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Harvard Commentaries
35320
Harvard Commentaries
Reviewed by the Faculty of Harvard Medical School


Minding Your Mind Minding Your Mind
 

Overcoming Insomnia


October 28, 2013

By Michael Craig Miller M.D.

Harvard Medical School

People with insomnia may be plagued by trouble falling asleep, waking 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 common. About 1 in 3 Americans are affected at least occasionally. Studies suggest that 9% to 15% of Americans experience problems functioning in the daytime as a result of insomnia. Insomnia is especially common in psychiatric disorders. It may affect as many as 50% to 80% of people in a typical mental health practice. Sleep problems are particularly common in those who have anxiety, depression, bipolar disorder and attention deficit hyperactivity disorder (ADHD).

Once insomnia starts to affect a person's health or ability to function, treatment becomes necessary.

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Types of insomnia

One way to classify insomnia is in terms of how long symptoms last.

  • Transient — Insomnia that lasts less than a month
  • Short-term — Insomnia that continues for one to six months
  • Chronic — Insomnia that persists longer than six months

Causes of transient or short-term insomnia are usually circumstances such as 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, a person learns to associate the bedroom with being awake. Taking steps to cope with sleep deprivation — napping, drinking coffee, having a nightcap, or forgoing exercise — only makes the problem worse. As insomnia persists, a person becomes more anxious about not sleeping. This leads to a vicious cycle in which fears about sleeplessness and its consequences keep the person awake at night.

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How Cognitive Behavioral Therapy Can Help

For chronic insomnia, the treatment of choice is cognitive behavioral therapy (CBT). It is just as effective as prescription medicine at treating chronic insomnia. It may be more effective in the long term. This appears to be true also for people who have a mental health problem along with insomnia.

CBT helps a person change negative thoughts and beliefs about sleep into positive ones. People with insomnia tend to become preoccupied with sleep and the consequences of poor sleep. This worry makes relaxing and falling asleep nearly impossible.

A clinician using CBT helps a person 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 person learns to replace negative 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 the person practices new thoughts and habits. CBT also involves lifestyle changes a person can use alone or as part of therapy.

In studies involving head-to-head comparisons, medicine tends to relieve symptoms faster than CBT, but the benefits end once the drug is stopped. In contrast, the benefits of CBT become more apparent with time.

The biggest obstacle to successful treatment with CBT is a person's commitment. Some people either don’t stick with the therapy or they don’t practice the techniques they are being taught. Internet-based programs are being tested to address this challenge.

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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.

Some sleep experts suggest starting with limiting time in bed to 6 hours at first, or whatever amount of time a person typically sleeps at night. Setting a rigid early morning waking time often works best. So, if the alarm is set for 7 a.m., the person stays awake until 1 a.m., no matter how sleepy he is. Once the person is sleeping well during the allotted 6 hours, he can add another 15 or 30 minutes until he's getting a healthy amount of sleep.

Reconditioning

This technique helps people associate the bedroom with sleep instead of sleeplessness and frustration. During this process, a person has to:

  • 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.
  • 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.

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When You Need Medicines

Some people with transient or short-term insomnia benefit from prescription medicines. Experts recommend using the lowest dose and for the shortest possible period of time. There are several different types of medicines to treat insomnia.

Benzodiazepines

Names: Estazolam (ProSom) and temazepam (Restoril); lorazepam (Ativan) and alprazolam (Xanax), which are also used to treat anxiety

Benzodiazepines 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.

Side effects/drawbacks: Taken at night, benzodiazepines can lead to next-day drowsiness and sedation. Benzodiazepines can also reduce slow-wave sleep, which helps a person to feel refreshed the next morning.

An unusual, but disturbing side effect that can occur with benzodiazepines is amnesia for several hours after taking a dose. This can also occur with nonbenzodiazepines (see below).

Tolerance, the need for more and more of the drug to obtain the same effect, can also be a problem.

Stopping any of these medicines abruptly after long-term use can cause lead to insomnia that is worse than the initial sleeping problem.

Nonbenzodiazepines

Names: eszopiclone (Lunesta), zaleplon (Sonata) and zolpidem (Ambien)

While benzodiazepines affect multiple brain receptors, the nonbenzodiazepines act only on a few. They have little or no effect on deep sleep. These 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 person'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. If taken it before bedtime, it may interfere with sleeping through the night. However, this drug may be a good choice for someone who wakes up in the middle of the night and can't fall back asleep.

Side effects/drawbacks: These drugs may still cause morning grogginess, tolerance and rebound insomnia, as well as headache, dizziness, nausea, and, in rare cases, amnesia, sleepwalking and sleep eating.

Antidepressants

Some clinicians believe antidepressants are safer for long-term use than benzodiazepines. And, because many people with depression also experience insomnia, taking an antidepressant may help relieve symptoms of both problems.

Names: Amitriptyline (Elavil, Endep), doxepin (Sinequan), trazodone (Desyrel), and mirtazapine (Remeron).

Side effects/drawbacks: Common ones 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 medicine can actually exacerbate insomnia. It's not clear if these medicines 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. Ramelteon's most common side effect is dizziness, and it may also worsen symptoms of depression.

Another option is synthetic melatonin supplements. Despite some initial enthusiasm for them, most subsequent research has found the supplements to have minimal benefits or none at all.

The most commonly reported side effects of melatonin supplements are nausea, headache and dizziness.

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Over-the-Counter Sleep Aids

Drug stores carry a confusing variety of over-the-counter sleep products. Most contain various types of antihistamines as active ingredients. For example, Nytol and Sominex contain the antihistamine diphenhydramine. A few, such as Unisom SleepTabs, contain doxylamine. The various pain relievers sold as "PM" drugs — for example, acetaminophen (Tylenol) and ibuprofen (Motrin) — combine antihistamines with the pain medicine.

Antihistamines have a sedating effect and are mostly safe. But they generally do not provide long-term relief of sleep problems.

Short-term side effects include nausea and, more rarely, fast or irregular heartbeat, blurred vision or heightened sensitivity to sunlight. Complications are more common in children and people over age 60. Alcohol heightens the effect of over-the-counter sleep medicines, which can also interact adversely with some other drugs.

A person considering taking a nonprescription sleeping pill, may want to check first with a clinician about how to avoid possible interactions with other medicines.

Simple lifestyle changes are likely to boost the effectiveness of any sleep medicine, so don't discount them.

 

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Michael Craig Miller, M.D. is the former editor-in-chief of the Harvard Mental Health Letter and an assistant professor of psychiatry at Harvard Medical School. Dr. Miller has an active clinical practice and has been on staff at Beth Israel Deaconess Medical Center for more than 30 years.

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