Chronic insomnia and epidemiology

Chronic insomnia and epidemiology

Chronic insomnia and epidemiology

Chronic insomnia is a common sleep disorder that is characterized by difficulty in falling asleep at an initial stage, waking up during the night, and waking earlier than expected. The prevalence of short-term insomnia affects 30% to 50% of the population (1). The prevalence of chronic insomnia disorder in developed countries is estimated at least 5% to 10% (2,3). While short-term insomnia is usually transient, stress-related, and tends to go away after weeks. On the contrary, chronic insomnia is often associated with a reduction in perceived health (4), quality of life (5), increases in workplace injuries and absenteeism (6), and even fatal injuries (7). Chronic insomnia has been identified as a significant predictor of the onset of depression, anxiety, alcohol abuse, and psychosis in comprehensive meta-analyses studies implicating a potentially increased risk for psychopathology (8). Notably, prolonged insomnia is recognized as an independent risk factor for heart disease, hypertension, and diabetes, especially when combined with a sleep duration of fewer than 6 hours per night (9).  Furthermore, a strong association between sleep disturbances and pain has also been reported in patients with chronic insomnia (10).

Social and economic impacts of chronic insomnia

While a substantial population worldwide may experience sleep disturbances, chronic insomnia exerts significant economic burdens on society, which comprises direct and indirect expenditures. In the US, Insomnia is one of the commonest sleep disorders that causes a significant burden to the US healthcare system and vulnerable patient groups. Direct costs may include higher economic burdens in using emergency and healthcare services and greater expenditures for prescribed medications in these patients with chronic insomnia. Likewise, indirect costs may lead to work absenteeism (11), loss of productivity, and insomnia-induced fatal injuries (7).  The estimated direct costs range from $2-16 billion and indirect costs from $75-100 billion annually, respectively (12).

DSM-V diagnostic criteria of chronic insomnia

The American Academy of Sleep Medicine(AASM) defines insomnia as the subjective perception of difficulty with sleep initiation, duration, consolidation, or quality that occurs despite the sufficient opportunity for sleep and that causes a substantial form of daytime impairment. According to DSM-V Diagnostic criteria for chronic insomnia, patients may experience sleep disturbance that may cause clinically significant distress or daytime impairment of at least one of the following symptoms (9):

  • Fatigue or low energy
  • Daytime sleepiness
  • Impaired attention, concentration, or memory
  • Mood disturbance
  • Behavioral difficulties
  • Impaired occupation or academic function
  • Impaired interpersonal or social function
  • Negative effect on caregiver or family functioning

The aforementioned sleep difficulties occur at least three times a week for at least three months, although the sufficient opportunity for sleep has been provided.

Cognitive behavioral therapy for Insomnia (CBT-I) is the first-line treatment for chronic insomnia

Evaluation of a patient with chronic insomnia should include a complete medical and psychiatric history, medication/ substance use, and a detailed assessment of sleep-related behaviors and symptoms. Cognitive behavioral therapy for insomnia (CBT-I) is recognized as one of the most effective first-line treatments for insomnia, which includes setting realistic goals for sleep, limiting time spent in bed, restructuring maladaptive benefits of sleeplessness, maintaining good sleep hygiene, and practicing relaxation skills. CBT-I is traditionally offered over six to eight meetings (9). The efficacy of CBT-I is proven to be as effective as sedative-hypnotics in acute conditions (4-8 weeks) and sedative-hypnotics on a long-term basis (normally has a long-lasting effect for more than 3 months after treatment) (13).

Given the high efficacy of CBT-I for patients with chronic insomnia, CBT-I has evolved in various alternative formats. CBT-I can be delivered in a group format. Several studies conducted in group format demonstrated significant improvement in sleep initiation, although the outcomes were less desirable compared to individual treatment (14–16). Possible reasons accounting for the difference might be due to the significant overlapping comorbidities of more anxiety-prone patients with insomnia.

Likewise, CBT-I can be delivered via telehealth (e.g. video conferencing), which facilitates CBT-I therapists to provide their CBT-I treatment and CBT-I training online nationwide. Moreover, the COVID-19 pandemic has indirectly expanded the development of CBT-I online and made it more readily available for patients who are reluctant to seek medical care.

Another approach to CBT-I was based on CBT-I apps that offer a convenient alternative to ‘self-help’ to patients. Without seeking help from a CBT-I therapist, patients can undergo treatment in comfortable settings by watching videos by key opinion leaders, patient testimonials, and so on. These CBT-I apps are data-driven and allow automated assessment and real-time monitoring for insomnia symptom progression with prompt reminders/ feedback. With the help of CBT-I apps, this alternative format of CBT-I reported substantial improvement in sleep continuity, sleep latency, and total wake time (17).

How Belun can facilitate CBT-I treatment

While traditional daily sleep diaries are often used to record sleep complaints over time, these include bedtime and time arising from bed, time to fall asleep, number and duration of awakening during night, time of final awakening in the morning, and daytime naps (18). Belun Sleep Platform (BSP) offers an automated and convenient digital sleep diary for patients.

Belun Sleep Platform (BSP) has the capability of monitoring and analyzing SpO2, heart rate variability (HRV), photoplethysmography (PPG) waveform, and accelerometer-derived actigraphy data. It can calculate an estimated apnea-hyponea index (bAHI). It can also differentiate wakefulness from sleep and perform sleep stage analysis and give REM sleep duration and NREM sleep duration using its artificial intelligence platform. Furthermore, autonomic nervous system (ANS) activities include sympathetic and parasympathetic activities throughout the monitoring period. From the assessment provided by Belun Sleep Platform, objective sleep impairments data (e.g., prolonged sleep latencies, reduced sleep time, elevation in heart rate, and reduced heart rate variability) can be provided to clinicians with more accurate diagnosis and monitoring of the efficacy of CBT-I or combined pharmacotherapy before and after treatment in the era of precision medicine. Although polysomnography is currently the gold standard for measuring sleep quality, the test is costly, not easily available, requires skilled sleep technicians for assessment, and most importantly, it is not a pre-requisite assessment for insomnia (18). Going forward, Belun Sleep Platform provides a cost-effective, readily available, automated, no-skilled technician-needed solution to clinicians and patients with insomnia population-wide.

Partnering with Belun :

Up to now, over 32 organizations, including HK hospital authority hospitals, medical groups, clinic groups, dentists, and elderly centers selected to use the Belun Sleep Platform, Belun® Ring and Sleep App, and Belun® remoVital monitoring system. Many doctors read our medical journal papers, including 1) “Belun® Ring Platform: a novel home sleep apnea testing system for assessment of obstructive sleep apnea” ( and 2) “Detection of obstructive sleep apnea using Belun Sleep Platform wearable with neural network based algorithm and its combined use with STOP-Bang questionnaire” ( If you would like to know more about how to adopt Belun’s solution in your organization or home use, pls feel free to contact us to schedule a meeting by filling out the form below:


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