Introduction
Insomnia, a sleep disorder that affects a significant proportion of the general population , can have a significant impact on physical and mental health , disabling a person's daytime performance and quality of life. One of the problems in interpreting insomnia lies in the different sets of questions and criteria used to assess and define insomnia. [1] There are several ways to define and subdivide insomnia. The etiology and pathophysiology of insomnia involve genetic, environmental, behavioral and physiological factors that culminate in hyperarousal. The diagnosis of insomnia is established by a patient history, which includes the characterization of sleep, known illnesses, medications, among others, complemented by a prospective record of sleep patterns (sleep diary). Insomnia is a risk factor for deterioration in function , the development of other medical disorders (including mental) and increased health care costs. [two]
Definition and Characterization of Insomnia
Insomnia is often characterized by a subjective complaint of difficulty in initiating or maintaining sleep, or by sleep that is not perceived as restorative, regardless of how long one sleeps. It results in fatigue, irritability, decreased concentration, among others. It varies in intensity and duration. [3] According to previous guidelines, insomnia was classified as primary (idiopathic) and secondary (comorbid) insomnia. According to current guidelines, insomnia can be classified as chronic insomnia disorder, short-term insomnia disorder, and other insomnia disorders. [9]
A chronic insomnia disorder is considered to be one that causes sleep problems that last at least three nights a week for at least 4 weeks . Chronic insomnia disorder includes:
(a) primary insomnia, that is, not attributable to other medical conditions;
(b) secondary insomnia, that is, comorbid insomnia, which is normally associated with psychiatric disorders, other medical pathologies, substance abuse and specific sleep disorders. [9]
Insomnia can be acute or short-lived , when it refers to sleep problems that last from one night to a few weeks. There is a wide variety of terminology used to define the duration of insomnia symptoms, which can increase confusion regarding the classification of insomnia. Diagnostic tools to detect insomnia are multifactorial. [3]
Research Diagnostic Criteria for Insomnia
To meet the investigational diagnostic criteria for general insomnia, the individual must meet each of the three criteria below:
1. Reports at least one of the following sleep-related complaints:
- difficulty initiating sleep
- difficulty staying asleep
- waking up too early
- chronically unrefreshing or poor-quality sleep.
Difficulty sleeping occurs despite adequate sleep opportunities and circumstances.
Experience at least one of the following forms of daytime disturbance related to nighttime sleep difficulty:
- fatigue/malaise
- decreased attention, concentration, or memory
- social/vocational dysfunction or poor school performance
- mood disturbance/irritability
- daytime drowsiness
- reduced motivation/energy/initiative
- propensity for errors/accidents at work or while driving
- worries or concerns about sleep.
- tension headaches and/or gastrointestinal symptoms in response to sleep loss
Most clinicians and researchers consider that ≥ 30 minutes of falling asleep and/or ≥ 30 or more minutes of wakefulness after sleep onset and a total sleep time of ≤ 6.5 hours per night represent the threshold between normal and abnormal sleep. . Although a frequent complaint of ≥ 3 nights per week is used as an inclusion criterion in many insomnia trials, this criterion is less frequently used clinically. [4]
There are numerous instruments for the independent assessment of sleep disorders. Among the most used are the Pittsburgh Sleep Quality Index [5], which provides a global assessment of sleep, and the Insomnia Severity Index [6], designed specifically for insomnia. Perhaps the most useful and easy-to-use measure is a sleep diary, which patients complete daily for 1-2 weeks. At a minimum, a sleep diary assesses bedtime, minutes to fall asleep, number and duration of awakenings, last awakening, and time to get out of bed. From these data, averaged over a period of 1 to 2 weeks, it is possible to determine the patient's sleep continuity. [4]
Importance of Diagnosis
Assessing insomnia correctly is crucial for effective treatment. Diagnosis involves analyzing the patient's sleep pattern, medical history, and sometimes sleep studies to rule out other conditions.
Impact and Prevalence
This disorder affects a substantial proportion of the population, with effects on mental health, risk of chronic diseases and impact on daily productivity and quality of life. The daily damage of insomnia is not limited to irregular sleep. Insomnia, when chronic, tends to be uninterrupted, disabling, costly and can pose a risk for other medical and psychiatric disorders. [8]
In a variety of studies, a prevalence of insomnia symptoms in the general population was found to vary between 10% and 48%. [ 1] Between 25% and 33% of the population in industrialized countries report problems with sleep disturbances at some point in their lives and around 10% suffer from persistent insomnia. [7] The prevalence of insomnia disorder (diagnosed) is considered to be around 10% to 20% in the general population, with around 50% having a chronic course.[2] The prevalence of chronic insomnia is believed to be between 5% and 11% [9].
Symptoms of Insomnia
The most common symptoms include:
- difficulty falling asleep;
- difficulty falling asleep;
- waking up earlier than desired;
- difficulty sleeping without being accompanied;
- resistance to going to sleep at reasonable times.
Additionally, patients may present daytime “after-effects” due to poor sleep, which may lead to [11]:
- excessive daytime drowsiness,
- fatigue,
- memory impairment,
- concentration and attention,
- mood disorders,
- irritability,
- impairment of motivation/energy and initiative,
- prone to accidents or errors,
- difficulties with occupational or academic performance.
Common Causes
The causes of insomnia are diverse, including psychological factors such as stress and anxiety, health problems, hormonal imbalances, and poor sleeping habits. Insomnia can also result from poor sleep hygiene, such as irregular waking times, naps longer than 20 minutes during the day, very bright, noisy and/or uncomfortable sleeping environments, exposure to light in the periods before sleep, including brightness of screens, inappropriate temperature in the resting place, intake of nicotine, alcohol or caffeine close to bedtime, misuse of anxiolytic medication and little physical exercise. [11]
Treatment
According to the existing literature, most meta-analyses support the effectiveness of behavioral, cognitive, and pharmacological interventions for insomnia. Brief behavioral interventions and Internet-based cognitive behavioral therapy show promise for use in primary care settings. [two]
There are many treatment options available for patients with insomnia. Behavioral therapies should be initiated as first-line treatment in most patients. For patients requiring pharmacological therapy, the drugs with the greatest evidence of benefit include benzodiazepines, benzodiazepine receptor agonists, melatonin receptor agonists and antidepressants. The selection of a specific agent must take into account several patient-specific factors. [3]
Conventional Treatment:
It focuses on behavioral and cognitive approaches, such as cognitive behavioral therapy for insomnia (CBT-I), which helps modify sleep-damaging thoughts and behaviors. This approach has shown effectiveness in improving sleep quality and duration.
Pharmacological Treatment:
It includes the use of medications such as benzodiazepines and non-benzodiazepine hypnotics. These are generally recommended for short-term use due to the risk of addiction and side effects. The most effective pharmacological therapies for insomnia are benzodiazepines, benzodiazepine receptor agonists, melatonin receptor agonists and antidepressants. The choice of a specific agent should be based on patient-specific factors, including age, proposed duration of treatment, primary sleep complaint, history of drug or alcohol abuse, and cost.[3] Among pharmacological interventions, benzodiazepine receptor agonist drugs are the most studied, although concerns persist regarding their safety compared to their modest efficacy. Behavioral treatments should be used whenever possible, and medications should be limited to the lowest dose necessary and the shortest duration possible. [ two]
Preventive Measures and Self-Help Strategies:
Non-pharmacological interventions for insomnia include sleep hygiene education, stimulus control therapy, relaxation therapy, and sleep restriction therapy. [3] These include sleep hygiene practices such as maintaining a regular sleep schedule, creating a peaceful sleeping environment, and avoiding stimulants before bed. Relaxation and stress reduction techniques are also beneficial.
Natural Supplementation:
Melatonin, a hormone naturally produced by the body, is often used as a supplement to regulate the sleep-wake cycle. There are more and more studies that indicate that melatonin may be effective for some forms of insomnia, especially in cases where the circadian cycle is dysregulated. [10]
So, what is melatonin?
Melatonin (N-acetyl-5-methoxytryptamine) is a neurohormone that is mainly synthesized in the pineal gland and released into the bloodstream exclusively at night, according to the circadian rhythm. Melatonin is associated with the day-night cycle, inducing drowsiness and helping to maintain circadian rhythms.
How does melatonin “treat” insomnia?
Insomnia, in part, is caused due to beta-blockers that suppress endogenous melatonin secretion at night. Exogenous melatonin can effectively treat insomnia by mimicking natural endogenous melatonin, binding to the same receptors and activating the same downstream pathways.
Is it safe to take melatonin, in what form? What dose should I take?
Melatonin is generally given in the form of oral tablets and has been approved for the treatment of primary insomnia by several agencies (e.g. the European Medicines Agency). Local guidelines for melatonin use in the US recommend that melatonin is safe and effective up to 10 mg in adults and children. [12]
It is well tolerated and has a low dependence potential, unlike other sleep medications. [13] Compared to conventional drugs , melatonin reduces adverse effects and it is expected that its agents can be used safely in the long term without negative consequences .
Isn't natural supplementation more of a placebo than anything else? Does melatonin actually have an effect?
Melatonin has been shown to be effective for sleep compared to placebo , so it may be an effective option for treating insomnia. [14] In these patients, melatonin supplementation significantly increased total sleep time, improved sleep efficiency, and decreased sleep onset latency to stage 2 [15].
Although it depends from case to case, melatonin has a significant effect on sleep quality [16] and alters specific aspects of sleep architecture, being increasingly adopted as a first-instance approach to treating insomnia. [17].
Conclusion
Insomnia represents a complex and multifaceted disorder, with profound implications for the health and well-being of individuals. The significant prevalence of this condition in the population requires a holistic understanding that ranges from its etiology to therapeutic approaches. Accurate assessment and implementation of individualized treatment strategies, which combine behavioral, cognitive and pharmacological interventions, are essential for the effective management of insomnia. The importance of preventive and self-help measures to mitigate associated risk factors is also recognized. Continuous research is crucial to improve existing therapies and develop new treatment modalities, thus contributing to improving the quality of life of patients with insomnia.
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