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?

Insomnia: Could Cranial Electrotherapy Stimulation Help?

If you’re leery of sleeping pills and haven’t fared well with cognitive behavioral therapy, maybe it’s time to think outside the box. There are quite a few alternative treatments for insomnia. Among the least known is Cranial Electrotherapy Stimulation, or CES. CES has been cleared by the FDA for treatment of anxiety, depression and insomnia. Here’s a summary of information about it.

Insomnia may respond to treatment with cranial electrotherapy stimulationIf you’re leery of sleeping pills and haven’t fared well with cognitive behavioral therapy, maybe it’s time to think outside the box. There are quite a few alternative treatments for insomnia. Among the least known is Cranial Electrotherapy Stimulation, or CES.

The “electro” in CES might give pause, recalling cruel shock treatments that characters in movies like One Flew Over the Cuckoo’s Nest were forced to undergo. As practiced today, that form of treatment–Electroconvulsive Therapy–delivers 800 to 1,000 milliamperes (mA) of current to the brain, inducing seizures to relieve severe mental illness.

In contrast, CES is a treatment you administer on your own with a device that delivers 1 to 4 mA of current to the brain. The sensation it produces ranges from a slight pulsing at contact points on the earlobes or the head to nothing at all. But proponents claim this tiny amount of transdermal electricity has the power to relieve anxiety, depression and insomnia. In June the FDA announced it would soon grant approval of CES for the treatment of these disorders with fewer restrictions and reclassify CES devices as belonging in the same risk category as acupuncture needles and power wheelchairs.

What Does CES Do to the Brain?

The claim is that CES can relieve insomnia, but so far there are only theories about how it works. Studies suggest that CES alters electrical activity in the brain, deactivating neurons in the cerebral cortex and down-regulating activity in other parts of the brain. Alpha waves, associated with relaxation and focus, are slowed and become more prominent.

Other mechanisms of action have also been proposed. CES may 1) promote the release of endorphins and other neurotransmitters that inhibit arousal and agitation, or 2) stimulate peripheral nerves, triggering processes that calm the brain. The particulars are not known, but any or all of these actions could give relief to people with insomnia.

How Safe Are the Devices?

The FDA’s reclassification announcement suggests that the risks associated with CES devices such as the Fisher Wallace Stimulator and the CES Ultra are low. Of 57 service members recruited to participate in a randomized controlled trial of the effects of CES on insomnia, one subject in the active treatment group complained of a headache and another reported sleeping worse after a single session.

Fisher Wallace states that 1 in 500 users experiences a mild headache and 1 in 250 experiences an increase in wakefulness immediately following treatment sessions. I haven’t been able independently to confirm these figures. But Kirsch and Nichols, reviewing studies of CES in an article in The Psychiatric Clinics of North America, note that “adverse effects are rare (<1%), mild, and self-limiting, consisting mainly of skin irritation under the electrodes and headaches.”

How Well Does CES Work as an Insomnia Remedy?

Now we’re on shakier ground. Of 18 studies of the treatment’s effects on mood and level of arousal, only 2 were rigorous enough to be included in a meta-analysis conducted by Klawansky et al. in 1995. These researchers concluded that CES was better than sham treatment only for anxiety—and not for insomnia. (But . . . insomnia and anxiety are closely related, so you may be heartened by this result.)

Scientists who study sleep and insomnia remedies haven’t shown much interest in CES. In the study of service members cited above, subjects received 5 treatments or 5 sham treatments. Male subjects, more numerous than females, reported sleeping nearly an hour more after the first and fourth sessions of active treatment. Female subjects did not. Overall, the results were “encouraging but not decisive,” identifying a “nearly significant” increase in total sleep time among all subjects after the third treatment. “Nearly significant” is not a slam dunk.

The results of older studies are mixed, suggesting that CES may help people with insomnia fall asleep more quickly and sleep more efficiently. Clinicians offer mostly favorable reports of CES on the Internet, but nothing more decisive is known about its effects on insomnia.

Liz, a librarian I interviewed for my book, wrote to ask about the Fisher Wallace Stimulator and said she thought it might be worth a try, given the company’s 60-day money back guarantee. I can’t vouch for it personally. But for people with treatment-resistant insomnia, it’s worth consideration.

If you have tried a CES device or try one out in the future, please share your experience here.

Insomnia? Do Whatever Works

“You know what I do that helps me sleep?” my husband’s Uncle Walter said to me. “You’re an expert on sleep, so you probably wouldn’t approve. But here it is: I listen to the radio. What do you think of that?”

“Do whatever works!” I replied.

Managing insomnia: do whatever worksMy husband’s Uncle Walter has talked about his insomnia before, and one night when I saw him in northern Michigan, he brought the matter up again:

“You know what I do that helps me sleep?” he said. “You’re an expert on sleep, so you probably wouldn’t approve. But here it is: I listen to the radio. What do you think of that?”

“Do whatever works!” I replied.

Listening to the radio at night is not an insomnia treatment recommended by the American Academy of Sleep Medicine . . . but I stand by my advice. While I have great respect for sleep specialists and the research-based solutions they set forth, I think homegrown insomnia remedies can sometimes work as well.

The Company Line

Once at a conference I asked a sleep therapist from the Stanford Sleep Center what she thought about using audiobooks to get to sleep.

“We don’t recommend it,” she said. “It reinforces the idea that you need something like an audiobook to help you sleep. The truth is, sleep is an involuntary behavior. All humans do it whether we want to or not, and we come fully equipped to do it without any props, whether audiobooks or sleeping pills.”

Well, OK, I found myself thinking in response. I’d rather fall asleep on my own than have to rely on “props” like audiobooks and radio shows. But where is the harm in using little assists if they enable us to feel OK about the sleep we get? Being shipwrecked on a deserted island might deprive us of our props at night, and our sleep might suffer as a result, but just how likely are we to find ourselves in that predicament?

Individual Solutions

I came away impressed, after interviewing dozens of insomnia sufferers for my book, at the strategies some had devised to manage insomnia on their own:

  • Visualization: At night, Jonathan recalls what he saw on various hiking trips he’s taken in the Sierra Nevada, which sets his mind at ease and puts him to sleep.
  • Resistance training: Larry finds that vigorous weightlifting sessions during the daytime are a fairly reliable way to assure a good night’s sleep.
  • Going with the flow: Toby, who has frequent wake-ups at night, does not spend her wakeful moments in bed. She gets up, drinks decaffeinated tea, reads a romance novel, and then returns to bed for another brief sleep. The cycle repeats itself a few times every night.
  • Taking a bath: Urania, whom I met years ago in Mexico, takes a late-night bath to relax herself enough to fall asleep.

I’m sure the ways I routinely manage my sleep—getting up at the same time every morning, exercising late in the afternoon, reading a novel before bed—would be endorsed by at least some members of the academy. But I don’t do them based on their say-so. I do them because for me they work.

If you’ve come up with some fairly reliable insomnia remedies, please share them!