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.

New Technology May Help Insomniacs Sleep

I don’t often write about technology developed to improve sleep. I’m frankly skeptical that most products could help me any more than the daily exercise I do and the habits I changed after going through CBT for insomnia.

But a few items have caught my attention recently because they sound like they have genuine potential to help—two I’ve blogged about before and one brand new. See if you agree.

Trouble sleeping alleviated with new devices and an appI don’t often write about technology developed to improve sleep. I’m frankly skeptical that most products (e.g., sleep trackers) could help me any more than the daily exercise I do and the habits I changed after going through CBT for insomnia.

But a few items have caught my attention recently because they sound like they have genuine potential to help—two I’ve blogged about before and one brand new. See if you agree.

High-Tech Earplugs

QuietOn Sleep earplugs were designed specifically to block out noises such as snoring and the droning of plane engines.

Earplugs—these or any others—may not interest you if you’re a homebody and/or you share a bed with a quiet sleeper. But if your sleep is often disturbed by a snoring partner or unpleasant, droning noises, these earplugs could be a real boon.

How They Work

QuietOn earplugs contain a microphone that continually samples sound in the environment. They then create a phase-shifted sound that’s played through a speaker, cancelling the exterior noise out. The earplugs are battery powered and come with a carrying case that functions as a charger.

You might not imagine all this technology could fit inside a gadget so small. Apparently, it does. Twenty-one of these earplugs can fit on a single credit card. Encased in soft material, they fit inside the ear canal, neither big enough to hurt you nor small enough to pop out.

The one downside is the price. While limited numbers are available via an Indiegogo campaign at $149 a pair (2 pairs for $199), the full price after product launch will be $239.

A Brain-Calming Headband

At last Ebb Therapeutics has come out with its novel insomnia therapy device, a headband that cools—and so calms—busy brains at night. Here’s why it might improve your sleep.

The brains of normal sleepers are quiet during sleep but insomniac brains are not. In neuroimaging studies, scientists have found evidence of excessive metabolic activity occurring in our brains at night. Some of it occurs in the frontal cortex, located behind the forehead. By cooling the forehead, Ebb Insomnia Therapy reduces activity in the front part of the brain and in turn makes it easier to fall asleep.

How It Works

The headband has a special pad that rests against the forehead. This pad is continuously supplied with cooling fluid via a tube connecting the headband to a temperature regulator that sits on your bedside table.

The circulating fluid eventually evaporates and, after about three months, the temperature regulator alerts you to the fact that the fluid cartridge needs to be replaced. The replacement kit contains a forehead pad and a fluid cartridge.

How and Where to Get One

You need a prescription to get one; they’re not sold over the counter. However, Ebb Therapeutics, planning to market the devices widely, says they’re now available at sleep centers in these cities:

  • Atlanta, GA
  • Clayton, NC
  • Fargo, ND
  • Newark, DE
  • Pittsburgh, PA
  • Raleigh, NC
  • Rehobeth Beach, DE
  • St. Louis, MO
  • St. Petersburg, FL
  • Wilmington, DE
  • Wilson, NC

For a review of how this device may improve sleep and the tests that went into its development, see my earlier post on Ebb Insomnia Therapy. Contact the company directly to find out how much the device (and replacement kit) costs.

A Sleep Training Smartphone App

You might not think sleep could improve with training. Michael Schwartz thinks otherwise, based on years of work as a sleep technologist and sleep educator. He’s developed an inexpensive smartphone app called Sleep On Cue that can help people fall asleep and fall back to sleep more quickly.

The idea behind the app is this: Chronic insomnia often gives rise to anxiety about sleep, lack of confidence in sleep ability, negative beliefs about sleep, and increased brain activity at night. So it’s easy to lose touch with the feeling of falling asleep. The app essentially retrains you to recognize what falling asleep feels like, alleviating anxiety about sleep and restoring your confidence in your sleep ability.

How the App Works

You conduct your sleep training sessions late in the afternoon or early in the evening after a poor night’s sleep. Lie in bed holding your smartphone. Via a simple call-and-response procedure involving soft tones and movement, the app detects when you’re falling asleep (although you may not).

To the question “Do you think you fell asleep?” you press “yes” or “no.” Then, you leave the bed a few minutes, awaiting the next sleep trial. When you decide to end your session, your phone displays a graph with feedback about your sleep ability and your awareness of your sleep. Gradually you get better at recognizing the feeling of falling asleep.

For details about the procedure and the testing behind it, see my earlier post about Sleep On Cue or go directly to the product website.

Tips for Stressed-Out Caregivers Seeking Better Sleep

Occasionally I get emails from people with take-charge, type A personalities wondering what to do about insomnia. Full of self-reliance, they’ve often scoured the internet for remedies—and tried every one—or amassed a mountain of books about sleep—and read them all—to little avail. Can I suggest anything that might help?

Here is Geri’s story (abbreviated to save space) and my response.

Insomnia can be relieved by focusing on stress reduction and self-careOccasionally I get emails from people with take-charge, type A personalities wondering what to do about insomnia. Full of self-reliance, they’ve often scoured the internet for remedies—and tried every one—or amassed a mountain of books about sleep—and read them all—to little avail. Can I suggest anything that might help?

Here is Geri’s story (abbreviated to save space) and my response.

A Caregiver’s Hectic Life

I have had insomnia since 2005. I have four children (13, 10, 9 and 7) and at time of onset only had one. Triggered by changing jobs and trying to get pregnant—so stressful! I am a community mental health nurse. I have a caseload of 22 adults with psychosis and am their primary support. . . . [At night] it can take 2 hours for me to fall asleep and then I usually wake between 12 and 2 a.m. I do not go back to sleep. . . . I am naturally an over thinker, I do stress easily and worry a lot. . . . I’ve never been a great sleeper but yes I used to sleep. We are struggling financially so not working is not an option. . . . I have a library of books on sleep, have spent hundreds of pounds on various remedies and treatments—but alas nothing really seems to help. Can you suggest anything?

Geri had a lot on her plate. She was on the go all the time, caring for patients during the workday and children at night. Her busy schedule didn’t leave much time for self-care.

She knew what she needed: fewer responsibilities. If she won the lottery, she said, she’d resign from nursing, fix up her house, and be the mother and relaxed partner she’d like to be. But that was not in the cards.

Adding Things In, Cutting Things Out

Despite her time constraints, Geri was resourceful in looking for insomnia remedies. She’d also established some habits conducive to sound sleep: eating healthy foods, getting plenty of exercise by cycling to and from work and her patients’ homes, and practicing mindfulness.

But she’d also tried a raft of insomnia remedies that didn’t seem to help, from herbs and homeopathic insomnia cures to acupuncture and CDs with “odd sleep-inducing sounds.” When Geri wrote to me, she was planning to ramp up her efforts to improve her sleep by:

  • Adding high-intensity interval training to the cycling she did everyday (though it was a struggle to find the energy for this activity)
  • Cutting out alcohol completely (which, in times of desperation, she used to get to sleep)
  • Cutting out processed sugar, including the “crap biscuits” (cookies) she was prone to eat when super tired

What did I think?

Regimentation, Stress and Sleep

My immediate reaction on reading Geri’s story was that I could never do half of what she does and expect to sleep consistently well. With so many responsibilities I’d be popping Valiums every day!

Seriously, though, Geri’s sleep problem may have been related to chronic stress and the double duty she was doing as caregiver for her patients and her children (i.e., caregiver stress). Even so, her inclination was not to find ways to make her responsibilities more manageable. It was to do still more, adding high-intensity interval training to an already busy schedule and restricting an already healthy diet still further.

I wondered if the restrictive regimen she was about to impose upon herself would sooner or later become yet another source of stress. It’s true that exercise is beneficial to sleep. But nowhere has it been suggested that a person should have to cycle to and from work and do high-intensity interval training to get better sleep.

Dietary Choices and Sleep

It’s also true that what we eat can affect our sleep. But having a cookie now and then is probably not going to make a difference. There’s a lot of information now suggesting that overindulgence in simple carbohydrates is harmful to health. We shouldn’t routinely have Hostess cupcakes washed down with Pepsi for lunch. But cut out sugar completely? I follow the literature on insomnia and sleep pretty closely, and not one study I’ve seen has shown that cutting sugar out altogether from our diets will improve sleep.

Likewise, it’s smart to avoid using alcohol for sleep. But a glass of wine at happy hour is probably not going to have much impact on the night at all. It sounds punitive for Geri to try to regiment her life still more than it already is.

Reduce Stress With Better Self-Care

It could be that Geri would benefit from consulting a sleep doctor or a sleep therapist and that cognitive behavioral therapy for insomnia, administered by a trained professional, might help. A sleep study might uncover an underlying sleep disorder (or show she was getting more sleep than she thought).

But I think Geri’s sleep would improve if she were to reduce her stress by engaging in more nurturing self-care. She’s got a head start on some of the ways to do this but other readers may not:

  • Take half an hour a day for yourself and do something purely for pleasure (gardening, reading a novel, playing the piano)
  • Learn and use stress reduction techniques such as meditation, yoga, or Tai Chi.
  • Stay current with your own healthcare needs.
  • Eat regular, healthy meals.
  • Exercise daily.
  • Take time off when you can.
  • Maintain ties with friends and supportive family members, and when possible seek and accept their support.
  • Seek counseling when you need it or reach out to friends

If you’re a full-time caregiver, what’s the best way you’ve found to take care of yourself?

Exercise Improves Sleep, Preserves Mental Fitness

You may have been a couch potato for most of your life, but now, if you’re middle-aged and envisioning a healthy retirement, you’d better change your ways.

Moderate-to-vigorous exercise can mitigate some effects of aging, including poor sleep quality and cognitive decline. Research generally supports this claim, so especially if you’re prone to insomnia, you’ll want to check this out.

Insomnia and mental decline can be alleviated with exercise
Me, returning from my first bike ride this year

You may have been a couch potato for most of your life, but now, if you’re middle-aged and envisioning a healthy retirement, you’d better change your ways.

Moderate-to-vigorous exercise can mitigate some effects of aging, including poor sleep quality and cognitive decline. Research generally supports this claim, so especially if you’re prone to insomnia, you’ll want to check this out.

Age-Related Sleep Problems and Exercise

Sleep tends to be less robust as we age. Middle-aged and older adults get less deep sleep (the restorative stuff) than younger people. Our sleep is less efficient, too, peppered with wake-ups during the night. In the morning, we wake up feeling less rested, with fewer resources to meet the demands of the day.

Investigators are now looking at lifestyle factors that might alleviate aged-related sleep problems. A majority of studies suggest that both male and female exercisers tend to experience better sleep quality and fall asleep more quickly than people who don’t exercise.

Newer Data From Objective Tests

The majority of such studies are based on reports from participants rather than objective tests. In two more recent studies, investigators used objective measures to assess the relationship between participants’ level of physical activity and their sleep.

The SWAN Sleep Study was an observational study involving 339 middle-aged women. Over 6 years, investigators collected data on their activity level in three domains: (1) Active Living (activities like watching TV and walking to work), (2) Household/Caregiving (housework and childcare), and (3) Sports/Exercise (recreational activities and sports).

Toward the end of the 6-year period, the women underwent in-home polysomnography (a sleep study) every night during one entire menstrual cycle or 35 days, whichever was shorter. They also kept sleep diaries and filled out sleep-related questionnaires.

Altogether this made for a lot of data on a lot of women. The findings reported here are both significant and clinically important:

  • Activities in the Active Living and Household/Caregiving categories had little impact on women’s sleep. Women typically spend a lot of time doing these activities, yet they may not be vigorous enough to affect our sleep.
  • Women with high Sports/Exercise activity over the 6-year period experienced better sleep, especially on measures of sleep quality and sleep continuity.
  • Greater recent Sports/Exercise activity was associated with better sleep quality and better sleep continuity—and more deep sleep (insomnia sufferers, take note!).

What About Men?

Routine exercise has similar benefits for men, a small exercise intervention study showed. Via polysomnography, the sleep of 13 men aged 60 to 67 was assessed 3 nights before and 3 nights after they participated in a 16-week exercise program. The program consisted of regular 60-minute workouts on the treadmill. The workouts were fairly rigorous and the results, impressive. Compared with their sleep before starting the exercise program, by the end of the program the men’s sleep

  • had significantly greater continuity. Acute exercise reduced their nighttime wakefulness by 30%.
  • was significantly deeper. On nights following exercise, they experienced a 71% increase in slow-wave (deep) sleep. (That 71% is not a typo, by the way!)

Exercise Protects Mental Fitness

If the sleep benefits of exercise don’t move you to action, maybe the high cost of inactivity to your brain will. Regular exercise helps improve cognitive function and protects against cognitive decline. How it does so has yet to be worked out, but one theory holds that exercise has a beneficial effect on the brain due to its positive effect on cerebral blood flow. For optimal functioning the brain has to have adequate blood flow. Moderate-intensity exercise increases blood flow to the brain in healthy adults.

But blood vessels may lose their ability to respond normally in the brain and elsewhere, a situation called vascular dysfunction, which is associated with cardiovascular disease. Systemic vascular dysfunction will likely reduce blood flow to the brain and manifest as cognitive impairment.

“Vascular dysfunction and altered blood flow regulation may be a key link between cardiovascular disease and cognitive decline,” writes Jill N. Barnes in a paper titled Exercise, Cognitive Function, and Aging.

Protecting vascular health—which typically declines with age—may also protect against cognitive decline. Barnes cites a few studies that suggest that exercise is the key to protecting vascular functioning. A few other human studies show that both aerobic exercise and strength training help maintain cognitive fitness. In addition, animal studies have shown that sustained aerobic exercise promotes the growth of new nerve cells in the hippocampus, a part of the brain associated with memory.

So particularly if you’re middle aged or older and prone to inactivity, check into starting an exercise program now. It will improve your physical and mental health and—perhaps more relevant if you’re looking for help with insomnia—it will likely improve your sleep.

Tips for Relieving Stress and Improving Sleep

Do stressful situations throw your sleep off track? You’d probably score high in sleep reactivity, a stable trait associated with insomnia. If a rough day at work kept you tossing and turning last night, then similarly charged situations—arguing with your spouse, getting bad news, preparing to speak in public—may disrupt your sleep now and then.

But what if the stress is chronic? Then it’s time to deal with it head on. Here are four ways to reduce stress and improve sleep.

Stress-related Insomnia can be alleviated with social supportDo stressful situations throw your sleep off track? You’d probably score high in sleep reactivity, a stable trait associated with insomnia. If a rough day at work kept you tossing and turning last night, then similarly charged situations—arguing with your spouse, getting bad news, preparing to speak in public—may disrupt your sleep now and then.

But what if the stress is chronic? Then it’s time to deal with it head on. Here are four ways to reduce stress and improve sleep.

Have a Physical Outlet for Stress

Persistent activation of the stress-response system results in higher-than-normal levels of cortisol and other stress hormones, all harmful to long-term health. Not only does this increase your susceptibility to chronic insomnia, but it also suppresses your immune system and elevates your risk of hypertension, heart disease, and depression. It interferes with learning and memory as well.

Exercise—jogging, swimming, bicycling, playing tennis—protects against development of stress-related disease. Immediately following a workout there’s a decrease in muscle tension and a release of body heat, which can hasten sleep onset and enhance sleep quality. Exercise can also help to elevate mood. Long-term, regular exercise tends to lower the resting heart rate, making it easier to relax.

But to maximize stress relief, choose a form of exercise you enjoy (or at least find tolerable). Regularity in the timing of workouts, like regularity in the timing of meals, is also conducive to regular sleep. Continuing practice of yoga and meditation can yield similar results.

Reach Out to Friends

Feeling overextended and stressed out can be isolating. Your instinct may be to cut people and relationships out of your life as you move full speed ahead on whatever you need to accomplish.

But having an active social support system is another key way to reduce chronic stress. Research suggests that regardless of who’s doing the talking and who’s doing the listening, interactions with friends and supportive family members help cut down on chronic stress. Participating in group activities can also help with stress relief.

Increase Your Sense of Control When Possible

Some situations are beyond control—diseases that have no cure, job losses due to economic factors, deaths that cannot be prevented. Trying to take control of these situations will likely send your stress off the charts.

But there are situations where exerting more control affords stress relief. For instance, if you’ve got too much on your plate, separate tasks into “musts” and “shoulds” and prioritize them accordingly. To nonessential tasks just say no.

And say no when someone else tries to foist on you a responsibility you cannot fit in. You’ve watched the grandkids for the past three days—now it’s someone else’s turn.

Yes, browsing the internet for the latest political news can be invigorating. But if it tends to work you up too much, vow to tear yourself away from the iPad by 8 p.m.

Increase Predictability

No one likes monotony. Yet a degree of predictability in life tends to lower stress. Says neuroendocrinologist Robert Sapolsky, “When it comes to what makes for psychological stress, a lack of predictability and control are at the top of the list of things you want to avoid.”

If your boss is liable to throw projects your way at any time, including 3 p.m. on Friday, muster up some negotiating skills and request advance notice. If late night phone calls tend to stress you out, ask friends and family to refrain from calling after 9 p.m. If you’re having trouble making ends meet, work up a monthly budget.

The more predictable life is, the better able you will be to plan coping strategies, which will make for better stress resilience and better sleep.

What activity or strategy do you find is most helpful in lowering stress?

2017: Resolve to Improve Your Sleep

Do you have a persistent sleep problem? Make cognitive behavioral therapy for insomnia your No. 1 New Year’s resolution for 2017.

Here’s what you stand to gain, what may stand in the way, and where to find help.

CBT for insomnia should be your no. 1 resolution for the new yearDo you have a persistent sleep problem? Make cognitive behavioral therapy for insomnia your No. 1 New Year’s resolution for 2017.

Here’s what you stand to gain, what may stand in the way, and where to find help.

A Treatment That Improves Sleep

Cognitive behavioral therapy for insomnia is focused on boosting sleep drive and removing psychological barriers to sleep. It’s become the front-line treatment for chronic insomnia because it gets results. Most people who undergo therapy can expect to:

  • Improve sleep efficiency. In other words, you’ll cut the time it takes to fall asleep in half, and cut the number of nighttime awakenings—and their duration—in half.
  • Improve sleep quality. You’re likely to sleep more soundly and wake up feeling more refreshed in the morning.
  • Sleep moderately longer, especially if you’re young or middle aged.

So why hesitate?

The First (and Maybe Biggest) Barrier to “Yes”

If you’re like I was, the biggest barrier to trying cognitive behavioral therapy (CBT) for insomnia may be the belief that nothing can improve your sleep. This is actually a logical way of thinking if you’ve had insomnia for a long time. After years of trying to improve your sleep by means you’ve read about elsewhere—chamomile tea, talk therapy, relaxation exercises—and getting poor results, why would your expectations for CBT for insomnia be anything but low? Hope is hard to come by after years of insomnia and failed attempts to improve sleep.

Gearing up to try yet another insomnia treatment can reawaken hope. But it also opens up the possibility of failing again. Just how comfortable is that? Besides, undertaking CBT for insomnia involves going through a process—and that process may not sound particularly quick or easy. It can be hard to silence these objections and commit yourself to another insomnia treatment.

A Second Possible Barrier: Fear of Sleeplessness

The prospect going through sleep restriction (the part of CBT for insomnia that involves curtailing your time in bed and observing prescribed bed and rise times) may make you uneasy. Sleep restriction was a red flag for me.

What if, during my allotted time in bed, I never fell asleep at all? This was scary to contemplate. As described in Chapter 8 of The Savvy Insomniac, my sleep anxiety was sky high when I went through treatment and drove me to do some pretty strange things.

No doubt my fear of sleeplessness made the first few days of treatment harder. But the gains I made were quick in coming. By the fourth night of treatment, I was falling asleep at my designated bedtime and sleeping right through the night—a pattern that was touch and go for a while but has held up very well over time. My sleep anxiety is now a thing of the past.

Take some advice from a lifelong insomnia sufferer who dithered around for 11 years longer than she should have before finally taking the plunge: just do it.

Finding a Sleep Coach

CBT for insomnia is typically administered by a trained sleep therapist over the course of 6 to 8 weeks. This is still the preferred form of treatment for the many insomniacs who like the idea of face-to-face coaching (and have insurance covering treatment or can afford to pay for it themselves).

Here’s how to find a sleep therapist certified in behavioral sleep medicine:

Some behavioral sleep medicine professionals offer a condensed form of CBT-I called brief behavioral treatment for insomnia (BBTI). Therapy takes place over 4 weeks (rather than 6 to 8) and involves two face-to-face meetings with the therapist and two follow-up phone calls. Read more about it in this blog post about BBTI.

CBT for Insomnia Online

What if you live in the hinterlands and there are no behavioral sleep medicine therapists nearby? With access to the internet, you’re still in business. Three interactive online programs—SHUTi, Sleepio, and CBT for Insomnia—are excellent resources for insomniacs in far-flung locales and those on a limited budget:

  • The SHUTi program ($135 for 16 weeks of access and $156 for 20 weeks of access) was recently shown in a clinical trial to get results equivalent to those obtained in standard face-to-face CBT-I.
  • A clinical trial of the Sleepio program ($300 for 12 months of access) is under way right now.
  • The CBT for Insomnia program is a 5-session program created by Dr. Gregg Jacobs, author of Say Goodnight to Insomnia, for the nominal cost of $44.95.

Insomnia sufferers, suspend your disbelief and try this out. I can’t promise it will relieve your insomnia—but the odds are greatly in your favor.

Good night, and good luck.

What doubts do/did you have about CBT for insomnia?

Protein-Rich Dieting Helps Sleep

I’m not going to plug the high protein diet as the surest path to weight loss (although some say it is). But I do want to pass on the news that going on a high protein diet may be a path to better sleep, especially in people who are overweight or obese.

This is not just the conclusion of single study, which may or may not hold up over time. Rather, a protein–sleep connection has been documented in a handful of recent studies. If you’ve got insomnia and can afford to lose a few pounds, consider these results.

high-protein diet improves sleep qualityI’m not going to plug the high protein diet as the surest path to weight loss (although some say it is). But I do want to pass on the news that going on a high protein diet may be a path to better sleep, especially in people who are overweight or obese.

This is not just the conclusion of single study, which may or may not hold up over time. Rather, a protein–sleep connection has been documented in a handful of recent studies. If you’ve got insomnia and can afford to lose a few pounds, consider these results.

A Link Between Protein Consumption and Sleep Quality

Two studies were conducted by nutritionists at Purdue University. In a pilot study, they enrolled 14 overweight men and women, average age 56. Participants went on low calorie diets for 12 weeks. The percent of calories from protein in their daily diet varied in 4-week periods: either 10%, 20%, or 30%, in random order.

The upshot: Diets higher in protein significantly improved sleep quality (as measured by scores on the Pittsburgh Sleep Quality Index) regardless of whether the main source of protein was beef and pork or soy and legumes.

A total of 44 overweight men and women, average age 52, participated in the second study. Again, all participants went on low calorie diets. But this time, about half ate meals containing a typical amount of protein (the control subjects). Meals consumed by the other half were about twice as high in protein. At the beginning of the study, the sleep quality of both groups (as measured on the Pittsburgh Sleep Quality Index) was the same.

The upshot: By the end of this 16-week study, the group eating the protein-rich diet reported significantly better sleep quality than the controls.

The researchers conclude that “the consumption of a greater proportion of energy from protein while dieting may improve sleep in overweight and obese adults.”

A Quick Look at Sleep and Protein in Other Research

Other researchers have found a link between protein consumption and sleep.

Authors of a Korean study analyzed data from over 14,000 subjects ages 20–79 to see if dietary factors modified the association between sleep duration and obesity. The results showed that sleep duration correlated positively with protein consumption and negatively with carbohydrate consumption.

So along with weight loss here’s another reason to avoid pasta and fill up on fish: it might help you sleep longer.

College students were the focus of yet another study, this one looking at how dietary factors and psychological distress predicted sleep quality. Food choices that reduced the odds of poor sleep quality were

  • healthy dairy (by about 14%) and
  • healthy protein (by over 32%).

Once again, protein consumption is linked to better sleep.

The specific relationship between protein consumption and the sleep of people with insomnia has yet to be studied. But if you can afford to lose a few pounds and want to improve your sleep, try bumping up the protein and cutting back on carbs.

Make Sure It’s Healthy Protein

But make sure it’s healthy protein and not the bad stuff. Complete proteins, which contain all essential amino acids, are abundant in these foods:

  • meat (leaner cuts that are antibiotic and hormone free)
  • poultry (organic and cage free, if possible)
  • fish (wild is usually healthier than farmed)
  • eggs (from organic cage-free chickens, when possible)
  • dairy products

Incomplete proteins, which come from non-animal sources, are healthy choices, too:

  • nuts
  • seeds
  • beans
  • whole grains

If these are your main sources of protein, take care to eat them in combination with supplementary protein. Not just beans, but rather beans and brown rice.

Protein sources to avoid are fatty and processed meats such as bacon, sausage, deli meats, and hotdogs.