Insomnia and Emotional Memories Linked

Situations like being bullied at school, getting fired from a job or losing your train of thought during an important speech can feel mortifying when they occur. But in time, and with the help of sleep, the shame and embarrassment fade away. You can recall the experience without re-experiencing the emotional charge. This may not be the case for people with insomnia, results of a new study in the journal Brain suggest. Insomnia may involve disruption of the brain’s processing of emotional experience, burdening poor sleepers with emotionally charged memories. Here’s more about it.

Situations like being bullied at school, getting fired from a job or losing your train of thought during an important speech can feel mortifying when they occur. But in time, and with the help of sleep, the shame and embarrassment fade away. You can recall the experience without re-experiencing the emotional charge.

This may not be the case for people with insomnia, results of a new study in the journal Brain suggest. Insomnia may involve disruption of the brain’s processing of emotional experience, burdening poor sleepers with emotionally charged memories. Here’s more about it.

Biological Aspects of Insomnia

Insomnia used to be blamed mainly on bad habits and faulty thinking, but increasing attention is being paid to biological factors that underlie insomnia. Results of gene studies point to genetic factors that make people vulnerable to insomnia. Many insomnia risk genes are located in the limbic area of the brain, where the processing of emotion occurs. The possibility that insomnia has to do with disturbed emotion processing is what researchers in The Netherlands set out to investigate.

Past research has established a few things:

  • When people experience a novel emotional event, such being shown graphic photos of war victims, functional MRIs (similar to movies showing activity in the brain) show strong evidence of activity in the limbic system. However, recall of those photos at a later time does not involve limbic activity.
  • People with insomnia do not experience the same overnight resolution of emotional distress as normal sleepers do. In fact, studies conducted by Rick Wassing and colleagues showed that in insomniacs, emotional distress resulting from an unpleasant situation could linger for over a week.

A Working Hypothesis

People with insomnia are prone to fragmented sleep (particularly, fragmented REM sleep). It could be that in insomnia, an area or areas of the brain that typically go offline during sleep are not fully deactivated, resulting in continuing secretion of neurochemicals associated with alertness. One consequence could be the storage of long-term emotional memories that still retain ties to the limbic system and hence their emotional charge.

The research team decided to investigate the responses of normal sleepers and insomnia sufferers to novel emotional experiences and memories of past emotional experiences and then compare them. Their hypothesis was that in people with insomnia, brain activity during recall of distant emotional events would look more like brain activity during novel emotional events than in normal sleepers.

Preparing for the Study

Fifty-seven people participated, aged 18 to 70 years. Twenty-seven participants had a diagnosis of insomnia disorder and 30 were classified as normal sleepers.

At an intake interview participants shared information about shameful experiences they could recall from their past. Each participant also underwent a structural MRI brain scan and made a karaoke-style audio recording in which he/she sang along to a familiar tune.

A week later testing began. Throughout the testing, each participant was wired with electrodes to assess galvanic skin response (changes in sweat gland activity that would reflect the intensity of the participant’s emotional state) and was undergoing functional MRI that would capture and record activity in the brain.

An Ingenious Test of Emotional Intensity

There were two tests, the first involving measurement of participants’ reactions to a novel shameful experience. Participants in both groups, the insomnia sufferers and the normal sleepers, were told they would be exposed to recordings of their own singing and the singing of others, and that two researchers would be listening in. Then each participant had to listen to 16-second fragments of their own solo singing, unaccompanied by music. The fragments were intermixed with neutral stimuli consisting of fragments of the same song sung by a semi-professional singer. How’s that for a novel shaming experience!

The second test involved recall of five shameful events from the distant past. For 16 seconds participants were asked to remember each shameful experience. In between each shameful experience, participants were asked to recall a trivial non-emotional experience from the past. After recounting each memory, participants rated its emotional intensity.

What the Research Team Discovered

Analyzing the data, researchers found, predictably, that emotional stimuli were on average rated as more intense than neutral stimuli. In addition, data from subjective participant reports and assessment of galvanic skin response showed the following:

  • The response to novel neutral and novel emotional experiences was similar in people with insomnia disorder and normal sleepers
  • Normal sleepers’ response to remembered shameful events was similar to their response to remembered neutral events (i.e., the emotional charge that accompanied the original experience was gone).
  • People with insomnia, however, had a stronger response to relived shameful memories than to neutral memories (suggesting continuing involvement of the limbic system).

Movies of the Brain Are Confirmatory

From the functional MRIs, investigators found the following:

  • The shame participants felt as they listened to their own singing triggered intense limbic activity in the brains of both normal sleepers and people with insomnia
  • Although memories of past shameful experiences did not induce a limbic response in normal sleepers, in insomnia sufferers, they did. In fact, in the brains of people with insomnia, limbic activity was noted in many of the same areas active during novel emotional experiences, notably, the anterior cingulate cortex.

“The findings,” write the authors, “suggest that normal sleepers activate a markedly different brain circuit while reliving emotional memories from the distant past as compared to when they are exposed to novel emotional experiences. In patients with insomnia, however, the brain circuits recruited with reliving distant emotional memories overlapped with the circuits recruited during a novel emotional experience.”

The restless REM sleep that often characterizes insomnia may be attributable to a failure to deactivate a part of the brain that, if shut down, could enable more restorative sleep and quicker recovery from emotionally painful experiences. There are ways to treat insomnia behaviorally, and some work pretty well. But only when more research into the causes of insomnia is conducted will researchers be able to find a cure.

Do the findings of these researchers ring as true to you as they do to me?

Vitamin D for Better Sleep?

Seasonal insomnia typically strikes at about this time of year. As the days get shorter, we’re exposed to shorter periods of sunlight, which can alter circadian rhythms and interfere with sleep.

A related problem has to do with our need for vitamin D, which may not be met in low sunlight conditions. Recent publications explore the effects of low levels of vitamin D on sleep, making supplements a good option in the cold weather.

Seasonal insomnia may be driven by vitamin D deficiencySeasonal insomnia typically strikes at about this time of year. As the days get shorter, we’re exposed to shorter periods of sunlight, which can alter circadian rhythms and interfere with sleep.

A related problem has to do with our need for vitamin D, which may not be met in low sunlight conditions. Recent publications explore the effects of low levels of vitamin D on sleep, making supplements a good option in the cold weather.

A Relationship Between Sleep and Vitamin D

It’s well established now that lack of exposure to sunlight has a negative effect on sleep. Interest in the relationship of vitamin D to sleep is relatively new, yet preliminary evidence suggests that low levels of D are associated with short sleep duration, a frequent complaint of people with insomnia. A recent meta-analysis of studies of vitamin D deficiency and sleep disorders also found an association between low levels of D and poor sleep quality.

Levels of vitamin D fluctuate seasonally. Our bodies make most of the vitamin D we need when our skin is exposed to sunlight, and typically there are fewer opportunities for sunlight exposure in the colder months of the year. Thus insufficient vitamin D could be a factor in seasonal insomnia.

Vitamin D Supplements: Will They Improve Sleep?

While a few studies document improved sleep as a result of higher levels of vitamin D, a causal relationship between vitamin D supplementation and better sleep has not been definitively established. However, for a host of health reasons including sleep — avoidance of infectious, autoimmune and neurological diseases, as well as neuromuscular disorders and increased pain sensitivity — vitamin D deficiency is a condition we should try to avoid.

It’s a good idea to pay attention to recommended dietary allowances — expressed in international units (IU) per day — especially in the wintertime. They were established by the Institute of Medicine based on vitamin D’s importance to the development and maintenance of healthy bones. Subsequently the Endocrine Society established recommended dietary allowances for people at risk for vitamin D deficiency. Here’s a table showing both sets of guidelines for daily intake of vitamin D:

Infants Ages 1–18 years Ages 19–70 years Ages 71 & older
Institute of Medicine 400 IU/day 600 IU/day 600 IU/day 800 IU/day
Endocrine Society 400-1000 IU/day 600-1000 IU/day 1500-2000 IU/day 1500-2000 IU/day

Foods Containing Vitamin D

Up to 80% of our D requirement may come from the complex metabolic processes triggered with exposure of the skin to sunlight. But we also get vitamin D from a limited number of foods. Some foods naturally contain D and other foods are fortified with it. Here are some common foods containing vitamin D and approximate amounts:

  • 3.5 oz salmon, fresh (wild): 600–1,000 IU
  • 3.5 oz salmon, fresh (farmed): 100–250 IU
  • 3.5 oz salmon, canned: 300–600 IU
  • 3.5 oz sardines, canned: 300 IU
  • 3.5 oz mackerel, canned: 250 IU
  • 3.5 oz tuna, canned: 236 IU
  • 3.5 oz shiitake mushrooms: 100 IU
  • 1 egg yolk: 20 IU
  • 3.5 oz beef liver, braised: 12–30 IU
  • 8 oz fortified milk or yogurt: 100 IU
  • 8 oz fortified orange juice: 100 IU
  • 3 oz fortified cheese: 100 IU

Breakfast cereals and soy products are also often fortified with vitamin D.

At Risk for Vitamin D Deficiency

You’re more likely to have low levels of vitamin D in these conditions:

  • You get little exposure to sunlight. This may occur if you live in a northerly latitude, spend all or most of your time indoors, habitually wear clothing covering your entire body or cover up with sunscreen all the time. (An SPF of 30 or higher, which confers important protection from cancer, decreases vitamin D synthesis in the skin by more than 95%.)
  • You have dark skin. Dark skin confers natural protection from harmful radiation from the sun but also makes it harder to synthesize vitamin D. Longer periods of sun exposure are required for sufficient vitamin D production to occur.
  • You’re vegan. Most natural sources of vitamin D are animal based.
  • You’re obese. Individuals with a body mass index of 30 or higher often have low blood levels of vitamin D.
  • You’re pregnant or lactating. Pregnant and lactating women may have decreased levels of vitamin D as well.
  • You’re older and have a history of falls and/or fractures. Older adults are somewhat less efficient at synthesizing vitamin D via sunlight exposure.

Vitamin D Supplementation

To remedy low levels of vitamin D, or to maintain adequate levels throughout the winter, take a vitamin D supplement. Take your daily supplement with a meal containing fat, as this will increase vitamin D absorption.

Supplementation and adequate exposure to sunlight (or bright light supplied by a light box) at the approach of the holidays and through the winter may help to protect you from the bane of seasonal insomnia.

Sleep Onset Insomnia: 8 Do’s and Don’ts for Better Sleep

Sleep-onset insomnia—trouble falling asleep at the beginning of the night—has been one of the biggest challenges in my life. By now, having gone through insomnia therapy and spent decades observing how changes in behavior and the environment affect my sleep, I know what I need to do—and what not to do—to get the best night’s sleep I can.

If you’ve got sleep-onset insomnia, here are 8 do’s and don’ts that may help to regularize your sleep.

Sleep-Onset Insomnia can be minimized by changing habitsSleep onset insomnia—trouble falling asleep at the beginning of the night—has been one of the biggest challenges in my life. By now, having gone through insomnia therapy and spent decades observing how changes in behavior and the environment affect my sleep, I know what I need to do—and what not to do—to get the best night’s sleep I can.

If you’ve got sleep onset insomnia, here are 8 do’s and don’ts that may help to regularize your sleep.

Do These Things to Fall Asleep Faster:

  • Get up at the same time every day, including on weekends. This one of the hardest—but most important—habits to adopt, and frankly it’s one I struggle with to this day. Especially after a late night or two, it’s hard to stay the course and get up at 6 a.m. But if I don’t stick pretty rigidly to what I’ve decided is the best rise time for me, if I allow myself more than a little flexibility, my sleep goes off the rails. Making up lost sleep at the beginning of the night, rather than at the end, is by far the easier course.
  • Sign off all devices with screens at least an hour before you usually go to bed—and that includes eReaders and smartphones. If you’re a news junkie like me, watching out for headlines so you can read new stories the minute they come out, this can feel like major deprivation. Yet the light emitted by these screens has been shown time and again to interfere with melatonin secretion, delaying sleep onset—exactly what none of us wants.
  • Get regular exercise and eat regular meals. Aerobic exercise late in the afternoon works best for me, and adhering to my daily workout routine has become so ingrained that when I miss my exercise fix my body doesn’t feel like winding down at night. Regular exercise and regular meals—in fact, regularity in almost all activities because it helps regularize internal circadian rhythms—will likely help you sleep better.
  • Pay attention to the temperature of your bedroom and make adjustments early if necessary. The ideal temperature for sleep is a few degrees lower than what you’re comfortable with during the daytime. So, particularly as research suggests that people with insomnia may have trouble down-regulating internal body temperature, get the window fan going well before bedtime so that by the time it comes you’re not too hot to sleep.

Don’t Do Things That Perpetuate Trouble Falling Asleep:

  • Don’t watch the clock at night. Nothing triggers my anxiety about sleep as much as glancing at the clock at, say, 1 a.m. and realizing I’m not sleepy yet. This is one association—between the clock registering time late at night and trouble sleeping—that I’ve never gotten rid of despite my improved sleep. Turning my clocks toward the wall after about 10 p.m. solves the problem, and it might help you sleep better, too.
  • Don’t jump in bed the minute you get home even if you get home late. For me, heading to bed right away gives my brain permission to trot out all the unfinished business of the day and chew on it while I toss and turn in bed. If you get home late, put on your pajamas, brush your teeth and so forth. But then take 20 or 30 minutes to unwind—read a book or listen to music—before you hit the sack.
  • Don’t stay in bed if, after 15 or 20 minutes, you find you can’t sleep. For me, remaining in bed almost always results in continuing wakefulness, exactly the opposite of what I want. Instead, get up and do some quiet, low-stimulation activity—page through catalogs, make a travel list, cull your bookshelves—until you feel sleepy. Then head back to bed.
  • Don’t beat yourself up—when you’ve adopted all the sleep-friendly habits you possibly can—if you’re still feeling wakeful when your normal bedtime comes around. There’s a genetic component to insomnia, and there are genetic factors that determine sleep onset latency. One day, it may be possible to alter gene expression and so improve sleep. For now, acceptance of the occasional bad night is something it pays all of us to learn to do.

If sleep onset insomnia is your problem, what behaviors seem to make it worse and which behaviors, if any, seem to help?

Anxiety About Sleep: Could Herbal Medicines Help?

“I have 5 years of anxiety about not being able to sleep to overcome,” began a query I received a month ago. “Once triggered, it is difficult to stop this downward spiral and sleep.”

Without a doubt, anxiety about sleep is one of the hardest aspects of insomnia to beat. Cognitive behavioral therapy for insomnia can help to reduce sleep-related anxiety, as can other adjunctive therapies. But here’s an alternative treatment that might lead to calmer nights: plant-based medicines found to be effective for anxiety.

Insomnia-driven sleep anxiety & herbal medicines“I have 5 years of anxiety about not being able to sleep to overcome,” began a query I received a month ago. “Once triggered, it is difficult to stop this downward spiral and sleep.”

Without a doubt, anxiety about sleep is one of the hardest aspects of insomnia to beat. Cognitive behavioral therapy for insomnia can help to reduce sleep-related anxiety, as can other adjunctive therapies. But here’s an alternative treatment that might lead to calmer nights: plant-based medicines found to be effective for anxiety.

Anxiety About Sleep: How It Develops

Anxiety about sleep is learned, and the learning is largely unconscious. The anxiety may develop during a stressful situation when you’re having trouble with sleep. You might be in a tight spot at work or in the midst of a contentious divorce. You might be worried about a new breast lump or how to make ends meet for the next 6 months.

Whatever the stress, it keeps you up at night and soon it extends to worry about sleep itself. What happens if you can’t get enough sleep? What if you’re too sleep deprived to meet the next work deadline? What negative effects will insomnia have on your long-term health?

Once anxiety becomes focused on sleep, it’s hard to root out. The triggers may remain unknown: a darkening sky, evening birdsong, the bed itself. A simple glance at the clock can set off alarms in your head. (“It’s already midnight and I’m still too wired to sleep!”) And feelings of anxiety — muscle tension, a rapid heartbeat, bodily warmth and perspiration — can sabotage sleep. If night after night this pattern is reinforced, no wonder it’s hard to break.

Herbal Remedies for Anxiety

Anxiety about sleep is situational, and therapies shown in clinical trials to lower sleep-related anxiety — cognitive behavioral therapy for insomnia (CBT-I), yoga, and mindful stress reduction — are probably the most reliable paths to relief. Exercise has stress-reducing effects as well. But GABA is the neurotransmitter most prominently associated with calming the brain, and plant-based medicines that act on the GABA system may be helpful, too.

A team of Australian researchers recently conducted a systematic review of plant-based medicines for anxiety including both clinical (human) and preclinical (in vitro and animal) studies. Following are herbal medicines the evidence shows are mostly likely to have anxiety-reducing effects.

Kava (Piper methysticum)

Kava, native to the South Pacific, is the hands-down winner when it comes to the amount of evidence amassed in support of its effectiveness as an herbal remedy for anxiety. “The number of positive findings from human studies of P. methysticum within randomised, well-controlled trials . . . supports its use as a treatment for various anxiety disorders and associated symptoms, demonstrating broad clinical utility,” the authors write.

The main active ingredients in kava are called kavalactones. Kava supplements contain specific concentrations of these kava extracts and are available in tablet form or as a tincture. See my earlier blog post for an in-depth treatment of kava’s effects on anxiety and sleep and possible adverse effects.

Valerian (Valeriana officinalis)

Valerian, native mainly to Europe, looks like the next most-promising herbal with anxiety-reducing properties. The root extract has been used as a sedative and anti-anxiety medicine for millennia. Tests on human subjects have found that valerian is particularly effective at reducing subjective feelings of anxiety that arise in stressful situations.

Two human studies suggest that valerian doesn’t negatively impact psychomotor and cognitive performance the way the benzodiazepines (medications often prescribed to reduce anxiety) tend to do. So regarding safety, valerian has a relatively clean bill of health.

Passion flower (Passiflora incarnata)

Passion flower, native to the Americas, has been used for millennia as an herbal remedy for anxiety and trouble sleeping. Investigators in 4 clinical trials studied its anxiety-reducing effects in patients who were about to undergo surgery. Results showed that passion flower significantly reduced anxiety in comparison with placebo. In fact, its effects were similar to those of anti-anxiety benzodiazepine medications, including, in one of the studies, reductions in blood pressure and heart rate.

Two more studies involving use of passion flower in people with anxiety disorders showed the herb’s anti-anxiety effects were similar to those produced by benzodiazepines.

Ashwagandha (Withania somnifera)

Ashwagandha, traditionally used in Indian Ayurvedic medicine, is a plant in the nightshade family. (It’s sometimes called Indian ginseng.) Ashwagandha powder, prepared from the root, leaves, or whole plant and taken orally, has been prescribed to reduce anxiety and improve sleep for centuries. Today it’s available as a dietary supplement in powder, capsule, and tablet forms.

In 5 clinical trials, ashwagandha was found to have at least one significant anti-anxiety, anti-stress benefit compared with control conditions. Another very recent clinical trial involving participants with chronic stress compared the use of 600 mg of ashwagandha extract daily to placebo capsules taken over 8 weeks. Significantly greater stress reduction occurred with the extract, as did decreases in salivary cortisol (a biomarker of stress and anxiety). See my earlier blog post for more information on ashwagandha’s effects on stress, anxiety, and sleep.

Chamomile (Matricaria recutita)

Chamomile, a flowering plant in the daisy family, is plentiful throughout Europe and Asia. It’s been used for millennia, mainly as a tea, for its calming and sedative effects. In an 8-week clinical trial in patients with generalized anxiety disorder (GAD), participants taking 220 mg of chamomile 1 to 4 times daily showed significantly greater reductions in anxiety than controls. In another 8-week study involving patients with GAD taking a 500-mg capsule of chamomile 3 times a day, 58% of the participants showed significant reductions in anxiety.

In a strange twist, a study of the effects of chamomile in 34 patients with insomnia found that chamomile was effective at improving sleep and daytime stamina but did not reduce symptoms of anxiety.

Final Caveat

If you plan to try herbal medicine as an alternative treatment for anxiety about sleep, consult a naturopath or other health professional about the correct dose. At least do some research yourself.

And don’t expect momentary relief. Herbal medicines, said Jerome Sarris, an author of the Australian review paper whom I also interviewed for The Savvy Insomniac, “generally take longer to work, whereas some people just want that quick fix. I think they may have more of a role in long-term assistance.” So use herbal medicines as indicated and wait at least a few weeks to start looking for results.

Don’t Let Insomnia Spoil the Summer

Do you experience a sudden onset of insomnia at about this time every year? Not much is written on seasonal insomnia that occurs in warm weather. Yet I’m convinced it’s a real phenomenon since my posts on summer insomnia get lots of traffic starting in May.

Here’s updated information—and speculation—on what could be causing the problem and how to get a better night’s sleep.

Waking up too early caused by bright summer sunriseDo you experience a sudden onset of insomnia at about this time every year? Not much is written on seasonal insomnia that occurs in warm weather. Yet I’m convinced it’s a real phenomenon since my posts on summer insomnia get lots of traffic starting in May.

Here’s updated information—and speculation—on what could be causing the problem and how to get a better night’s sleep.

Excessive Heat and Light

Late spring and summer are the hottest, lightest times of the year, and excessive heat and light are not very conducive to sleep.

In humans, core body temperature fluctuates by about 1.5 degrees Fahrenheit every day. Sleep is most likely to occur when core body temperature is falling (at night) and at its low point (some two hours before you typically wake up). Some research suggests that impaired thermoregulation may be a factor in insomnia, that sometimes you may simply be too hot to fall asleep. If so, a bedroom that’s too hot may exacerbate that problem, interfering with your body’s ability to cool down.

Light, too, can interfere with sleep. It does so by blocking secretion of melatonin, a hormone typically secreted at night. Exposure to bright light late in the evening or early in the morning—a phenomenon more likely to occur in months around the summer solstice—may keep you from sleeping as long as you’d like.

Other Possible Challenges to Sleep in the Summer

Swedish researchers have found that people with environmental intolerances to things like noise and pungent chemicals are more prone to insomnia than people without these intolerances. Depending on where you live, sleeping with open windows in the warm weather—if it leads to more noise or bad odors in the bedroom—could interfere with sleep.

Finally, new research conducted at Poznan University of Medical Sciences found that medical students in Poland had higher levels of circulating cortisol—a stress hormone—in the summer than in the winter. This is a preliminary result, and whether it can be confirmed or will hold true for the general population is unknown. Yet if humans do have higher levels of cortisol in the summer than in the winter, this, too, could have a negative effect on sleep.

Sleep Better in the Hot Weather

Climate control is the answer to many environmental triggers of insomnia in the spring and summer. Yet not everyone has air conditioning. If at night you’re too hot to sleep, take care to cool your sleeping quarters down in advance:

  • In the daytime, keep window shades and curtains closed to block out heat from the sun.
  • Later in the evening, use a window fan (facing outward) to draw cool air through the house. Open and close windows strategically so the bedroom is cool by the time you’re ready to sleep.
  • If your bedroom is on an upper floor that simply won’t cool down, sleep on a makeshift bed downstairs.

If keeping windows open at night exposes you to too much outside noise, block it out with silicone ear plugs or high-tech ear plugs, or mask it with white or pink noise using a small fan, a white noise machine, or SleepPhones.

Manage Your Exposure to Sunlight

Daily exposure to bright light helps keep sleep regular—but not if the exposure comes early in the morning or at night. Sunlight that awakens you at 5 a.m. or keeps you up past your normal bedtime may shorten your summer nights, depriving you of the full amount of sleep you need. If you’re sensitive to light,

  • Install light-blocking shades, curtains, and skylight covers on bedroom windows.
  • Purchase a lightweight eye mask for use during sleep.
  • Wear sunglasses if you’re outside in the evening.
  • At home, lower shades and curtains by 8:30 or 9 p.m. even if it’s still light outside, and start your bedtime routine at the same time as you do in other seasons.
  • Avoid devices with a screens in the hour leading up to bedtime.

Reduce Stress

If circulating stress hormones are an issue during the summertime (or if for any reason you’re feeling stress), then kicking back and relaxing, typical in the summer, is not necessarily going to be a dependable path to sound sleep. To reduce stress and sleep better, find a way to make regular aerobic exercise part of your day despite the heat:

  • Do the outdoor sport of your choice—walking, jogging, bicycling—early in the morning or early in the evening. Mall-walking may not be very sexy, but it sure beats walking in 100-degree heat.
  • Buy a seasonal membership in a gym or recreation center, where you can work out in air conditioning.
  • Take up swimming.

A woman recently wrote me wondering if the allergies she normally experiences late in April could trigger seasonal insomnia. I couldn’t find any information on this. But insomnia that routinely occurs at certain times of year is probably triggered by environmental or situational factors. Figuring out what the triggers are is the first step to finding a remedy.

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.

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.