Wellness LetterFoundations of WellnessHealthy LivingGuide to Understanding and Treating Insomnia

Foundations of Wellness

Guide to Understanding and Treating Insomnia

An estimated one-third of us have insomnia, sometimes severe and chronic, sometimes “secondary,” meaning that it arises from such sleep disrupters as anxiety, pain, illness, travel, late-night work, or too much alcohol. Insomnia can make you feel exhausted all the time, adversely affecting your ability to work, play, think, and drive.

Your doctor’s role

Many people deal with insomnia at first by taking a sleeping pill. Such drugs can help you get past jet lag, illness, or other temporary causes of insomnia. But if your problem persists over several weeks, you should talk to your doctor about it—not just call for a prescription. Most people never mention their sleep problems to their doctors, and not all doctors are interested in discussing them. Your first step should be a consultation with a doctor who listens and asks questions. Illness, depression, medications, and other possible causes of insomnia should be considered.

If pain at night keeps you awake, for instance, your doctor can help you manage it. Sleep apnea is another problem than can ruin your sleep and can be treated (see box below). Restless legs syndrome (characterized by uncontrollable leg movements and a jumpy feeling at night) can interfere with sleep, too, and you may decide to try a prescription drug for it.

You’ll need to describe your problems: For example, you may fall asleep but then wake up for hours; you may not fall asleep at all; you may toss and turn and never feel rested; or perhaps you wake up too early in the morning.

Before you see your doctor, keep a sleep log for a week. Record the following:

  • Time of retiring; periods of wakefulness; how many hours you think you actually slept; time of awakening.
  • Napping habits.
  • Factors disrupting your sleep (bed partner’s snoring, pets, children, pain, worry, and so on).
  • Drugs you take; smoking; alcohol and caffeine consumption.
  • Whether you feel rested in the morning.

You may also want to keep a log of your daily activities to help you pinpoint the cause of your insomnia.

Insomnia triggers you can control

The following steps can help many people with insomnia:

  • Limit alcohol. It may make you sleepy initially, but alcohol produces unsettled sleep (it reduces REM sleep, the phase when you dream) and middle-of-the-night wake-ups. Don’t use alcohol to help you sleep or induce drowsiness. Drink moderately, if at all—no more than one drink a day for a woman, two for a man.
  • Cut down on caffeine, especially in the late afternoon and evening.
  • Don’t smoke. Nicotine keeps some people awake.
  • Eliminate noise. Try earplugs or a “white noise” machine.
  • Make your bedroom sleep-friendly. Put up darker shades or make other changes to keep the room dark. A sleep mask can help. Your bed, linens, and pillows should feel comfortable. Replacing a lumpy, worn-out mattress can be helpful, but despite the ads, an expensive mattress will not necessarily banish insomnia. Most people sleep better in a cool (but not cold) room. Have an extra blanket in reach for those 3 a.m. wake-ups.
  • Drink less liquid after dinner, so the need to urinate does not wake you. (Older people may have to get up anyway.)
  • If stress keeps you awake, try to deal with the problems that cause it. You may need professional advice.
  • Try to retreat from your problems at bedtime. Read, listen to music, knit, meditate, work a puzzle—anything that qualifies as quiet relaxation.
  • Set a regular time to retire and arise, and stick to it, even if you haven’t had enough sleep and on weekends. If you wake
    up in the night, get up and do something quiet, such as reading.
  • Use your bed only for sleep and sex. Don’t bring paperwork or food to bed. Limit pillow talk, especially if the subject is upsetting.
  • If you nap, keep it to 30 minutes maximum, and try to nap early in the day.
  • Daytime exercise can relax you and promote sleep later, but don’t exercise strenuously in the evening, since that may have the opposite effect.

Cognitive behavioral therapy

If these self-help steps don’t solve your sleep problems, you may want to consult a therapist who specializes in cognitive behavioral therapy. As the name indicates, such therapy involves not only changing your behavior, but also altering the way you think. For insomnia, the goal is to recognize and try to change thoughts and feelings about sleep that elevate stress levels and thus cause or exacerbate sleeplessness. Studies show that such therapy—done in-person or online—can often help more than sleeping pills.

Checking Into a Sleep Center

Sleep disorders centers, usually attached to hospitals, can be found in most states. Physicians and technicians in these centers have the training and equipment to diagnose a wide range of sleep problems, such as narcolepsy (characterized by falling asleep suddenly and unpredictably during the day), sleep apnea, and chronic insomnia. If your sleep problems don’t yield to the suggestions in this article, talk with your doctor about a referral. You may be required to stay overnight so that your sleep patterns can be observed and recorded. The American Academy of Sleep Medicine accredits these centers; its website (www.sleepcenters.org) can help you locate the nearest accredited center.

OTC options

Ideally, no one should need sleeping pills. However, millions do take them. Most people start with over-the-counter remedies. These are usually first-generation antihistamines, which cause drowsiness. Though relatively risk-free, they can reduce alertness and impair driving performance the next day, even if you don’t feel drowsy—especially in older people. Antihistamines can also worsen urinary retention in men who have an enlarged prostate. Since tolerance can develop, don’t take the pills for more than three or four nights in a row. “Nighttime pain relievers” (such as Tylenol PM) also contain antihistamines to promote drowsiness. Melatonin supplements and herbal remedies (such as valerian), besides being unregulated, have unpredictable effects.

Many prescription choices

More than 60 million prescriptions for sleeping pills, costing billions of dollars, are filled in the U.S. each year. Most fall into two categories:

Benzodiazepines, popularly called tranquilizers. Shorter-acting benzodiazepines such as temazepam (Restoril is one brand), triazolam (Halcion), estazolam (ProSom), and lorazepam (Ativan) are most often prescribed for insomnia. In addition, some doctors prescribe alparazolam (Xanax), diazepam (Valium), quazepam (Doral), clonazepam (Klonopin), and similar drugs that are also used to treat anxiety. These tend to stay in the blood longer and are more likely to cause impairment or “hangover” the next day, especially in older people.

One advantage of benzodiazepines is that nearly all are available as generics and are cheap. Thus, you won’t see ads for them.

Nonbenzodiazepines include zolpidem (Ambien), eszopiclone (Lunesta), zaleplon (Sonata), and ramelteon (Rozerem). Many of these newer drugs are now also available as generics. Only eszopiclone and ramelteon are FDA-approved for long-term use.

Some ads have implied that these newer drugs are almost revolutionary. The manufacturers claim that they produce milder side effects than the benzodiazepines. But this varies from one person to another and under different circumstances.

Each drug has its advantages and disadvantages. For instance, zolpidem and eszopiclone should be used only when you expect to sleep for eight hours. Zaleplon wears off after four hours and can be taken at the beginning of the night or for wee-hour wakefulness, if you know you have at least four hours to sleep. Low doses of some benzodiazepines work like this, too.

Note: Some doctors prescribe antidepressants for insomnia, notably trazodone (brand name Desyrel) and doxepin. They were not designed for insomnia, but some people find them useful.

The truth about sleeping pills

All sleeping pills, new and old, share some drawbacks. You may develop a tolerance over time, so they become less effective. If you use them every night, you may become dependent—and dependency can be difficult to shake. When you stop taking them, you may have “rebound insomnia.” In older people sleeping pills stay in the body longer, thus increasing grogginess or impairment the next day. Studies have linked sleeping pills in older people to falling, fractures, and accidents. A study in the American Journal of Geriatric Pharmacology concluded that long-term use of sleeping pills of any kind has never been shown to be safe for older people.

In 2013 the FDA issued a warning about sleeping pills and driving, especially for women taking zolpidem. Since it takes women longer to metabolize the active ingredient, their blood levels tend to remain elevated much longer. Thus, the FDA advised women to take only half the dose previously recommended, and it made drug companies change their labels accordingly. It also suggested that men start with lower doses.

The sleeping pill made me do it

If you take certain prescription sleeping pills, beware of unusual behavior while under their effect, such as sleepwalking, sleep driving, or engaging in other activities while not fully awake. For years, people have reported such incidents, usually after taking zolpidem, so the FDA has required a warning in the package inserts. But in 2019 the FDA started requiring stronger boxed warnings about this risk on zolpidem as well as two other sleep aids, eszopiclone and zaleplon.

The FDA had received dozens of reports of serious injuries in users of the drugs, such as falls, burns, near-drownings, exposure to extreme cold temperatures leading to loss of limb or near-death, and gunshot wounds. Twenty reported deaths were caused by carbon monoxide poisoning, drowning, falls, hypothermia, motor vehicle crashes, and apparent suicide. The incidents can occur after the first use of these drugs or after longer use. When dispensing these drugs, pharmacies are required to provide a patient medication guide that explains their proper use and the risks.

If you take sleeping pills, follow these precautions:

    • Take the smallest effective dose. And don’t drink if you plan to take a pill. The pills are more likely to produce side effects
      when taken in large doses or combined with alcohol.
    • If you are a doctor or nurse on call, a pilot, or the sole caretaker of a small child or anyone else who may need help in
      the night, don’t take a sleeping pill.
    • If you take a pill and feel groggy or exhausted in the morning, don’t drive a car or operate heavy machinery. Even if you don’t feel groggy, you may be impaired. If you have to get up early and drive or attend an early business meeting, you may be better off not taking a pill the night before.

Bottom line: There is no “best” sleeping pill. Your goal should be not to need sleeping pills. Your doctor should not simply renew. your prescription without asking you about your progress and any side effects you’ve experienced.