Sleep and wakefulness are regulated by many neurotransmitters including the brain’s principle inhibitory neurotransmitter gamma-amino-butyric acid (GABA). Changing brain levels of GABA and other neurotransmitters are believed to be related to normal changes in sleep with healthy aging. What constitutes ‘normal’ sleep varies considerably between different cultures and demographic groups. For example healthy elderly individuals sleep less at night compared to young and middle-aged individuals, and may make up for reduced night-time sleep by spending more time napping during the day.
Chronic insomnia affects at least one third of the world’s population. Insomnia and daytime sleepiness are major public health issues because they result in enormous losses in work productivity and significantly increase the risk of work-place and motor vehicle accidents. Diverse social, cultural, psychological and biological factors affect sleep and most cases of insomnia are caused by multiple factors. Approximately two thirds of individuals treated for any mental health problem complain of chronic insomnia. Individuals who struggle with depression or anxiety or who abuse alcohol or drugs are especially at risk of insomnia. Depending on the particular drug insomnia may be a direct result of substance abuse or a symptom of withdrawal following a prolonged period of abuse.
Insomnia is a core symptom of bipolar mania and post-traumatic stress disorder (PTSD). Insomnia frequently accompanies diverse medical problems such as chronic pain, sleep apnea, diabetes, lung diseases, thyroid disease, dementia and neurological disorders. Sleep apnea is a medical condition in which difficulty breathing when asleep causes frequent waking episodes throughout the night resulting in severe daytime sleepiness. Sleep apnea is associated with a significantly increased risk of depressed mood, overweight and heart disease. Insomnia is a frequently reported adverse effect of many prescription medications. Individuals who do shift-work (i.e. whose work schedule begins late night and continues until early morning) or travel extensively across many time-zones often experience insomnia related to a disturbance in their ‘biological clock.’ Elderly persons who have serious medical or mental health problems are especially at risk of chronic insomnia.
Limitations and safety issues associated with conventional treatments
Prescription sedative-hypnotic medications such as benzodiazepines are used to treat 80 to 90% of all complaints of insomnia in Western countries. This practice has led to over-prescribing or inappropriate prescribing of potentially addictive sedative-hypnotics to millions of individuals. Morning drowsiness, dizziness and headache are common adverse effects of benzodiazepines. Inappropriate long-term use or high doses of benzodiazepines frequently result in confusion, daytime somnolence and short-term memory impairment. Benzodiazepine use in the elderly is especially problematic because of the significantly increased risk of serious fall injuries associated with their use in this population. Many antidepressants including doxepin (Siniquan™), trazodone (Desyrel™), and mirtazapine (Remeron™) are moderately sedating, and their use in the management of insomnia has steadily increased since the mid 1980s. However, research findings suggest that antidepressants used to treat insomnia cause serious adverse effects more often compared to benzodiazepines, including elevated liver enzymes, dry mouth, nausea, weight gain, orthostatic hypotension, daytime sleepiness, and dizziness.
Diphenhydramine, an antihistamine, is frequently prescribed for insomnia because of its sedating side effects. In recent years atypical antipsychotics with sedating side effect profiles have been increasingly used to manage insomnia in the absence of FDA approval for this clinical application, and in spite of the absence of findings from controlled trials supporting the efficacy and safety of these drugs for the treatment of insomnia. Atypical antipsychotic agents frequently prescribed for insomnia include quetiapine (Seroquel™) and olanzapine (Zyprexa™). In many cases the conventional pharmacologic management of insomnia is inappropriate or potentially unsafe because of a non-disclosed history of alcohol abuse or prescription drug dependence, concurrent use of medications that interact with sedative-hypnotics, or the existence of medical conditions that make the use of benzodiazepines unsafe. Meta-analyses of conventional treatment approaches suggest that conventional drugs are probably more effective in the acute management of insomnia, while cognitive-behavioral approaches are more effective over the long term.
Non-medication approaches used to treat insomnia
The limited effectiveness and safety issues associated with available mainstream pharmacologic treatments of insomnia invite serious consideration of non-medication approaches. Simple changes in nutrition can significantly improve the quality of sleep and reduce daytime fatigue. Melatonin is especially effective for management of insomnia caused by disruption of circadian rhythms as in jet lag or shift work. Sustained-release preparations are most effective for increasing the duration of sleep while immediate-release formulations are most effective for individuals who have difficulty falling asleep. Valerian root extract is widely used to self-treat insomnia. A systematic review of placebo-controlled studies of valerian extract for insomnia concluded that 600mg to 900mg taken at bedtime improves the quality of sleep and has few adverse effects. The amino acids L-tryptophan and 5-hydroxytryptophan are sedating at certain doses and are widely used by naturopaths to treat situational insomnia. A special kind of electroencephalographic (EEG) biofeedback that employs alpha-theta training and provide feedback in the form of an individual’s unique “brain music” may be a more effective treatment of situational insomnia than progressive muscle relaxation. Other non-medication approaches to insomnia include taking a sauna or hot bath before bedtime, acupuncture and mind-body therapies.
If you are struggling with insomnia, taking a medication that isn’t helping you sleep better, experiencing adverse effects, or you simply can’t afford to continue taking a prescription sleep aid that is working you will benefit from my book Insomnia: The Integrative Mental Health Solution. In the book I provide practical information about a variety of non-medication alternatives that will help you sleep better such as herbals, vitamins and other natural supplements, whole body approaches, meditation and mind-body practices, and energy therapies.
Insomnia: The Integrative Mental Health Solution will help you:
• Understand insomnia better
• Take inventory of your symptoms
• Learn about non-medication treatments of insomnia
• Develop a customized treatment plan that is right for you
• Re-evaluate your treatment plan and make changes if your initial plan doesn’t work
Click here to preview or buy my book, Insomnia: The Integrative Mental Health Solution.