Insomnia

Disease Description (Causes and Symptoms)

• Definition summary: Insomnia refers to a condition in which a person continuously has difficulty falling asleep (sleep-onset difficulty) for more than 2 weeks despite having an appropriate sleep environment, frequently wakes during the night (middle-of-the-night awakenings), or wakes early in the morning and cannot fall back asleep.
• Main causes: Lifestyle habits (caffeine, alcohol, smoking, irregular bedtime), environmental factors (noise, light, temperature), physical illnesses (sleep apnea, pain, acid reflux, etc.), psychiatric disorders (depression, anxiety), medications (anticancer drugs, thyroid medications, antidepressants, etc.), and abnormalities in the sleep–wake rhythm.
• Pathophysiology (brief): Chronic insomnia is explained by cognitive and physical hyperarousal, imbalance in sleep–wake homeostasis and circadian rhythms, and interactions with underlying conditions.
• Main symptoms: Difficulty falling asleep, frequent awakenings, insufficient sleep due to early waking, and daytime fatigue, reduced concentration, and mood changes (anxiety and depression). Physical symptoms such as rough skin, decreased appetite, and weight loss may also occur.

Treatment Methods

• First-line treatment (standard for chronic insomnia): Cognitive Behavioral Therapy for Insomnia (CBT‑I)
  • Components: Sleep restriction, stimulus control, cognitive therapy (correcting negative beliefs about sleep), relaxation techniques, and sleep hygiene education.
  • Effect: Lowers the long-term relapse rate and reduces medication dependence. Recommended as the priority treatment.
• Medication treatment (short-term or adjunctive use)
  • Nonbenzodiazepine sleeping pills (‘Z-drugs’: zolpidem, eszopiclone, etc.) — short-term use is recommended; lower doses and caution are advised in older adults.
  • Benzodiazepines — used during the acute phase and for short-term treatment, but caution is needed regarding dependence and the risk of falls.
  • Low-dose doxepin, ramelteon (a melatonin agonist) — useful in some patients.
  • Orexin receptor antagonists (suvorexant, lemborexant) — effective for both sleep-onset and sleep-maintenance difficulties; side effects and interactions must be checked.
  • Melatonin adjunctive therapy — considered particularly for circadian rhythm disorders or in older adults.
  • Caution: Long-term use may lead to reduced effectiveness, dependence, daytime sleepiness, cognitive impairment, and an increased risk of falls. The decision to take medication should be based on an individual assessment of benefits and risks.
• Treatment of underlying conditions: If underlying conditions such as sleep apnea, liver disease, thyroid disease, or depression are present, treating those conditions takes priority.
• Lifestyle management (sleep hygiene)
  • Maintain a regular wake-up time, limit caffeine, nicotine, and alcohol before bedtime, limit naps, limit electronic device use before bedtime, and create a comfortable sleep environment.
• Other treatments
  • Relaxation therapy, meditation, muscle relaxation, and light exercise (avoid vigorous exercise before bedtime).
  • Alternative options such as digital CBT‑I and group therapy.

Outpatient Visit Checklist (Including Items to Bring and Sample Questions)

• Items to bring
  • A list of medications currently being taken (including prescription drugs, OTC medications, herbal medicines, and supplements) and the times they are taken
  • A sleep diary from the past 2–4 weeks (bedtime, wake-up time, number of awakenings, naps, and records of caffeine and alcohol use)
  • Previous test results (such as blood tests, thyroid tests, and polysomnography results) and medical certificates
  • Results of sleep-related questionnaires (e.g., the Epworth Sleepiness Scale), if available
  • Records related to coexisting conditions (depression, anxiety, pain, respiratory conditions, and cardiovascular conditions)
• Things to consider in advance of the outpatient visit
  • When the symptoms began, aggravating factors (stress, medications, environmental changes), daytime activities (sleepiness and reduced concentration), and previously attempted treatments (sleeping pills and nonmedication treatments), including their effects and side effects.

Examples of General Questions to Ask the Doctor

• What are the effects and expected duration of use for this medication (the recommended sleeping pill, antidepressant, etc.)? What are its side effects?
• Is CBT‑I appropriate for me? Where can I access treatment (in person or online)?
• How likely is it that my sleep problem is caused by a medical condition (sleep apnea, thyroid disease, etc.)? Will I need testing?
• How should I stop taking sleeping pills (tapering plan), and what withdrawal symptoms may occur?
• What lifestyle advice can I follow right away to reduce daytime sleepiness and impaired functioning?

Examples of Condition-Specific Questions

• Could my symptoms be related to sleep apnea? Do I need testing (polysomnography or a simplified sleep test)?
• Could any of the medications I am currently taking (e.g., antidepressants, thyroid medications, blood pressure medications, etc.) be causing insomnia? Are there alternative medications?

Note: The information above is general medical information. Individual diagnosis and treatment should be determined through consultation with the treating physician.