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  • More Than a Symptom

    Over the past several decades, insomnia has been studied more closely than ever.2-4 With growing acknowledgment that insomnia can be more than a symptom, it became necessary to update the official diagnostic criteria.2,3

    Now, there is a distinction between insomnia symptoms and insomnia disorder.3,4

    Are you up for learning the latest about insomnia?

    Approximately one-third of adults experience insomnia symptoms.4

    6% to 10% meet the current diagnostic criteria for insomnia disorder.4

    Insomnia disorder can now be diagnosed whether it occurs independently or is
    comorbid with another medical condition or psychiatric disorder.4

    This shift in diagnostic criteria highlights the need for an isolated focus on diagnosing and treating insomnia disorder, regardless of other psychiatric or medical conditions that may be present.3

    Epidemiology and Diagnosis

    You may already be aware that insomnia symptoms are widely experienced, but
    insomnia disorder is underaddressed in the United States.1,5-7 This could be due to
    differing and varying perceptions of the disorder, its impact, and the role of treatment.8

    Insomnia symptoms are more common in8

    Women

    Middle-Aged
    Adults

    Elderly

    Risk factors for insomnia disorder can include: mood and anxiety disorders, type 2 diabetes, cardiovascular disease, and arthritis.9

    The major diagnostic criteria for insomnia disorder include4:

    Symptoms

    Difficulty falling asleep or
    staying asleep or waking too
    early in the morning that
    leads to dissatisfaction with
    sleep quantity or quality

    Impairment

    Sleep disturbance that leads to
    impairment in social, work,
    educational, behavioral, or other
    areas of functioning, or that may
    cause significant distress

    Chronicity

    Experiencing sleep difficulty
    while having adequate
    opportunity to sleep, at least
    3 nights per week for at least
    3 months

  • Next-Day Functional Impact

    Inadequate sleep from insomnia can have next-day consequences1:

    Fatigue

    Impaired Cognitive
    Function and Memory

    Daytime
    Sleepiness

    Because insomnia is a chronic condition, it can have a substantial impact on a person’s quality of life.

    Patients with insomnia have reported reduced quality of life in the following areas10,11:

    • Physical functioning
    • Physical health problems
    • Bodily pain
    • General health perceptions
    • Vitality
    • Social functioning
    • Emotional health problems
    • Mental health problems

    The burden of insomnia has been calculated in studies as the number of quality-adjusted life-years
    (QALYs) lost to insomnia. These studies reported that insomnia has a significantly higher QALY loss
    than other medical conditions and psychiatric disorders,
    such as depression, arthritis, and other
    health conditions.9

    ~67 billion Insomnia-related presenteeism and
    annual loss of work performance12,13
    ~32.3 billion Insomnia-related accidents or errors13,14 

    In the workplace, patients with insomnia have10,15,16:

    • Higher risk of accidents
    • Higher rates of work absenteeism
    • Diminished job performance

    For patients already being treated for insomnia, the next-day impact may be due to the residual effects of their insomnia medications. These effects can manifest as17:

    • Headache
    • Grogginess
    • Difficulty concentrating
    • Difficulty remembering

    Approximately

    of patients taking insomnia
    medications reported experiencing
    residual next-day effects.17

  • Medical and Psychiatric Impacts

    If left untreated, insomnia may increase the risk of certain conditions, including:

    Neurologic

    • Parkinson’s disease18
    • Dementia19
    • Alzheimer’s disease/cognitive impairment20

    Cardiovascular

    • Cardiovascular disease21
    • Heart attack22
    • Stroke21
    • Heart failure23

    Inflammatory

    • Autoimmune disease24
    • Asthma25

    Cancer

    • Breast cancer26

    Psychiatric

    • Major depressive disorder27
    • Anxiety disorder27
    • Bipolar disorder28
    • Schizophrenia28
    • PTSD in military personnel29
    • Substance-related disorders28
      • Alcohol abuse27

    Endocrine

    • Type 2 diabetes in patients with pre-diabetes30

    Chronic Pain

    • Chronic widespread musculoskeletal complaints31

    Also, insomnia has been shown to increase the risk of mortality-related events:

    • Suicide attempts32
    • All-cause mortality33
    • Cardiovascular-related mortality22,34

    PTSD=posttraumatic stress disorder.

    Treating both insomnia and a comorbidity individually may result in better outcomes than treating the comorbidity alone.35,36

  • Pathophysiology

    The sleep-wake cycle is regulated by sleep promotion and wake promotion pathways. Wake
    promotion is regulated by orexin, a neuropeptide in the brain that plays a critical role in stabilizing
    the switch from sleep to wake states.37,38

    Orexin physiology in the sleep-wake system37

    Sleep state

    To enable sleep states,
    neurons dampen wakefulness
    via GABA neurotransmitter
    and inhibit orexin activation of
    wake-promoting neurons of
    the brain.37

    = inhibition

    = activation


    Wake state

    To enable wake states, increased orexin activates wake-promoting neurons. In turn, sleep-promoting neurons are inhibited.37

    = inhibition

    = activation


    When the sleep-wake system functions normally, as shown above, the 2 parts complement each other and result in healthy sleep patterns.37

    Insomnia is thought to be the result of one having a chronic state of hyperarousal. Patients who have insomnia may have overactive wake-promoting neurotransmitters that are independent of any psychological, medical, or drug-related stressors.38,39

    5-HT=serotonin; ACh=cholinergic; DA=dopamine; GABA=Gamma-amino butyric acid; His=histamine; NA=noradrenaline.

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