Sleep problems in Norway
The prevalence of insomnia has increased considerably in Norway over the last decade.
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- One in seven adults have chronic insomnia (sleep problems), and about one in three have weekly symptoms of insomnia.
- Adolescents sleep less than before.
- The use of electronic media before bedtime is associated with a later bedtime and shorter sleep duration among children and adolescents with sleep problems.
- Insomnia increases the risk of developing health problems and dropping out of the workforce.
- Insomnia has significant socioeconomic consequences.
- Sleep medication (hypnotics) is still the most common treatment in Norway, although cognitive behaviour therapy has a better and more lasting effect.
One in seven adults has insomnia
The main symptoms of insomnia are difficulty falling asleep, frequent nocturnal awakenings or experiencing non-restorative sleep, which leads to impaired daytime function.
Studies from several countries show that:
- Nearly a third of the population report weekly sleep problems, with nearly 70 per cent of patients in primary care reporting insomnia (Shochat 1999).
- About 10 per cent of the adult population in the Western world meet the diagnostic criteria for insomnia (Ohayon, 2002).
- Sleep problems that are not caused by a known physical or mental illness (primary insomnia) are estimated to account for around 20-25 per cent of insomnia cases.
Prevalence of sleep problems has increased
Recent figures from Norway show that the prevalence of insomnia among adults increased from 11.9 per cent to 15.5 per cent between 2000 and 2010 (Pallesen, 2014). The increase was particularly evident among middle-aged women. The increase came primarily from problems with sleep onset (from 13.1 to 15.2 per cent), dissatisfaction with sleep quality (from 8.2 to 13.6 per cent), and impaired daytime function due to inadequate sleep (from 14.8 to 18.8 per cent). The increase was not related to other health outcomes.
Differences in population
Women have most sleep problems
Insomnia occurs more frequently among women (Sivertsen, 2009). In particular, older women often report insomnia (Pallesen, 2014) but the gender gap is already present in adolescence (Hysing, 2013).
Common in all age groups
- Sleep problems are common in all age groups. Recent figures from Norway show that:
- Frequent nocturnal awakenings are very common among toddlers (Hysing, 2014).
- 1 in 5 preschool children has a diagnosable sleep problem where insomnia is the most common (Steinsbekk, 2013).
- Insomnia is also common among adolescents, where one in four meet the diagnostic criteria (Hysing, 2013).
- Insomnia increases with age among adults; to almost 25 per cent in people over 60 years.
Adults sleep as long as before, while adolescents get too little sleep
In the adult population, the average sleep time has been relatively stable in recent decades (6 hours, 52 minutes for men and 7 hours, 11 minutes for women) (Ursin, 2005), but new Norwegian figures show that we have shifted patterns considerably since 1980 (Sivertsen, 2011).
Many Norwegian adolescents appear to not get enough sleep, which was shown in a large Norwegian study where youths slept on average two hours less on weekdays than recommended. They slept 6 hours, 25 minutes compared to the recommended 8 -9 hours (Hysing, 2013).
There are many similarities in the development of sleep problems across age groups but there are also some age-specific characteristics. In young children, a high degree of parental involvement in the child’s sleep routine can interrupt the development of good sleep patterns, since the child does not acquire the ability to regulate their sleep and wakefulness alone (Sadeh, 2010). Co-sleeping is linked to frequent nocturnal waking in infancy and early childhood (Hysing, 2014).
In adolescence, disturbed circadian rhythms which often occur as a result of biological and social causes can contribute to, or aggravate, insomnia symptoms (Pallesen, 2011).
Socioeconomic differences in sleep problems
In a large Norwegian study, symptoms of insomnia were more than twice as common among people with a lower education (19 per cent) compared with people with university or college education (9 per cent) (Sivertsen, 2009). This association is present even among children, where those from families with a poor financial situation have a greater degree of difficulty sleeping (28 per cent) compared with children from families with a comfortable financial situation (10 per cent) (Boe, 2012).
We know little about the underlying physiological mechanisms of insomnia, but predisposing, precipitating and perpetuating factors seem to influence development (Spielman, 1991).
For example, acute insomnia may be triggered by an illness or other negative life event, while cognitive and behavioural factors may play a role in maintaining and possibly worsening sleep problems. Persistent sleep-related anxiety and poor night sleep often lead to increased sleeping during the day, which in turn helps to maintain the difficulties.
“Sleeping in” at the weekends contributes further to disrupting the body's own circadian rhythms that control the need for sleep and wakefulness.
Electronic equipment and social media as "sleep thieves”
One of the trends that may have influenced our sleep patterns is the increased use of electronic devices and social media. Figures from the USA show that 95 per cent of the population now uses electronic media (mobile, tablet, video games, etc.) in the hour before retiring to bed.
A large literature review showed that the use of electronic media prior to bedtime was related to a later bedtime and shorter sleep duration in children and adolescents with sleep difficulties (Cain, 2010). A study of Norwegian adolescents recently found that the use of electronic devices in bed was also associated with increased incidence of insomnia and short sleep duration (Hysing, 2015).
Prevention of sleep problems
Although there are good research data about insomnia treatment, few studies have examined the efficacy of preventive measures against insomnia. Several cross-sectional studies in the general population have shown that use of sleep hygiene advice is linked to good sleep quality (Yang, 2010). It can therefore be assumed that good sleep hygiene may help to prevent the development of sleep problems.
The majority of people with sleep problems (about 80 per cent) usually have co-existing mental or physical problems. It has therefore been common to look at prevention of sleep problems as part of the measures associated with these conditions.
Although prevention of anxiety and depression are also likely to have a transmissible effect on sleep problems, there is still a great need for further studies to examine the effects of preventive measures that are more targeted towards sleep problems.
Implications and challenges
Sleep problems affect, and are affected by, our somatic and mental health (Sivertsen, 2012).
- In children, sleep problems are associated with both poorer school function (Dewald, 2010) and the development of somatic and mental health problems (Shochat, 2014).
- In adolescence, sleep problems are linked to increased mental health problems, problematic alcohol use, as well as more school absence and poor academic performance (Hysing 2015, Hysing 2016, Sivertsen 2014, Sivertsen 2015).
- In adults, sleep problems have a negative impact on health in a variety of areas (Sivertsen, 2013). Sleep problems are also associated with reduced work capacity and a doubled risk of needing to take sick leave and claim disability benefits (Sivertsen, 2009b; Sivertsen, 2006).
- In the USA, the economic costs of insomnia are estimated at over 90 billion dollars a year. This includes both direct medical costs and indirect costs such as sleep-related accidents and lost working capacity (Kessler, 2011). There are no corresponding figures for Norway.
Incorrect treatment can increase difficulties
Half of the patients in primary care and the mental health care service report symptoms of insomnia (Reigstad, 2010; Shochat, 1999), but only a few of these are detected by healthcare professionals (Sivertsen, 2010). In addition, we know that 2 out of 3 people with insomnia have no or poor knowledge of available treatment options (Ancoli-Israel, 1999). Many use alcohol and health food products in an attempt to improve their sleep.
Benzodiazepines (with active substances such as alprazolam, diazepam, clonazepam, midazolam, nitrazepam and oxazepam) have been mostly used to treat insomnia. However, continuous use is associated with the development of adverse side effects, recurrence of symptoms and dependence on the drug (Ashton, 1994).
Newer benzodiazepine hypnotics (with active substances as zopiclone, zolpidem) have proven to be as effective for treating acute insomnia as traditional benzodiazepines. With short-term use, the newer drugs also had slightly fewer adverse side effects and do not alter sleep patterns to the same extent as the older drugs. However, there is general agreement that this type of hypnotics should be used with caution in patients with chronic insomnia, and prolonged use beyond 3-4 weeks should be avoided (National Institute of Health, 2005).
The prescription of alimemazine (antihistamine) for children between 0 and 3 years is not uncommon in Norway (Slørdal, 2008) despite the substantial risk of adverse side effects and lack of evidence of efficacy. The use of hypnotics among adults has also been shown to be related to the use of similar sleep medication by their infants and young children, regardless of the child’s health (Holdø, 2013).
Alternatives to drug treatment
Drug therapy is still the most commonly used treatment of insomnia (Sivertsen, 2010). This is despite the fact that non-drug treatments, such as cognitive-behavioural therapy (CBT) has been shown to be more effective in both the short and long term. CBT is a treatment that includes several factors, such as training in sleep hygiene (psychoeducation), sleep restriction, stimulus control, cognitive therapy and relaxation techniques. Several systematic reviews and meta-analyses show that 8 out of 10 patients improve if they complete such treatment (Morin, 1994; Pallesen, 1998).
It is important that treatment for people with chronic insomnia increasingly includes non-pharmacological interventions, such as CBT, with drug therapy being limited to short-term use for acute insomnia.
Types of sleep problems (insomnia)
- Primary insomnia: Sleep problems that cannot be attributed to a known physical, mental or environmental cause.
- Comorbid insomnia: Sleep problems that occur with a physical illness (2/3) or mental illness (1/3).
- Transient insomnia: Transient insomnia lasting from a few days to a week. Often caused by a less severe illness, negative life event or environmental cause (noise, jet lag).
- Acute insomnia: Sleep problems that can last several weeks. Same causes as transient insomnia but often of a more serious nature.
- Chronic insomnia: Sleep problems lasting more than 6 months, often for several years. Same causes as transient or acute insomnia but often maintained by other factors.
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