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At a glance

  • Only 6% of the population consults with a health-care provider.
  • Data suggest that insomnia predicts future psychiatric disorders, including depression, anxiety and alcohol abuse.
  • Obtaining a thorough medical and psychiatric history is necessary when evaluating a person who has insomnia.
  • Melatonin is one of the few dietary supplements promoted to treat insomnia that has been studied extensively.

Sleeplessness caused by insomnia — a common disorder that affects 10% to 17% of the population — leads to a variety of functional impairments, including difficulty coping; accomplishing tasks; and entering into, developing and maintaining relationships. Additionally, those who suffer from insomnia often find themselves struggling with depression and anxiety.

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While many people are aware that they suffer from a lack of sleep or an inability to maintain sleep, this condition is often not communicated to the health-care professional. It is incumbent on the treating clinician to inquire as to the patient’s sleep habits and patterns and to be cognizant of other conditions that could potentially interrupt what would otherwise be normal sleep, leading to insomnia.

Normal sleep

As anyone who has battled insomnia knows, sleep is considered essential for everyday functioning. Furthermore, sleep is considered a reversible behavioral state, unlike a coma. When one sleeps, he or she is considered to be “perceptually disengaged” from the surrounding environment, although not completely disengaged: The activity of sleep involves every organ of the body and is controlled by the central nervous system (CNS). The sleep process involves two remarkably different states: rapid eye movement (REM) sleep and non-REM (NREM) sleep.1

The sleep-wake cycle involves alternating periods of REM and NREM sleep, with REM sleep accounting for approximately 25% of one’s sleep pattern. During REM sleep, brain activity and oxygen consumption are increased, which is not the case in NREM sleep.2 The heart rate is variable, and respiration is irregular because the body’s ability to regulate or maintain low levels of carbon dioxide is compromised. The result is an increase in the effects of certain breathing disorders, including chronic obstructive pulmonary disease (COPD), sleep apnea, and asthma.

Most voluntary skeletal muscles are actively paralyzed during REM sleep. The majority of dreaming occurs during REM sleep as well. Patients with sleep disorders that affect the REM sleep cycle are able to move in response to their dreams. Such movement can be dangerous to the patient and possibly others if these dreams are violent in nature.

NREM sleep accounts for the remaining 75% of sleep time. In this cycle, the heart rate is steady and respiration is slow and monotonous. Brain activity and oxygen consumption also decrease during NREM sleep.

How much sleep is needed?

According to the National Sleep Foundation, most people get seven to eight hours of sleep per night.3 Is this enough? To answer this, one must examine an individual’s sleep requirements by assessing daytime sleepiness.

The Epworth Sleep Scale (ESS) assesses how likely a person is to fall asleep in such everyday situations as driving or riding in a car. Any score greater than 10 is considered abnormal and identifies a sleep problem requiring attention. Based on the ESS, one third of Americans are too sleepy, meaning they are either not getting enough sleep, not getting enough sound sleep, or some combination of the two.4

When assessing sleep behaviors and needs, ask two simple questions: (1) How much sleep do you require to feel refreshed and alert for the entire day? And (2) How much sleep do you need to stay awake even during the most soporific conditions?


Insomnia appears to be slightly more prevalent among women. Approximately 2.5% of primary-care patients report all three components of the diagnosis (i.e., difficulty falling asleep, difficulty staying asleep, and waking too early). Approximately 10% of the population reports a problem with just one of those three symptoms. Only 6% of the population consults with a health-care provider to specifically address sleep issues, whereas an astounding 70% never discuss sleep problems with a clinician.5-11


Statistical data show a correlation between insomnia and various functional impairments. Although a direct cause-and-effect relationship has yet to be determined, patients who have trouble sleeping often report having difficulties with coping, accomplishing tasks, maintaining satisfactory personal and familial relationships, and controlling moods. Depression, anxiety, and loss of vitality are more common among those suffering from insomnia.

Additionally, insomnia affects one’s job performance: One study showed a 16% incidence of absenteeism at work in those suffering from insomnia. And, when at work, these same individuals performed poorly at their assigned tasks and were more dissatisfied with their jobs in general.12-15

Accidents are another consequence of insomnia. One study found a 9% incident rate of serious accidents in chronic insomniacs, while another showed that people with sleep problems were 3.5 times more likely to have a motor-vehicle accident than those who slept well.15

The three Ps

Persons predisposed to insomnia—whether such predisposition exists because of one’s personality, individual sleep-wake cycle, or circadian rhythm—are often influenced by a variety of life events that can be situational, medical, or environmental. While these factors may precipitate insomnia, others—such as drug and alcohol abuse or poor sleep hygiene—can perpetuate it.

To help explain the progression of chronic insomnia, remember the three Ps—Predisposing, Precipitating, and Perpetuating factors.16-18

Predisposing factors:

  • Personality
  • Sleep-wake cycle
  • Circadian rhythm
  • Coping mechanisms
  • Age

Precipitating factors:

  • Situational
  • Environmental
  • Medical
  • Psychiatric
  • Medications

Perpetuating factors:

  • Conditioning
  • Substance abuse
  • Performance anxiety
  • Poor sleep hygiene