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Pear Therapeutics has announced the availability of Somryst, the only US Food and Drug Administration-authorized digital therapeutic for chronic insomnia to date. (Read 

, MD, chief medical officer at Pear Therapeutics.)

“We’re excited to offer patients who have been struggling to find a long-term solution for chronic insomnia with a meaningful, first-line treatment,” Corey McCann, president and chief executive officer of Pear Therapeutics, said in a statement.

A prescription digital therapeutic (PDT), Somryst offers 6 to 9 weeks of cognitive behavioral therapy (CBT) via a tablet or smartphone. Clinical studies on the efficacy of this therapeutic have appeared in 

The prescription reduced the time needed to fall asleep by 45%, time spent awake during the night by 52%, and the severity of insomnia symptoms by 45%. Improvement continued 6 and 12 months after treatment.

At present 30 million Americans suffer from chronic insomnia, but McCann noted that treatment options are especially “important now, more than ever, as we continue to navigate the COVID-19 pandemic.”

Indeed, sleep disorders have soared during the pandemic. Nearly half of respondents to a Pear Therapeutics survey reported pandemic-related sleep loss. The number reporting poor sleep almost doubled (from 15% to 27%), and younger generations have been especially affected, with nearly one-third of Gen Z and Millennials admitting to poor sleep quality.

Digital prescriptions may be good options for patients who cannot access a clinician. “Despite CBTi being the recommended first line treatment for chronic insomnia, there aren’t enough clinicians who are trained to deliver CBTi therapy,” Michelle Primeau, MD, medical director of the Palo Alto Medical Foundation Sleep Medicine Center in San Carlos, CA, told the press. “Somryst has been shown to address the underlying issues of chronic insomnia by training the brain and body to fall asleep faster and stay asleep longer.”

Are your patients experiencing increased insomnia? 

Share comments with your colleagues by emailing 

. Comments may be shared online pending review and may be edited for style.

Ritterband LM, Thorndike FP, Ingersoll KS, et al. Effect of a web-based cognitive behavior therapy for insomnia intervention with 1-year follow-up: a randomized clinical trial

Christensen H, Batterham PJ, Gosling JA, et al. Effectiveness of an online insomnia program (SHUTi) for prevention of depressive episodes (the GoodNight Study): a randomised controlled trial. 

Batterham P, Christensen H, Mackinnon A, et al. Trajectories of change and long-term outcomes in a randomized controlled trial of internet-based insomnia treatment to prevent depression. 

Potential relief for millions of Americans with pandemic-related sleep issues. 

A New Digital Therapeutic for Chronic Insomnia

The US Food and Drug Administration (FDA) granted a De Novo clearance to a prescription Apple watch and iPhone app meant to improve sleep quality for those with nightmare disorders or posttraumatic stress disorder-related nightmares.

 uses the watch’s sensors to track the user’s heart rate and movement as they sleep. A baseline profile is created for the patient within 1 to 2 nights of sleep. In this short time frame, the learning algorithm will spot heart rate of movement abnormalities likely caused by a nightmare. If the app senses a disturbance, the Apple watch will vibrate enough to interrupt the dream, but not enough to fully wake them up and disturb their sleep cycle.

“Sleep is an essential part of a person’s daily routine,” Carlos Peña, PhD, director of the Office of Neurological and Physical Medicine Devices in the FDA’s Center for Devices and Radiological Health, said to the press. “However, certain adults who have a nightmare disorder or who experience nightmares from PTSD are not able to get the rest they need. Today’s authorization offers a new, low-risk treatment option that uses digital technology in an effort to provide temporary relief from sleep disturbance related to nightmares.”

Data submitted to the FDA included information from a 30-day trial of 70 patients who were randomly assigned to receive either the NightWare app or a placebo app with no vibrations. While both groups self-reported improved sleep quality, the benefit was greater for those provided with the Nightware product.

Further trials are being conducted, one of which hopes to include 240 patients from several Department of Veterans Affairs hospitals. It is projected to finish in the second half of 2021.

“NightWare was founded and built to support veterans and active duty service members who have so unselfishly given of themselves to preserve our freedoms, and suffer emotional, physical and mental distress as a consequence of severe nightmares,” NightWare CEO Grady Hannah said in a statement. “Helping our current and past military members and all people with this condition is NightWare’s mission and we are excited to introduce this first and only therapeutic for nightmares. The use of the NightWare Therapeutic Platform provides an effective treatment for clinically significant nightmares; avoids drug side-effects; and reduces the need for time intensive and often-unavailable psychological therapy sessions.”

The NightWare therapy is currently available on a limited basis through physician recommendation, but will hopefully launch in the early months of 2021. It will require a prescription and is intended for use among adults aged 22 years or older. It is not recommended for patients who sleepwalk or have violent episodes during nightmares. It is also not recommended as a standalone treatment for PTSD.

1. NightWare. We won’t rest until those with PTSD can. Accessed November 13, 2020. 

2. Muoio D. FDA grants De Novo clearance to prescription Apple Watch app for nightmare disorder. 

https://www.mobihealthnews.com/news/fda-grants-de-novo-clearance-prescription-apple-watch-app-nightmare-disorder

A new prescription smartwatch app may improve sleep quality for those with nightmare disorders. 

A New Way to “Watch” Your Nightmares

Sleep apnea, according to Dr Miller, is extraordinarily common. A big takeaway of his: CPAP works, but only if you use it. 

is a physician and entrepreneur who has founded and held senior positions at 11 companies in healthcare/life sciences over the last 30 years. He is currently co-founder, CEO and Chair of Apnimed, Inc in Cambridge, MA. Previously, he was co-founder and CEO of Macrolide Pharmaceuticals, Inc. His other companies include HPR, PharMetrics, Serenex and Tetraphase; all have been acquired except Tetraphase, which is publicly traded. He has also been an investor in more than 15 healthcare/life sciences companies, first at Hambrecht & Quist Capital Management and subsequently as co-founder and partner at the Mediphase Funds. Previously, he led a neurochemistry laboratory at Tufts University and has published nearly 100 scientific papers. He received his AB and MD at Harvard and completed clinical training at the Massachusetts General Hospital and Harvard Medical School. He is Board certified in Internal Medicine, Pulmonary Disease, and Clinical Pharmacology.

Larry Miller, MD, CEO of Apnimed, discusses the ins and outs of sleep apnea.

Treating Obstructive Sleep Apnea 

Over 30 million Americans live with diagnosable chronic insomnia. It can impair their everyday functions when awake and affect their mood. Chronic insomnia is also a risk factor for other chronic illnesses and psychiatric disorders (up to 40% also have depressive symptoms).

Existing pharmacological treatments are designed for short-term use, which may not be enough to combat a long-term illness. In this Mental Health Minute, Yuri Maricich, MD introduces Somryst, the first FDA-authorized prescription digital therapeutic (PDT) for treating chronic insomnia. It is a 9-week program that is accessible through mobile devices, including smartphones and tablets. He discusses two studies on the effectiveness of this new PDT.

(Note: in the video, Dr Maricich says that the FDA authorized Somryst in 2023. The FDA authorized it in 2020.)

A new treatment has been found effective for treating a common sleep disorder.

Introducing the First FDA-authorized Prescription Digital Therapeutic for Chronic Insomnia

Primary insomnia is a decreased ability to fall asleep and/or stay asleep, with resulting daytime effects of sleep deprivation, such as fatigue, dozing off, and irritability. The sleep problems of primary insomnia are not associated with lifestyle habits or a medical or psychiatric cause. Primary insomnia is diagnosed using DSM-5 and the International Classification of Sleep Disorders, 3rd Edition (ICSD-III) classification 

 Primary insomnia is a type of chronic insomnia as defined by the ICSD-III, and it tends to persist or recur for many years throughout a person’s life, often beginning during childhood.

This type of insomnia is usually idiopathic, although it can be impacted by mild to moderate stress. Primary idiopathic insomnia occurs without any identifiable cause and in the absence of anxiety. And people who have a history of primary insomnia may also have episodes of sleep state misperception (SSM), also known as paradoxical insomnia. With paradoxical insomnia, a person feels that they are experiencing insomnia, although they are getting enough sleep and don’t experience daytime signs of sleep deprivation. SSM is believed to affect 9% to 50% of the adult population, and it is 

 among people who also have bouts of primary insomnia.

Primary insomnia has 3 subtypes: idiopathic, stress-related, and SSM. Idiopathic insomnia is truly without any identifiable contributory factor, while stress-related insomnia can be characterized by mild stress, such as rumination or other thoughts throughout the night. Someone who has had episodes of idiopathic insomniacan also experience worsening symptoms when dealing with mild stress or can experience SSM during phases of adequate sleep.

The frequency of sleep symptoms can vary—primary insomnia can occur occasionally or frequently, and it can affect someone for just 1 night at a time or for many nights in a row. An individual affected by the condition can have trouble sleeping, may toss and turn in bed, or may get up from bed at night. Symptoms can also include 1 or more episodes of waking up during the night, often for less than an hour in total. People who have primary insomnia may be very concerned about the causes and effects of not getting enough sleep, and anxiety about sleep can exacerbate the insomnia.

A diagnostic work-up of insomnia includes a medical history, physical examination, and diagnostic tests. Daytime symptoms can include restlessness, feeling tired, falling asleep easily during waking hours, trouble concentrating, moodiness, and sadness. These symptoms are not usually present in SSM. A sleep study may show delayed sleep latency, sleep fragmentation, decreased sleep efficiency, and 

total sleep time in patients who have idiopathic primary insomnia.

 A sleep study would not be expected to show any abnormalities in SSM.

Treatments for primary insomnia include lifestyle modification, therapy, and prescription medications. Non-medical therapies include counseling, cognitive behavioral therapy, biofeedback, avoiding naps or inconsistencies in sleep schedule, managing caffeine and alcohol intake, and avoiding stimulation from factors like bright lights before sleep.

 Medications commonly used for the treatment of primary insomnia 

benzodiazepines, antihistamines, and melatonin

A 42-year-old woman complains that she isn’t sleeping well at night. Although she is in good health, she reports that she has had trouble falling asleep for as long as she can remember. She recalls being tired in the mornings when she was a child, during her teenage years, and throughout her adult years. This is not related to stress, as she says she had always been even tempered and ambitious, and she isn’t prone to anxiety.

Her current sleep pattern is that she tosses and turns for hours before falling asleep, sometimes wakes up during the night around 4 AM, and generally falls back asleep until her alarm clock wakes her at 6:30 AM. At home, sounds of rain or cars outside wake her from sleep. And when she stays in a hotel, the sound of other people talking or shutting doors wakes her up.

She is a chemist and works full time as a vice president at a manufacturing company. She has a regular 8 to 5 schedule, working from home several days per week for the past several years. This practice is consistent with her company culture because most of the work involves communicating electronically. She says that sometimes she gets very tired during the day, but she works through the fatigue because she does not want to prolong her workday.

She then prepares dinner for her children and husband. After dinner, she usually takes a walk or exercises and later watches television with her family. She has a daughter who is attending college abroad for the year, and two kids in high school. The family often calls their college student daughter in the evening. The patient generally goes to bed around 11 PM after picking up around the house. Overall, although she is busy, she says she doesn’t have anything especially stressful going on in her life.

The patient is having an evaluation of insomnia at the urging of her daughter, who is studying pre-health classes in college. The main concern that she expresses is whether her insomnia could be caused by a health problem or whether she could be at risk of developing chronic health issues due to lack of sleep.

The patient’s physical examination was normal. She had a complete blood count and electrolyte blood levels that were normal. She had a home sleep study, which showed diminished sleep quality and delayed sleep latency, without evidence of issues like sleep apnea. She was presumptively diagnosed with primary insomnia, which was considered to be idiopathic.

She was offered the option of taking medication for her insomnia. She instead asked about whether there are any natural therapies, such as herbs, that she could take. In fact, there have been studies suggesting that herbal treatment may have an effect on insomnia. In one 

evaluating 50 patients, use of oil extracts for 8 weeks was associated with a reduction in scores on the Insomnia Severity Index (ISI) and the Pittsburgh Sleep Quality Index (PSQI).

 However, one challenge with using herbal remedies for treatment of insomnia is that there isn’t a consistent protocol or safety and efficacy profile when it comes to the products. In fact, very 

Her doctor suggested that she begin with lifestyle strategies that include avoiding looking at electronic devices for several hours before sleep, avoiding caffeine after noon, and adopting a more consistent exercise schedule. After a month, she did not experience improvement of her symptoms and asked to try prescription medication. Her doctor gave her a prescription for temazepam. After 1 month, she was pleased with the results, but she was concerned about the potential for addiction, so she asked if she could switch to melatonin. Her doctor gave her a schedule to taper the prescription and wanted to reevaluate the situation before starting the patient on another medication. After she discontinued the medication, the patient felt she was still getting better quality sleep and felt less tired during the day. The decision was made to hold off on any new medications as long as her symptoms were not troublesome.

• Patients who have primary insomnia might be concerned about medical causes of insomnia. Often, ruling out underlying causes can be a great relief for patients.

• Herbal treatments and alternative therapies may be beneficial in the management of primary insomnia, but doses and adverse effects are not well established.

• Treatment of chronic insomnia can be more effective when the patient is given several treatment options and has a voice in the plan.

• Sometimes temporary treatment can be effective for a bout of chronic primary insomnia that’s idiopathic.

 is Adjunct Professor at John Carroll University, and Instructor, Case Western Reserve University in Cleveland, OH. She is the editor in chief emeritus of 

1. Momin RR, Ketvertis K. Primary Insomnia. 

 Treasure Island (FL): StatPearls Publishing; 2020. 

https://www.ncbi.nlm.nih.gov/books/NBK554516/

2. Martucci M, Conte M, Ostan R. Both objective and paradoxical insomnia elicit a stress response involving mitokine production. 

https://pubmed.ncbi.nlm.nih.gov/32420904/

3. Melo DLM, Carvalho LBC, Prado LBF, Prado GF. Biofeedback Therapies for Chronic Insomnia: A Systematic Review. 

https://pubmed.ncbi.nlm.nih.gov/31123938/

4. Taherzadeh Z, Khaluyan H, IranshahyM. Evaluation of sedative effects of an intranasal dosage form containing saffron, lettuce seeds and sweet violet in primary chronic insomnia: A randomized, double-dummy, double-blind placebo controlled clinical trial. 

https://pubmed.ncbi.nlm.nih.gov/32736046/

5. Akram M, Daniyal M, Munir N, et al. Medicinal Plants Combating Against Insomnia: A Green Anti-Insomnia Approach. 

https://pubmed.ncbi.nlm.nih.gov/31663928/

When provided with an array of treatment options, patients tend to feel a sense of ownership by playing a role in their care. 

Primary Insomnia: A Lifelong Problem

Ten sleep specialists assessed widely accepted beliefs and here's what they found.

6 Sleep Myths: Experts Weigh In

Lucid dreams are both voluntary and involuntary events. What this means is that a person is aware that they are dreaming during a lucid dream. It can occur spontaneously, typically during REM 

. People experience lucid dreams only rarely, and they aren't typically distressing.

This type of dream has also been promoted as a means of self-reflection and problem solving. Proponents of the technique suggest that lucid dreams are a type of 

, in which a person could potentially reach another state of awareness to achieve greater insight than during the full waking state. The safety of this technique hasn't been established, however, in terms of psychological well-being or restorative sleep. And the idea of using lucid dreaming as a problem-solving method is not supported by the medical community.

There is more to dreaming than meets the (shut) eye.

Lucid Dreams: Many Questions Remain

Disordered sleep disturbances associated with alcohol use disorders (AUD) can 

for several years, even when patients experience sustained recovery.

 One naturalistic, longitudinal study found that over 60% of patients with alcohol dependence and insomnia at baseline continue to have insomnia at 6 months, regardless of current alcohol use status (abstinent, moderate, or heavy drinking).

When evaluating treatment options in these patients, there are differential considerations compared with patients with primary insomnia without 

 comorbidity, including reducing risk of alcohol relapse as well as abuse issues with some pharmacologic agents. Indeed, sleep disturbance is associated with alcohol relapse risk after a period of abstinence.

of addiction medicine physicians, only 22% offered pharmacological treatment to more than half of patients with sleep problems in early recovery from AUD.

 reviewed current and potential pharmacologic treatments for patients with insomnia and alcohol use disorders. Study authors searched Medline, EMBASE, and PsycINFO from 1990 through December 2019. They included studies that prospectively evaluated drug effects on insomnia-related sleep parameters in participants with alcohol disorder who were treatment-seeking or abstinent at study entry

The authors also attempted to identify novel molecules in development in the United States that may be useful in the treatment of insomnia. The authors screened 190 abstracts and reviewed 36 full-text articles for eligibility. A total of 18 studies (15 randomized controlled trials [RCTs] and 3 open-label studies) were included, including studies of antidepressants, anticonvulsants, melatonin agonists, and antipsychotics.

Trazodone 50 mg to 200 mg/day was shown to improve sleep in two RCTs, although 1 study showed evidence of an increased risk for alcohol relapse. Overall, trazodone is the most frequently prescribed medication for the treatment of 

One double-blind active comparator trial found evidence for significant improvements in sleep quality in patients with mild-to-moderate alcohol withdrawal for treatment with carbamazepine (versus lorazepam).

Six RCTs have evaluated the efficacy of gabapentin 400 mg to 1800 mg/day. Three of these trials showed significant improvements in sleep parameters, and 4 showed a positive effect on drinking outcomes. The authors noted that gabapentin is non-hepatically metabolized, does not lower seizure threshold, and does not require blood monitoring, although it has been associated with abuse liability and suicidal thoughts and behaviors.

A small, open-label, 4-week study found improvement in sleep parameters with 8 mg ramelteon. Another small, open-label, 6-week study found improvements in subjective sleep quality with agomelatine 25 mg to 50 mg/day. The authors noted that agomelatine has potential hepatoxicity and is not approved by the United States Federal Drug Administration (FDA).

Two placebo-controlled RCTs found that quetiapine at doses up to 400 mg/day significantly improved sleep parameters in patients with AUD.

Two RCTs showed significant improvements with acamprosate in patients with AUD during abstinence.

In a 13-week RCT in veterans with post-traumatic stress disorder and comorbid AUD, prazosin 16 mg/day did not improve sleep parameters or alcohol use compared to placebo.

One placebo-controlled RCT found that the tumor necrosis factor-alpha blocker etanercept at 25 mg significantly reduced the amount and percentage of REM sleep.

The authors identified 8 novel compounds currently being studied in the United States. Three of these agents target the orexin system. Another compound targets gamma-aminobutryic acid receptors. Piromelatine, a melatonin and serotonin agonist is in development for sleep disorders and Alzheimer disease. The atypical antipsychotic lumateperone is also being studied in Phase 2 trials for sleep disorders associated with neuropsychiatric disorders. A nociceptin/orphanin-FQ receptor agonist is also being evaluated in a Phase 2 study in adults with AUD.

The authors note that the prevalence of insomnia in patients with AUD is high, but there is limited data on the persistence of sleep-related disorders for patients with AUD who are in sustained remission. The use of sedative-hypnotic agents (eg, benzodiazepine receptor agonists) are limited due to risk of abuse liability, overdose, and alcohol relapse in this patient population. There is some evidence for other pharmacologic interventions, although these have not been extensively studied and are not approved by the FDA, and several other agents are in development.

There is a need for safe and efficacious treatment options for vulnerable patients with AUD in early and sustained recovery. The following cases serve to illustrate scenarios that could take place in clinical practice. The cases are for illustrative purposes and the identity and details of patients have been changed.

“Mr J” has a longstanding history of schizophrenia and severe AUD, currently with 2 years’ sobriety. His psychosis is currently stable on quetiapine 300 mg nightly, but he reports worsening insomnia over the past 2 months resulting from anxiety associated with the coronavirus pandemic. He has remained abstinent from alcohol but expresses concern about a relapse of drinking. His psychiatrist increased his quetiapine to 400 mg nightly. Over the following month, his insomnia abated, though he noted increased appetite with an associated 3 lb weight gain.

“Ms K” has a 10-year history of moderate AUD and comorbid fibromyalgia. After 3 years of sobriety, she relapsed on alcohol. One month after alcohol detoxification, she noted onset of initial and middle insomnia. Her psychiatrist subsequently initiated treatment with gabapentin 300 mg nightly, and she noted subjective improvements in insomnia and sleep quality, as well as mild improvements in her pain levels.

“Mr M” is a 22-year-old male currently in a long-term residential treatment facility following a first hospitalization for severe AUD. He has been in residential treatment for 2 months. Although he has noted sleep disturbance since he completed alcohol detoxification, he recently reported symptoms of middle and terminal insomnia to his physician. He was prescribed trazodone 50 mg nightly. In the first month of treatment, his insomnia resolved, though he had a slip and consumed 1 alcoholic beverage.

 is professor, Department of Psychiatry and Health Behavior, Augusta University, Augusta, GA. He is the Schizophrenia Section Chief for 

 The author reports that he receives research support from Augusta University, the National Institute of Mental Health, the Brain and Behavior Research Foundation, and the Stanley Medical Research Institute.

1. Chakravorty S, Chaudhary NS, Brower KJ. 

Alcohol dependence and its relationship with insomnia and other sleep disorders

2. Brower KJ, Krentzman A, Robinson EA. Persistent insomnia, abstinence, and moderate drinking in alcohol-dependent individuals. 

3. Arnedt JT, Conroy DA, Brower KJ. Treatment options for sleep disturbances during alcohol recovery. 

4. Friedmann PD, Herman DS, Freedman S, et al. 

Treatment of sleep disturbance in alcohol recovery: a national survey of addiction medicine physicians

5. Roehrs TA, Auciello J, Tseng J, Whiteside G. Pharmacological treatment options for insomnia in patients with alcohol use disorder in recovery. 

6. Schubert JR, Arnedt JT. Management of insomnia in patients with alcohol use disorder. 

Clinical considerations for evaluating treatment options for patients with insomnia and AUD versus patients with primary insomnia without substance use comorbidity.

Understanding Comorbid Insomnia and Alcohol Use

Shift work sleep disorder is characterized by insomnia and excessive sleepiness lasting for at least 3 months in association with fluctuating work schedules. Patients who have this disorder experience an overall decreased amount of sleep. As defined by the 

International Classification of Sleep Disorders

, the condition also known as circadian rhythm sleep-wake disorder, shift work type or circadian rhythm sleep disorder (in DSM-5) is estimated to affect 

Because the inherent circadian rhythm is largely regulated by the 24-hour light/dark cycle, people who work overnight generally feel sleepier at night than during the day, even when they are at work or have slept during the day. Patients who work schedules with some or all shifts during the night when they would otherwise be sleeping may consequently experience disruptions in their circadian rhythm. These disruptions affect one’s ability to get adequate sleep, even when they have enough time to sleep. Most people who have shift work sleep disorder have 

Sleep disruption is also associated with behavioral manifestations of mood changes, such as irritability and social withdrawal. In addition to fatigue as a contributing factor, when mood changes like depression and anxiety are associated with shift work sleep disorder, they are thought to be caused by molecular alterations linked to circadian rhythm disruption. Research 

that the circadian clock is likely to regulate monoaminergic signaling, which mediates changes in dopamine, serotonin, and noradrenaline levels throughout the day.

 A disturbance in the circadian rhythm causes deregulation of these hormones at the level of molecular transcription, and this may result in symptomatic mood alterations.

Many shift workers are unable to adjust their circadian rhythm to their altered sleep wake schedules. This is evidenced by samples of salivary melatonin concentration, which normally 

 The diagnosis of shift work sleep disorder is a clinical diagnosis based on a patient’s medical history. The combination of insomnia, excessive sleepiness during waking hours, lack of sleep, and chronic shift work that is inconsistent with a regular day/night wake/sleep schedule leads to the diagnosis. Research 

that between 10% to 30% of shift workers fit the criteria for shift work sleep disorder, and it unclear why some shift workers are more prone to the condition than others.

Many pharmacological treatment strategies have been used to treat this acquired sleep disorder, including melatonin, zopiclone, lormetazepam, and modafinil. For example, one 

that was fairly representative of the effects of medications on the condition showed that pharmacological therapies increased sleepiness in some patients but did not improve overall sleep for the majority of patients.

 Non-pharmacological interventions include sleep education, use of bright light, napping, and physical exercise. These 

also have not been consistently effective.

A 47-year-old man has trouble falling asleep and reports not getting enough sleep throughout the night. He says he has no energy to do anything other than work and sit around at home.

His wife and daughter have accompanied him to the office visit. They explain that his moodiness has gotten worse over the past year. They say that he is irritable and sometimes seems down and uninterested in talking with them at home.

The patient works rotating shifts in a factory and has had the same job and schedule for about 5 years. He works 10-hour shifts with a schedule that varies weekly. He is scheduled to work from 10 PM to 8 AM on any 4 days of 1 week, followed by a week of working any 4 days from 10 AM to 8 PM. When an extra shift opens up with bonus pay, he takes it. He has often come home and gone back to work within 6 hours for an additional 10-hour shift when he can fit it in, which happens approximately 3 times per month.

The patient often tosses and turns in bed for hours before falling asleep, and sometimes he only gets a few hours of sleep before his next shift. He has not established a consistent sleeping pattern. He and his wife have installed heavy curtains with full window coverage to made sure their bedroom is completely dark during the daytime.

He agrees with his wife and daughter that he is quiet sometimes and irritable at others, but his family says these issues are getting progressively worse and he is very difficult to be around. The patient says he isn’t sad or anxious; instead, he is just tired and “zoned out.”

He gets enough to eat, and his wife is very attentive to planning healthy meals at home and packs healthy meals for him on his works days. He drinks 2 cans of caffeinated cold beverages at the beginning of every shift, and he doesn’t consume caffeine at any other time.

The patient smoked 1 pack of cigarettes per day since his 20s, but he quit about 5 years ago when a friend was diagnosed with lung cancer. He does not have any medical problems, and he isn't stressed at work or home. His physical examination is completely normal.

This patient was preliminarily diagnosed with shift work sleep disorder on his first visit. He and his wife agreed to keep a sleep diary over the course of 1 month. When they returned, they discussed the diary, which showed he had a very inconsistent sleeping schedule. He often came home and went to bed right away after a day or night shift, and sometimes he delayed going to bed for 3 to 7 hours after a day or an evening shift.

While shift work sleep disorder can cause diminished attention and increase the risk of accidents,

 this did not seem to be a problem for him. However, because he did not directly deal with equipment and rarely drove anywhere except work, he had limited opportunities to get into an inattention-induced accident.

The patient said that he did not want to look for a different job, as his pay rate and benefits were the best he had ever had in his life. He was advised to try to regulate his sleep schedule by going to bed at the same time every day during his week of night work and at the same time every day during his week of daytime work. He also wanted to try melatonin.

After several months, he was able to regulate his sleep on the weeks of his daytime shifts, but he still had an inconsistent sleep schedule on his week of nighttime work because he did not want to sleep during the day on his 3 days off. He continued to accept extra shifts whenever possible. He believed the melatonin helped him fall asleep and he felt that he was getting more rest on the days when he took it.

Overall, he did not have more energy, but he tried to be less irritable. His wife and daughter agreed he was more pleasant, yet still not very interactive. The family felt satisfied that learning about the disorder helped all of them cope with its clinical effects. They also all agreed the patient would aim eventually to get a job with a more regular schedule if he could find one without having to take a pay cut.

• Some people are more susceptible to shift work sleep disorder than others, and the reasons for this predisposition are unclear.

• Shift work sleep disorder is extremely difficult to overcome with medication. Because some patients’ symptoms improve with medication, it may be worth trying for those who can’t change their work schedule.

• Alternative therapies have shown limited success in the management of shift work sleep disorder. Nevertheless, sleep education can help patients and families cope and may serve as a motivation to eventually change circumstances when possible.

is Adjunct Professor at John Carroll University, and Instructor, Case Western Reserve University in Cleveland, OH. She is the Editor in Chief Emeritus of 

1. Boivin DB, Boudreau P. Impacts of shift work on sleep and circadian rhythms. 

https://pubmed.ncbi.nlm.nih.gov/25246026/

2. Gumenyuk V, Roth T, Drake CL. Circadian phase, sleepiness, and light exposure assessment in night workers with and without shift work disorder. 

https://pubmed.ncbi.nlm.nih.gov/22823876/

3. Albrecht U. Molecular Mechanisms in Mood Regulation Involving the Circadian Clock. 

https://pubmed.ncbi.nlm.nih.gov/28223962/

4. Liira J, Verbeek JS, Costa G, et al. Pharmacological interventions for sleepiness and sleep disturbances caused by shift work. 

https://pubmed.ncbi.nlm.nih.gov/25113164/

5. Slanger TE, Gross JV, Pinger A, et al. Person-directed, non-pharmacological interventions for sleepiness at work and sleep disturbances caused by shift work. 

https://pubmed.ncbi.nlm.nih.gov/27549931/

A case of a patient with difficult-to-treat insomnia highlights the pervasive daytime effects of this condition.

Insomnia Associated With Shift Work Sleep Disorder

Insomnia is characterized by difficulty falling asleep, trouble staying asleep, and/or early waking. The result is usually inadequate sleep, with daytime effects associated with sleep deprivation. Up to 50% of adults 

they have experienced insomnia at some point in their life.

While not as common as insomnia, anxiety and depression are also fairly prevalent among adults. 

 surveyed a random sample of 3406 participants ranging from aged 18 to 79 years. Of the participants, 13.9% (10.0% men, 17.0% women) reported they had received a diagnosis of anxiety; 6.4% (5.5% of men, 7.1% of women) had received a diagnosis of depression; 28.6% (23.5% of men, 32.7% of women) reported a diagnosis of insomnia; and 14% reported self-perceived stress.

Anxiety and stress are closely linked, and they are among the chief causes of insomnia. The exact prevalence of stress and/or anxiety among persons with insomnia is unknown, but stress and anxiety have an 

 because of a variety of emotional and physical factors.

 As with insomnia due caused by other factors, sleep deprivation due to anxiety-associated insomnia can bring about a variety of distressing symptoms during the day. Fatigue, irritability, anxiety, and depression are common consequences of sleep deprivation of any cause. Health problems like weight gain, hyperglycemia, and elevated lipid levels are associated with chronic sleep deprivation as well.

A 61-year-old man complains of insomnia, with difficulty falling asleep, frequent waking throughout the night, and early morning awakening. He estimates this has been going on for at least 6 months to a year, but he reports it is getting worse. He has been having trouble sleeping every night for the past few months and he naps during the weekend and in the evenings after work. He notes that he feels tired throughout the day and drinks cold caffeinated beverages “all the time,” to stay awake, totaling about 6 standard 8 oz cans per day.

He has gained 35 pounds in the past year. He used to regularly ride his bike for about 20 miles 3 or 4 times per week, but he stopped because of a stressful situation at work that has been distracting him. 

For the past 2 years, he has been embroiled in a lawsuit related to an accidental injury of an employee at his place of business, where he is a manager. The lawsuit is related to what is described as inadequate safety equipment, and he explains that he is part of the group of people who are responsible for implementing safety at his workplace. The patient says the employee’s injury and disability have been upsetting for him. He also says the lawsuit has been stressful. He was disturbed when he heard about the injury, but he was able to manage the stress because he thought the employee would have a quick recovery and the legal proceedings would be resolved within a month or so.

As he began to realize the issue would not be resolved quickly, he became more and more anxious about it. He explains the work environment is anxiety-provoking because there are meetings about the lawsuit approximately once per month, often with just a few hours’ notice. It should be noted that the business and his own salary have not been impacted and he says he is not stressed about the financial implications of the situation.

He lives with his wife and he says he has maintained a calm demeanor at home. He has 2 sons in their late 20s who live on their own and he says there is no strain in his relationships with his family. Over the past years, he has been going to fewer social outings and often leaves gatherings early because he feels bored. He explains his loss of interest in social gatherings began around the same time as the lawsuit.

He reports he has felt anxious and worried for as long as he can remember, but he doesn’t remember ever complaining of insomnia, and he has never felt the need to talk to a doctor about it. The patient mentions he experienced anxiety for a year after his father died because he had to manage his mother’s home and finances when she didn’t know what to do.

Past medical history consists of allergic asthma diagnosed in his 30s for which he takes nasal steroids as needed. He also is sensitive to many foods, which give him a stomach upset and heartburn.

Stress and anxiety are linked with each other. Stress is typically a response to a situation, while anxiety is a lingering feeling of disturbance or unease. Stress can cause anxiety, which is the case in this patient’s situation. The patient’s history strongly suggests a correlation between his difficult experience at work, his anxiety, and his insomnia.

During a clinical workup, it is important to keep in mind that underlying medical issues can contribute to insomnia and anxiety. Thyroid disease and heart disease, in particular, can exacerbate patients’ symptoms. When other causes are not found, it is helpful for patients to understand symptoms such as weight fluctuation, indigestion, stomach upset, sweating, appetite changes, and sexual dysfunction can all be symptoms of anxiety.1 This patient has noted some of these effects.

, especially without a precipitating factor that is out of the ordinary, it is often described as generalized anxiety disorder (GAD).

 The patient suggests he might have GAD, but based on his detailed history, it appear he is not excessively prone to anxiety out of proportion to the circumstances of his life.

The patient described in the vignette also has signs of depression. He has lost interest in socializing and exercise, which he used to enjoy. A depression screening would be beneficial as well. Major depression occurs in almost two thirds of patients with anxiety.

Treatment of comorbid anxiety, depression, and insomnia requires a treatment strategy that is designed to avoid exacerbating any of the 3 issues. Serotonin reuptake inhibitors (SSRIs) are among the 

 Additionally, SSRIs can help reduce symptoms of insomnia for some patients.

This patient started taking paroxetine (Paxil) but became very tired. He was unable to tolerate the fatigue, so the medication was discontinued. He wanted to try another medical treatment, however. He was prescribed amitriptyline (Elavil), a tricyclic antidepressant. He was more satisfied with the treatment and wanted to continue to take it. He also agreed he might benefit from counseling, as he did not see a clear light at the end of the tunnel regarding his situation at work, and he didn’t anticipate an improvement of his symptoms until the issue resolved.

• Anxiety and GAD are not the same conditions, even though people with anxiety may be prone to recurrent episodes.

• Insomnia is caused by and can cause anxiety and depression.

• Treatment of insomnia with anxiety and depression entails a strategy that is mindful of all 3 conditions.

The above case is for illustrative purposes only. Identifying factors have been changed. -Ed

1. Pharmacological Treatment of Mental Disorders in Primary Health Care. In: World Health Organization. 

Pharmacological Treatment of Mental Disorders in Primary Health Care.

https://www.ncbi.nlm.nih.gov/books/NBK143206/

2. Höglund P, Hakelind C, Nordin S. Severity and prevalence of various types of mental ill-health in a general adult population: age and sex differences. 

. 2020;20:209. doi: 10.1186/s12888-020-02557-5 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7212684/

3. Kalmbach DA, Anderson JR, Drake CL. The impact of stress on sleep: Pathogenic sleep reactivity as a vulnerability to insomnia and circadian disorders. 

Anxiety and stress are closely linked, and they are among the chief causes of insomnia. Watch for a variety of emotional and physical factors that may play a role in worsening depression. More in this case report.

Sleep Disorders