Sleep Aids and Insomnia
If you have trouble falling or staying asleep, or you wake up feeling unrefreshed, you may be suffering from insomnia. Insomnia is a symptom. It may be caused by stress, anxiety, depression, disease, pain, medications, sleep disorders or poor sleep habits. Your sleep environment and health habits may also play a role in your sleep problems.
Some medications can lead to insomnia as well. These include medications for cold and allergy (some antihistamines and decongestants, high blood pressure (antihypertensives), heart disease (betablockers), thyroid disease and birth control (hormones), as well as asthma and pain medications (containing caffeine).
Some common sleep disorders can also cause poor sleep. These disorders range from restless legs syndrome (a creeping, crawling sensation in the legs only relieved by movement) to a bed partner's sleep apnea (a breathing disorder with loud snoring and brief periods when breathing stops).
Insomnia may be experienced for a few days, for two to three weeks, or it may be chronic, lasting for three weeks or more. Chronic insomnia is more difficult to treat, and doesn't go away on its own. You may need to see a physician or sleep specialist.
Many people experience insomnia, particularly women before and at the onset of the menstrual cycle, during pregnancy and menopause.
- Forty-eight percent of Americans report insomnia occasionally, while 22 percent experience insomnia every or almost every night.*
- Women are 1.3 times more likely to report insomnia than men.
- People over age 65 are 1.5 times more likely to complain of insomnia than younger people.
- Divorced, widowed and separated people report more insomnia.
Before you can treat insomnia, you need to identify its cause. Your doctor may ask about your mood. Are you depressed? Anxious? Under stress? Could your insomnia be caused by pain, medications, disruption in your life due to travel across time zones, or working non-traditional shifts? Could caffeine, alcohol, nicotine or spicy foods play a part in your difficulty sleeping? Questions you answer with a "no" may help point to a diagnosis of primary insomnia.
Insomnia can have a very serious impact on quality of life, productivity and safety:
- People with insomnia are four times as likely to suffer from depression than people who sleep well.
- Lack of sleep due to insomnia may contribute to illness, including heart disease.
- Safety on the job, at home, and on the road may be affected by sleepiness.
- People with insomnia may miss more time from work or receive fewer promotions.
- After a poor night's sleep, many people report accomplishing fewer daily tasks and enjoying activities less.
While individual suffering is hard to measure, researchers can estimate specific direct and indirect costs to the nation. Direct costs include dollars spent on insomnia treatments, healthcare services, hospital and nursing home care. The most recent annual estimate of the direct costs of insomnia is nearly $14 billion!
Indirect costs - such as work loss, property damage from accidents, and transportation to and from healthcare providers - are estimated at double the direct costs near $28 billion. One conservative report places total costs at up to $35 billion. (A National Sleep Foundation 1997 survey calculated that lost productivity alone from insomnia topped $18 billion!)
Treating insomnia with medication is the most common treatment for these sleep problems. Twenty-five percent of Americans take some type of medication every year to help them sleep.
Medications may be taken when:
- The cause of insomnia has been identified and is best treated with medication.
- Sleep difficulties cause problems in accomplishing daily activities.
- Behavioral approaches have proven ineffective and the person is unwilling to try them.
- A person is suffering insomnia-related distress and beginning behavioral therapy.
- Insomnia is temporary or short-term.
- Insomnia is expected or occurs in association with a known medical or biological condition (e.g. Premenstrual Syndrome) or an event such as giving a speech or traveling across time zones.
Treatment with medications should:
- begin with the lowest possible effective dose
- be short-term, if used nightly
- be intermittent, if used long-term
- be used only in combination with good sleep practices and/or behavioral approaches
Prescription medications that promote sleep are called hypnotics. These are the most effective sleep aids available.
The particular medication prescribed to treat insomnia should depend on a patient's diagnosis, medical condition, use of alcohol or other drugs, age, and need to function when awakened during the usual sleep period. If the cause of the sleep problem is depression, an antidepressant may be the best solution. Anti-anxiety drugs (anxiolytics) are prescribed if anxiety is related to insomnia.
Note: Some antidepressants cause insomnia, so patients should be sure to discuss their sleep problems with their doctor. Also, some antidepressants (the tricyclics) may worsen restless legs syndrome and periodic limb movements (characterized by jerking legs during sleep).
Increasingly, some sedating antidepressants have been prescribed in low doses for insomnia. However, many experts believe that in the absence of clinical depression, there is little evidence to support the use of these drugs for insomnia.
Among the prescription hypnotic drugs, a group of hypnotics called benzodiazepine agonists were developed in the l960's. These sleep-promoting drugs have since proven effective and safe. Benzodiazepine agonists can be either benzodiazepines or nonbenzodiazepines; each has a different chemical structure. All hypnotics induce and maintain sleep. The benzodiazepines agonists work by acting at areas in the brain believed to be involved in sleep promotion. They are the drugs of choice because they have the highest benefit and the lowest risk as sleep-promoting drugs.
Hypnotics differ by half-life as well as chemical structure. Half-life refers to how long a drug is active in the body. Drugs that have a shorter half-life are effective in the body for a shorter time. Shorter half-lives are usually preferred so that daytime functioning is not impaired the next day or after waking. The benzodiazepine triazolam has a short half-life, as do the non-benzodiazepines zolpidem and zaleplon.
Hypnotics also differ in the dose range over which they are effective. Scientists have established the effective dose range for each hypnotic. Dose becomes a problem when higher doses than those established as effective are used. Use of high doses increases the risk of rebound insomnia. Rebound insomnia occurs when a person stops taking the medication and experiences one or two nights of insomnia that is worse than they experienced before treatment. It only occurs with short half-life hypnotics and can be avoided by gradually tapering the dose. Consult your physician before increasing your dose or stopping high dose treatment.
Studies have examined data on the effectiveness of hypnotics and have concluded that they are effective and reliable for:
- shortening the time it takes to fall asleep
- increasing total sleep time
- decreasing the number of awakenings
- improving sleep quality
This conclusion is based on studies of short-term use of hypnotics at appropriate doses in comparison with a placebo or sugar pill. Some studies demonstrate little decrease in the effectiveness of hypnotics over the course of months.
The length of treatment depends on various circumstances:
- Accepted insomnia guidelines call for short-term treatment, but long-term use of sleep aids is not uncommon.
- Four weeks is the recommended limit.
- Not prescribing hypnotics may cause unnecessary patient distress, particularly when the person does well on the same dose and has no side effects.
- Still, most sleep specialists share the belief that sleep aids shouldn't be a long-term answer to poor sleep for most people who have trouble sleeping.
More studies are needed on long-term effects of the use of sleep aids.
All individuals who take sleep aids need to also focus on improving their sleep practices. The sedating or calming effects of hypnotics may lead to falls for those awakening at night. Hypnotics may also increase the risk of sleepwalking in some people.
One study also found a higher risk for car accidents in older adults taking long-acting sleeping medications, particularly during the first week of use.
Moreover, many persons taking hypnotics need to understand that sleep aids should be gradually decreased rather than stopped all at once. Without gradual tapering, stopping hypnotic use may cause insomnia to come back. Individuals should work with their doctors to discontinue medication gradually.
People at risk while taking hypnotics include:
- Individuals who drink alcohol. Why? The two drugs taken together intensify the action of both.
- The elderly, and anyone who needs to get up during the night. Why? The sedating effects of hypnotics increase the risk for falls. Doses should be lower for the elderly.
- Those who have to operate machinery soon after awakening. Why? In medications with long half-lives, the risk of accidents may be increased.
- People who have sleep apnea. Why? Breathing may be further impaired.
While many people worry about prescription sleep aids, believing them to be addictive (or habit-forming), researchers offer a reassuring picture. Studies show that people with insomnia don't tend to abuse sleep aids. They don't tend to take higher doses than prescribed.
Negative effects or abuses tend to be linked to excessive doses or to individuals who abuse other drugs or alcohol. Side effects of prescription sleep aids are related to the person's age, dose and half-life. Selecting the proper dose is especially important for older people. When hypnotics stay in the body longer, they remain active and can cause daytime sleepiness or forgetfulness.
Younger people can be at risk for side effects too. People who use higher doses and hypnotics with longer half-lives tend to experience more side effects. To avoid these side effects, sleep specialists often advise the use of hypnotics with short half-lives. Any change in dosage should be discussed with your doctor.
Many people use sleep medications that are available without a prescription. These sleep aids are available "over-the-counter" (OTC) because they have been found to be safe when used according to their directions. However, OTC sleep aids may be less effective and they may have been subjected to less rigorous testing. Many non-prescription sleep products include antihistamines. These substances are designed to block chemicals released during a cold or allergy attack, not to promote sleep. However, many have sedating (calming) effects. Some OTC sleep aids may also include pain relievers.
As with hypnotics, OTC sleep aids should not be used by individuals who are also taking alcohol or other drugs with sedating effects. Older persons should be cautious about these drugs because of their slower metabolisms. Drugs stay in the body longer and can then cause daytime sleepiness. In addition, OTC sleep aids should be avoided by people with breathing problems, glaucoma, chronic bronchitis, and difficulty urinating because of an enlarged prostate gland, or women who are pregnant or nursing.
Other products sold to promote sleep include:
- valerian (a root that may be steeped in hot water for tea)
- melatonin (an artificial or animal form of a substance produced by humans that is linked to sleep)
Herbal products and nutritional supplements (such as melatonin) are not required to undergo the same rigorous testing as drugs do in order to meet government standards. Their long-term impact, side effects and possible interactions with other drugs or medical conditions are often not known. More research is needed.
OTHER TYPES OF TREATMENT:
Fortunately, sleep specialists have devised a variety of approaches for treating insomnia. Behavioral approaches involve actions you can take. Medication may help you sleep as you try these sleep-friendly practices. Combining behavioral and medical approaches works well for many people.
Behavioral approaches range from limiting the time spent in bed to making a stronger mental connection between bed and sleep. This latter approach is called stimulus control. Studies suggest that these two strategies are the most effective behavioral approaches.
Stimulus control focuses on the association between your bed and sleep. Do you find yourself balancing a checkbook or writing a letter in bed? In this way you link bedtime with alerting activities rather than sleeping. The stimulus control approach helps you think more about your bed as a place for sleeping.
Also, put relaxation back in your bedroom by using your bed only for sleep and sex, getting in bed only when you're tired, and getting out of bed if you don't fall asleep within 15 minutes. Try a relaxing activity.
A sleep specialist may help you use stimulus control and sleep restriction strategies properly.
If you suffer from insomnia, consider the following guidelines for better sleep:
- Exercise regularly, about six hours before you want to sleep.
- Avoid napping.
- Go to sleep and wake at the same time every day.
- Save your worries for daytime. (If concerns come to mind in bed, write them down in a "worry" book, then close the book until the morning).
- Select a relaxing bedtime ritual, like a hot bath or listening to calming music.
If sleep problems persist, it may be time to seek professional help. Your doctor can help determine how to treat your problem and may refer you to a sleep specialist.
J. Christian Gillin, MD; Timothy Roehrs, PhD; and Thomas Roth, PhD.
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