CBT for Insomnia: Where to Find the Help You Need

Here’s a question that often comes my way: “I’d like to try cognitive behavioral therapy for insomnia [CBT-I], so where can I find a sleep therapist?”

The availability of CBT-I providers varies depending on where you live. Here’s where you’re likely to find help and where you’re not, and alternative ways to get the insomnia treatment you’re looking for.

Where to find a therapist who does CBT for insomniaHere’s a question that often comes my way: “I’d like to try cognitive behavioral therapy for insomnia [CBT-I], so where can I find a sleep therapist?”

The availability of CBT-I providers varies depending on where you live. Here’s where you’re likely to find help and where you’re not, and alternative ways to get the insomnia treatment you’re looking for.

Why CBT for Insomnia?

It’s the most effective insomnia treatment known at this time, improving sleep for 70 to 80 percent of the people who try it. CBT-I is more effective and long lasting than treatment with sleeping pills, and it’s effective for many people with chronic insomnia who also have other health problems such as depression, anxiety, or sleep apnea.

For more information on CBT-I, take a quick look at this blog post I wrote at the beginning of last year.

Where Can I Find Treatment?

It depends on where you live, say authors of a paper published last year in Behavioral Sleep Medicine. If you live in New York or California, insomnia therapy is likely close at hand. If you live in Hawaii, South Dakota, Wyoming, or New Hampshire, you’ll have no luck in finding a doctor, psychologist, or nurse practitioner trained in behavioral sleep medicine. Authors of the paper were unable to find a single provider practicing in those states.*

Here’s a chart showing the number of behavioral sleep medicine providers in the US by state:

No. of providers States
73–33 CA, NY, PA, IL, MA, TX
27–22 FL, OH, CO, MN, MI, WA
17–10 MD, NC, TN, AZ, MO, DC
9–6 CT, VA, WI, AL, OR, AR, SC, WV, IN, ME, NJ
5–3 AK, DE, GA, KS, LA, NE, RI, KY, NM, NV, OK, UT, MS
2–0 ID, ND, IA, MT, VT, HI, NH, SD, WY

 

Canada has 37 behavioral sleep medicine providers, but no other country outside the US has more than 7.

Do I Really Need a Sleep Therapist for CBT-I?

There are alternatives to working with a doctor or therapist trained in behavioral sleep medicine. But working with a professional—someone with a clear grasp of the protocol who can lead you through it step by step, motivating you to continue if the going gets rough—is probably the best way to ensure success and maximize the gains you’re going to make.

“Having somebody who’s experienced with this telling me that, if I do this, there’s a good chance everything will turn around is very inspiring,” said a man I interviewed for my book, The Savvy Insomniac, after we finished a group course in CBT-I.

Find a professional trained to administer CBT-I by clicking on this provider directory.

What If I Can’t Get Insomnia Therapy Nearby?

Your next best bet is to take an online course in CBT-I. These interactive courses have been found to be as effective as the face-to-face coaching you’d receive from a sleep therapist, the only downside being that research shows people going through an online course are more likely to drop out. Check these programs out:

  • CBT for insomnia is a 5-week course developed by sleep specialist Gregg D. Jacobs at Harvard Medical School. The cost is $49.95.
  • SHUTi sells its 6-week course, developed by Canadian sleep specialist Charles Morin, for $149. The price includes access to the site for 26 weeks. The extended access might appeal to you if (1) you’re not ready to jump right into the course, (2) something unforeseen happens during therapy and you have to start all over again, or (3) you feel you might like to continue tracking your sleep after the course ends.
  • Sleepio, developed by UK sleep specialist Colin Espie, offers a 6-week course plus a year’s access to the website and a host of supplementary materials for the hefty price of $400. What you’d gain from a whole year’s access to the website isn’t clear to me. But you may be able to access Sleepio for free by agreeing to take part in a research study.

Couldn’t I Just Read a Book?

You could. Stephanie Silberman’s book, The Insomnia Workbook: A Comprehensive Guide to Getting the Sleep You Need, leads you step by step through everything you need to know to go through CBT-I using the book as your guide. But here’s a warning: while I know it’s possible to succeed in self-administering CBT-I using only a book as a guide (I did), I hear some people complain of failure. Make sure you succeed by starting out right:

  1. Read all you can about the CBT-I protocol before starting therapy. It’s important to understand the process before you begin.
  2. For 1 to 2 weeks before you start therapy, keep a sleep diary (download a sleep diary here), recording bed and rise times and relevant habitual activities.
  3. From the data you’ve gathered, calculate your average nightly total sleep time and set your initial sleep window accordingly. (But if you sleep less than 5 hours a night, set your sleep window at 5 hours.)

Stick closely to the protocol and hang tight. Your sleep should start to improve in a couple of weeks.

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*To gather data, the authors consulted a directory of professionals certified in behavioral sleep medicine, BSM provider lists, and BSM listservs.

Off-Label Prescribing for Insomnia: What to Expect

Several drugs approved for insomnia are in the doghouse these days, and physicians are doing a fair amount of off-label prescribing. What medications should we expect to be prescribed in lieu of zolpidem (Ambien) and temazepam (Restoril)?

Using a “translational approach,” McGill University researchers have reviewed a host of medications with sedative properties and found the evidence base for some is stronger than for others. Here are the drugs they’ve found are most likely to work.

Insomnia treated with sleeping pill substituteSeveral drugs approved for insomnia are in the doghouse these days, and physicians are doing a fair amount of off-label prescribing. What medications should we expect to be prescribed in lieu of zolpidem (Ambien) and temazepam (Restoril)?

Using a “translational approach,” McGill University researchers have reviewed a host of medications with sedative properties and found the evidence base for some is stronger than for others. Here are the drugs they’ve found are most likely to work.

Why Not Stick With the Tried and True?

Z-drugs such as zolpidem and benzodiazepines such as temazepam may be fine for short-term or occasional use. But lots of people who take these sleeping pills go on to become chronic users.

This can cause problems. People who take a Z-drug or a benzodiazepine nightly for months and years often experience adverse effects: a decrease in deep (or slow-wave) sleep and/or cognitive and motor impairments the next day. Some develop drug dependency.

The Off-Label Prescribing Dilemma

So where’s the next generation of sleeping pills in line to replace the ones we’re using now? A few new drugs are in the pipeline, but none I’m aware of are going up for FDA approval soon. As often happens, we’ve got to fall back on drugs already approved to treat other health problems. It’s perfectly legal for doctors to prescribe such drugs off label as treatment for insomnia.

The problem lies in knowing which other drug(s) to choose. Medications approved for insomnia have demonstrated their efficacy in at least two randomized clinical trials (RCTs) conducted on people with insomnia (and no other related condition). Compared with placebo, they’ve been found to significantly improve sleep. Medications approved for other health conditions—such as depression, anxiety, or neuropathic pain—may have known sedative properties. But in many cases they haven’t been tested for efficacy on people with simple insomnia.

A Translational Approach

In an in-depth review paper published this month in Pharmacological Reviews, the McGill University researchers propose instead using a translational approach to evaluate these drugs for efficacy in treating insomnia. This involves integrating what basic scientific research has shown about a drug’s pharmacology and mechanism of action with clinical data and current medical practice.

Using this approach, the researchers went on to identify medications most likely to serve as effective alternatives for Z-drugs and benzodiazepines. Here they are:

Drugs That Act on the Melatonin System

1. Prolonged-release melatonin (PRM): FDA-approved dietary supplement sold over the counter in the United States; sold as a prescription drug (2 mg/day) in Europe. “Good evidence,” based on 4 RCTs, that PRM is effective for insomnia disorder in adults over age 55 (particularly in reducing time to sleep onset). There’s no evidence that PRM is effective for younger adults with insomnia. (Caveat: The quality control of dietary supplements sold in the United States is not nearly as reliable as the control of prescription medications. Your physician may be able to steer you toward a reliable brand.)

2. Ramelteon (Rozerem): FDA-approved drug for treatment of sleep onset insomnia. “Strong evidence,” based on 2 meta-analyses, that the drug reduces subjective time it takes to fall asleep but no evidence that it helps people sleep longer.

3. Agomelatine (Melitor): Not available in the United States but approved for treatment of major depressive disorder in Canada and Europe. “Good evidence,” based on 1 review and 2 RCTs, that this drug reduces sleep latency in people with depression. Unlikely to improve sleep in people with simple insomnia.

A Drug That Acts on the Orexin System

4. Suvorexant (Belsomra): FDA-approved drug for treatment of insomnia disorder. “Strong evidence,” based on 2 systematic reviews, that the drug reduces insomnia symptoms at doses of 15 mg and higher. It purportedly increases total subjective sleep time and decreases subjective time to sleep onset. (Caveat: Because this drug is a relative newcomer, less is known about its real-world effectiveness and actual side effects. For more information, read my earlier post about Belsomra and take a look at the reader comments.)

Sedating Antidepressants

5. Low-dose doxepin (Silenor): FDA-approved drug for treatment of sleep maintenance insomnia that acts on the histamine system. “Strong evidence,” based on 1 systematic review, that this drug enhances sleep maintenance by reducing nighttime wake-ups. It has not been found to cut down on time to sleep onset.

6. Trazodone: FDA-approved drug for treatment of depression. At low doses, commonly prescribed off label for treatment of insomnia. It acts on the histamine, serotonin, and catecholamine systems. “Good evidence,” based on 2 RCTs, that trazodone reduces insomnia symptoms in people who are taking selective serotonin reuptake inhibitors (SSRIs) to manage depression. This is the only conclusion drawn by the McGill researchers about trazodone. It does not account for the drug’s great popularity with physician prescribers, who for decades have been prescribing trazodone for insomnia rather than Z-drugs and benzodiazepines.

More on Trazodone

So I looked at another paper, this one a systematic review of trazodone for insomnia published in Innovations in Clinical Neuroscience in August 2017. From a pool of 45 studies (the inclusion criteria were evidently less stringent for these researchers than for the McGill researchers, who reviewed 16 studies of trazodone), the second team of researchers concluded that trazodone “is a generally safe therapeutic that has been repeatedly validated as an efficacious treatment for insomnia, particularly for patients with comorbid depression,” with some evidence that it decreases sleep latency, increases sleep duration, and improves sleep quality. Side effects, which may show up in people taking doses higher than 100 mg, include daytime sleepiness, headache, and hypotension, increasing the risk of falls.

The evidence base for trazodone’s effectiveness as a drug for people with simple insomnia is sparse yet suggestive of similar benefits, the second research team reports. (Results of a recent 6-week clinical trial comparing 3 active insomnia treatments—behavioral therapy, zolpidem, and trazodone—are not yet available. Stay tuned.)

An Anticonvulsant Drug

7. Pregabalin: FDA-approved drug for treatment of neuropathic pain, seizures, and fibromyalgia. There is “good evidence,” based on 2 review papers, that pregabalin is effective in reducing symptoms of insomnia in generalized anxiety disorder. There is also “good evidence,” based on 1 review, that the drug is effective in reducing symptoms of insomnia in fibromyalgia. But no evidence base for pregabalin as a treatment for simple insomnia exists.

The medical treatment of insomnia has always been problematic, even more so in the past than today. While your physician may be reluctant to keep writing prescriptions for zolpidem, other, possibly safer medications may be available when behavioral treatments for insomnia don’t suffice.

Insomnia: Are Primary Care Doctors Still Getting It Wrong?

It’s not always easy to find help for insomnia. Several people I interviewed for “The Savvy Insomniac” reported that their primary care doctors didn’t seem to take the complaint seriously or prescribed treatments that didn’t work.

I thought the situation must have changed since persistent insomnia is now known to be associated with health problems down the line. But a recent report on the Veterans Affairs (VA) health system shows that insomnia is still overlooked and undertreated by many primary care providers.

Here’s what you may find—and what you deserve—when you talk to your doctor about sleep.

Insomnia is not always treatable by primary care providersIt’s not always easy to find help for insomnia. Several people I interviewed for “The Savvy Insomniac” reported that their primary care doctors didn’t seem to take the complaint seriously or prescribed treatments that didn’t work.

I thought the situation must have changed since persistent insomnia is now known to be associated with health problems down the line. But a recent report on the Veterans Affairs (VA) health system shows that insomnia is still overlooked and undertreated by many primary care providers.

Here’s what you may find—and what you deserve—when you talk to your doctor about sleep.

Insomnia Addressed in Primary Care

Investigators surveyed 51 primary care providers (PCPs) in the VA system as to their perceptions and treatment of insomnia. About 80% of the respondents said they felt insomnia was as important as other health problems. Yet they tended to underestimate its prevalence and often failed to document its presence.

Other research has shown that the prevalence of poor sleep quality among veterans is extremely high: over 70% in veterans without mental illness and even higher in veterans with a mental health diagnosis. Yet most PCPs surveyed estimated that only 20% to 39% of their patients experienced insomnia symptoms. When insomnia emerged as a problem, only 53% said they regularly entered it into their patients’ medical records.

Insomnia Conceived Of as Secondary Problem

Scientists now have plenty of evidence that insomnia is a disorder in its own right—regardless of whether it occurs alone or together with another disorder. Yet many PCPs seemed to view it as merely a symptom or a condition secondary to another disorder.

All of the PCPs endorsed the belief that when insomnia occurs together with a health problem such as depression and PTSD, successful treatment of the depression or PTSD will eradicate the trouble sleeping. Current scientific evidence does not support this belief.

Insomnia Treated With Sleep Hygiene

The first-line insomnia treatment recommended by the American Academy of Sleep Medicine and other professional organizations is cognitive behavioral therapy for insomnia (CBT-I). CBT-I is available at VA facilities.

Even so, the insomnia treatment PCPs most often recommended to their patients was counseling on good sleep hygiene. But sleep hygiene doesn’t work as a stand-alone treatment for insomnia. What’s more, it may make the prospect of CBT-I less palatable, given that some CBT guidelines call for behavioral changes that resemble the rules of good sleep hygiene.

Still Getting It Wrong

It seems like primary care doctors are just as outdated in their conception and treatment of insomnia as they were 10 and 20 years ago. I’m not alone in voicing this concern. Here’s how Michael Grandner and Subhajit Chakravorty titled their commentary on the survey results: “Insomnia in Primary Care: Misreported, Mishandled, and Just Plain Missed.”

There’s no ambiguity here.

Help You Deserve From Your Doctor

Your PCP may be responsive to your complaint of insomnia and current in his or her knowledge of how to diagnose and treat the condition. If so, well and good.

But your doctor may not be quite so on the ball when it comes to dealing with trouble sleeping. Don’t let that deter you from seeking help for insomnia elsewhere. A good doctor will:

  1. Respond to concerns about insomnia as attentively as he or she would to concerns about double vision or shortness of breath. Insomnia can be debilitating, and chronic insomnia can result in changes that compromise health and quality of life. A doctor who dismisses it as trivial or hands you the rules for good sleep hygiene before waving you out the door is not the right doctor.
  2. Ask questions about the duration, frequency, and severity of your problem, and possible underlying conditions. This type of inquiry is crucial to arriving at an accurate diagnosis and appropriate treatment. Doctors who don’t have the time or knowledge to ask these questions should refer you to someone who does.
  3. Discuss treatment options that are research based and individualized. CBT-I may require referral to a specialist, yet there may be no specialist certified in behavioral sleep medicine practicing in the area. Likewise, a prescription for sleeping pills is useless to a patient who has no intention of filling it. Treatment discussions should be dialogs, and doctors should encourage patient participation.

This is the kind of response we deserve when we bring up the topic of insomnia with PCPs.

But it may not be the kind of response we get. How has your doctor reacted when you’ve mentioned trouble sleeping? (If you found this post helpful, please like and share on social media. Thanks!)

7 New Insomnia Genes: What’s in It for Us

A flurry of articles recently announced the discovery of seven new risk genes for insomnia. In an era when new genes are being identified for everything from infertility to schizophrenia, you might regard this discovery as simply the soup du jour.

Not me. Growing up when trouble sleeping was attributed to psychological factors, coffee, and alcohol, I was elated by this news. We stand to gain so much from knowing the genetic underpinnings of insomnia.

Causes of insomnia are closer to being figured outA flurry of articles recently announced the discovery of seven new risk genes for insomnia. In an era when new genes are being identified for everything from infertility to schizophrenia, you might regard this discovery as simply the soup du jour.

Not me. Growing up when trouble sleeping was attributed to psychological factors, coffee, and alcohol, I was elated by this news. We stand to gain so much from knowing the genetic underpinnings of insomnia.

A Biological Basis for Insomnia

The most immediate benefit of the discovery is that it affirms what scientists have suspected for years: there is a biological basis for insomnia. This is common knowledge among sleep researchers but not so well known among members of the public or even doctors. They may still blame insomnia on psychological factors and poor self-control and dismiss it as a complaint unworthy of attention or treatment.

“Insomnia is all too often dismissed as being ‘all in your head,’” said Eus Van Someren, a lead researcher on the project, quoted in a press release. “Our research brings a new perspective. Insomnia is also in the genes.”

Genes contain the information needed to make proteins, and proteins do most of the work in the cells in our bodies and brains. The identification of insomnia risk genes suggests that vulnerability to insomnia has a neurobiological basis. It is likely driven by an excess or deficit of key neurochemicals or abnormalities in the circuitry of the brain.

What the Discovery Doesn’t Mean

People sometimes confuse the idea of genetic risk with biological determinism—the belief that hereditary factors are the sole determinants of who we are and the health challenges we face. The assumption is that if constitutional factors predispose a certain disease or health condition, then nothing can be done to alter its course.

There are a small number of irreversible diseases caused by mutations in a single gene. If you’re born with a certain mutation in the HTT gene, for example, you inevitably develop Huntington disease. Nothing can be done to change this.

But most diseases and conditions—insomnia included—are complex. No single gene determines whether you get them or not. Multiple genetic factors likely come into play, increasing the odds of developing a disorder but not making it inevitable. Environmental, social, psychological, and behavioral factors may play as big a role in determining whether you develop insomnia or not.

It might be possible to inherit several insomnia risk genes but, thanks to a privileged set of circumstances, never experience trouble sleeping a day in your life. Likewise, despite being biologically predisposed to experience insomnia, you may be able to manage the disorder some or even most of the time with cognitive and behavioral techniques.

Benefits of Genetic Studies

Genetic studies such as this one will enable scientists to trace the pathways by which insomnia develops and identify the biological mechanisms involved. In turn, insomnia treatments can be developed that alter these particular systems, rather than being aimed at systems merely suspected of involvement. Drugs can be developed to target the root causes of insomnia rather than simply tranquilizing the brain.

Other Discoveries and Implications

  • The insomnia risk genes are known to be associated with disorders that often occur with insomnia: restless legs syndrome, anxiety disorders, depression, and type 2 diabetes. Likewise, insomnia was found to have a shared genetic background with neuroticism and poor sense of well-being, traits that often occur in people with insomnia.
  • Some genetic variants associated with insomnia in women were different from the variants associated with insomnia in men, so the biological mechanisms driving insomnia may in some cases be different. If this is true, insomnia treatments prescribed for women may in some cases need to be different from those prescribed for men.

Every new genetic study brings us closer to the time when trouble sleeping will be treated based on the cause of the insomnia rather than its symptoms. Surely that’s something to celebrate!

Lifelong Insomnia? Don’t Give Up on It Yet

Have you had insomnia all your life? Have your parents said you were a poor sleeper even as a baby?

Trouble sleeping that starts early in life is called idiopathic insomnia. If insomnia is still the black box of sleep disorders, then idiopathic insomnia is the little black box inside the black box.

Here’s what is known about the disorder and options for management.

Lifelong insomnia can be treated by sleep specialist or therapistHave you had insomnia all your life? Have your parents said you were a poor sleeper even as a baby?

Trouble sleeping that starts early in life is called idiopathic insomnia. If insomnia is still the black box of sleep disorders, then idiopathic insomnia is the little black box inside the black box.

Here’s what is known about the disorder and options for management.

What Is Idiopathic Insomnia?

Idiopathic insomnia begins in childhood, sometimes at or soon after birth. Trouble falling or staying asleep or reduced sleep duration is pretty much a nightly affair regardless of situational changes. The disorder is uncommon, affecting less than 1% of the population.

There is no identifiable cause. The presumption is that idiopathic insomnia is driven mainly by biological factors, and at least some of them are probably inherited. Abnormalities in the circadian system or the homeostatic process may be involved and/or there may be a problem in the circuitry controlling sleep and waking in the brain.

A Chronic Sleep Disorder, but How Well Defined?

Idiopathic insomnia is a chronic sleep disorder with familiar insomnia symptoms:

  • Trouble falling or staying asleep, or sleeping long enough, for more than 3 months despite adequate sleep opportunity
  • Daytime distress and impairment, including reduced stamina, low mood, and trouble thinking and learning

Research on the defining features of idiopathic insomnia is mixed. On one hand are a few studies showing significant differences between people with idiopathic insomnia (IdI) and those with psychophysiological insomnia (PI), the garden-variety insomnia that typically develops later in adolescence or adulthood. PI is often triggered by a stressful event; situational factors do not figure in IdI. PI is said to persist mainly due to psychological and behavioral factors that develop in response to poor sleep: conditioned arousal in bed, poor sleep hygiene (going to bed early to catch up on sleep, for example), and anxiety about sleep. Psychological factors are less typical in IdI.

On the other hand is research showing no major differences between PI and IdI when assessed by polysomnography (the overnight test in the sleep lab) or by self-report of psychological symptoms. Research suggests that arousal levels are higher among people with IdI than in people with other kinds of insomnia, though, leading some sleep experts to speculate that IdI is simply a more severe manifestation of PI.

What Can Be Done?

Without scientific certainty about the causes of IdI or whether the disorder is distinct from other kinds of insomnia, IdI is best treated on a case-by-case basis by a sleep specialist. Following are options for treatment.

Especially if a person with IdI has misconceptions and/or anxiety about sleep,

  • Cognitive behavioral therapy for insomnia (CBT-I) may help. CBT-I typically consists of two behavioral components—stimulus control therapy and sleep restriction therapy—and a cognitive component designed to decrease psychological barriers to sleep. Sometimes just changing your attitude about sleep can bring about demonstrable sleep improvements.
  • Acceptance and commitment therapy (ACT) may help. ACT focuses on building mindfulness skills so that, rather than trying to suppress, manage, and control emotional experiences, people develop psychological flexibility and learn to behave in ways that reflect their values and increase well-being. This approach, too, can change the way you feel about sleep and in the process improve your sleep.

If round-the-clock hyperarousal is driving IdI, then therapies designed to decrease arousal may help.

  • Regular, moderate-to-vigorous exercise—activities such as aerobics, calisthenics, biking, running, and weight-lifting—has been shown in recent studies to increase total sleep time and decrease levels of cortisol (a stress hormone).
  • Yoga, too, has been shown to decrease feelings of arousal and promote stress tolerance.

Medication for Idiopathic Insomnia

The issue of sleeping pills for chronic insomnia is increasingly fraught. Many drugs approved for the treatment of insomnia, taken nightly over time, may degrade sleep quality and result in alarming side effects, especially in older adults.

That said, while the medication prescribed for IDI is usually a benzodiazepine or a Z-drug such as zolpidem or eszopiclone, a second pharmacological approach, according to a paper by Michael Perlis and Philip Gehrman, involves use of a melatonin agonist such as ramelteon (Rozerem). No studies of the effects of this sleeping pill on the sleep of adults with IdI have been conducted. But in two studies of children aged 6 to 12 years with chronic idiopathic childhood sleep-onset insomnia, melatonin put them to sleep significantly sooner—by 1 hour.

If you’re contemplating managing lifelong insomnia with drugs, get some professional advice. This is one place where you really need the help of a specialist knowledgeable in the medical treatment of chronic insomnia.

At what age did your trouble sleeping start? What kinds of treatments—if any—have helped?

Sleeping Pills: New Prescribing Guidelines

Let’s say you go to the doctor hoping to get a prescription for sleeping pills to relieve your insomnia. You’ve been through cognitive behavioral therapy and it has helped. But there are nights when you’re wound up so tightly that nothing—push-ups, meditation, a hot bath—will calm you down enough so you can get a decent night’s sleep. What then?

The American Academy of Sleep Medicine recently released a clinical practice guideline for the medical treatment of chronic insomnia in adults. Here’s what the academy now recommends.

New guideline for sleeping pills may change doctors' prescribing habitsLet’s say you go to the doctor hoping to get a prescription for sleeping pills to relieve your insomnia. You’ve been through cognitive behavioral therapy and it has helped. But there are nights when you’re wound up so tightly that nothing—push-ups, meditation, a hot bath—will calm you down enough so you can get a decent night’s sleep. What then?

The American Academy of Sleep Medicine recently released a clinical practice guideline for the medical treatment of chronic insomnia in adults. Here’s what the academy now recommends.

Why the Need for a Clinical Practice Guideline?

Most experts in sleep medicine are well acquainted with the literature on sleeping pills and know how to diagnose and treat insomnia. When medication for insomnia is warranted, they know the best drug to prescribe based on your symptoms and medical history.

But most people with sleep complaints take them first to primary care providers. And when it comes to prescribing sleeping pills, not all doctors are on the same page. In fact, a new study from Harvard Medical School shows that, rather than prescribing based on individual patients’ symptoms and history, many doctors find one or two sleep medications they’re comfortable with and prescribe the same drug or drugs again and again.

The new clinical practice guideline contains recommendations that are evidence based. It has the potential to change physicians’ prescribing habits and thus to affect people with insomnia who use sleeping pills, now and in the future.

The Guidelines Are Based on Weak Evidence

The four sleep experts who created the guideline first conducted a literature review. They concluded that no sleeping pill or sleep aid on the market today has been tested in multiple clinical trials and found to be extremely effective and carry very few risks. So the evidence base for their recommendations is, they note, “weak.”

This doesn’t mean that a given medication would not be appropriate and effective for a particular individual with insomnia. It just means as a general treatment for everyone with chronic insomnia, no sleeping pill is backed up strongly by the evidence.

These Sleeping Pills Got a Thumbs-Up

Perhaps predictably, the medications judged to be appropriate—based on the quality of evidence, the balance of benefits and harms, and patient values and preferences—are medications approved by the FDA for the treatment of insomnia. The guideline does not suggest that one drug is better than another since so few studies comparing the efficacy of two or more sleeping pills have been conducted. So the medications listed here are in no particular order:

MEDICATION

SLEEP ONSET INSOMNIA

SLEEP MAINTENANCE INSOMNIA

suvorexant (Belsomra)  X
eszopiclone (Lunesta) X  X
zaleplon (Sonata) X
zolpidem (Ambien) X
triazolam (Halcion) X
temazepam (Restoril) X X
ramelteon (Rozerem) X
doxepin (Silenor) X

These Sleep Aids Were Not Recommended

The following medications and supplements are sometimes prescribed and used for chronic insomnia. Depending on an individual’s symptoms and history, they may help. But the published data on these substances is insufficient in quantity and/or quality to warrant a recommendation for general use as a treatment for chronic insomnia.

  • trazodone (a sedating antidepressant)
  • tiagabine (an anticonvulsant approved for the treatment of epilepsy and used off-label to treat anxiety and panic disorders)
  • diphenhydramine (the antihistamine found in most over-the-counter sleep aids, including ZzzQuil, Sominex, and Tylenol PM)
  • tryptophan (a supplement containing an amino acid found in milk and other sources of dietary protein)
  • melatonin (a supplement which is bio-identical to a hormone produced in the body, useful for jet lag and delayed sleep phase disorder)
  • valerian (a plant-based supplement)

If you’ve used any of these medications or supplements, how effective were they, and did you experience any side effects?

Insomnia: How Do You Score?

You may know you’ve got insomnia. But could you prove it?

Researchers use pencil-and-paper tests to assess different aspects of sleep: sleep quality, insomnia severity, sleep reactivity, and sleep-related beliefs. If you’re unfamiliar with these questionnaires, you may find it interesting to look at them and see how you score.

How do you score on tests given to people with insomniaYou may know you’ve got insomnia. But could you prove it?

There is no lab test for insomnia that would back you up.

An overnight sleep study, then?

Maybe—but probably not. Sleep studies don’t discriminate very well between insomniacs and good sleepers.

Genetic factors?

There may be genetic markers associated with insomnia, but researchers have no definitive understanding of what they are or how they add up to insomnia. The diagnosis of insomnia disorder is still made subjectively, based on questions and answers about sleep.

The list of questions doctors often ask to make the determination is fairly short and sweet.  But researchers use pencil-and-paper tests to assess different aspects of sleep: sleep quality, insomnia severity, sleep reactivity, and sleep-related beliefs. If you’re unfamiliar with these questionnaires, you may find it interesting to look at them and see how you score.

At the Doctor’s Office

If you take your complaints about sleep to the doctor, he or she may attempt to rule out other disorders before asking questions related to insomnia. You’ll get a diagnosis of insomnia disorder if

  • you have trouble falling or staying asleep, or sleep that doesn’t feel restorative, at least 3 times a week,
  • your sleep problem has persisted for at least 3 months, and
  • you experience impairment(s) during the daytime: moodiness, for example, or trouble concentrating or a lack of stamina that interferes with social, occupational, and other types of functioning.

Researchers, however, use pencil-and-paper assessment tools to evaluate subjects’ sleep and sleep improvements. Following are some of these questionnaires, downloadable as PDF files.

Pittsburgh Sleep Quality Index (PSQI)

In 1989 University of Pittsburgh sleep scientists introduced the PSQI in an attempt to quantify an aspect of sleep acknowledged to be important but difficult to measure.

The scoring of the PSQI questionnaire—with 19 self-rated questions—is a bit involved, but explicit scoring instructions are given at the end of the test. (Five more questions are to be answered by your bed partner or roommate if you have one. But these questions are not scored.) The 19 self-rated questions are divided into 7 “component” scores. The component scores are then added together to get the global score, which can range from 0 to 21. A global score of over 5 is indicative of poor sleep quality.

Sample question: During the past month, how often have you had trouble sleeping because you wake up in the middle of the night or early morning?

Insomnia Severity Index (ISI)

Some people experience insomnia occasionally while others experience it practically every night. The severity of a person’s insomnia may predict how likely he or she is to respond to various treatments. So it’s seen as a key variable to take into account when diagnosing insomnia and recommending a treatment, and when assessing improvements in study participants’ sleep.

Scores on this 7-item ISI questionnaire range from 0 to 28. Trouble sleeping is considered to be severe enough to warrant a diagnosis of insomnia disorder if scores are 8 or higher.

Sample question: How worried/distressed are you about your current sleep problem?

Ford Insomnia Response to Stress Test (FIRST)

The FIRST is the newest of the tests, introduced in 2004. This questionnaire is said to measure people’s overall level of “sleep reactivity,” a trait hypothesized to increase the likelihood of a person’s sleep being disturbed during stressful situations. The claim is that people who score higher on the FIRST are more likely to develop persistent insomnia.

FIRST scores range from 9 to 36. Scores of 20 and above indicate that stressful situations experienced prior to sleep—or the anticipation of stressful situations ahead—may routinely knock your sleep off track and make you vulnerable to chronic insomnia. Access this questionnaire by looking at Table 1 on the third page of this article about stress-related sleep disturbance.

Sample questions: How likely is it for you to have difficulty sleeping (a) after an argument? (b) before having to speak in public?

Dysfunctional Beliefs and Attitudes About Sleep Scale (DBAS)

If you don’t sleep well, you may find yourself having negative thoughts about sleep. Over time, these thoughts may coalesce into ideas, attitudes, and beliefs about sleep that give rise physiological arousal, making it harder TO sleep. In turn, the sensations of increased warmth, muscle tension, and faster heart rate that accompany arousal reinforce the negative thoughts, giving rise to a vicious circle.

The 16-item DBAS identifies misconceptions about sleep and assesses how big a role these and other cognitive factors likely play in perpetuating a person’s insomnia. A high score suggests that dysfunctional beliefs and attitudes may be a significant component of your insomnia, amenable to treatment with cognitive therapies.

Sample item: When I sleep poorly on one night, I know it will disturb my sleep schedule for the whole week.

If you’re curious enough to take any of these tests and end up learning something about your sleep, please take a moment to share it by leaving a comment. Thanks!

Going Off Sleeping Pills

Occasionally I hear from long-term users of sleeping pills who suspect the pills are doing more harm than good. Their sleep is not very satisfying and they don’t feel rested during the day.

Here’s why you might want to explore the idea of discontinuing sleeping pills and what to expect if you decide to do it.

Fear of insomnia can make some long-term users of sleeping pills afraid to stop themOccasionally I hear from long-term users of sleeping pills who suspect the pills are doing more harm than good. Their sleep is not very satisfying and they don’t feel rested during the day. They’re toying with the idea of going off sleeping pills but afraid that if they do, their insomnia will return worse than ever.

If these are your concerns, discuss them with your doctor or a sleep specialist. Stopping sleeping pills is a medical issue requiring assistance from a medical professional.

That said, here’s why you might want to explore the idea of discontinuing sleeping pills and what to expect if you decide to do it.

 

Why Consider Going Off Hypnotics?

Sleeping pills have their place. They can be a godsend on long transmeridian flights, after traumatic events, and for occasional situational insomnia. But there are several reasons to consider discontinuing a hypnotic if you’ve used it nightly for months and years.

The first is the one I’ve mentioned: it doesn’t feel like the pill is doing your sleep—or your energy levels—much good. Used long-term, many hypnotics tend to degrade sleep quality. You may be sleeping an acceptable number of hours, but your sleep isn’t as deep and refreshing as you’d like it to be.

Sleeping pills come with a number of health risks, too. Every hypnotic is different, so it’s hard to make generalizations about the harm they may do. But long-term use of many sleeping pills is associated with increased vulnerability to infections, depression, some cancers, and cognitive impairment. Some studies (but not all) suggest long-term users may have an increased risk of mortality.

Older adults are the group most likely to be using sleeping pills on a nightly basis. Yet as we age, our bodies process drugs more slowly. Older adults taking sleeping pills are at increased risk for daytime grogginess, car crashes, and falls.

Finally, concerns about drug tolerance (the need to take more of a drug to get the same effect) and drug dependency may make you uncomfortable enough to want to explore the idea of discontinuing your sleeping pills.

How Not to Kick the Habit

Researchers and clinicians agree: if you’ve used sleeping pills for a long time, it’s not wise to go cold turkey. Rebound insomnia (a temporary worsening of sleep) will likely occur, tempting you to start taking the pills again. In addition to rebound insomnia, you may suffer withdrawal symptoms: anxiety, restlessness, tremor, sweating, agitation, and even seizures. Weaning off sleeping pills gradually is a better strategy.

A Drug Tapering Regimen

This is where the doctor comes in. Knowing your medical history and the particulars of the sleeping pill you’re taking, he or she can plan with you what the best tapering strategy will be.

It’s going to depend on a number of things:

  • How long you’ve been taking the drug.
  • The half-life of the drug and the likelihood of withdrawal symptoms. Some drugs take longer to pass through your system than others. Withdrawal symptoms can occur within 1 to 2 days for sleeping pills with short half-lives and within 3 to 7 days for sleeping pills with longer half-lives. The taper can be planned accordingly.
  • The nightly dose you’re taking. “Providers should consider moderate reductions at higher doses and smaller reductions at lower doses to prevent excessive withdrawal symptoms,” writes Sarah T. Melton, Doctor of Pharmacy, in a paper for Medscape.com.

The taper should occur slowly and gradually. Two commonly recommended dose reduction schedules are these:

  • A 25% reduction of the dose every 2 weeks
  • A 25% reduction the first week, a 25% reduction the second week, and a 10% weekly reduction thereafter

But in difficult situations, drug tapers may take as long as 6 months. The schedule the doctor proposes has to feel comfortable to you, too.

Tapering off sleeping pills while going through cognitive behavioral therapy for insomnia (CBT-I) can greatly improve your chances of success with the taper and improve your sleep at the same time. For details, check out this blog post on CBT and stopping sleep meds.