and having difficulty paying attention or remembering after a sleepless night, resulting in poor school or work performance. Insomnia also increases the risk of industrial and traffic accidents as you are too tired to operate heavy machinery or drive vehicle.   

Poor sleep may also lead to irritability and more conflicts in family or at work. The adverse impact is more obvious in case of chronic insomnia, even causing mental disorders such as depression and anxiety disorder. Drug and alcohol dependence may develop if one resorts to them to promote sleep. Chronic insomnia can also increase the risk of hypertension, coronary heart disease, diabetes, etc.

Causes of Insomnia

1. Work Pressure

Concerns about school, work and family can keep your mind active at night, causing palpitation, muscle tension, etc. Those who are prone to disruption in circadian rhythms, e.g. working at night/being on a rotating shift (such as medical personnel, stock traders) or travelling across different time zones at work (such as airline personnel) are at greater risk of insomnia. 

2. Poor Sleep Habits

You may experience a backflow of acid from the stomach into the esophagus if you eat too much late in the evening, or frequent urination if you drink too much water. Smoking and drinking coffee, strong tea and alcohol at night also keeps you awake.

You may also find it difficult to fall asleep after watching television or using mobile phone/laptop in bed, or due to bright light and uncomfortable temperature in your bedroom.

3. Medical Conditions

Prostatic hyperplasia, overactive bladder and diabetes can cause frequent urination at night. Patients with overactive thyroid may also find it difficult to get to sleep, while those with chronic obstructive pulmonary disease or heart failure can suffer insomnia due to breathing difficulty.

4. Mental Health Disorders

Insomnia can be a symptom of depression, anxiety disorder or post-traumatic stress disorder.

5. Medications

Some medications may lead to insomnia, e.g. SSRI antidepressant, bronchodilators (for treatment of asthma) and certain antihypertensive drugs. Certain over-the-counter drugs may have the same effect if they contain pseudo-ephedrine, e.g. decongestants.

6. Sleep Disorders

Sleep disorders like sleep apnea, periodic limb movement disorder, restless legs syndrome may affect sleep quality.

7. Primary Insomnia

Primary insomnia is diagnosed when all the above causes are ruled out during clinical assessment.

Assessment of Insomnia

Your doctor will try to understand your sleep pattern through consultation, body check-up and tests. To find out the underlying causes of insomnia, a sleep test may also be conducted to monitor your brainwave activity, breathing, heartbeats as well as eye and body movements during sleep.

Treatment of Insomnia

Targeted treatment is required for insomnia once the underlying condition is identified. As the first-line treatment, proper sleep hygiene and lifestyle modifications can help promote better sleep.   

• Psychological Treatment

As one of the treatment options for insomnia, cognitive behavourial therapy is no less effective and far safer than sleeping pills. It helps patients identify the causes of insomnia and correct some wrong ideas about sleep, e.g. the misconceptions that one needs at least 7 to 8 hours of sleep each day, or one cannot fall asleep without sleeping pills.

• Over-the-counter Drugs

Over-the-counter drugs refer to medications that you can buy in a pharmacy or supermarket without a doctor’s prescription. Examples include the first-generation antihistamines (often used as cold medicine). They can cause drowsiness after use, and are unsuitable for patients with glaucoma and prostatic hyperplasia.

Melatonin may help promote sleep, though to a limited extent, in those who are on a rotating shift or needs to travel across different time zones at work.

• Prescription Drugs

You may be prescribed sleeping pills as short-term treatment if all of the above treatment options fail or before cognitive behavourial therapy takes effect. Sleeping pills can help you fall asleep faster and sleep longer.

Benzodiazepines are commonly used as sleeping pills, e.g. Lorazepam and Diazepam. It helps one fall asleep faster, extend sleeping time and reduce tiredness after sleep. Prescribed as short-term treatment, benzodiazepines may lead to dependence when used for weeks at a time, causing poor memory, hallucination, breathing difficulty and increased falls risk in the elderly.

Also known as ‘Z’ drugs, non-benzodiazepines, despite different chemical structure, are the same as benzodiazepines in terms of effect, adverse reactions and risks. Common examples are Zolpiclone and Zolpidem.

With proper treatment, patients with insomnia can enjoy better mental health and quality of life. Instead of using supplements of unknown origin or adjusting the dosage on your own, consult your doctor for any sleep-related problems. Wish you good sleep and good health!