Insomnia

Insomnia

If you suffer from insomnia, you may be plagued by trouble falling asleep, unwelcome awakenings during the night, and fitful sleep. You may feel drowsy during the day, yet still be unable to nap. You may frequently be anxious, irritable, forgetful, and unable to concentrate.

Although it’s the most common sleep disturbance, insomnia is not a single disorder, but rather a general symptom like fever or pain. Finding a remedy requires uncovering the cause. Nearly half of insomnia cases stem from psychological or emotional problems.

Stressful events, mild depression, or an anxiety disorder can keep you awake at night. With proper treatment of the underlying cause, the insomnia usually recedes. If it doesn’t, additional treatment focusing on sleep may help.

The two main approaches to treating insomnia—behavioral therapy and medications—are both effective. But behavioral therapy has proven to be longer lasting and doesn’t have the side effects that can occur with medications.

Types of insomnia

One way doctors classify insomnia is by its duration. Insomnia is considered transient if it lasts only a few days, short-term if it continues for a few weeks, and chronic if the problem persists.

The causes of transient or short-term insomnia are usually apparent to the sufferer—the death of or separation from a loved one, nervousness about an upcoming event (such as a wedding, public speaking engagement, or move), jet lag, or discomfort from an illness or injury. Chronic insomnia may be caused by a number of medications or medical conditions. In these instances, treating the condition or changing the medication may relieve the insomnia.

One common form of persistent sleeplessness is conditioned (learned) insomnia. After experiencing a few sleepless nights, some people learn to associate the bedroom with being awake. Taking steps to compensate for sleep deprivation—napping, drinking coffee, having a nightcap, or forgoing exercise—only fuels the problem. As insomnia worsens, anxiety regarding the insomnia may also worsen, leading to a vicious cycle in which fears about sleeplessness and its consequences become the primary cause of the insomnia.

Non-drug treatments for insomnia

First-line treatment: Behavioral changes

For chronic insomnia, the treatment of choice is behavioral therapy, which uses a variety of behavioral techniques, such as changing your lifestyle and habits, to improve sleep. A careful evaluation can pinpoint habits that keep you up at night. A sleep specialist trained in behavioral medicine can help people with learned insomnia replace their bad habits with positive ones.

Sleep restriction

People with insomnia often spend more time in bed, hoping this will lead to sleep. In reality, spending less time in bed—a technique known as sleep restriction—promotes more restful sleep and helps make the bedroom a welcome sight instead of a torture chamber. As you learn to fall asleep quickly and sleep soundly, the time in bed is slowly extended until you obtain a full night’s sleep.

Some sleep experts suggest starting with six hours at first, or whatever amount of time you typically sleep at night. Setting a rigid early morning waking time often works best. If the alarm is set for 7 a.m., a six-hour restriction means that no matter how sleepy you are, you must stay awake until 1 a.m. Once you are sleeping well during the allotted six hours, you can add another 15 or 30 minutes, then repeat the process until you’re getting a healthy amount of sleep.

Stimulus control

Developed in the 1970s, this technique (also known as reconditioning) trains people with insomnia to associate the bedroom with sleep instead of sleeplessness and frustration. These are the rules:

  • Use the bed only for sleeping or sex.
  • Don’t spend time in bed not sleeping. Go to bed only when you’re sleepy. If you’re unable to sleep, move to another room and do something relaxing. Stay up until you are sleepy, then return to bed. If sleep does not follow quickly, repeat.
  • During the reconditioning process, get up at the same time every day and do not nap, regardless of how much sleep you got the night before.

Relaxation techniques

For some people with insomnia, a racing or worried mind is the enemy of sleep. In others, physical tension is to blame. Techniques to quiet a racing mind—such as meditation, breathing exercises, progressive muscle relaxation, and biofeedback—can be learned in behavior therapy sessions or from books or classes.

Progressive muscle relaxation, which involves progressively tensing and relaxing your muscles starting with your feet and working your way up your body, is a tried-and-true, drug-free technique for achieving both physical and mental relaxation.

A typical approach is this:

  • Lie on your back in a comfortable position. Put a pillow under your head if you like, or place one under your knees to relax your back. Rest your arms, with palms up, slightly apart from your body. Feel your shoulders relax.
  • Take several slow, deep breaths through your nose. Exhale with a long sigh to release tension.
  • Focus on your feet and ankles. Are they painful or tense? Tighten the muscles briefly to feel the sensation. Let your feet sink into the floor or the bed. Feel them getting heavy and becoming totally relaxed. Let them drop from your consciousness.
  • Slowly move your attention through different parts of your body: your calves, thighs, lower back, hips, and pelvic area; your middle back, abdomen, upper back, shoulders, arms, and hands; your neck, jaw, tongue, forehead, and scalp. Feel your body relax and your lungs gently expand and contract. Relax any spots that are still tense. Breathe softly.
  • If thoughts distract you, gently ignore them and return your attention to your breathing. Your worries and thoughts will be there when you are ready to acknowledge them.

Another way to release physical tension and relax more effectively is to use biofeedback. This approach involves using equipment that monitors involuntary body states (such as muscle tension or hand temperature) and makes you aware of them. Immediate feedback helps you see how various thoughts or relaxation maneuvers affect tension, enabling you to learn how to gain voluntary control over the process. Biofeedback is usually done under professional supervision.

Cognitive behavioral therapy

Cognitive behavioral therapy (CBT) teaches people new ways of thinking about and then doing things. CBT has proved helpful in treating addictions, phobias, and anxiety—as well as insomnia.

CBT for insomnia aims to change negative thoughts and beliefs about sleep into positive ones. People with insomnia tend to become preoccupied with sleep and apprehensive about the consequences of poor sleep - is worry makes relaxing and falling asleep nearly impossible - a phenomenon some experts refer to as “insomniaphobia.”

The basic tenets of this therapy include setting realistic goals and learning to let go of inaccurate thoughts that can interfere with sleep. Here are some common types and examples of these thoughts:

  • Misattributions: “When I feel nervous during the day, it’s always because I did not sleep well the night before.”
  • Hopelessness: “I’ll never get a decent night’s rest.”
  • Unrealistic expectations: “I need eight hours of sleep tonight” or “I have to fall asleep before my spouse does.”
  • Exaggerating consequences: “If I don’t get to sleep soon, I’ll embarrass myself at tomorrow’s meeting.”
  • Performance anxiety: “It will take me at least an hour to fall asleep.”

A cognitive behavioral therapist helps you replace these maladaptive thoughts with accurate and constructive ones, such as “All my problems do not stem from insomnia,” “I stand a good chance of getting a good night’s sleep tonight,” or “My job does not depend on how much sleep I get tonight.” The Therapist also provides structure and support while you practice new thoughts and habits. Typically, you meet with the therapist once a week for an hour, for six to eight weeks.

In recent years, CBT for insomnia has been refined, expanded, and dubbed “CBT-i.” It includes teaching people the behavioral treatments explained above (sleep restriction, stimulus control, and relaxation) as well as the sleep hygiene techniques.

In a 2014 review article in Annals of Internal Medicine, researchers combined data from 20 different trials of CBT-i involving more than 1,100 people with chronic insomnia. On average, people treated with CBT-i fell asleep almost 20 minutes faster and spent 30 fewer minutes awake during the night compared with people who didn’t undergo CBT-i.

These improvements are as good as, or better than, those seen in people who take prescription sleep medications such as zolpidem (Ambien) and eszopiclone (Lunesta). And unlike medications, the effects of CBT-i last even after the therapy ends—at least six months, according to one study. Medications, in contrast, stop working when you stop taking them.

The biggest obstacle to successful treatment with CBT-i is the commitment it requires. Some people fail to complete all the required sessions or to practice the techniques on their own. Internet-based programs might help address that problem. Several small studies suggest that online CBT-i programs that teach people good sleep hygiene, relaxation techniques, and other strategies can help insomniacs sleep better.

One such program, called SHUTi (Sleep Healthy Using the Internet), helped long-term insomniacs boost their sleep efficiency by an average of 16%, and participants were about half as likely to wake up after falling asleep, compared with a control group. Another study documented at least mild improvements in about 80% of people who completed five weeks of online CBT, with 35% reporting that their sleep was “much improved” or “very much improved.” And a Scottish study, which used an automated virtual therapist, also showed clear improvements in sleep and daytime functioning in people with insomnia. The benefits largely persisted two months after the intervention.

Many health insurance plans cover CBT-i, which falls under mental health coverage. There’s only one problem: not many therapists are trained in this specific type of talk therapy. Even in the medical mecca of Boston, only about five clinicians offer CBT-i. You can find lists of certified specialists throughout the country from the American Board of Sleep Medicine and the Society for Behavioral Sleep Medicine.

Prescription medications for insomnia

Prescription medications help some people with insomnia, but it’s best to use them at the lowest effective dose and for the shortest possible period of time. These drugs are most appropriate for short-term problems that disrupt sleep, such as traveling across time zones or coping with a death in the family. For longer term insomnia, behavioral therapies should be tried first, as they are often just as effective and may have longer-lasting benefits—without negative side effects.

Medications to treat insomnia include benzodiazepines, which are also used to treat anxiety; related medications known as nonbenzodiazepines, which selectively target sleep receptors in the brain; and antidepressants, which are typically prescribed in doses lower than those used to treat depression. Two newer sleep drugs target two different brain chemicals—melatonin and orexin—involved in sleep regulation.

Sleeping pills and sleep eating. Several news reports in 2006 drew attention to a strange side effect of zolpidem (Ambien): sleep eating. People were seen foraging for food at night but were unable to remember the episodes in the morning, or they reported finding evidence of a midnight feast with no recollection of the event. Several people even gained quite a lot of weight.

Other unusual side effects seen with Ambien and related drugs include sleepwalking, short-term amnesia, and, rarely, sleep driving. Some of the driving cases occurred when people took sleep medication after drinking alcohol.

As a result of these incidents, in 2007 the FDA ordered the drugs’ manufacturers to issue strong new label warnings about the risks of unusual behavior and to produce brochures about safe use.

Although rare, these incidents highlight the need for people who use sleep medications to be aware of the potential side effects and to use them properly. Always allow enough time for sleep, use only as directed, and avoid alcohol. If you experience any unusual occurrences, talk to your doctor right away.

Prescription Medications for Insomnia
Generic name (brand name) Side effects Comments
Benzodiazepines (for short-term treatment of insomnia)

alprazolam* (Xanax)

clonazepam* (Klonopin)

diazepam* (Valium)

estazolam (ProSom)

flurazepam (Dalmane)

lorazepam* (Ativan)

quazepam (Doral)

temazepam (Restoril)

triazolam (Halcion)

Clumsiness or unsteadiness, dizziness, lightheadedness, daytime drowsiness, headache Should be used with caution by people with sleep apnea or other breathing difficulties; not to be used with alcohol or other depressants; tolerance may develop; withdrawal symptoms occur if stopped abruptly. Triazolam is a short-acting medication.
Nonbenzodiazepines (for insomnia)

eszopiclone (Lunesta)

zaleplon (Sonata)

zolpidem (Ambien, Ambien CR)

Headache, daytime drowsiness, dizziness, nausea, drugged feeling Don’t take these medications with alcohol and certain depressants (including antihistamines, muscle relaxants, and sedatives).
Antidepressants (for insomnia, nonrestorative sleep, and depression)

Serotonin modulator

trazodone* (Desyrel)

Dizziness, dry mouth, headache, nausea, constipation or diarrhea, painful erections Do not take with a monoamine oxidase inhibitor (MAOI) or while recovering from a heart attack.

Selective serotonin reuptake inhibitors (SSRIs)

citalopram* (Celexa)

fluoxetine* (Prozac)

fluvoxamine* (Luvox)

paroxetine* (Paxil)

sertraline* (Zoloft)

Dry mouth, drowsiness, dizziness, sexual dysfunction, nausea, diarrhea, headache, jitteriness, sweating, insomnia, weight gain Do not take with a monoamine oxidase inhibitor (MAOI) or while recovering from a heart attack.

Serotonin and norepinephrine reuptake inhibitor (SNRI)

venlafaxine* (Effexor)

Upset stomach, excitement or anxiety, dry mouth, skin sensitivity to sunlight, weight gain, headache Do not take with a monoamine oxidase inhibitor (MAOI) or while recovering from a heart attack.

Tetracyclic

mirtazapine* (Remeron)

Dry mouth, constipation, weight gain, headache, dizziness Do not take with a monoamine oxidase inhibitor (MAOI) or while recovering from a heart attack.

Tricyclics

amitriptyline* (Elavil)

doxepin (Sinequan,* Silenor)

nortriptyline* (Aventyl, Pamelor)

trimipramine* (Surmontil)

Dry mouth, dizziness, constipation, incomplete urination, weight gain, sunsensitivity, sweating, faintness upon standing, increased heart rate, sexual dysfunction Do not take with a monoamine oxidase inhibitor (MAOI) or while recovering from a heart attack.
Melatonin-receptor agonist (for insomnia at bedtime)
ramelteon (Rozerem) Dizziness May exacerbate depression; not to be used by people who have severe liver damage or who take fluvoxamine (Luvox).
Orexin-receptor antagonist
suvorexant (Belsomra) Dizziness, headache, unusual dreams, dry mouth, cough New medication, so full range of side effects not yet known.

* Although the FDA has not approved these drugs for insomnia, physicians have found that they often help people with insomnia and therefore prescribe them. The only antidepressant with FDA approval for insomnia is Silenor. (Sinequan has the same active ingredient, but it does not have approval for this use.)

Over-the-counter sleep aids

Drugstores carry a bewildering variety of over-the counter (OTC) sleep products, and there’s clearly a market for them. One small survey of people ages 60 and over found that more than a quarter of them had taken nonprescription sleep aids in the preceding year—and that one in 12 did so daily. But do these products work? And if you try them, should you choose a sleeping pill, an herbal remedy, or a dietary supplement?

Standard nonprescription sleeping pills

Behind the riot of competing brands, this class of products is surprisingly straightforward. Each one—whether a tablet, capsule, or gelcap—contains an antihistamine as its primary active ingredient. Most over-the-counter sleep aids—including Nytol, Sominex, and others—contain 25 to 50 milligrams (mg) of the antihistamine diphenhydramine. A few, such as Unisom SleepTabs, contain 25 mg of doxylamine, another antihistamine.

Over-the-counter antihistamines have a sedating effect and are generally safe. But they can cause nausea and, more rarely, fast or irregular heartbeat, blurred vision, or heightened sensitivity to sunlight. Complications are generally more common in children and in people over age 60. Diphenhydramine blocks the brain chemical acetylcholine, which is essential for normal brain function. A study that pooled findings from 27 studies on the effect of medications like diphenhydramine found that elderly people who took these drugs faced a higher risk of cognitive problems, including delirium. Alcohol heightens the effect of these medications, which can also interact adversely with some drugs. If you take nonprescription sleeping pills, be sure to ask your physician about the possibility of interactions with other medications.

Sleep experts generally advise against using these medications, largely because of their side effects but also because they are often ineffective. And there’s no information about the safety of taking these drugs over the long term.

Dietary supplements

According to one survey, about 1.4% of adult Americans have used some form of alternative medicine (mostly herbal supplements) for insomnia or trouble sleeping.

As with other dietary supplements, the FDA does not regulate these products, so they aren’t tested for safety, effectiveness, quality, or accuracy of labeling. Although marketed as “natural,” these products may contain biologically active substances that can have side effects or interact with other medications or supplements.If you’re thinking about using such products (or already do so), be sure to tell your doctor.

Many herbal products include a variety of active ingredients, some of which might interact unfavorably with other medications you’re taking. Even a single herb is a complex chemical stew. Valerian root extract, for example, contains more than 100 specifically identified substances. Researchers don’t know precisely which one of these accounts for the herb’s effect, nor can they say exactly how they might interact with other medications. Finally, the per-dose price of these remedies varies far more than that of standard sleeping pills.

Scientific understanding of these substances is limited, and what we know generally comes from small, short-term studies. Thus, most doctors discourage the use of herbal medicines as sleep aids. But the market for such products is booming.

Readily available alternative sleep remedies include:

Valerian (Valeriana officinalis). A few studies suggest that valerian is mildly sedating and can help people fall asleep and improve their sleep quality. However, a review in the Journal of Clinical Sleep Medicine pointed out that most of the studies were small and flawed, and that even the positive studies showed only a mild effect. The most common reported side effects are headaches, dizziness, itching, and gastrointestinal disturbances.

As with other unregulated remedies, the quality of valerian-containing products varies widely. A report by ConsumerLab—a commercial laboratory that periodically tests the quality of herbal remedies—found that nearly a quarter of valerian-based products appeared to contain no valerian whatsoever, and an equal number had less than half the amount claimed on their labels.

Chamomile. Tea made from this flower, a member of the daisy family, is a traditional remedy long used to help people relax and become drowsy. Chamomile is both mild and safe, although rare allergic reactions, including bronchial constriction, can occur. If you’re allergic to plants in the daisy family, which includes ragweed, you should probably avoid this herb. There are no scientific studies showing chamomile is effective in treating insomnia.

Synthetic melatonin. The brain’s production of the hormone melatonin peaks in the late evening, in conjunction with the onset of sleep. Since the 1990s, a synthetic version has been widely available in the United States as a supplement at health food stores and pharmacies. In Great Britain and Canada, melatonin is classified as a medicine and available by prescription only.

Despite some initial enthusiasm for synthetic melatonin, most subsequent research has been disappointing, finding either minimal benefits or none at all. A review of the melatonin research by the federal Agency for Healthcare Research and Quality (AHRQ) concluded that the supplement “is not effective in treating most sleep disorders.” However, a subset of people do appear to benefit: those whose insomnia results from delayed sleep phase syndrome, a circadian rhythm disorder in which people don’t start to feel sleepy until hours after the conventional bedtime. The AHRQ review found that melatonin enables people with this disorder to fall asleep an average of nearly 40 minutes faster than they would with a placebo.

Melatonin has a short half-life (one or two hours) and does not appear to pose any major health risks when taken for a short time. The most commonly reported side effects are nausea, headache, and dizziness. Its long-term effects are unknown. A controlled-release version with a longer duration of action, called Circadin (available in some other countries but not in the United States) may help some people with insomnia according to European research.

Gadgets that promise better sleep: Worth a try?

In recent years, a number of smartphone apps, gadgets, and specialized devices that pledge to deliver a more satisfying slumber have hit the market, aimed directly to sleep-deprived consumers. They include a range of products, from wristband or mattress sensors that record your movement in bed to specialized lights that claim to either help you fall asleep or wake up.

Be aware that there’s little research demonstrating the effectiveness of any of these products, which don’t require a great deal of evidence to gain marketing approval. There are no known downsides to trying any of them, save for the cost (if any). If you try one but still have troubling symptoms, consult your health care provider.