Insomnia has plagued humanity since ancient times, but over the past 20 years, scientists have made significant strides in understanding chronic sleep deprivation. In England, about one-third of adults report frequent insomnia symptoms, making it one of the most common psychological problems in Britain.
What Causes Insomnia?
One of the biggest shifts in scientific understanding is that insomnia rarely occurs alone. Most people with insomnia also have other mental or physical health conditions, such as diabetes, hypertension, chronic pain, thyroid disease, gastrointestinal issues, anxiety, or depression. Historically, this was called secondary insomnia, meaning it was considered a consequence of other underlying conditions. As a result, clinicians often did not treat secondary insomnia directly.
However, in the early 2000s, research and clinical evidence began to challenge this view. Scientists argued that insomnia could precede or persist long after the primary condition resolved. Abandoning the primary-secondary distinction was a major advance, acknowledging insomnia as an independent disorder requiring its own treatment. Moreover, studies show that addressing sleep problems can improve other health conditions, including chronic pain, heart failure, depression, psychosis, alcohol dependency, bipolar disorder, and PTSD.
Who Gets Insomnia?
International data over the past two decades reveal how widespread insomnia is. It affects nearly everyone, but women, older adults, and people of lower socio-economic status are more vulnerable. These groups face a combination of biological, psychological, and social risk factors that lead to prolonged sleep disruption. For instance, women often experience hormone fluctuations, pregnancy, breastfeeding, menopause, domestic violence, caregiving roles, and higher rates of depression and anxiety—all contributing to sleep issues.
Current research focuses on understanding different types of insomnia symptoms and their links to health risks. For example, difficulty falling asleep is associated with an increased risk of depression, compared to difficulty staying asleep or waking early. Scientists also investigate changes in brain activity, heart rate, and stress hormones that accompany insomnia. However, biomarkers for insomnia remain elusive, as with other mental health disorders.
Research has identified strategies to prevent acute insomnia from becoming chronic, which is harder to treat. Chronic insomnia is diagnosed when symptoms occur more nights than not for over three months.
Common Habits to Avoid
One harmful habit during insomnia is lying in bed awake trying to sleep. This leads to cognitive arousal and teaches the brain to disconnect bed from sleep. Instead, if you cannot sleep, get up and do something calming, like reading, writing a to-do list, listening to soothing music, or breathing exercises. Return to bed only when sleepy. If tired the next day, a short nap (under 20 minutes) in the afternoon is acceptable, but be cautious as daytime sleep can reduce nighttime sleepiness.
Effective Treatments
Cognitive behavioural therapy for insomnia (CBTI) is the recommended treatment. It includes techniques to maximise sleepiness at bedtime by modifying behaviour and mental activity. Success predictors include shorter insomnia duration (years rather than decades), less depression or pain, and positive expectations. CBTI is broadly effective across all groups.
Despite its efficacy, only a small fraction of people with insomnia seek medical help, often due to trivialising symptoms, unawareness of options, or limited availability. CBTI remains largely unavailable in clinical practice due to clinician unfamiliarity and funding constraints. This leads patients to sleeping tablets, which are not suitable long-term due to cognitive and motor impairment, fall risk, dependence, tolerance, withdrawal, daytime lethargy, dizziness, and headaches.
A newer class of pills, dual orexin receptor antagonists (DORAs), approved in the UK in 2022, show a better safety profile, especially regarding dependence. However, they are not risk-free, and long-term data are lacking. A decent alternative is online self-delivered CBTI, such as the free platform Sleepful.
Great progress has been made in sleep medicine over the past 20 years. The challenge now is to realise the potential of these changes by providing appropriate help to those suffering from insomnia.
