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Overcoming insomnia
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.

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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.

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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.

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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

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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. 200515.
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. 97111.
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. 69298.
Siebern AT, et al. "Insomnia and its Effective Non-Pharmacologic Treatment," Medical Clinics of North
America (May 2010): Vol. 94, No. 3, pp. 58191.
Sullivan SS. "Insomnia Pharmacology," Medical Clinics of North America (May 2010): Vol. 94, No. 3, pp.
56380.
Source: https://www.health.harvard.edu/newsletters/Harvard_Mental_Health_Letter/2011/February
/overcoming-insomnia
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