Insomnia and associated stress take their toll on people and can be associated with more serious conditions but independent pharmacists can help people regain some semblance of normal life. Steve Titmarsh reports…

It is estimated that around 46 per cent of adults in Britain sleep for less than six hours a night. The figure comes from a nationally representative 2023 survey of 3,726 people commissioned by Kalms.

Around half (52 per cent) had difficulty falling asleep and 54 per cent woke frequently in the night. As a result 55 per cent felt groggy, while 51 per cent said they were tired and irritable the next day. Around half of the people who had too little sleep said they found it difficult to concentrate, and were less productive and made more mistakes.

A study comparing self-reported insomnia symptoms with GP records found that while 29 per cent reported insomnia symptoms, only 10 per cent had it documented in their GP records, suggesting underreporting.¹

Insomnia can affect people at any age but it is most common among older people who are likely to suffer with the condition for longer. It is more common among people with other conditions such as chronic obstructive pulmonary disease, heart failure, chronic pain and mental health conditions. Insomnia is closely associated with depression and may be linked to other conditions such as obstructive sleep apnoea, restless legs syndrome and periodic limb movement disorder. These comorbid conditions need to be identified and managed.²

Short-term insomnia can be triggered by:²

• Stressful events such as bereavement, illness, changes in employment, exams, pending deadlines or financial difficulties.

• Changes in sleeping patterns due to childbirth or environmental factors such as excess noise or light or temperature extremes.

Causes of chronic insomnia (ie insomnia lasting more than three months) are varied and not well understood but it commonly occurs alongside other conditions, including:

• Mental health conditions such as anxiety, depression and bipolar disorder.

• Substance misuse such as alcohol and illicit drugs.

• Other medical disorders such as COPD, cardiovascular disease, neurological conditions (such as stroke, Parkinson's disease, epilepsy, migraine, and traumatic brain injury), malignancy, diabetes mellitus, musculoskeletal conditions and chronic pain.

• Other sleep disorders, such as obstructive sleep apnoea syndrome and restless legs syndrome.

Figures from the Mental Health Foundation in 2018 suggest that almost three quarters (73 per cent) of adults felt so stressed at some point in the previous year that they felt overwhelmed or unable to cope. The rates were higher among women (81 per cent) than men (67 per cent), and highest among those aged 18–24 years (83 per cent) compared with those aged 55 years and over (65 per cent). Almost a third (32 per cent) of adults said they had experienced suicidal feelings as a result of stress; 16 per cent reported self-harming due to stress.³

Survey data from 2020 show that work-related stress was the most common – reported by 79 per cent of respondents.⁴

Additionally, a study found that insomnia may mediate the relationship between stress and anxiety, with 43.6 per cent of university students reporting insomnia and 21.9 per cent reporting anxiety disorder.⁵

Reasons for high insomnia rates

Stressful life events and inability to cope with stress are closely linked to the onset of chronic insomnia.^6,7 High levels of stress can precipitate insomnia in predisposed individuals, and some personality traits such as anxiety, rumination and inhibition of emotions are associated with insomnia.⁷

Comorbidities like psychiatric disorders (depression, anxiety), medical conditions and sleep disorders (sleep apnoea, restless legs syndrome) increase the risk of insomnia.^7,8 

Why do stress and insomnia occur?

There are several key reasons why stress and insomnia occur and are closely interlinked.

Stress associated with insomnia

Stressful life events like work dissatisfaction, marital/family issues, grief, major life changes, and low income can precipitate the onset of chronic insomnia.⁹ Stress acts as a trigger, especially in predisposed individuals.

Certain personality traits like anxiety, rumination, inhibition of emotions and inability to cope with stress make people more vulnerable to developing insomnia under stressful conditions.

Acute stress has physiological consequences – increased heart rate, blood pressure, and levels of hormones like cortisol and adrenaline.⁹ This can interfere with the ability to fall and stay asleep.

Psychiatric disorders like depression, anxiety and substance abuse that are closely linked to stress can manifest with insomnia as a symptom.⁷ 

Insomnia perpetuating stress

Worry and anxiety about the inability to sleep at night can further elevate stress, perpetuating insomnia.^9,10

Chronic sleep deprivation associated with insomnia can dysregulate the body's stress systems like the hypothalamic-pituitary-adrenal (HPA) axis, leading to increased physiological stress.⁷

Treatment options

Establishing good sleep hygiene is important for people who find it hard to sleep. That includes looking at the sleep environment and daily routine (see Box).

People with a formal diagnosis of insomnia (ie symptoms that meet official criteria such as those outlined in ICD-11, which include daytime impairment in functioning or wellbeing as well as difficulties in actually sleeping)¹¹ who are struggling significantly during the day as a result of poor sleep may be offered cognitive-behavioural therapy for insomnia (CBTi) where it is available. If that does not work or is unavailable then pharmacological treatments may be considered, such as a short course (ideally less than a week) of non-benzodiazepine hypnotic (sometimes referred to as z-drugs).²

Sleepio, which uses an artificial intelligence (AI) algorithm to provide people with tailored digital CBTi, is now recommended by NICE.¹² It can be accessed through a website (www.sleepio.com/sleepio/nhs/391#1/1).

People with insomnia that has lasted more than three months need to see a doctor.²

 Sleep hygiene advice²

• The sleeping environment needs to be comfortable – not too hot, cold, noisy, or bright.

• The bedroom should only be used for sleep and intimacy.

• Do not check or watch the clock throughout the night.

• Exposure to bright light (including all technology) should be minimised. ‘Blue light’ displays on electronic devices and televisions suppress melatonin production so they should not be used for at least an hour before bed.

• Go to bed when feeling sleepy — do not go to bed too early.

• Wake up and get up at the same time every morning, including weekends, and even after a poor night's sleep. This help increase exposure to bright light in the morning.

• Do not nap during the day.

• Relax before going to bed (for example, by reading a book, having a bath, or listening to music).

• Caffeine should be avoided after midday and nicotine, alcohol, and large meals within 2 hours of bedtime.

• Self-medication with alcohol can lead to poor sleep-maintenance.

• Do not exercise vigorously exercise within an hour of bedtime; it is beneficial earlier in the day.

Role of community pharmacists

In an analysis of 34 studies, most of which were conducted in community pharmacies, researchers from the School of Pharmacy, Newcastle upon Tyne concluded that pharmacists have three clear roles in the management of sleep disorders:¹³

• deprescribing – usually associated with benzodiazepines),

• collaboration with other healthcare professionals, organisations and patients, and

• educators – teaching people how to monitor and review their sleep as part of self-care and about sleep hygiene, for example. 

References 

1. de Lange MA, Richmond RC, Eastwood SV, et al Insomnia symptom prevalence in England: a comparison of cross-sectional self-reported data and primary care records in the UK Biobank BMJ Open 2024;14:e080479.

2. Clinical Knowledge Summaries. Insomnia (https://cks.nice.org.uk/topics/insomnia; accessed June 2024).

3. Mental Health Foundation. Stressed nation: 74% of UK 'overwhelmed or unable to cope' at some point in the past year (www.mentalhealth.org.uk/about-us/news/survey-stressed-nation-UK-overwhelmed-unable-to-cope#:~:text=A%20UK%2Dwide%20stress%20survey,overwhelmed%20or%20unable%20to%20cope; accessed June 2024).

4. Statista. Most common types of stress experienced in the United Kingdom (UK) in 2020 (www.statista.com/statistics/1134359/common-types-of-stress-in-the-uk; accessed June 2024).

5. Manzar MD, Salahuddin M, Pandi-Perumal SR, Bahammam AS. Insomnia May Mediate the Relationship Between Stress and Anxiety: A Cross-Sectional Study in University Students. Nature and Science of Sleep 2021;13:31–8.

6. Drake CL, Pillai V, Roth T. Stress and Sleep Reactivity: A Prospective Investigation of the Stress-Diathesis Model of Insomnia. Sleep 2014;37:1295–1304.

7. Basta M, Chrousos GP, Vela-Bueno A, Vgontzas AN. Chronic insomnia and stress system. Sleep Med Clin 2007;2(2):279–91.

8. Roth T. Insomnia: definition, prevalence, etiology, and consequences. Journal of Clinical Sleep Medicine 2007;3(5 Suppl):S7–10.

9. Sleep Foundation. Stress and insomnia (www.sleepfoundation.org/insomnia/stress-and-insomnia; accessed July 2024)

10. Dusang K. How stress can affect your sleep (www.bcm.edu/news/how-stress-can-affect-your-sleep; accessed July 2024).

11. World Health Organization. International Statistical Classification of Diseases and Related Health Problems (ICD) (www.who.int/standards/classifications/classification-of-diseases; accessed July 2024).

12. National Institute for Health and Care Excellence. Sleepio to treat insomnia and insomnia symptoms. Medical technologies guidance [MTG70] (www.nice.org.uk/guidance/mtg70/chapter/1-Recommendations; accessed July 2024).

13. Ashkanani FZ, Lindsey L, Rathbone AP. A systematic review and thematic synthesis exploring the role of pharmacists in supporting better sleep health and managing sleep disorders. International Journal of Pharmacy Practice 2023;31(2):153–64.