Dear Doctor Column, December 12, 2005

Treating Insomnia: Sleeping Difficulties are Common

Question:

I've been suffering from insomnia for about a month. I can fall asleep, but I usually wake up in the early morning and can't go back to sleep. During the day, I'm irritable and have trouble working. Over-the-counter sleep aids leave me feeling sluggish and unfocused. Are prescription medications better? I'm concerned about becoming dependent on a drug, but can't continue going without enough sleep.

Answer:

Insomnia, the most common sleep complaint, is difficulty falling or staying asleep. More than a third of American adults have at least occasional trouble sleeping and about 10% report long-term insomnia. Insomnia causes daytime problems such as fatigue, irritability, and trouble working and concentrating. People with insomnia experience one or more of the following:

• trouble falling asleep
• waking up often during the night and having trouble getting back to sleep
• waking up too early in the morning
• poor-quality sleep

Insomnia is not a disease, but a symptom of an underlying problem. Stress, anxiety, medication, poor sleep habits, and some illnesses, such as acid reflux, asthma, arthritis, cancer, and sleep apnea, can cause insomnia. Women and older adults are more likely to suffer from insomnia, as are people with depression. Women going through menopause also commonly report trouble sleeping. Determining the cause of your insomnia can help pinpoint the best treatment.

Almost everyone experiences transient insomnia — the occasional sleepless night caused by temporary anxiety or excitement. You don't mention your personal situation, but people who are undergoing more persistent stress — the loss of a loved one, a job change, or caring for a chronically ill child or parent — can experience short-term insomnia, defined as sleeping problems for 1 to 6 months. Chronic insomnia, difficulty sleeping lasting 6 months or longer, is more complex and often results from a combination of physical and emotional factors.

Poor sleeping environments can contribute to insomnia. A bedroom that is too light, noisy, or too hot or cold can interfere with normal sleep patterns, as can certain lifestyle factors, including pets that frequent your bedroom and snoring bed partners. Caffeine and nicotine are stimulants and can keep you awake when used in the hours before going to bed. When considering your total caffeine intake, bear in mind that caffeine is found in most cola drinks, coffee, and tea. Alcohol may help you fall asleep, but can cause you to wake up during the night and reduce the quality of the sleep you do get.

Lifestyle changes that promote good sleep habits may relieve insomnia. Try these tips:

• Aim for consistent sleep patterns. Try to go to sleep and wake up at the same time each day. Limit daytime napping, which can make you less sleepy at night.
• Only get in bed when you are sleepy. Avoid falling asleep on a couch or in a chair.
• Avoid bright lights just before bed.
• Use your bedroom only for sleeping and sex. Don't eat or watch television in bed.
• Make your bedroom comfortable. It should be dark and quiet. If outside lights make your bedroom too bright, try a sleeping mask. Reduce noise with earplugs or a fan.
• A calming routine before bed can help you relax and fall asleep. Try a warm bath, reading, or listening to soothing music.
• If you can't fall asleep within 15 to 20 minutes of turning in, try getting up and reading relaxing material until you feel sleepy. Don't watch television or log onto your computer — these activities are too stimulating and can keep you awake.
• Get regular exercise. It can reduce stress and promote sleep. However, exercising also is stimulating, so take your jog or walk at least 3 hours before bed.
• A heavy dinner can keep you awake, but a light protein-based snack shortly before bed may help you sleep.
• Worrying about your insomnia can also keep you from sleeping. Try to focus on keeping a regular schedule, good sleep habits, and reducing anxiety and stress.

Sources: Adapted from the National Institutes of Health and the American Insomnia Association.

As you've noticed, over-the-counter remedies can leave you feeling groggy and are not recommended for treating insomnia. Because your insomnia is interfering with your sense of well being and daytime functioning, you may want to consider talking with your doctor about prescription sleep aids or behavioral therapy.

Behavioral therapy such as relaxation exercises, biofeedback techniques, and sleep-restriction therapy can often relieve insomnia. Several types of prescription medication can provide temporary relief for people with transient or short-term insomnia. Options include hypnotic benzodiazepines such as ProSom (estazolam) and Restoril (temazepam), some antidepressants, and nonbenzodiazepine hypnotics such as Ambien (zolpidem), Lunesta (eszopiclone), and Sonata (zaleplon). Some of these drugs are short acting, meaning they help you fall asleep, while others release more slowly to prevent waking during the night. Your doctor can help you decide which formulation is best based on your particular type of sleeping problem.

The risk of dependance on prescription insomnia medications is low, especially with nonbenzodiazepines, but using these sleep aids for more than a few weeks is not generally recommended. Many can cause rebound insomnia, a return of sleeplessness for a night or two, when they are stopped. Individuals with chronic insomnia should consider consulting with a sleep specialist who can offer behavioral therapy, sleep studies, or a combination of therapy and medication.

People with insomnia often try herbal remedies sold at health food stores, and melatonin, a hormone involved in sleep regulation, may help induce sleep, but it is not known whether it is useful for maintaining sleep. Other herbal products such as valerian and kava kava are not well-studied. It is important to know that products sold in health food stores are not required to undergo rigorous clinical testing evaluating safety and effectiveness and can be harmful. Always check with your physician before trying any of these products.

For more information on insomnia, visit the National Center on Sleep Disorders, www.nhlbi.nih.gov/sleep; the American Academy of Sleep Medicine, www.aasmnet.org, and the National Sleep Foundation, www.sleepfoundation.org.