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Insomnia - The Apeiron Life Perspective

6 min read

Updated: Feb 15, 2023


What it is:


More than half of the population experiences insomnia from time to time. This usually occurs during periods of heightened stress but may also be familiar to those who travel frequently or have irregular work schedules. The human body clock does best with consistent routines, so changes in bedtime, mealtimes, or work schedules require an adjustment period.


Sometimes, however, sleep problems persist. Some people struggle to fall asleep, wake up often during the night, or wake up in the early morning and cannot fall back asleep. If this continues for at least 3 nights per week for 3 months or more, this could indicate an insomnia disorder.


There are two treatment options for people with insomnia disorder: pharmacological or behavioral therapies. Sometimes a combination of the two is used. This article will describe what the science shows about insomnia treatments and why cognitive behavioral therapy for insomnia (CBTi) is the first-line recommendation by the American College of Physicians.



The purported claims:

  • Pharmacological therapies are highly effective but can promote dependence and are associated with adverse side effects.

  • CBTi takes longer but is more effective and longer lasting.

  • Digital CBTi is becoming an increasingly popular alternative to traditional in-person therapies for those with limited access.


What the science says:


Sleep is a naturally recurring process that happens mainly on its own. Still, it requires a few factors for success: a safe, comfortable environment, a relaxed mind, and sufficient opportunity to get enough of it.


While some of us can sleep through an earthquake, most need routines that set us up for success. We can think of these good habits as “sleep training,” just as we might train for a marathon. Running a marathon requires being in shape, and staying in shape requires resources, such as healthy produce, cookware, and a pair of running shoes. It also requires consistency – we can’t run two blocks once in a blue moon and expect to miraculously achieve 26 miles on the big day. Lastly, it requires positive beliefs about who we are and what we are capable of, especially when things get tough. Sleep is no different.


Sleep resources range from an eye mask to a white noise machine. Consistency involves getting into and out of bed at a reasonable time night after night. And if we have the occasional night of tossing and turning, it’s important to remind ourselves that this doesn’t mean we’re incapable of sleeping well, but rather that we might have to tweak a few things.


Insomnia – when it appears – generally has a cause. We might have an injury or chronic pain that prevents us from getting comfortable. We might be drinking too much coffee too late in the day or taking a new medication that promotes alertness. Our circadian rhythm could be out of sync due to un-checked ambient light levels from spending too little time outside or too much time staring at screens at night.


Taking the time to understand why you are struggling to sleep is the first step in treating insomnia. For example, if you find yourself lying awake the night before an important meeting, it’s perfectly normal. Occasionally, we can expect this type of insomnia and know our bodies can cope with it in the short term.


However, if insomnia persists, the first step is objectively examining your sleep habits. Ask yourself:

  • Are you allowing yourself plenty of time to wind down before bed?

  • Do you have a dark, quiet, comfortable place to sleep?

  • Are you reducing your screen time in the evening?

All of these can promote better sleep. Sometimes, however, we do everything correctly, and still, we find ourselves lying there wondering why we can’t drift off. An appointment with a behavioral sleep specialist might be necessary at this stage.


The first step is to speak with your doctor. They may offer one of several sleep medications, including:

  • Benzodiazepines (e.g., Klonopin) – These are an older style of sleeping pills with numerous side effects. They are sedatives that can be addictive or even lethal when mixed with alcohol or if a person suddenly withdraws from high doses. After long-term use, withdrawal can also cause rebound insomnia which can be a stressor.

  • Non-benzodiazepine “Z-Drugs” (e.g., Ambien) – These are also sedatives, but typically preferred over benzodiazepines. They can still cause dependence and side effects, including headaches, daytime sleepiness, and next-day grogginess.

  • Antidepressants (e.g., Desyrel) – These are prescribed when insomnia and depression co-occur and can effectively treat both. They can produce adverse side effects, including hallucinations and a rapid heart rate.

  • Orexin blockers (e.g., Belsomra) – Orexin neurons in the brain promote wakefulness, appetite, reward, and motivation. Orexin blockers prevent this neuron transmission leading to mood alteration and intense dreams.

While many of these drugs are highly effective at offering short-term solutions for sleep problems, the side effects often make them less desirable for long-term use. Therefore the first-line treatment recommended by the American College of Physicians is CBTi.


CBTi is a short-term therapy (typically 6-8 sessions) provided by a behavioral sleep medicine specialist. It can take place either in-person or online and is highly effective at recalibrating a person’s relationship with sleep.


There are three fundamental principles that a practitioner will address during CBTi:

  1. The thoughts or anxiety that a person has about not being able to sleep.

  2. How a person can reduce the stimuli in their bedroom that may prevent them from sleeping (e.g., cellphones, television).

  3. Sleep restriction, where a person has restricted time in bed (and thus is banned from lying awake tossing and turning.) This helps to retrain the brain only to associate the bed with sleep (and sex).


While medications can be highly effective in the short term, they do not address the root cause of insomnia. Therefore, when most people stop taking drugs because of adverse associated side effects, insomnia tends to return and can even be worse than before. Numerous clinical trials have demonstrated that CBTi promotes long-term insomnia remission. It has also been shown to improve depression. A recent clinical trial by Dr. Philip Cheng and colleagues (2019) found that 51% of the 358 participants who received CBTi reported no depression at 1-year follow-up.


This clinical trial, and many others, used digital CBTi (dCBTi), which is growing in popularity as a way of offering therapy without needing physical access to a clinic. This is particularly useful for those living in rural areas or frequently traveling for work. Platforms such as Sleepio and Somryst are new, evidence-based, fully automated modalities that allow users to take control of their insomnia through goal setting and a program tailored to their needs through a phone or tablet.


CBTi is not just effective for those with depression but also for populations such as older adults, menopausal women, and those with cancer. It can also be beneficial when insomnia co-occurs with sleep apnea and is used in conjunction with continuous positive airway pressure (CPAP) or other breathing aids.



Our take:


Insomnia can occur for many different reasons, such as aging, hormonal changes, and illness, which are all inevitable. However, if you suspect it’s happening because of stress and you find it challenging to wind down in the evening, consider implementing some stress-busting tools into your routine. Make time for sufficient exercise, eat a healthy diet at least 80% of the time, and aim to spend at least 30 minutes outside every day to synchronize your brain’s circadian rhythm. Mindfulness practices such as yoga and meditation can also be helpful.

If it feels as though you have tried all these things and nothing seems to be helping, do not feel as though you have to suffer in silence. Discuss your concerns with your Apeiron Life Client Advocate, who can help you find the right solution.



Will this benefit you?


It's now well understood that healthy sleep is essential for long-term physical, mental, and emotional wellbeing. Many lifestyle factors that contribute to better sleep also promote better general health. While CBTi or medication may be needed to help those experiencing insomnia, everyone can benefit from healthy sleep routines that promote relaxation at night.


Still curious to try it? If you do, here's what to keep an eye on:

Insomnia can sometimes co-occur with other sleep disorders, such as obstructive sleep apnea (OSA) or restless leg syndrome (RLS.) If you snore or experience discomfort in your legs that keep you up at night, be sure to tell your doctor as additional treatments may be available that address the root cause of your insomnia.


Another thing to consider is whether your wearable sleep tracker is becoming a source of stress. If you check your sleep data each morning and fret that you haven't achieved your sleep goals, consider taking a break from the device and trusting your gut instinct instead. Even though these devices are becoming increasingly popular among consumers and sleep studies, they are inaccurate and should not replace how we feel about our sleep.

Most of us will experience insomnia from time to time, and it can be helpful to know that a few nights here and there is normal and will pass. Prevention is vital, so establish healthy habits for sleep, exercise, and diet, which will help in the long term. If insomnia persists, do not hesitate to speak to your doctor – there are plenty of solutions that can get your sleep back on track.


References:


dCBTi comparable to in-person - https://pubmed.ncbi.nlm.nih.gov/26615572/

CBTi vs pharmacologic treatment - https://pubmed.ncbi.nlm.nih.gov/8037252/

Tapering off medication during CBTi - https://pubmed.ncbi.nlm.nih.gov/19454639/

Insomnia and cooccurring conditions - https://pubmed.ncbi.nlm.nih.gov/34792177/




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