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.

Transitioning to Menopause? Don’t Give Up on Sound Sleep

I often hear sleep complaints from women approaching menopause. Hot flashes and mood swings are other common complaints. What can be done to improve sleep and reduce perimenopausal symptoms?

The key, say authors of a review paper published this year, is to use a variety of approaches based on individual women’s symptoms, history and needs.

Insomnia and hot flashes can be relieved with multi-pronged treatmentI often hear sleep complaints from women approaching menopause. Hot flashes and mood swings are other common complaints. What can be done to improve sleep and reduce perimenopausal symptoms?

The key, say authors of a review paper published this year, is to use a variety of approaches based on individual women’s symptoms, history and needs.

Sleep Problems in the Menopausal Transition

The transition to menopause begins 4 to 6 years before menstruation stops (the median age for menopause is 51 years). It’s a time of fluctuating reproductive hormone levels. Not all women suffer ill effects during this period but many do.

Sleep problems are one of the most common complaints, reported by up to 56% of women approaching menopause, say authors of the review, published in the journal Nature and Science of Sleep. In turn, trouble sleeping often compromises midlife women’s quality of life, mood and productivity.

There’s an uptick in sleep-disordered breathing (sleep apnea) among women transitioning to menopause. There’s also an uptick in insomnia. A study involving 982 perimenopausal women interviewed by phone found that 26% had symptoms qualifying them for a diagnosis of insomnia disorder as medically defined.

Not Just in Our Heads

Fluctuating levels of hormones—follicle-stimulating hormone, estradiol (an estrogen) and progesterone—likely play a role in insomnia that occurs during the menopausal transition. Hot flashes, too, which typically emerge as estrogen levels decline, are associated with poorer reported sleep quality and chronic insomnia.

As for objective evidence of menopausal sleep problems, results of population studies of midlife women involving polysomnography (PSG) are inconsistent. But in a recent study published in Psychoneuroendocrinology, investigators found “stark differences in PSG measures in women with, relative to women without, insomnia disorder developed in the menopausal transition.”

Women who developed insomnia during the menopausal transition

  • had poorer sleep efficiency
  • experienced more wakefulness after sleep onset
  • had shorter total sleep time, with 50% sleeping less than 6 hours
  • were more likely to have hot flashes, which predicted their number of awakenings per hour of sleep.

A Role for Depression and Stress

Symptoms of depression typically increase during the menopausal transition. Depression and insomnia are closely linked, with depression sometimes preceding insomnia and insomnia sometimes leading to depression. The results of one interesting study suggest that trouble falling asleep at the beginning of the night is associated with anxiety while nonrestorative sleep is linked to depression.

Chronic exposure to stress could be another factor in midlife women’s greater susceptibility to insomnia. And during the transition to menopause, traits associated with insomnia—increased tendency toward rumination, anxiety, generalized hyperarousal, stress reactivity, and neuroticism—are similar to tendencies predictive of hot flashes and other perimenopausal symptoms.

Treatments for Insomnia in the Menopausal Transition

Since insomnia in the menopausal transition is likely due to many factors, it’s challenging to treat. The reviewers recommend “flexible and individualized” treatments for insomnia depending on each woman’s current symptoms and history.

Hormone Therapy

Hormone therapy generally improves sleep quality in women who experience hot flashes during the transition. It may be a good option if, based on a woman’s history and health concerns, the overall potential benefits outweigh the risks. The reviewers note that abrupt discontinuation of hormone therapy is associated with hot flash relapse, which could in turn lead to insomnia.

Non-Hormonal Pharmacological Therapies

Sleeping pills, which are generally prescribed for short-term or intermittent use, are not a front-line treatment for insomnia in perimenopausal women. Taken nightly over time, many sleeping pills degrade sleep quality and have other negative effects. Following are the medications the reviewers suggest considering for perimenopausal women with insomnia and hot flashes:

  • Low-dose selective serotonin reuptake inhibitors—such as citalopram (Celexa) and escitalopram (Lexapro)—and low-dose serotonin norepinephrine reuptake inhibitors—such as duloxetine (Cymbalta) and venlafaxine (Effexor XR). Note that discontinuation of SSRIs is associated with hot flash relapse, which could lead to insomnia.
  • Gabapentin, shown to improve sleep quality in perimenopausal women with hot flashes and insomnia.
Non-Pharmacological Therapies
  • Cognitive behavioral therapy for insomnia (CBT-I) is the overall gold standard in drug-free treatments for insomnia. In a randomized clinical trial recently conducted on peri- and postmenopausal women experiencing at least 2 hot flashes daily, women who underwent CBT-I “had significantly greater reduction in insomnia symptoms and greater improvements in self-reported sleep quality” compared with controls. The improvements were maintained at 6 months after treatment.
  • Soy isoflavones—phytoestrogens found mainly in legumes and beans—have been shown in randomized controlled trials to reduce menopausal symptoms, including self-reported sleep disturbance. They’re available as dietary supplements.
  • High-intensity exercise and yoga are reported by the reviewers to be modestly beneficial in reducing menopausal symptoms and improving sleep.

Because many factors can combine to disrupt sleep in the period leading up to menopause—sleep disorders, mood disorders, medical conditions, and life stressors—no one-size-fits-all treatment will improve sleep and minimize menopausal symptoms. Instead, the reviewers recommend a multi-pronged approach to treatment based on individual women’s needs.

Was My Insomnia Due to Lack of Light?

A daily routine and daily exposure to sunlight help regulate sleep. Research backs this up and I see it in myself. My best sleeps come after days when I get up and out and do the things I do at the usual time.

Last night my sleep went off the rails, and I’m convinced the problem was at least partly related to light. Let me explain.

Insomnia can develop with too little exposure to daylightA daily routine and daily exposure to sunlight help regulate sleep. Research backs this up and I see it in myself. My best sleeps come after days when I get up and out and do the things I do at the usual time.

Last night my sleep went off the rails, and I’m convinced the problem was at least partly related to light. Let me explain.

An Unusual Tiredness

My husband and I were viewing old slides last night, and around 9 p.m. I complained about how tired I was.

“Why?” he asked. Normally at 9 p.m. my evening has barely begun.

I couldn’t explain it. I’d gotten up at the regular time, had coffee, eaten regular meals. Worked in the morning, exercised late in the afternoon. Had a glass of wine before dinner and a decent night’s sleep the night before. Nothing that came to mind could explain how really bone tired I felt.

Staving Off Sleep

Even so, I didn’t go to bed right away. If I’ve learned anything about sleep, it’s that going to bed early can start people like me on a path to perdition. It can lead to:

  • Sleep onset insomnia, or trouble falling asleep at the beginning of the night
  • Sleep maintenance insomnia, or broken sleep with awakenings every hour or two
  • Early awakening insomnia, or waking up in the twos, threes, or fours and being unable to fall back to sleep

So tired though I was, I headed for my favorite easy chair, where I typically read for a couple hours until I’m sleepy enough to fall asleep. Then at some point I went to bed.

A Short Night—Or Was It?

The next thing I knew I woke up in the dark and it felt like morning. I hurried to turn off the alarm clock because my husband was going to sleep in. But when I looked at the time (my clock stays dark at night except when I press the button on top) I saw it wasn’t even close to 5:30, my normal wake-up time. It was only 2:15.

So I went back to bed. At the next awakening, I asked my husband what time it was and he whispered it was almost 5:30. I turned off the alarm.

Only it wasn’t 5:30, and I didn’t turn off the alarm, I later learned from my husband. That whispered exchange must have been a dream. Because when I went downstairs and turned on a light, the clock on the stove said 4 a.m.

What the heck?!

I’d thought my early awakening insomnia was a thing of the past. It was so far from normal now that I was determined to parse it out.

Reconstructing My Day

Two clues lay beside the easy chair where I sat down to read last night.

  • My book: It was open two pages beyond the bookmark, where I’d stopped reading the night before. Guess I didn’t read for very long!
  • Medicine I take every night to help with digestion: Two capsules lay on the desk beside the chair together with a full glass of water, untouched.

Obviously I’d fallen asleep in my chair way earlier than usual. But what had knocked me out so quickly and completely that I forgot to take my medicine? Read just two pages when normally I’d read for at least two hours?

Was Lack of Light the Culprit?

Suddenly it came to me. I had done something out of the ordinary in the middle of the afternoon. I went to a concert, where for two hours I sat under low light listening to Haydn string quartets.

That wasn’t all: the first violinist was super-animated as he played and kept swinging his feet up into the air. Every time those feet came off the ground I thought of a plane taking off, and that image juxtaposed onto the Haydn was jarring. I decided to close my eyes—and kept them closed for the rest of the concert.

So for two hours in the afternoon, at a time when my brain would normally be exposed to light, I sat in near-total darkness. That, added to our half-hour session viewing slides in a dark living room, might have affected my body clock, causing sleepiness to occur earlier than usual and early morning wake-ups.

Bright Light Exposure: Rules to Live By

As ubiquitous as it is, light might not seem like it would have much impact on sleep. But it does. People contending with circadian rhythm disorders have to pay special attention to light, and light or a lack thereof may figure in insomnia, too. Keep these things in mind:

  • Lack of sufficient light exposure during the daytime tends to have a negative effect on sleep duration and sleep quality. Get exposure to sunlight every day by spending time outside or inside near a window.
  • Exposure to bright light early in the morning will help you fall asleep earlier.
  • Exposure to bright light in the evening tends to delay the onset of sleep.

 

Stay Healthy Over the Holidays Despite Insomnia

When my family gathers for a few days over the holidays, usually someone brings along a sore throat or a cough. Try though that unlucky person may to keep the germs from spreading, they almost inevitably do.

I catch colds fairly easily, and I’ve often wondered if insomnia has a part in that. A new study suggests that chronic insomnia does—at a minimum—increase our susceptibility to influenza. Here’s more about the study and precautions poor sleepers can take to stay healthy over the holidays.

Insomnia compromises immunityWhen my family gathers for a few days over the holidays, usually someone brings along a sore throat or a cough. Try though that unlucky person may to keep the germs from spreading, they almost inevitably do.

I catch colds fairly easily, and I’ve often wondered if insomnia has a part in that. A new study suggests that chronic insomnia does—at a minimum—increase our susceptibility to influenza. Here’s more about the study and precautions poor sleepers can take to stay healthy over the holidays.

Sleep and the Immune System

A robust immune system confers protection from colds and flu. In order to stay robust, the immune system needs ongoing attention, and it’s during sleep when the body’s metabolic resources are freed up to do this maintenance work. During sleep antibodies are created to fight invading viruses. Short sleepers develop fewer antibodies, past research has shown, and this puts them at higher risk for developing infections.

Insomnia Compromises Immunity

Chronic insomnia—trouble sleeping and daytime impairment—may also compromise the immune system, according to new research published in Behavioral Sleep Medicine. Participants in this study were 133 healthy college students, half meeting diagnostic criteria for insomnia and the other half experiencing no insomnia.

Via blood draws, the students’ influenza antibody levels were assessed twice: once before, and once 4 weeks after, they received flu shots (containing influenza vaccine). The expectation was that 4 weeks after receiving the flu shots, participants in the Insomnia group would have lower levels of influenza antibodies than participants in the No Insomnia group.

What the researchers found was telling. Both groups showed increases in antibody levels from pre- to postvaccine. But not only did the Insomnia group have lower antibody levels than the No Insomnia group 4 weeks after receiving the flu shots. The Insomnia group also had lower antibody levels to begin with.

Researchers can only speculate about why. But the result lends support to something I’ve thought (and sleep researchers have suspected) for a long while: chronic insomnia dysregulates the immune system, making insomniacs less able to fight off colds and flu.

Recipe for a Healthy Holiday Season

So if you’ve got persistent insomnia it’s wise to take extra precautions around the holidays. Here are suggestions for how to avoid colds and flu:

If you’re traveling: People with insomnia are said to sleep better away from home. Not me—I’m susceptible to sleep onset insomnia wherever I go. If you’re going away for the holidays, pack along all the accoutrements you need for a comfortable night’s sleep at home: ear plugs, eye mask, pillows, white noise machine, etc. I take a foam rubber futon for use in case the sleeping accommodations aren’t quite right.

Travel by plane: Airplanes are virus magnets. Pack along a couple face masks for use if nearby passengers are coughing or sneezing. Use antibacterial wipes on seatbelt buckles, tray tables, overhead air vents, and bathroom fixtures before touching them.

Avoid airborne viruses: Viruses are mostly spread through the air via coughing and sneezing and then inhaled. Steer clear of Uncle Dalbert if he has the bad manners to come down to Happy Hour hacking away. A hug for a sister who’s obviously contagious can wait for another day.

Hard surfaces that harbor viruses: Touching doorknobs, light switches, faucets and then absentmindedly touching your face is another way infection spreads. To lower your risk of infection, wash your hands with soap and water frequently (take along hand cream so your hands don’t dry out). Better yet, avoid use of your hands altogether. To open doors and turn on lights and faucets, use your arms instead. (It’s amazing what dexterous forearms and elbows I’ve developed since I set my mind to it.)

Pass on communal towels: Avoid sharing them—or give the sick one a towel of their own.

Passing dishes at the table: Leave the sick one out of the loop.

When you’re out and about: Carry a small bottle of hand sanitizer in your pocket or purse and use it often, especially after handling money, signing for credit card purchases, and pumping gas.

A final suggestion: I have a brother who swears that daily nasal irrigation (with dilute salt water or a commercial sinus rinse) keeps him from coming down with colds. I don’t have enough discipline to incorporate this habit into my daily ablutions. But I use a sinus rinse when I’m bothered by allergies or feel a sinus infection coming on, and it helps.

Got any tips for staying healthy during flu season? Please share them in a comment below!

The To-Do List: A Sleep-Friendly Bedtime Activity?

If you’ve got insomnia, you’ve probably heard of “worry lists.” Sleep doctors for years have been urging insomniacs to write our worries down before going to bed, claiming this will alleviate anxiety and sleep will come more easily.

Really? Write about looming deadlines and all the upcoming functions I have to prepare for before I go to bed? That’s sure to send my anxiety through the roof! (not to mention keeping me up for hours).

But the idea may not be as counterproductive as it sounds.

Insomnia because you're worried about tomorrow? Make a to-do-list in the eveningIf you’ve got insomnia, you’ve probably heard of “worry lists.” Sleep doctors for years have been urging insomniacs to write our worries down before going to bed, claiming this will relieve anxiety and sleep will come more easily.

Really? Write about looming deadlines and all the upcoming functions I have to prepare for before I go to bed? That’s sure to send my anxiety through the roof! (not to mention keeping me up for hours).

But the idea may not be as counterproductive as it sounds, a new study suggests.

Nighttime Challenges for Insomniacs

No one likes arguments or bad days at work, but experiences like these can be doubly disruptive for people with insomnia. At night these upsetting events cycle over and over in your head, making it hard—sometimes impossible—to sleep.

Likewise, it can be hard to sleep when you’re looking at challenges ahead. Tests to study for, deadlines to meet, presentations to deliver, events to organize, flights to catch—any unfinished business, especially lots of it, can keep you wakeful long into the night.

Could making a to-do list before going to bed relieve anxiety about tasks ahead and enable sleep to come more quickly? The jury is still out concerning insomnia sufferers per se. But a new study of healthy, normal sleepers conducted at Baylor University and Emory University Medical School suggests it might be helpful.

Polysomnography and a Pencil-and-Paper Task

This study—the first part of a larger study—was simple in design. Participants were recruited on campus and screened for various disorders, including sleep disorders. Sixty participants aged 18–30 were chosen (three were later disqualified). They were randomly divided into two groups.

The evening of the study, participants in both groups went to a sleep lab, where technicians prepared them to undergo an overnight sleep study, wiring them up for polysomnography.

After that, participants in one group were given a sheet of paper and told to spend the next five minutes writing down everything they had to do the next day and in the next few days. Participants in the other group were given a sheet of paper and told to spend five minutes writing down everything they’d accomplished that day and in the past few days.

The sheets were then collected. Lights went out at 10:30 p.m., and participants’ cerebral activity was monitored through the night.

To-Do List More Helpful Than List of Accomplishments

The results were all significant:

  • Participants who made a to-do list at bedtime fell asleep faster than those who wrote about completed tasks. (On average, the to-do list makers fell asleep in about 16 minutes while the others who listed accomplishments fell asleep in about 25 minutes.)
  • Among participants who made the to-do list, the greater the number of items on their list, the faster they fell asleep.

So making a detailed to-do list might actually be a good activity to add to your wind-down routine at night.

Results in Perspective

Other studies suggest these findings aren’t as unusual as they may seem. Researchers studying adults in highly stressful situations, such as having a son or daughter diagnosed with cancer, found that the more specifically parents could map out concrete steps they were going to take to contend with the child’s problem, the less stressed out they felt. Another study showed that first-time pregnant women who could simulate in detail how their labor would go were less worried than women that were less successful in simulating labor.

But back to doctors’ advice about worry lists: It seems to me there’s a difference between a worry list and a to-do list. The one sounds problem focused while the other is focused on solutions—which may make a difference in their effects.

At any rate, if you have insomnia and at night your mind is constantly drifting toward tomorrow and all the things you have to do, try writing down the steps you’re going to take to make things happen before you get in bed. It might relieve your anxiety and slow your busy brain just enough to hasten sleep.

New Sleep Book Is a Fascinating Read

Matthew Walker, author of the new book Why We Sleep, is on a mission. Elucidating the many benefits of sleep, he’s out to persuade us that the key to health, attainment, and longevity lies in 8 hours of shut-eye every night.

Use of the familiar 8-hour yardstick as a measure of sleep need may give insomnia sufferers pause. We’d be happy to sleep 8 hours a night . . . if only we could.

Don’t let Walker’s prescriptiveness stand in the way of reading his book. Its appeal rests on the author’s account of discoveries relating to the wonderful things sleep does for us—which should be of interest to us all.

Matthew Walker's new book examines why we sleep and dreamMatthew Walker, author of the new book Why We Sleep, is on a mission. Elucidating the many benefits of sleep, he’s out to persuade us that the key to health, attainment, and longevity lies in 8 hours of shut-eye every night.

Use of the familiar 8-hour yardstick as a measure of sleep need may give insomnia sufferers pause. We’d be happy to sleep 8 hours a night . . . if only we could.

Don’t let Walker’s prescriptiveness stand in the way of reading his book. Its appeal rests on the author’s account of discoveries relating to the wonderful things sleep does for us—which should be of interest to us all.

A Sleep Scientist Writes for a Lay Audience

I’ve been following Walker, a professor of neuroscience and psychology at U.C. Berkeley and director of the Center for Human Sleep, for years. He’s done important research on the effects of sleep and sleep deprivation on learning, memory, and emotional memory processing.

With Why We Sleep: Unlocking the Power of Sleep and Dreams, Walker steps outside the world of academia to engage with the general public. That’s a point in his favor, in my book, because research scientists who endeavor to write for a lay audience don’t have much to gain from it personally. No kudos from colleagues, no burnishing of the CV.

Yet now could not be a better time for scientists like Walker to translate their research into terms we can all understand. And it quickly becomes clear that Walker is bent on doing this out of a passionate conviction that as members of a 24/7 culture, many of us are suffering from sleep deprivation.

Knitting Up “the Ravelled Sleave of Care”

For decades scientists have been searching for an answer to the question of why we sleep. It turns out there’s not just one but rather many reasons.

“We sleep for a rich litany of functions,” Walker writes, “an abundant constellation of nighttime benefits that service both our brains and our bodies.”

What are some of the functions sleep performs? It

  • improves our ability to learn, memorize, make logical decisions and choices
  • strips negative experiences of their emotional charge, improving our mood and sense of balance
  • enhances creativity
  • shores up the immune system
  • regulates appetite and gut health
  • lowers blood pressure and maintains heart health

Says Walker, with all the benefits sleep affords living organisms and how damaging the state of wakefulness can be, perhaps the real question is this: Why did life ever bother to wake up?

Diving Into the Research

Why We Sleep has four parts. In part 1 we learn about the basics of sleep. Parts 2 and 3 contain accounts of recent discoveries relating to the functions of sleep and dreams, which Walker presents together with personal anecdotes and easy-to-grasp analogies.

One discovery pertains to the question of why sleep deprivation makes us emotionally reactive and why a good night’s sleep sets us back on an even keel. Walker and others found the answer in the prefrontal cortex—the seat of rational thought that rests just above the eyeballs—and the amygdala, the emotion center deep in the brain. It could only be seen with the help of brain scanning technology.

“After a full night of sleep,” Walker writes, “the prefrontal cortex . . . was strongly coupled to the amygdala, regulating this deep emotional brain center with inhibitory control. . . . Without sleep, however, the strong coupling between these two brain regions is lost. We cannot rein in our atavistic impulses—too much emotional gas pedal (amygdala) and not enough regulatory brake (prefrontal cortex). Without the rational control given to us each night by sleep, we’re not on a neurological—and hence emotional—even keel.”

Caveat for People With Insomnia

Walker’s target audience is the multitude of healthy, normal sleepers who, out of necessity or by choice, do not alot 8 hours of the day to sleep. Insufficient sleep can have dire consequences: microsleeps while driving, often deadly; poor decision making; increased susceptibility to a host of health conditions and illnesses, including depression, stroke, dementia, cancer, diabetes, heart attacks. By dwelling on the alarming results of sleep deprivation studies, Walker means to wake us up to the dangers of “just getting by” on 5 or 6 hours a night.

But what if we’re willing to set aside 8 hours a day for sleep—and regularly do—but all we can sleep is 5 or 6? Lying in bed for 8 hours when we’re only sleeping 5 or 6 is precisely what insomnia sufferers should not do, because this only serves to perpetuate our insomnia.

Keep These Things in Mind

  1. The sleep deprivation literature Walker refers to throughout the book is based on studies of healthy, normal sleepers whose sleep need is presumably in the 7- to 8-hour range. On a steady diet of anything less, they experience sleep deprivation.
  2. The sleep needs of people who want to sleep more but can’t may be different from the needs of those who can sleep but do not sleep their fill.

While Walker’s book contains a short section on insomnia in part 4, Why We Sleep is not the go-to resource if you’re looking for help with insomnia. But it’s an excellent resource if you want to learn about sleep and the benefits it bestows.

Early Treatment of Insomnia May Improve Mental Health

Insomnia and mental health problems go hand in hand. It’s firmly established now that insomnia can be a causal factor in depression and that treatment for insomnia can improve both sleep and mood.

A new study shows that insomnia may also be a causal factor in psychotic experiences such as paranoia and hallucinations, and that CBT for insomnia (CBT-I) may lead to better mental health. Here’s a quick look at the research and what it suggests for us.

Web-based cognitive behavioral therapy for insomnia improves sleep & moodInsomnia and mental health problems go hand in hand. It’s firmly established now that insomnia can be a causal factor in depression and that treatment for insomnia can improve both sleep and mood.

A new study shows that insomnia may also be a causal factor in psychotic experiences such as paranoia and hallucinations, and that CBT for insomnia (CBT-I) may lead to better mental health. Here’s a quick look at the research and what it suggests for us.

Sleep and Mood: An Intimate Relationship

People with mood disorders and other mental health problems often experience insomnia. Until recently their trouble sleeping was viewed as a symptom or a consequence of the mental health problem. Successful treatment of that problem would take care of the insomnia, too—or so they thought.

Then along came research that upset the apple cart. It showed that insomnia was sometimes a causal factor in depression, and that treatment with CBT for insomnia (CBT-I) helped to resolve both problems better than treatment for depression alone. This led to a related question: could other psychiatric symptoms linked with insomnia—paranoia, hallucinations, anxiety, mania—be triggered in part by insomnia and could treatment with CBT-I head off their development?

A Large-Scale Study

Paranoia and hallucinations have strong links to insomnia. Researchers in the UK recruited 3,755 university students with insomnia from 26 different college campuses to see if treating their insomnia with CBT-I would lessen their risk of experiencing these psychotic symptoms.

Randomly the researchers divided student participants into two equal groups. One served as a control group. Students in the other group participated in an individualized online insomnia treatment program called Sleepio.

Similar to other research-based online insomnia treatments (SHUTi and CBT for Insomnia, for example), Sleepio is a 6-week program that delivers CBT-I over the internet. It includes behavioral components such as sleep restriction and stimulus control; cognitive components that challenge unhelpful beliefs; and education about sleep and sleep hygiene.

Student participants in both groups also took a battery of pencil and paper tests at four different times during the 6-month study period to assess the severity of their insomnia symptoms and the state of their mental health. Statistical analysis of the data included looking at whether reductions in insomnia symptoms correlated with better mental health outcomes.

Insomnia Treatment Improves Sleep, Reduces Psychotic Symptoms

Here are the main results, all statistically signficant. Compared with participants in the control group, participants who underwent the Sleepio treatment ended the program with

  • greatly improved sleep
  • fewer experiences of paranoia and hallucinations

The Take-Away

The results of this relatively large study led to the following claims:

  1. Online insomnia treatment programs like Sleepio work for university-age students with trouble sleeping. They’re inexpensive and can be accessed at home.
  2. While insomnia might not be the principal cause of psychotic experiences, it may well be a contributing cause.
  3. CBT-I may have promise as an early intervention for some psychiatric problems.

Caveats for the Sleepless Whether or Not Mental Health Is an Issue

CBT-I, for all its effectiveness, involves commitment to a weeks-long process and the discipline to follow a rigorous set of guidelines. In this study there was a 50% drop-out rate among participants assigned to the Sleepio program—higher than the dropout rate for the control group. Feeling sleep deprived and lacking stamina, some insomniacs may be unsuccessful at completing a CBT-I program in the absence of face-to-face coaching and encouragement from a trained sleep therapist.

But 50% of the participants stuck with the Sleepio program long enough to reap sleep benefits. This success rate is comparable to that found in research on other web-based insomnia treatment programs.

Our options do not stop with online treatment programs. I’ve found it’s also possible to improve sleep by following instructions in books about CBT-I (see, for example, The Insomnia Workbook by Stephanie Silberman, The Insomnia Answer by Paul Glovinsky and Arthur Spielman, or chapter 8 of my book, The Savvy Insomniac). I myself used CBT-I to improve my sleep after reading a training guide for sleep therapists (Cognitive Behavioral Treatment of Insomnia: A Session-by-Session Guide by Michael Perlis and colleagues).

Regardless of how it’s accessed, CBT-I remains our best defense against sleepless nights and draggy days—and it may also preserve our mental health and well-being.

If you’ve tried CBT-I, how did you access treatment and how useful was it in helping to improve your sleep?

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!)