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Daniel Buysse, MD (Distinguished Professor of Psychiatry, Medicine, and Clinical and Translational Science, and UPMC Endowed Chair in Sleep Medicine), is an internationally recognized expert in sleep medicine research, specializing in the diagnosis, assessment, pathophysiology, and treatment of insomnia. 

In a recent Clinical Practice article published in the New England Journal of Medicine, Dr. Buysse reviewed the management of chronic insomnia through the lens of a case study. We spoke with Dr. Buysse about understanding and treating insomnia, including the use of cognitive behavioral therapy and medication.

What causes insomnia?

Many conditions are associated with insomnia—for example, most mental disorders, substance use disorders, and medical and neurological conditions—but it’s hard, if not impossible, to say that these cause insomnia. 

In general, the causes of insomnia can be considered from two perspectives: neurobiological and psychological. Sleep normally occurs when brainstem and hypothalamic arousal systems get switched off in the brain. In insomnia, the balance between wake- and sleep-promoting systems is shifted toward wakefulness. This so-called hyperarousal is an example of a neurobiological explanation for insomnia. Moreover, sleep and arousal are not uniformly distributed in the brain. We’ve learned from functional neuroimaging that in people with insomnia, some portions of the brain just don’t shut off effectively when they go to sleep. 

The psychological causes of insomnia can be similar: people have difficulty quieting the chatter in their mind at night. They ruminate on what happened during their day, or what’s coming up in the future. Some people develop a learned arousal associated with bedtime: Sleeplessness leads to frustration, frustration leads to more arousal, and more arousal leads to more sleeplessness. 

In the New England Journal of Medicine, you discuss cognitive behavioral therapy as a treatment for insomnia. How does that work?

Cognitive behavioral therapy for insomnia, known as CBT-I, is the recommended first-line treatment for insomnia. It involves using a set of behavioral or psychological techniques including education, behavioral restructuring, and cognitive approaches to decrease arousal. The behavioral component is the most potent and includes strategies like reducing time in bed to match the ability to sleep, establishing regular wake and bedtime routines, and associating the bed and the bedroom as a stimulus for sleep—not with tossing and turning. Another strategy is to only go to bed when you’re feeling tired, which may seem obvious, but people with insomnia can become so frustrated that they go to bed earlier and earlier. But because sleep is not a voluntary process, going to bed early, before you’re sleepy, leads to a vicious cycle of sleeplessness.

What should a person do if their primary care provider is not well-informed about insomnia?

CBT-I used to only be offered in sessions with a trained therapist, but the recent development of digital CBT-I offers the same content in an automated form, which increases access for people who need it. A variety of digital CBT-I options are available as an app or through web-based programs. 

In addition, the Society of Behavioral Sleep Medicine website has a list of sleep health providers, and locally, the UPMC Sleep Medicine Center can help. 

Does the presentation of insomnia differ across the lifespan?

In young children, the criteria can include acute bedtime resistance. In teenagers and young adults, insomnia can mean difficulty falling asleep, because circadian rhythms drift later at this age. In adulthood, including midlife and older adulthood, the pattern shifts toward repeated awakenings that can be related to numerous issues including sleep apnea or, in midlife women, perimenopause and menopause. 

What else should we know about management of insomnia?

As with the treatment of any other condition, medications can help, but they have the potential for side effects. Three categories of medications can be prescribed for insomnia. First, benzodiazepine receptor agonist hypnotics, including benzodiazepines and Z-drugs, are clearly efficacious. The concern with these is side effects including cognitive impairment, increased risk of falling, and increased risk of dementia. These are greater concerns for older adults.

Second, a new category of medications called dual orexin receptor antagonists are FDA-approved for insomnia and work by shutting off arousal signals. Dual orexin receptor antagonists are efficacious, and present less risk of cognitive impairment, but are more difficult to access.

Third, low-dose sedating antidepressant drugs are commonly prescribed. These aren’t as well tested, but seem to be effective and have mild side effects at low doses.

Management of Insomnia
Morin CM, and Buysse DJ
New England Journal of Medicine 2024;391:247-58.DOI: 10.1056/NEJMcp2305655