Rob wrote to Ask The Savvy Insomniac complaining about insomnia and wondering if Belsomra might help.
I’ve had insomnia since my teens. Never could get to sleep before 2:30. And that’s when I’m lucky. Sometimes it’s 3:30 or 4.
I do everything I’m supposed to do. I work out at the gym every day. I have a few beers when I get home but that’s it. I use a blue light blocking app on my computer and anyway I’m usually off it by 11. But nothing I do changes the situation. I just don’t feel sleepy. No matter how sleep deprived I am, I feel wired.
When the alarm goes off at 7:20 I feel exhausted. Coffee doesn’t help. I fight to stay awake at the office and by the end of the week it’s a losing battle. Early morning meetings are the worst.
What saves me is being able to sleep in on weekends. That and sleeping pills. Ambien will sometimes put me to sleep by 1. So my question is: Do you think Belsomra could work for me?
Barking up the Wrong Tree
I’m no doctor, but I suspect that if Rob were to consult a sleep specialist, his diagnosis would not be insomnia disorder but rather delayed sleep phase disorder (DSPD). The symptoms he reports are classic:
- a preference for going to sleep several hours later than normal
- difficulty sleeping at more conventional times
- feeling alert, not sleepy, at night
- struggling to wake up and function in the morning
- catching up on sleep on the weekends
Rob might not have a sleep problem if his work began at noon. But most jobs start earlier, and for people with DSPD, trying to function on a conventional schedule is a major ordeal. It can quickly lead to sleep deprivation and trouble meeting obligations. It limits prospects down the line.
A 25-Hour Circadian Period
We humans can’t choose our sleep time preferences. Whether you’re a night owl, an early bird, or somewhere in between depends on a mix of genetic factors. These preferences can be modified, though, and may also evolve with age-related changes.
Sleep experts have long suspected that people with DSPD have body clocks that run slow, taking longer to complete their daily cycle. While the average circadian period in humans is 24 hours 11 minutes, scientists have hypothesized that the period length in people with DSPD is closer to 25 hours.
The results of two recent studies confirm that circadian rhythms are quite a bit more delayed in people with DSPD than in normal sleepers:
- Investigators in Australia assessed study participants’ core body temperature rhythms over 78 hours and found that under conditions of a constant routine, DSPD patients’ temperature rhythms were delayed by about one hour a day. This suggests “that DSPD patients, on average, must advance their circadian rhythm by almost an hour each day to maintain stability of their sleep–wake cycle to the 24-hour world.”
- Using a similar, 30-hour study protocol, the same team found that melatonin secretion began almost 3 hours later in DSPD patients than in normal sleepers. While in normal sleepers the melatonin secretion began with a surge, in DSPD patients, it started out gradually.
No wonder people like Rob have trouble getting to sleep!
Therapies: Bright Light and Melatonin
The most effective treatment for night owls wanting to get to sleep sooner is not sleeping pills but rather bright light therapy. The light source can be the sun or a light box that disseminates light at 10,000 lux. Light exposure should occur first thing in the morning. The largest phase advances occur in sessions lasting for 2 hours.
Phase advances are also larger when morning bright light sessions are combined with a melatonin supplement taken late in the afternoon or around dinnertime. Combined with 0.5 mg of melatonin taken late in the afternoon, continuous exposure to bright light for 30 minutes early in the morning was found, in another recent study, to produce 75% of the phase shift that occurred with the 2-hour exposure.
But the bright light–melatonin regimen is not a cure for DSPD. Stop it and your circadian rhythms will revert to their natural cadence. This will also happen if you allow yourself to sleep in late on weekends. You’ll function best if you maintain the same sleep-wake schedule all 7 days of the week.
As for sleeping pills like Ambien and Belsomra, why assume the risks these pills confer when bright light therapy and melatonin supplements, which have few if any side effects, can work even better?
If you’re a night owl, have you tried bright light therapy and/or melatonin supplements? How have they worked?