What can we do about it?

When we are facing occasional sleep problems, simple tips can be helpful to prevent any worsening and to fast track the return to better sleep. However, when insomnia problems get more serious, regular and persist over time, treatment is required.

Here is a summary of recommendations for the management of chronic insomnia:

1. Chronic insomnia should be treated even when it happens at the same time as another condition that can influence sleep, like menopause, depression, or cancer.

Insomnia disorder is not just a symptom of other mental or physical health conditions. Regardless of whether sleep issues started before or after these other conditions, leaving insomnia untreated can further worsen health and hinder the healing process.

2. The first treatment that should be provided for insomnia disorder is cognitive behavioral therapy for insomnia (CBT-I).

CBT-I addresses the root causes of what makes us transition from the occasional bad nights to chronic insomnia. This is the first treatment that people should receive after getting a diagnosis of insomnia disorder. Sleep hygiene is not the same thing as CBT-I and is not sufficient to treat insomnia. There is a need to make CBT-I more accessible to Canadians.

3. There is insufficient scientific evidence to support over-the-counter and off-label medications for treating insomnia.

• Some over-the-counter medications that people often use in attempt to sleep better (e.g., antihistamines) can pose safety risks that are worse than the benefits they provide.

• In Canada, there is a need to improve how we monitor the safety and quality of natural products that may be used in attempt to improve sleep.

• More research is required on cannabis products and their long-term effects on sleep.

• Prescribed medications that have been designed and approved for other conditions than insomnia (i.e. “off-label”), are increasingly used for sleep. For example, this includes certain antidepressants (e.g., amitriptyline, mirtazapine, trazodone), antipsychotics (e.g., quetiapine), and anticonvulsants (gabapentin, pregabalin). However, these “off-label” medications may have safety risks that are worse than the benefits they provide.

4. When sleep medications may be required, we should make sure to i) use effective medications, ii) keep them at the lowest possible dose, and iii) take them over the shortest possible period. Sleep medications should be used after we had a chance to try CBT-I.

• Benzodiazepines (e.g., flurazepam, temazepam) and z-drugs (e.g., eszopiclone, zolpidem, zopiclone) can be effective for short-term management of insomnia. However, most of these medications have side effects. This can include: daytime drowsiness, memory issues, increased risk of falls and car accidents, increased risk of addiction and abuse, and insomnia worsening after stopping these medications. Also, the positive effects of most of these medications can decrease with repeated use (i.e. tolerance).

• Dual orexin antagonists (DORAs) may have greater benefits than the risks they create. They may have less side effects than benzodiazepines and z-drugs. There are some early indications that the effectiveness of some DORAs may not decrease over a 12 months period, but more research is required.

For more information:

• Ontario quality standards for insomnia disorder

• Morin, C. M., Khullar, A., Robillard, R., Desautels, A., Mak, M. S., Dang-Vu, T. T., ... & Carney, C. E. (2024). Delphi consensus recommendations for the management of chronic insomnia in Canada. Sleep Medicine, 124, 598-605.