Montgomery Medicine No. 804

“Why Can’t I Sleep?”

Insomnia is one of the most common complaints we hear in primary care. Whether it’s a farmer who’s worried about the next rain, a teacher juggling papers and parenting, or a retired couple worrying about how tariffs are going to affect their retirement nest egg, sleep disruption affects nearly everyone at some point. In the United States, it’s estimated that nearly one in three adults suffers from some form of insomnia. The consequences are real: tens of billions of dollars lost in productivity, increased risk of chronic diseases, and a daily toll on mental health and well-being.

It’s important to recognize that insomnia is not a disease itself but a symptom, much like a fever or pain. That means the root cause must be identified before effective treatment can begin. Insomnia is typically divided into three types. Transient insomnia lasts less than a week and is often triggered by a temporary stressor, like travel, illness, or emotional upset. Short-term insomnia lasts from one to six months and is often related to ongoing stress, such as job changes or grief. Chronic insomnia, lasting more than six months, usually reflects deeper medical, psychological, or behavioral problems.

Recent research has expanded our understanding of chronic insomnia. One particularly striking finding is that insomnia changes how the brain regulates emotion. Functional MRI studies reveal that sleep-deprived brains show heightened activity in the amygdala, the part of the brain responsible for processing fear and anxiety, while connections to the prefrontal cortex, responsible for rational thought, are weakened. This may help explain why poor sleep is linked to anxiety, depression, and even suicidal thinking. Sleep, in a very real sense, is essential for emotional regulation.

Anxiety is a major contributor to insomnia. People often describe a racing mind that keeps them from falling asleep, especially those who tend to multitask and carry a heavy mental load. Depression, by contrast, often shows up as early morning waking and an inability to get back to sleep. Medical conditions such as chronic pain, fibromyalgia, congestive heart failure, and COPD can all disturb normal sleep cycles. More recently, chronic insomnia has also been identified in patients suffering from Long Covid, possibly related to autonomic nervous system dysregulation or persistent inflammation.

Certain neurological conditions can also play a role. Restless Leg Syndrome, for example, causes an uncontrollable urge to move the legs at night, often preventing sleep onset. Sleep apnea, particularly obstructive sleep apnea, causes repeated interruptions in breathing that lead to multiple brief awakenings. Both conditions are treatable but often go unrecognized, particularly in women or older adults who may present with more subtle symptoms such as fatigue or mood changes.

Our daily habits can also fuel the problem. Caffeine, which stays in the system for up to eight hours, is a frequent culprit. Many people drink coffee, soda, or energy drinks throughout the day to combat fatigue, only to find themselves wide awake at bedtime. Alcohol, too, is extremely problematic and is a leading cause of insomnia and fragmented sleep. While it may initially help people fall asleep due to its sedative effects, it disrupts the deeper, restorative stages of sleep later in the night, leading to early morning wakening and next-day grogginess.

Another hidden factor is our relationship with artificial light. The blue light from screens suppresses melatonin, the brain chemical that tells our body it’s time to wind down. Teenagers are particularly vulnerable. Their natural sleep cycle is already shifted forward (late to sleep, late to rise) due to changes in circadian rhythm during adolescence. Add in late-night video games or social media scrolling, and it’s no surprise that many teens report difficulty falling asleep and struggle to stay awake during the school day.

Sleeping pills, whether over-the-counter or prescription, can be effective in the short term but are not without problems. Tolerance can develop quickly, meaning people need more of the drug for the same effect. In older adults, these medications increase the risk of falls, fractures, and cognitive impairment. Rebound insomnia, or a worsening of symptoms after stopping these medications, is also common.

One overlooked insight from recent research, highlighted by Dr. Allison Siebern of Stanford University, is that people with chronic insomnia often develop an unhealthy relationship with sleep itself. They may spend hours lying in bed worrying about whether they will sleep or not. This actually makes it less likely that they will. Behavioral interventions, primarily cognitive behavioral therapy for insomnia (CBT-I), have been very effective in breaking this cycle of worry.

Insomnia is not just frustrating. It is a medical issue with real health consequences. Next week, I’ll cover proven strategies for prevention and treatment. Until then, take a moment to reflect on your own sleep habits. Sometimes, understanding the cause is the first step toward healing.