HEALTH TIPS: When Sleep Will Not Come: Understanding and Managing Insomnia

By Dr Tariq Jagnarine
Fam Med, Endocrinology

The house is quiet, the lights are off, and everyone else appears to be asleep. Yet you remain awake, watching the clock and worrying about how you will manage tomorrow. For some people, the difficulty is falling asleep. For others, sleep comes easily but is interrupted repeatedly, or ends too early.
Persistent sleeplessness can affect mood, concentration, relationships and the ability to function safely. Understanding the pattern and identifying what keeps it going are essential to effective treatment.

Understanding insomnia
Insomnia involves difficulty falling asleep, staying asleep, or returning to sleep after waking too early, despite having a reasonable opportunity to sleep. It becomes clinically significant when it causes distress or affects daytime functioning.
Someone who sleeps too little because of long working hours or late-night activities may have insufficient sleep without having insomnia. The distinction matters because treatment must address either the lack of opportunity to sleep or the difficulty sleeping when that opportunity exists.
Short-term insomnia may follow stress, illness or a major life change. Chronic insomnia persists for at least three months and requires a more structured assessment.

Risk factors, causes and triggers
Stress is a common starting point. Financial difficulties, work pressures, grief, relationship problems, and caregiving responsibilities can keep the mind alert at bedtime. Eventually, worrying about sleep itself may become part of the problem.
Risk increases with older age, and insomnia is more common in women. Pregnancy and menopause may contribute through physical discomfort or hormonal changes. Shift work, irregular schedules, noise, excessive heat, and light can also disrupt sleep.
Lifestyle triggers include late caffeine use, nicotine, alcohol, long daytime naps and inconsistent bedtimes. Alcohol may initially cause drowsiness but can produce lighter, more interrupted sleep later in the night.
The assessment must also consider pain, mental health difficulties, medical illness and medicines that interfere with sleep. Depression and anxiety may coexist with insomnia and require treatment alongside it. Patients should tell their clinician about prescription medicines, supplements, stimulants and cold remedies, rather than stopping prescribed treatment themselves.

Signs and symptoms
Typical symptoms include taking a long time to fall asleep, waking repeatedly, remaining awake for prolonged periods during the night, or waking earlier than intended.
During the day, patients may experience fatigue, irritability, poor concentration, reduced motivation, and difficulty remembering information. Some feel exhausted but still struggle to fall asleep when they have the chance. Concern about bedtime can become increasingly prominent.
Other symptoms may point to a different or additional sleep disorder. Loud snoring, witnessed pauses in breathing, and waking while gasping suggest obstructive sleep apnoea. These symptoms warrant assessment, especially when accompanied by significant daytime sleepiness.

Diagnosis and diagnostic criteria
Insomnia is primarily diagnosed through a careful clinical history. For chronic insomnia disorder, the central criteria include:
• Difficulty initiating sleep, maintaining sleep, or returning to sleep after waking too early.
• Associated daytime impairment or significant distress.
• Adequate opportunity and circumstances for sleep.
• Symptoms occurring at least three nights each week.
• Symptoms lasting at least three months.
• The sleep difficulty not being better explained by another sleep disorder.
Patients do not need to wait three months before seeking help. Earlier assessment is appropriate when symptoms affect daily life.
A sleep diary kept for one to two weeks can be useful. Record bedtime estimated time taken to fall asleep, awakenings, waking time, naps, caffeine and alcohol use, and daytime symptoms. The consultation also reviews medical conditions, medicines, mood and work schedules.
Investigations are guided by the history and examination. Blood tests may help identify an underlying medical problem, while a sleep study may be needed when sleep apnoea or another sleep disorder is suspected.

Treatment: rebuilding reliable sleep
The recommended first treatment for chronic insomnia is cognitive behavioural therapy for insomnia, or CBT-I. This structured approach addresses the habits, thoughts and learned patterns that maintain sleeplessness. General sleep advice alone is often insufficient once insomnia becomes chronic.
CBT-I may include establishing a consistent waking time, going to bed when sleepy, and leaving the bed temporarily when unable to sleep. A quiet activity in dim light can help until sleepiness returns. It also addresses clock-watching, anxiety about the consequences of a poor night, and spending excessive time awake in bed.
Another component adjusts time in bed to strengthen the relationship between bedtime and sleep. This should be individually planned with a trained clinician, particularly when there is substantial daytime sleepiness or another significant health condition. Treatment often takes several weeks.

The role of medication
Medication may be appropriate for selected patients, with review and a clear plan for its duration. Evidence-supported options include zolpidem, eszopiclone, low-dose doxepin, and medicines such as suvorexant. Selection depends on the sleep pattern, other illnesses, interactions and local availability. In Guyana, the prescriber and pharmacist should confirm the available medicine and formulation.
Current guidance advises against routine treatment of chronic insomnia with benzodiazepines, diphenhydramine, trazodone or antipsychotic medicines. These drugs may have other clinical uses, but sedation alone does not establish an effective insomnia treatment.
Some sleeping medicines can cause next-day impairment or unusual activities during sleep, including walking, eating or driving without full awareness. Patients should discuss adverse effects promptly and avoid combining sleep medicines with alcohol.
Melatonin is widely marketed, but it has not been established as an effective general treatment for chronic insomnia. Supplements should be discussed with a clinician rather than assumed to be harmless.

Practical steps and prevention
A regular waking time provides an anchor for the sleep schedule, including after a poor night. Allow enough time for sleep, but avoid repeatedly extending time in bed to compensate.
Limit caffeine later in the day, including coffee, strong tea and energy drinks. Avoid nicotine and alcohol near bedtime. Reduce long or late naps, keep the bedroom dark, quiet and comfortably cool, and establish a relaxing evening routine.
Put work and stimulating screen activities aside before bed. Reading, gentle relaxation or calming music may help the transition to sleep. Addressing persistent stress and maintaining these habits after improvement can reduce the likelihood of recurrence.

When prompt assessment is needed
Seek prompt medical assessment if very little sleep is accompanied by unusually high energy, racing thoughts, excessive talking or impulsive behaviour. A reduced need for sleep can be a feature of mania. Thoughts of self-harm require immediate help.
Anyone struggling to remain awake should avoid driving or operating machinery until it is safe to do so.
In a clinical assessment, “I cannot sleep” is the beginning of the conversation. The next questions concern the sleep pattern, daytime functioning, emotional wellbeing, medicines, breathing during sleep and the demands of everyday life.
A sleeping tablet may offer temporary relief for some patients, but lasting improvement depends on understanding the problem and treating the factors that sustain it. The goal is reliable sleep, improved daytime function, and greater confidence that bedtime can once again be restful.