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Overcoming insomnia

FEB 2011

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Options include lifestyle changes, psychotherapy, and medication.

People with insomnia — the inability to sleep — may be plagued by trouble falling asleep, unwelcome awakenings during the night, and fitful sleep. They may experience daytime drowsiness yet still be unable to nap, and are often anxious, irritable, and unable to concentrate.

Insomnia is one of the most common types of sleep disturbance, at least occasionally affecting about one in three Americans. Epidemiologic studies suggest that 9% to 15% of Americans experience problems functioning in the daytime as a result of insomnia. Because insomnia often occurs in conjunction with a psychiatric disorder, insomnia may affect as many as 50% to 80% of patients in a typical mental health practice. Sleep problems are particularly common in patients with anxiety, depression, bipolar disorder, and attention deficit hyperactivity disorder (ADHD).

Types of insomnia

One of the most common ways to classify insomnia is in terms of duration of symptoms. Insomnia is considered transient if it lasts less than a month, short-term if it continues for one to six months, and chronic if the problem persists longer than six months.

The causes of transient or short-term insomnia are usually apparent to the individual affected. Typical circumstances include the death of a loved one, nervousness about an upcoming event, jet lag, or discomfort from an illness or injury. Chronic insomnia, on the other hand, is most often learned through conditioning. After experiencing a few sleepless nights, some people learn to associate the bedroom with being awake. Taking steps to cope with sleep deprivation — napping, drinking coffee, having a nightcap, or forgoing exercise — only worsens the problem. As insomnia persists, anxiety regarding the insomnia may grow more intense, leading to a vicious cycle in which fears about sleeplessness and its consequences become the primary cause of the insomnia.

Treatment becomes necessary once insomnia impairs sleep quality to the degree that it adversely affects a person's health or ability to function during the day.

Cognitive behavioral therapy

For chronic insomnia, the treatment of choice is cognitive behavioral therapy. Both the American Academy of Sleep Medicine and the National Institutes of Health recommend using cognitive behavioral therapy (CBT) before medication, based on research concluding that CBT is just as effective as prescription medication at alleviating chronic insomnia in the short term and may be more effective in the long term. Although most of these studies have been restricted to people without psychiatric disorders, a smaller body of research suggests that CBT is also helpful for people who have a mental health problem along with insomnia.

When used to treat insomnia, CBT helps patients 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. This worry makes relaxing and falling asleep nearly impossible. A clinician using CBT helps a patient to set realistic goals and learn to let go of inaccurate thoughts that can interfere with sleep, such as hopelessness ("I'll never get a decent night's rest"). Instead, the patient learns to replace maladaptive thoughts with more constructive ones, such as "Not all my problems stem from insomnia," or "I stand a good chance of getting a good night's sleep tonight." The therapist also provides structure and support while patients practice new thoughts and habits. CBT also involves lifestyle changes that may be used alone or combined as part of therapy (see "Lifestyle changes that promote sleep").

In studies involving head-to-head comparisons, medication tends to relieve symptoms faster than CBT, but the benefits end once patients stop taking the drug. In contrast, the benefits of CBT become more apparent with time. For example, one study compared CBT alone with the combination of CBT and zolpidem (Ambien). At the six-week mark, patients in both groups improved, but those who received combination treatment improved faster, sleeping an average of 20 minutes longer per night than those assigned to CBT alone. However, in the second, longer-term phase of the study, benefits of drug therapy faded. After initially receiving combination therapy, patients were randomized to maintenance therapy with CBT alone or continued combination therapy (CBT and zolpidem). At the six-month mark, 68% of the patients receiving only maintenance CBT achieved remission, significantly more than the 42% receiving combination therapy.

The biggest obstacle to successful treatment with CBT is patient commitment — some people fail to complete all the required sessions or to practice the techniques on their own. Internet-based programs are being tested to address this challenge. Several small studies suggest that online CBT programs that teach people good sleep hygiene, relaxation techniques, and other strategies are promising. For example, one program, called SHUTi (Sleep Healthy Using the Internet), consisted of six online modules based on CBT techniques. In a pilot study, researchers found that SHUTi helped patients with long-term insomnia (lasting an average of 10 years) improve their ability to fall and stay asleep compared with a control group.

Lifestyle changes that promote sleep

The following approaches may be used on their own or combined with cognitive behavioral therapy.

Sleep restriction. People with insomnia tend to 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 the patient learns to fall asleep quickly and sleep soundly, the time in bed is slowly extended until it provides a full night's sleep.

Some sleep experts suggest starting with six hours at first, or whatever amount of time the patient typically sleeps 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 staying awake until 1 a.m., no matter how sleepy. Once the patient is sleeping well during the allotted six hours, he or she can add another 15 or 30 minutes until attaining a healthy amount of sleep.

Reconditioning. This technique reconditions people with insomnia to associate the bedroom with sleep instead of sleeplessness and frustration. It incorporates elements of stimulus control and sleep hygiene education by suggesting strategies such as these:

  • Use the bed only for sleeping or sex.

  • Go to bed only when sleepy. If unable to sleep, move to another room and do something relaxing. Stay up until feeling 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.

Relaxation techniques. For some people with insomnia, a racing or worried mind is the enemy of sleep. In others, physical tension is to blame. A variety of techniques — such as meditation, breathing exercises, progressive muscle relaxation, and visualization of peaceful settings — can calm the mind and relax the body enough to foster sleep.

Medications for insomnia

Prescription medications can be useful for some people with transient or short-term insomnia. Because behavioral therapies are as effective and may have longer-lasting results, however, drugs should be used at the lowest dose and for the shortest possible period of time. Clinicians recommend several different types of medications to treat insomnia.

Benzodiazepines. These medications enhance the activity of GABA, a neurotransmitter that calms brain activity. Different benzodiazepines vary in how quickly they take effect and how long they remain active in the body. Taken at night, benzodiazepines can lead to next-day drowsiness and sedation. If a patient's main problem is getting to sleep, a clinician may prescribe a benzodiazepine that begins working quickly and is short-acting. An example is triazolam (Halcion). Although in theory it is an advantage to take a drug that will be eliminated from the body by morning, many clinicians have hesitated to recommend short-acting benzodiazepines because patients can develop rebound insomnia or a disconcerting amnesia for several hours after taking a dose of these drugs. Other benzodiazepines approved by the FDA for sleep problems are estazolam (ProSom) and temazepam (Restoril). These drugs last longer and so may help a person stay asleep through the night. In practice, many of the benzodiazepines used for treating anxiety — such as lorazepam (Ativan) and alprazolam (Xanax) — are also used to induce sleep.

One drawback of benzodiazepines is that they reduce duration of deep or slow-wave sleep, which is necessary for a person to feel refreshed the next morning. Another problem is tolerance, the need for more and more of the drug to obtain the same effect. Stopping any of these medications abruptly after long-term use can cause rebound insomnia that is worse than the initial sleeping problem.

Nonbenzodiazepines. While benzodiazepines affect multiple brain receptors, the nonbenzodiazepines act only on a few. As a result, they tend to cause fewer side effects than benzodiazepines, and have little or no effect on deep sleep. Nonbenzodiazepines include eszopiclone (Lunesta), zaleplon (Sonata), and zolpidem (Ambien). All three drugs help people fall asleep quicker, but may be useful in different circumstances.

Eszopiclone lengthens total sleep time. It takes a little longer to take effect than the other two drugs but also lasts longer.

Zolpidem also lengthens total sleep time. It acts faster than eszopiclone (within 20 minutes) and, for the most part, wears off before a patient's typical waking time. A long-acting version of zolpidem (Ambien CR) is intended to help people stay asleep as well as fall asleep.

Zaleplon acts as quickly as zolpidem, but wears off faster. As a result, taking this medication before bed may not enable a patient to sleep the whole night. However, this drug may be the one to choose if a patient wakes up in the middle of the night and can't fall back asleep.

While nonbenzodiazepines have fewer drawbacks than benzodiazepines, they're not perfect for everyone. Some people find the drugs aren't powerful enough to put them to sleep. And the drugs may still cause morning grogginess, tolerance, and rebound insomnia, as well as headache, dizziness, nausea, and, in rare cases, sleepwalking and sleep eating. The long-term effects of nonbenzodiazepines remain unknown.

Antidepressants. Some clinicians believe antidepressants have fewer side effects and are safer for long-term use than benzodiazepines. Further, these drugs may be appropriate because many people with depression also experience insomnia, and taking an antidepressant may help relieve symptoms of both problems. Sedating tricyclics such as amitriptyline (Elavil, Endep) and doxepin (Sinequan) are frequently prescribed for insomnia. Other antidepressants that work on serotonin receptors, particularly trazodone (Desyrel), nefazodone (Serzone), and mirtazapine (Remeron) — each with its own set of advantages and disadvantages — may also be prescribed for insomnia.

Studies in people with depression who also have sleep problems show that antidepressants reduce the time it takes to fall asleep and nighttime arousals. How these drugs work isn't clear, although presumably their sedative effects promote sleep. In addition, the drugs' ability to ease anxiety and mild depression may make it easier for people with these problems to relax and fall asleep.

The effect of antidepressants on sleep quality varies; in general, they reduce REM (dreaming) sleep but have little impact on deep sleep. Common side effects include dizziness, dry mouth, upset stomach, weight gain, and sexual dysfunction. These drugs also can increase leg movements during sleep. Some people find certain antidepressants make them feel nervous or restless, so the medication can actually exacerbate insomnia. It's not clear if these medications lead to tolerance or rebound insomnia.

Melatonin. The hormone melatonin helps control the circadian cycle of sleep and wakefulness. The brain's production of melatonin peaks in the late evening, in conjunction with the onset of sleep. Drugs or supplements that act on melatonin try to take advantage of this natural sleep aid by boosting levels of this chemical before bedtime.

Ramelteon (Rozerem) triggers melatonin receptors and is approved to treat insomnia for people who have trouble falling asleep at bedtime. Because people produce less melatonin as they age, theoretically this drug may be more likely to benefit older rather than younger people. In reality, however, most older people with insomnia tend to have problems with nighttime awakenings, not with falling asleep — suggesting that ramelteon should be prescribed on the basis of symptoms rather than age.

Ramelteon's most common side effect is dizziness, and it may also worsen symptoms of depression. To avoid a drug interaction that elevates blood levels of ramelteon, people who use the antidepressant fluvoxamine (Luvox) shouldn't take it. People with severe liver damage should also avoid taking ramelteon.

Another option is synthetic melatonin, sold as a supplement. Despite some initial enthusiasm for this approach, however, most subsequent research has been disappointing, finding either minimal benefits or none at all. The most commonly reported side effects of melatonin supplements are nausea, headache, and dizziness.

Over-the-counter sleep aids

Drugstores carry a confusing variety of over-the-counter sleep products that usually contain various types of antihistamines as active ingredients. Most over-the-counter sleep aids, including Nytol and Sominex, contain the antihistamine diphenhydramine. A few, such as Unisom SleepTabs, contain doxylamine. Aspirin-Free Anacin PM and Extra Strength Tylenol PM combine antihistamines with the pain reliever acetaminophen.

Over-the-counter antihistamines have a sedating effect and are generally safe. Sleep experts usually advise against using these medications, however, not only because of their side effects (discussed below) but also because they are often ineffective in relieving sleep problems. Furthermore, there is no information about the safety of taking such medications over the long term.

Short-term side effects include nausea and, more rarely, fast or irregular heartbeat, blurred vision, or heightened sensitivity to sunlight. Complications are generally more common in children and people over age 60. Alcohol heightens the effect of over-the-counter sleep medications, which can also interact adversely with some other drugs. A patient considering taking a nonprescription sleeping pill may want to check first with a clinician for advice about how to avoid the possibility of interactions with other medications.

Morin CM, et al. "Cognitive Behavioral Therapy, Singly and Combined with Medication, for Persistent Insomnia: A Randomized Controlled Trial," Journal of the American Medical Association (May 20, 2009): Vol. 301, No. 19, pp. 2005–15.

Ohayon MM. "Epidemiology of Insomnia: What We Know and What We Still Need to Learn," Sleep Medicine Review (April 2002): Vol. 6, No. 2, pp. 97–111.

Ritterband LM, et al. "Efficacy of an Internet-Based Behavioral Intervention for Adults with Insomnia," Archives of General Psychiatry (July 2009): Vol. 66, No. 7, pp. 692–98.

Siebern AT, et al. "Insomnia and its Effective Non-Pharmacologic Treatment," Medical Clinics of North America (May 2010): Vol. 94, No. 3, pp. 581–91.

Sullivan SS. "Insomnia Pharmacology," Medical Clinics of North America (May 2010): Vol. 94, No. 3, pp. 563–80.