What is Insomnia?
The term insomnia refers to problems with falling asleep, staying asleep, or with waking up earlier than planned. An episode of insomnia that lasts only one or two nights is often due to stress or excitement. But often this condition becomes a chronic disorder that persists for months or even years, especially when the root cause is tension, anxiety or depression. Some 20% to 40% of all adults report sleeping problems, but the rate rises sharply among older people. About 80% of those over age 60 experience fragmented sleep and often wake up repeatedly during the night. Also 30% to 40% of women going through menopause experience insomnia, most likely due to hot flashes, night sweats, anxiety, and/or fluctuations in hormone levels.
A complicating factor for insomnia is the wide natural variation in individuals' sleep requirements. One person may need nine or 10 hours of sleep a night to feel rested, while another appears to flourish on five or six. Studies, however, have shown that some of those who claim to function well on five hours' sleep would, in fact, benefit substantially from more rest. On the other hand, many people who complain of insomnia are actually sleeping longer than they realize.
No single remedy can be applied to the cluster of sleep disorders known as insomnia. However, a wide variety of treatments have proved effective--sometimes dramatically so--in minimizing its impact and duration.
Difficulty falling asleep Fragmented sleep (waking frequently during the night) Waking earlier than expected Fatigue, impaired concentration, mood changes due to lack of sleep
Insomnia is essentially a symptom of other conditions or factors. Short-term insomnia may be brought on by jet lag, which upsets the body's biological clock. Illness or pain can disrupt sleep patterns, as can stressful situations--a divorce, a new job--or such environmental factors as noise, light, or room temperature. Once the specific problem is resolved, sleep usually returns to normal.
Insomnia can also be triggered by numerous other factors, including:
Persistent insomnia can be more difficult to diagnose. Tension, anxiety, and depression are often at the root of insomnia. However, attempts to link sleep disorders with personality traits have been inconclusive.
Whatever its original causes, many experts believe that insomnia is prolonged by such behavior patterns as excessive time in bed, overuse of medications, and habitual napping. Researchers also find, ironically, that the harder individuals try to fall asleep, the more anxious they usually become--making success even more elusive.
Finally, fragmented sleep is sometimes the result of a potentially dangerous disorder called sleep apnea, which is particularly problematic in association with obesity. Someone with this condition temporarily stops breathing numerous times during the night, then breathes very vigorously (with loud snoring) in an effort to recover--making restful sleep nearly impossible to maintain. There are a range of treatments for apnea, from a special mask that exerts pressure on the airway to surgery on the soft tissues at the back of the throat which are often involved with creating an upper airway obstruction. Snoring may also be problematic for the bedmate who is awakened by the noise.
Medications are the principal option conventional practitioners choose to treat occasional insomnia, particularly when it is stress-related. There are a number of drugs--medically known as "hypnotics"--that are aimed specifically at improving sleep. Your doctor may prescribe one of these sleeping pills and may suggest it for temporary use, on an "as needed" basis.
Undeniably, some people benefit from regular medication for sleep in the short term. For those who simply cannot sleep without “something,” it’s better to sleep than to lie awake and be exhausted the next day. Depending on the nature of the insomnia, an antidepressant or an anti-anxiety medication may work better than a hypnotic. Discuss various options with a doctor.
Commonly prescribed medications include benzodiazepines (tranquilizers), anti-anxiety drugs that act as sedatives and are very widely prescribed for people suffering from insomnia. Some of these are: alprazolam (Xanax), clonazepam (Klonopin), diazepam (Valium), estazolam (ProSom), flurazepam (Dalmane), lorazepam (Ativan), oxazepam (Serax), quazepam (Doral), temazepam (Restoril), and triazolam (Halcion). All are less likely to create physical dependence than were the once-popular barbiturates. But some side effects, including disorientation, confusion, "hangover," and blurred vision, have been reported with the use of benzodiazepines, usually occurring if individuals try to function normally once the medication is in the bloodstream.
One of the newer prescription sleeping aids, zolpidem (Ambien), belongs to a group of non-benzodiazepine medicines that slow down the nervous system and help bring about sleep with fewer side effects and less next-day drowsiness. Also, the new sleeping medication known as zaleplon (Sonata) is fast-acting, with fewer next-day aftereffects; it has the advantage of being so short-acting that patients can actually use it upon middle-of-the-night awakenings for help getting back to sleep. However, the FDA in 2007 updated its warning that all of these medications have the potential for serious side-effects including anaphylaxis (severe allergic reactions) and “complex sleep-related behaviors”—recently described instances of people performing complex tasks, e.g. raiding the refrigerator or driving a car during the night, with no recall of the behavior the following day (1), and persons with sleep apnea are more at risk for respiratory depression with use of prescription sleep medications.
Antidepressants can help if the insomnia is linked to depression. Over-the-counter (OTC) medications are also marketed as sleeping pills. Most of these drugs are antihistamines, which may also induce drowsiness.
Hormone replacement therapy (HRT) may be an option for menopausal women whose sleep is primarily disturbed by hot flashes. Taking a low dose of estrogen and/or progestin by pill, patch, cream or vaginal ring has been shown to improve insomnia associated with menopause as well as improving bone density. Both synthetic and natural forms of HRT are available, but users should be aware of a slightly increased risk of breast cancer with long-term use of either variety. See the WholeHealthMD Reference Library entry on menopause for more information.
If sleep problems are persistent or difficult to diagnose, a more detailed evaluation and treatment plan can be obtained at a sleep disorders clinic, which usually involves staying overnight in a sleep center where multiple measures of sleep activity can be made in a process called polysomnography. The
An array of self-help measures and supplements can be used to alleviate insomnia. And alternative medical therapies, such as acupuncture, homeopathy, reiki, and massage, as well as mind-body exercises, such as yoga, tai chi and meditation (discussed below), can all aid in sounder, more restful sleep. In many cases, these will prove equally or more effective and have fewer side effects than prescription sleeping pills. However, those who are regularly taking a prescription drug for insomnia should not discontinue use without talking to a doctor.
Just a reminder: For those with a serious medical condition, it's always a wise idea to talk with your doctor before beginning a supplement program.
More than 100 studies have proven the herb valerian to be an effective sleep aid for many people. It may take several weeks to work; so don’t despair if there is not immediate relief. For best results, it should be rotated with other sedating herbs such as chamomile, melissa (also known as lemon balm), and kava. (The FDA has recently issued warnings on kava due to its adverse effects on the liver. Before using this herb, please read the entry on kava in the WholeHealthMD Reference Library.) In the brain, at least some of the components of valerian are thought to affect levels of a neurotransmitter (nerve signaling substance) called GABA (gamma-aminobutyric acid). By increasing GABA levels, the herb seems to shorten the amount of time it takes to fall asleep as well as improve the quality of sleep that results. And, unlike some of the more commonly prescribed sleep medications, valerian is not addictive. Nor does it cause morning grogginess or impaired mental function when taken at recommended doses, as some prescription drugs do. In addition, some of valerian’s other constituents that do not bind to GABA receptors also seem to produce sedative effects. In studies to date, the whole root compound has been more effective than any identified individual components. Valerian, therefore, may be useful in improving sleep in healthy patients, insomniacs, and in patients who have trouble sleeping as a result of other medical conditions, such as ADHD in children, fibromyalgia, or chronic fatigue syndrome. For a more detailed description see the WholeHealthMD Reference Library entry on valerian.
Preliminary evidence also indicates the sedative effects of melissa may help to improve insomnia, particularly when combined with valerian. In a 1999 double-blind, placebo-controlled, multi-center study, a combination product containing 160 mg of valerian root extract and 80 mg of melissa seemed to improve the quality and quantity of sleep in healthy people. (2) More research is needed to determine the effects of melissa when taken alone.
The herb chamomile, most often taken as a delicious, therapeutic tea, has mildly sedating and muscle-relaxing effects that may help those who suffer from insomnia to fall asleep more easily. The German species of chamomile seems to increase GABA levels, thus helping to improve sleep latency and sleep quality; however most evidence in this area is anecdotal, stemming from a long history as a folk remedy for insomnia. Chamomile tea, for instance, has long been used for its calming, sedative effects. But scientific research evaluating the use of chamomile for insomnia is limited. In a 2005 animal study, a significant decrease in sleep latency was observed in sleep-disturbed rats after treatment with chamomile extract. Researchers concluded that chamomile showed benzodiazepine-like hypnotic action in the rats. (3) However, a 2005 review of herbal remedies and alternative therapies for insomnia found that studies evaluating the use of chamomile for insomnia are sparse, and no solid evidence of a hypnotic effect exists. (4) Further research is needed to determine the efficacy of chamomile in treating insomnia.
Melatonin is an Over the Counter form of the sleep hormone produced naturally in the pineal gland. It is primarily involved in regulating our sleep-wake cycles also known as circadian rhythms. The conventional drug ramelteon (Rozerem), also appears to work by stimulating melatonin receptors. Some studies of young and elderly adults have shown that taking a small amount of melatonin (0.3 mg) before bedtime helps to both hasten sleep and improve its quality. Many of the doses sold OTC are substantially larger. According to researchers at MIT, these are less effective for long-term use because the receptors stop responding when they’re overloaded. In the studies, the reduction in sleep latency amounted to about 12 minutes, which, depending on sleep latency, may not be considered clinically relevant, however some patients also report improvement in subjective feelings of sleep quality, which may have to do with increased amnesia for the night’s events. (5-7) These benefits were seen in insomniacs as well as in individuals who struggle with only occasional sleep problems. However, further evidence suggests elderly patients with insomnia may benefit most from melatonin supplementation as they are more likely to have age-related deficiencies in melatonin compared to younger adults or children. (8-13) In children with insomnia in the form of delayed onset of sleep, melatonin seems to shorten sleep latency and increase the duration of sleep. (14)
Melatonin is a metabolic product of serotonin. Thus valerian can be rotated with supplemental GABA, or with 5-HTP (a form of the amino acid tryptophan), which raises levels of the sleep-producing chemical serotonin to get similar results. Several elements of a good night's sleep appear to be influenced by 5-HTP. In addition to reducing the amount of time it takes to nod off, this compound actually may enhance the quality of sleep itself, increasing both the duration of dream states (REM sleep) and of deep slumber. Several studies in the 1970s showed results indicating 5-HTP was a viable treatment for promoting and maintaining sleep and the sense of feeling rested upon waking in both normal and insomniac subjects. (15-20) Some of those studies have shown the key benefit of 5-HTP – increasing the quality of sleep – occurs by increasing REM sleep by about 25 percent while simultaneously increasing deep sleep stages 3 and 4 without increasing total sleep time. To compensate for the increase in these deep sleep stages, non-REM stages 1 and 2, the least important stages of sleep, are reduced. (18, 19) In one of the studies, sleep quality was evaluated in a group of alcoholics receiving either 200 mg or 600 mg of 5-HTP daily. The group taking 200 mg daily increased REM sleep time by 15.5 minutes during the five-night study, and the group taking 600 mg increased REM sleep time by an average of 20 minutes during the study. Dream time increased by three to four minutes a night. Although the higher dosage led to longer REM sleep, the lower dosage is sufficient in most cases. Taking too much 5-HTP may increase sleep to an abnormal level, lead to an increased risk for nightmares, and cause mild nausea. (18)
Deficiencies of calcium or magnesium can create sleeping difficulties in some cases; taking supplements to enhance the levels of these minerals may thus be beneficial. Magnesium is especially effective when taken with 5-HTP.
If you believe there's a component of depression to your insomnia, then start with the herb
Once the problem has been identified, treatment may entail multiple behavioral strategies that include restricting your sleeping time, using your bed only for sleeping, and relaxation training.
Follow a regular sleep schedule, and maintain good “sleep hygiene” prior to sleep. That is, be aware of any behavioral and environmental factors that precede or may interfere with sleep. Resist the temptation to take naps, which can quickly become a substitute for regular sleep. Prior to sleep, keep TV watching to a minimum, avoiding overly stimulating shows such as “sensationalizing” local news or programs with excessive violence. Allow some time between eating and sleeping. Spend an hour or more relaxing before bedtime – reading or listening to music are excellent preparations for sleep. Prepare a comforting, peaceful sleeping environment. (25)
Avoid alcohol, tobacco, and caffeine, especially in the late afternoon and throughout the evening.
Get regular exercise. It reduces stress and promotes sleep. (Exercise should be avoided in the evening, however, as it can rev up the body, making it more difficult to fall asleep.)
Take a soothing bath. The experience can be enhanced by lacing the warm water with the mildly sedating herb chamomile. Place a half cup of dried chamomile or lavender flowers in some cheesecloth, tie it securely, and allow the running water to spill over the packet as the tub fills; the resulting fragrant bath will produce a relaxing effect. Alternatively, try sipping a cup of double-strength chamomile tea at bedtime.
Reserve your bed only for sleeping and intimacy--not for reading, working, checking email, talking on the telephone, or watching television.
Get out of bed and read quietly (preferably in another room) if it takes more than 10-15 minutes to fall asleep or if you wake up during the night and cannot fall back to sleep; return to bed only when you grow tired.
Using a sound machine that plays soothing music, sounds of nature, or “white noise” may help to block out disturbing outside noises and to promote relaxation. (26, 27)
Wear a nasal dilator strip, which increases the diameter of the nasal passageway to allow for easier breathing. In particular, patients with snoring problems may find these products especially useful, as they have been shown to decrease the number of awakenings in patients with sleep-disordered breathing. (28, 29)
Avoid the herbs ginseng, guarana and kola nut. They all have stimulating effects that can make sleep difficult.
Undergoing acupuncture therapy, the use of hair-thin needles at specific points on the body to prevent or treat illness, may also help to improve sleep. Practitioners believe acupuncture sends a complex series of signals to the brain to increase certain substances, such as serotonin, to promote relaxation and sleep. In a four-year German study in the 1980s, 520 patients were treated with acupuncture for varying conditions, including insomnia. In the insomnia treatment group, 100 percent of the patients undergoing acupuncture treatments for a year and a half reported significant improvement in sleep without the aid of medications. (30) And in 1999, another German study of 40 patients also found acupuncture to be efficacious in treating sleep disorders. In this randomized study, the subjects were divided into two groups: one group received true acupuncture, and the control group was treated with needles at non-acupuncture points for three to five sessions at weekly intervals. Sleep quality was measured objectively by polysomnography in a specialized sleep laboratory before and after treatment, and additional subjective results were obtained from questionnaires. The objective measures showed a statistically significant effect only in the subjects treated with true acupuncture, and the subjective results also were better in the true acupuncture group than in the control group. (31) In a 2004 study in Toronto, 18 adults with insomnia as a result of anxiety underwent five weeks of acupuncture treatment, which was associated with a significant nocturnal increase in melatonin secretion, significant improvements in polysomnographic measures of sleep latency, arousal index, total sleep time, and sleep efficiency. Acupuncture treatment also resulted in a reduction in anxiety scores. (32) However, a 2005 Chinese meta-analysis of studies evaluating the use of acupuncture to treat insomnia found the randomized controlled trials involving 585 patients were of low quality. Researchers found acupuncture to possibly be effective, but higher quality trials are needed. (33) And a 2007 Cochrane Database meta-analysis of seven trials including 590 subjects with insomnia also found that the few randomized controlled trials were of poor methodological quality and that the current evidence is not conclusive for support of acupuncture for insomnia. Larger, higher quality studies are needed. (34)
Preliminary evidence indicates the calming effects of yoga can lead to improved sleep. In a 2004 study, 20 participants with insomnia practiced simple daily yoga postures and maintained sleep-wake diaries for two weeks prior to yoga and eight weeks during yoga therapy. At the end of the study, the subjects reported significant improvements in sleep efficiency, total sleep time, total wake time, sleep latency, and wake time after sleep onset. (35) And in a 2005 study comparing yoga with an Ayurvedic herbal preparation and a control group with no intervention in 120 nursing home patients with insomnia, the yoga group showed a significant decrease in sleep latency by an average 10 minutes, an increase in the total number of hours slept by one hour, and an improvement in the feeling of being rested in the morning while the other groups showed no significant changes. Yoga was an efficacious treatment for improving different aspects of sleep in this elderly population. (36)
Other forms of relaxation, including massage and meditation also may help to promote sleep. While anecdotal evidence indicates massage therapy may be useful in treating insomnia, studies in this area are limited. Research is needed to determine efficacy. However, pilot studies are examining the potential efficacy of mindfulness meditation, which involves quiet contemplation focusing on the present moment to acknowledge sensations and thoughts as they come up without judgment. A 2008 pilot study evaluating the use of mindfulness meditation in 19 patients with insomnia due to anxiety found that treatment resulted in improved sleep scores at the end of eight weeks of treatment. Analysis of sleep and anxiety scales, including the Penn State Worry Questionnaire, showed that mindfulness meditation reduced worry-associated sleep disturbances, thereby effectively reducing insomnia. (37) And another 2008 study evaluated the use of mindfulness meditation in combination with cognitive-behavior therapies such as sleep restriction, stimulus control, sleep education, and sleep hygiene in 30 patients with insomnia. After six weeks of treatment, results indicated statistically and clinically significant improvements in several symptoms of insomnia, as well as a reduction in pre-sleep arousal, sleep effort, and dysfunctional sleep-related cognitions. Additionally, a significant beneficial correlation was found between the number of meditation sessions and reductions in sleep arousal. (38)
Preliminary studies also are underway regarding the efficacy of tai chi to improve insomnia. This ancient Chinese therapy uses a series of continuous exercises, or forms, to integrate the mind, body, and spirit. The results include reduced stress, which can lead to improved sleep. In a 2004 randomized, controlled study published by the Journal of the American Geriatrics Society, 118 men and women aged 60 to 92 participated in either tai chi or low-impact exercise for 60-minute sessions three times a week for six months. After treatment, the tai chi group reported significant improvements in five of the Pittsburgh Sleep Quality Index (PSQI) scores – sleep quality, sleep latency, sleep duration, sleep efficiency and sleep disturbances – compared to the scores of the low-impact exercise participants. The tai chi group reported an average sleep latency of about 18 minutes less per night, and sleep duration of about 48 minutes more per night than the low-impact exercise group. (39) And in a similar 2008 study of 112 subjects aged 59-86 with moderate sleep complaints, the subjects were randomly allocated to either tai chi or health education for 25 weeks. After treatment, those in the tai chi group showed significant improvement in PSQI global score, as well as in rated sleep quality, sleep efficiency, sleep duration, and sleep disturbance. (40)
Practitioners using classical homeopathy may recommend some individualized remedies based on specific insomnia symptoms as well as general constitutional and personal attributes. Homeopathic combination remedies are also a popular OTC option, however, few studies have examined their clinical efficacy. A preliminary 2008 study found the homeopathic preparation Neurexan may be an effective and well-tolerated alternative to conventional, valerian-based insomnia remedies. In this open-label, prospective cohort study in 89 German centers offering both conventional and complementary therapies, 409 subjects were treated with either the homeopathic preparation or varying doses (at their physician’s judgments) of valerian for 28 days. After 14 days of treatment, both groups reported improved sleep latency and duration: the duration of sleep increased by 2.2 hours in the Neurexan group and by 2 hours in the valerian group. Differences between the groups in improvement on sleep duration were significantly in favor of Neurexan therapy at days 8, 12 and 14, but by day 28, quality of sleep was improved in both groups with no significant differences between the treatments. However, significantly more patients reported lack of daytime fatigue with Neurexan (49%) than with valerian therapies (32%). (41)
Some studies also have shown that bright-light therapy, called light therapy or phototherapy, may help to restore normal sleep patterns in people who can’t fall asleep at night, or who wake up too early in the morning (there are dawn/dusk simulators sold by light box companies for this purpose). In a 1987 study of nine subjects with “midwinter insomnia” (occurring during the winter “dark period” in locations north of the arctic circle), melatonin and cortisol levels were measured after five days of exposure to intensive light for a half hour each morning. Eight control subjects did not receive light therapy. Before treatment, the insomnia group had significantly lower levels of plasma melatonin in the evening than the controls. But after light exposure, plasma melatonin increased in the treatment group to the same level as in the controls, and sleep latency was moderately but significantly shortened in the treatment group. (42) Another pilot study in 1993 found that light therapy improved total sleep time by about an hour in nine subjects with early morning awakening insomnia. (43) Several studies followed. Interestingly, a 1995 review of studies found that light therapy adversely affected insomniacs by causing an alerting, or activating, effect of the central nervous system. The activating effect, it appeared, did not interfere with subsequent sleep onset in healthy individuals, but patients with insomnia due to depression experienced insomnia and hypomanic activation after light therapy. (44) A 2002 Cochrane Database Review of studies of patients 60 or older found that no studies met the criteria for inclusion in the review. Researchers, however, noted that promising results of light therapy in other populations with insomnia justifies further researcher into the effectiveness with older populations. (45)
If the insomnia lasts a month or more, and has no obvious cause. If the sleeping problems follow the loss of a job, the death of a loved one, or other life-altering trauma. If you feel tired most of the time or begin to doze off frequently during the day. If tiredness becomes so severe that it interferes with normal activities.
The Evidence Based Rating Scale is a tool that helps consumers translate the findings of medical research studies with what our clinical advisors have found to be efficacious in their personal practice. This tool is meant to simplify which supplements and therapies demonstrate promise in the treatment of certain conditions. This scale does not take into account any possible interactions with any medication/ condition/ or therapy which you may be currently undertaking. It is therefore advisable to ask your doctor before starting any new treatment regimen.
1. FDA Requests Label Change for All Sleep Disorder Drug Products, http://www.fda.gov/bbs/topics/NEWS/2007/NEW01587.html, accessed August 18, 2008.
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