Health Tip: Chronic Insomnia

Poor sleep may contribute to increased risk for heart disease, diabetes, and depression, yet physicians often forget to ask their patients about their sleep habits until it becomes a crisis. Sleep specialists recommend that insomnia be treated at the same time as other medical conditions. It is common for clinicians to hope that if the other conditions are treated first, good sleep will follow. But that is rarely the case.

Chronic sleep deprivation can be exasperating, and impact everyday life. It is a vicious cycle where one feels too tired to exercise, and then lack of exercise contributes to further health deficits. The best treatment for insomnia may depend on its underlying cause, and a thorough sleep history (complete with a sleep diary or sleep lab analysis) may be necessary to confirm the source.

There is a genetic component to insomnia that is often ignored - up to 57% of patients with insomnia¹ have a strong family history of it. Also, anxiety disorders and depression often co-mingle with sleep disorders. One study suggested that young people with anxiety disorders may go on to have chronic insomnia in 73% of cases. For other youth, insomnia preceded depression in 69% of cases.² Life stressors, sleep apnea, and a sedentary lifestyle may contribute as well. So what works for chronic insomnia?

Cognitive Behavioral Therapy (CBT) is an effective, non-pharMORE effective than most medications.³ CBT is a form of psychotherapy that focuses on solutions, encouraging patients to challenge distorted beliefs and change destructive patterns of behavior.
maceutical option for those who are willing to invest the therapy time - to set and reinforce good sleep hygiene. Studies have shown that CBT is actually

Regular Aerobic Exercise - research suggests that exercise is as effective as benzodiazepines in treating insomnia.⁴  Exercise reduces anxiety and depression, increases serotonin levels, and promotes immune function. It's important not to exercise right before bedtime, however. Wait at least 3 hours before you go to sleep (after exercising) for optimal effects.
Now, if you've given both of these (CBT and regular exercise) a good and sustained effort, and still need some assistance to sleep or stay asleep (i.e. you sleep <6.5 hours per night for a month or more), there are medications that may help. This is a very quick overview and I encourage you to talk to your healthcare provider before starting any of these.

Over-the-counter sleep aides:
Anti-histamines: non-selective (H1) antihistamines (such as diphenhydramine or doxylamine - aka Benadryl and Unisom) used for severe allergies have a drowsiness side-effect that can increase sleep. The problem is that people adapt fairly quickly to these drugs, rendering them less effective if used too frequently. In addition, they have long half-lives and can cause daytime drowsiness and cognitive impairments for 16 hours or more at a time.

Melatonin: our sleep/wake cycles are influenced by a gland (pineal gland) deep in our brains. This gland makes a hormone called melatonin which is available in pill form in the vitamin aisle of most grocery or pharmacy stores. Melatonin has very few side effects other than regulating sleep/wake cycles. Studies suggest that it may take 4-6 weeks of daily use before improvements are noted in regular sleep patterns.

Prescription Medications:
Benzodiazepines: (common trade names - Ativan, Xanax, Valium, Restoril). These are "sedative-hypnotic" medications that inhibit certain neurotransmitters, resulting in anti-anxiety, anti-spasmodic, and sleep-enhancing effects. Some are longer acting than others (Valium has a much longer half life than Xanax, for example) and can affect daytime cognition. They should be used sparingly, and rarely in those over age 65 because they dramatically increase their risk for falls and may be associated with an increased risk for Alzheimer's disease to boot.

Non-Benzodiazepine Hypnotics: (common trade names -Ambien, Lunesta) - these drugs work on a slightly different receptor in the brain, but are close relatives of the benzodiazepines. The exact mechanism of action of Lunesta is unknown. Sleep walking, nausea, and diarrhea are potential side effects of Ambien, headaches are the most common complaint for those using Lunesta.

Anti-depressants: (Trazodone, Paxil). Trazodone blocks Serotonin reuptake and also has some antihistamine effects, and Paxil is a Selective Serotonin Reuptake Inhibitor (SSRI). Both may improve insomnia, anxiety, or depression. Rare cases of suicidal thoughts can occur.

Anti-psychotics: (Seroquel, Risperdal, Zyprexa) These medicines are used to manage sleep disturbances caused by mania or dementia with agitation. They may be helpful in specific cases, but come with a small risk of long term movement disorders and should be used with caution.

Orexin-Blockers: (Belsomra) selectively targets and downregulates the "awake" centers of the brain. This is a newly approved drug, and less is known about its long-term side effects. Nightmares may occur.
In my view, natural methods for addressing sleep deprivation are less risky and have higher long term success rates than medications. Nevertheless, there are some cases where a short-term medication intervention may be necessary to break the cycle of chronic insomnia. I hope you find a solution for your (or your loved one's) insomnia.

Sweet dreams!

References
https://www.psychologytoday.com/basics/cognitive-behavioral-therapy
¹ Rieman D et al. Lancet Neurol 2015; 14(5):547-558.
² Johnson E O et al. J Psychiatr Res 2006; 40(8):700-708.
³ Jacobs GD et al. Arch Intern Med 2004; 164:1888-1896.
⁴ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3370319/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1325284/

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