What does it look like?
Insomnia is characterized by difficulty falling asleep, staying asleep, or waking too early despite adequate opportunity for sleep. Stress and life changes, such as those experienced during the pandemic, may trigger insomnia. Shift work is a significant risk factor for insomnia. Acute insomnia is defined as insomnia experienced for less than 3 months. Chronic insomnia is defined as 3 nights of insomnia per week on average for 3 months of more.
Social isolation and spending long periods of time indoors may influence the circadian system, one of the systems which controls sleep. Variable sleep-wake schedules exacerbated by quarantine may also negatively influence the circadian system.Some patients may be curtailing the amount of time they devote to sleep due to increased obligations, such as additional time spent homeschooling children and additional errands or tasks around the house. Specific issues to consider in patients include the amount of natural light they are obtaining, especially in the morning; their exposure to light (especially via personal electronic devices, including computer screens, phones, tablets) within 2 hours of bedtime and through their time in bed period; regularity in their time in bed schedule (particularly their wake time, as this sets the circadian clock); and whether they are able to devote sufficient time to sleep.
How do I screen for it?
ISI: Insomnia Severity Index
Measures insomnia severity in adult patients.
Frequency: every 14 days
Age Range: 18+
0-7: No clinically significant insomnia
8-14: Subthreshold insomnia (mild severity)
15-21: Clinical insomnia (moderate severity)
22-28: Clinical insomnia (severe)
MiChart Name: UM AMB INSOMNIA SEVERITY INDEX (ISI)
What are the treatment options?
Patients who have experienced insomnia for more than 3 months and who score >14 on the Insomnia Severity Index should be provided with treatment options, including online cognitive-behavioral therapy for insomnia (sleepio.com) or a referral to specialty care. Cognitive-behavioral therapy for insomnia is the first-line treatment for chronic insomnia.
Patients who have experienced insomnia for less than 3 months: consider pharmacotherapy, CBT-I Coach app, and/or bibliotherapy.
Short-term insomnia (less than 3 months of symptoms) may be treated using pharmacotherapy. Melatonin may be considered (1-3 mgs taken one hour before bed) for short-term use in short-term insomnia. It is not recommended for chronic insomnia.
- The American Academy of Sleep Medicine has published guidelines for insomnia pharmacotherapy; note that all available evidence is judged to be “weak” in terms of strength:
- Difficulty with sleep onset: Zaleplon, Triazolam, Ramelteon
- Difficulty with sleep maintenance: Suvorexant, Doxepin
- Difficulty with both sleep onset and maintenance: Eszopiclone, Zolpidem, Temazepam
[Treatment guidelines from: Sateia MJ, Buysse DJ, Krystal AD, Neubauer DN, Heald JL. Clinical Practice Guideline for the Pharmacologic Treatment of Chronic Insomnia in Adults: An American Academy of Sleep Medicine Clinical Practice Guideline. J Clin Sleep Med. 2017;13(2):307-349. Published 2017 Feb 15. doi:10.5664/jcsm.6470]
CBT-I Coach -- Download app at Apple App store or Google Play
- CBT-i Coach is for people who are engaged in Cognitive Behavioral Therapy for Insomnia with a health provider, or who have experienced symptoms of insomnia and would like to improve their sleep habits.
- The app guides users through the process of learning about sleep, developing positive sleep routines, and improving their sleep environments. It provides a structured program that teaches strategies proven to improve sleep and help alleviate symptoms of insomnia.
- CBT-i Coach is intended to augment face-to-face care with a healthcare professional. It can be used on its own, but it is not intended to replace therapy for those who need it.
For: Adults; evidence-based online treatment for chronic insomnia
- Sleepio is a digital sleep improvement program for people who may have insomnia. Sleepio teaches you Cognitive Behavioral Therapy (CBT) techniques that have been shown to work for many individuals. The program provides six online sessions, personalized to your needs.
- Sleepio also offers additional features to help you get to sleep, including a sleep diary, online community, and articles written by sleep experts.
Self-Help Insomnia Books:
Quiet Your Mind and Get to Sleep (Carney and Manber)
Overcoming Insomnia and Sleep Problems (Espie)
Sateia MJ, Buysse DJ, Krystal AD, Neubauer DN, Heald JL. Clinical Practice Guideline for the Pharmacologic Treatment of Chronic Insomnia in Adults: An American Academy of Sleep Medicine Clinical Practice Guideline. J Clin Sleep Med. 2017;13(2):307-349. Published 2017 Feb 15. doi:10.5664/jcsm.6470
Altena E, Baglioni C, Espie CA, et al. Dealing with sleep problems during home confinement due to the COVID-19 outbreak: Practical recommendations from a task force of the European CBT-I Academy [published online ahead of print, 2020 Apr 4]. J Sleep Res. 2020;e13052. doi:10.1111/jsr.13052
Xiao H, Zhang Y, Kong D, Li S, Yang N. Social Capital and Sleep Quality in Individuals Who Self-Isolated for 14 Days During the Coronavirus Disease 2019 (COVID-19) Outbreak in January 2020 in China. Med Sci Monit. 2020;26:e923921. Published 2020 Mar 20. doi:10.12659/MSM.923921
Huang Y, Zhao N. Generalized anxiety disorder, depressive symptoms and sleep quality during COVID-19 outbreak in China: a web-based cross-sectional survey. Psychiatry Res. 2020;288:112954. doi:10.1016/j.psychres.2020.112954
Pappa S, Ntella V, Giannakas T, Giannakoulis VG, Papoutsi E, Katsaounou P. Prevalence of depression, anxiety, and insomnia among healthcare workers during the COVID-19 pandemic: A systematic review and meta-analysis [published online ahead of print, 2020 May 8]. Brain Behav Immun. 2020;S0889-1591(20)30845-X. doi:10.1016/j.bbi.2020.05.026