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

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

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

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

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

Sleep Problems in the Menopausal Transition

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

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

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

Not Just in Our Heads

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

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

Women who developed insomnia during the menopausal transition

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

A Role for Depression and Stress

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

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

Treatments for Insomnia in the Menopausal Transition

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

Hormone Therapy

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

Non-Hormonal Pharmacological Therapies

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

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

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

Use OTC Sleep Aids With Caution

The sleeping pill of choice for many Americans with insomnia can be purchased over the counter at drug and grocery stores. But a new study shows that many older adults who use OTC sleep aids know little about them and may be using them in ways that do more harm than good.

Sleeping pill users should read the label of OTC sleep medicationsIt annoys me when people dismiss sleeping pills as categorically harmful. Yes, they can be used inappropriately and it’s important to be informed about their downsides. But the existence of downsides doesn’t necessarily mean the risks associated with using them outweigh the benefits.

The sleeping pill of choice for many Americans with insomnia can be purchased over the counter at drug and grocery stores. But a new study shows that many older adults who use OTC sleep aids know little about them and may be using them in ways that do more harm than good.

Older Americans Use Them and Like Them

Participants in the new study were adults in the United States aged 60 and older who were managing their sleep problems with nonprescription sleep aids. University of Pittsburgh investigators interviewed 116 by telephone and found that well over half were satisfied with their medication and felt it improved their sleep.

Asked about her satisfaction with one such drug, an interviewee replied that she was “pretty satisfied. It does help me fall asleep and stay asleep, and go back to sleep when I invariably get up once or twice a night.”

“There is a dramatic difference when I use it versus when I don’t,” another explained.

This jibes with the results of other, quantitative research. The prevalence of insomnia and other sleep problems among older adults is high and OTC sleep aids are widely available. About 17% of older adults in the United States turn for relief to antihistamine-containing sleep aids like Unisom and Simply Sleep.

How OTC Sleep Aids Work

Diphenhydramine and doxylamine are the active ingredients in antihistamine sleep aids. They block the action of histamine neurons, which are generally active when we’re awake and inactive when we’re asleep.

“Marked drowsiness may occur,” is the type of warning that usually appears on the label. This propensity to cause sedation is likely why, despite few controlled trials supporting their efficacy for insomnia, these drugs are seen as effective by many older adults. The trials that have been conducted suggest these antihistamine sleep aids may have more to offer sleep maintenance insomniacs than people who need help falling asleep at the beginning of the night.

Side Effects of OTC Sleep Aids

But like most prescription medications, OTC sleep aids are not intended for nightly or long-term use. Continuous use has been found to lead to the development of tolerance, tempting users to take more of the drug to get the same sedative effect. Yet in the Pittsburgh study, nearly half of the participants reported using OTC sleep meds daily or very often. Over half reported using them for more than a year.

Fewer than a quarter of the study participants had studied the label on their medication to find out about the recommended dosage or about warnings and possible side effects.

“I never really paid any attention to the directions,” an interviewee said. “I take a couple before I go to bed, about twenty minutes before I go to sleep, I go upstairs and go to bed. That’s it.”

Common side effects to be aware of are morning grogginess (our bodies process drugs more slowly as we age) and blurred vision, constipation, and trouble urinating (for more on this, see my post on OTC sleep aids and anticholinergic effects).

Drug-Drug Interactions

Possible drug-drug interactions is another factor to take into account, given that almost 40% of older Americans are taking five or more prescription medications. Studies have shown that diphenhydramine (the main ingredient in many OTC sleep aids, including Benadryl, Sominex, Nytol, ZzzQuil, and Simply Sleep) interferes with the body’s metabolizing of at least three commonly prescribed drugs:

  1. tamoxifen, an anti-estrogen drug used to treat breast cancer and lower breast cancer risk
  2. metoprolol (Lopressor), a beta blocker used to treat high blood pressure and heart problems
  3. venlafaxine (Effexor), a selective serotonin and norepinephrine reuptake inhibitor (SSNRI) used to treat depression

Reducing the effectiveness of a drug taken to manage a serious health condition isn’t something most of us would want to do. But information about all possible drug-drug interactions isn’t necessarily listed on the label of OTC sleep aids.

Americans seem to have the attitude that OTC meds are harmless—but that isn’t necessarily true. If you’re going to use an OTC sleeping pill, read the label for information about the proper dosage and potential side effects. Take concerns about possible drug-drug interactions to your doctor or pharmacist.

9 Ways to Keep Worry From Sabotaging Sleep

These days people are worried about jobs, health care, the environment, the possibility of worldwide war. Uncertainty about the future, and fear of negative outcomes, may rob even reliable sleepers of sleep from time to time.

But for many insomnia sufferers, worry and anxiety about sleep itself—“It’s two o’clock and I haven’t slept a wink!”; “If I don’t get to sleep now I’ll get sick!”—is an equally powerful enemy of sleep.

Here’s more about worry and insomnia and how to keep them from spoiling the night.

Insomnia sufferers should incorporate a bath into their bedtime routineThese days people are worried about jobs, health care, the environment, the possibility of worldwide war. Uncertainty about the future, and fear of negative outcomes, may rob even reliable sleepers of sleep from time to time.

But for many insomnia sufferers, worry and anxiety about sleep itself—“It’s two o’clock and I haven’t slept a wink!”; “If I don’t get to sleep now I’ll get sick!”—is an equally powerful enemy of sleep.

Here’s more about worry and insomnia and how to keep them from spoiling the night.

Worrying Around the Clock

Worry and sleep don’t mix. Like anxiety, which is more intense, worry—or repetitive thinking about issues of concern—triggers the release of neurochemicals that prepare the body for action rather than for rest.

Some people are by nature inclined to worry day and night. Allison Harvey, in her cognitive model of insomnia (2002), hypothesized that round-the-clock worry about sleep led to arousal, resulting in the sleep problems experienced by insomniacs at night.

Worrying at Night

More recently, research has suggested that it’s worry in bed—rather than worry day and night, or trait-level worry—that is connected to trouble sleeping, and a new study published in Behavioral Sleep Medicine supports this conclusion. Researchers administered a series of questionnaires to 139 insomnia sufferers and had them complete sleep diaries every day for 10 days. Neither trait-level worry nor trait-level rumination (repetitive thinking about negative emotions) was shown to have a relationship with any aspect of sleep.

The researchers then conducted a similar study with another group of insomniacs. Sixty-four participants were asked to fill out two diaries: one at 6 a.m., to record the sleep-related worries experienced during the night, and the other at 7 p.m., to record sleep-related worry and stress experienced during the day.

The results? Nighttime sleep-related worry had a significant and negative effect on every aspect of sleep, including trouble falling asleep, being awake longer during the night, and sleeping less efficiently. In contrast, daytime sleep-related worry had a negative impact on sleep quality only.

“Cognitive activity during the day is relatively benign,” the study authors concluded, “but cognitive activity in bed plays an important role in development and persistence of sleep problems in insomnia.”

The Take-Away

Do your worrying during the daytime rather than at night!

Because that’s easier said than done, here are nine ways to check your worries—sleep-related or not—at the bedroom door.

  1. Write your worries down early in the evening. Preempt nighttime worrying by taking 10 or 15 minutes to write down the issues you’re worried about, whether or not they’re related to sleep. Beside each concern, write what action you’ve taken/you’re taking/you will take to deal with the problem. Some problems may be clearly outside your control (or feel that way), yet resolving to take some small action to manage the problem can afford relief.
  2. Share your worries with an empathic listener at dinner. Sharing your concerns with an empathic partner or friend over the evening meal can also help to preempt worry at night. And when it comes to figuring out how to deal with a problem, two heads are often better than one. Further, research suggests that regardless of who’s talking and who’s listening, interactions with friends and supportive family members help tone down stress.
  3. Create a pre-sleep routine. It’s important to end the day with a wind-down period (ideally, at least an hour) in the run-up to bedtime. Think of it as a time to indulge in self-care, incorporating activities that make you feel good—such as listening to slow jazz and bathing by candlelight. The aim is to create an end-of-day ritual that’s worry free. Doing the activities in the same sequence every night will establish a clear association between your wind-down routine and sleep.
  4. Train your attention on something outside yourself. Watch a movie or a sit-com. Read or listen to a novel with complex, interesting characters. Do a crossword puzzle or play a word game such as Scattergories (Pick a category: Food. Pick a letter of the alphabet: L. Think of all the foods that begin with the letter L.) If you can do so without disturbing others at home, play a musical instrument. Engaging your mind will free it from repetitive thinking and enable you to go to bed feeling more relaxed.
  5. Adjust your perspective with cognitive restructuring. Confront your worries head on by asking a series of questions to find out how realistic your repetitive thoughts about a worrisome situation really are. In the process you’ll often find your anxiety level going down. Click on cognitive restructuring to find out more.
  6. Do a low-key physical activity. Underlying worry and anxiety are neurochemicals that trigger the urge to fight or flee. Low-key physical activity, such as walking outside or around the house, enables you to work the stress out.
  7. Do a deep breathing exercise. Deep diaphragmatic breathing triggers the relaxation response, enabling the body to move out of fight-or-flight mode and into a relaxed and restful state. Sitting in a chair, slowly inhale to a count of 4, pause briefly, and exhale to a count of 4. Focus on your breathing. If you find your mind wandering, gently guide your attention back to your breathing. Repeat this cycle as many times as needed.
  8. Do progressive relaxation. Sitting or lying down, one by one, tense and release every group of muscles in your body. Start with the muscles in your toes and move upward through your trunk to your head. Then move downward through the arms to the fingers.
  9. Do a guided meditation. Allow someone else to lead you through meditations designed to quiet your mind and relax your body. Jon Kabat-Zinn, whose guided meditations are available on the internet, is a master at this.

Please share any strategies you’ve found to cut down on worry at night.

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.

What’s That Antidepressant Doing to Your Sleep?

Most—but not all—antidepressants tend to suppress and/or delay REM sleep (the stage associated with dreaming). This can be helpful for people with depression.

It’s not necessarily helpful for people with insomnia. In fact, REM sleep irregularities may be a causal factor in insomnia. So it pays to know a bit more about antidepressants if you’re taking them now or before you head down that path.

Most antidepressants suppress and delay REM sleepAntidepressants are the third most commonly taken medication in the United States today, prescribed for depression and health problems such as insomnia, pain, anxiety, headaches, and digestive disorders. Most—but not all—antidepressants tend to suppress and/or delay REM sleep (the stage associated with dreaming). This can help people with depression.

It’s not necessarily helpful for people with insomnia—or for people who might be inclined to sleep problems if pushed in the wrong direction. There’s mounting evidence that REM sleep irregularities may actually be a causal factor in insomnia. So it’s worthwhile knowing about the REM and other sleep effects of antidepressants if you’re taking them now or before you head down that path.

Importance of REM Sleep

Intact, sufficient REM sleep has many benefits. They include the enhancement and consolidation of learned tasks and skills in long-term memory and the regulation of emotion.

Fragmented REM sleep, in contrast, may lead to the inadequate processing of emotion and then to hyperarousal, in turn giving rise to insomnia. Loss of the final REM period, a phenomenon identified in some “short sleepers” (often defined as those who sleep less than 5 hours a night), may increase your appetite and make you more vulnerable to weight gain and obesity.

In short, reduced or compromised REM sleep is not something you generally want.

Selective Serotonin Reuptake Inhibitors (and Relatives)

SSRIs are widely prescribed because they’re effective for depression and have relatively few major side effects. But as a class, they tend to suppress REM sleep. (They may also bring about changes in the frequency, intensity, and content of your dreams.) They also tend to delay the onset of sleep and increase awakenings and arousals at night, reducing sleep efficiency.

If you have both depression and insomnia, it’s probably best to steer clear of SSRIs. But here’s a caveat. SSRIs and other drugs that act on the serotonin system (which is very complex) are known to have different sleep–wake effects on different people. Trying out a drug like fluoxetine (Prozac) may be the only way to ascertain for sure how it will affect your sleep.

The story is basically the same for serotonin and norepinephrine reuptake inhibitors (SNRIs). Drugs such as duloxetine (Cymbalta) and venlafaxine (Effexor XR) markedly suppress REM sleep and tend to disrupt sleep continuity.

Tricyclic Antidepressants

TCAs aren’t prescribed as often as SSRIs because they tend to cause more side effects. However, like SSRIs, most TCAs (except trimipramine) markedly suppress REM sleep. Also, TCAs like desipramine and protriptyline give rise to increased norepinephrine, which tends to promote wakefulness rather than sleep. In studies of desipramine, the drug degraded the sleep of people with depression by extending sleep onset latency, decreasing sleep efficiency, and increasing their number of awakenings at night.

Most TCAs are not sleep friendly. However, low-dose amitriptyline is known to have sedative effects and is sometimes prescribed for people with depression and insomnia.

Low-dose doxepin has been shown to have sedative effects as well, blocking secretion of histamine, a neurotransmitter associated with wakefulness. Sold today as Silenor, it’s the only antidepressant approved by the FDA for the treatment of insomnia. Clinical trials suggest that Silenor is effective in treating sleep maintenance insomnia but not insomnia that occurs at the beginning of the night.

Atypical Antidepressants

Some antidepressants are atypical in that they don’t fit neatly into any category. Although not approved for the treatment of insomnia (the requisite trials were never conducted), low-dose trazodone (Desyrel) and mirtazapine (Remeron) are often prescribed for people with insomnia because of their sedative effects. Unlike most antidepressants, these drugs have not been found to markedly suppress REM sleep. And the results of a very few studies suggest that they may help people fall asleep more quickly and sleep more deeply.

If you’re taking an antidepressant now (for whatever reason) and you think it may be interfering with your sleep, talk about it with your doctor. And if you’re having sleep problems and considering an antidepressant, be selective about the one you use.

Can Heavy Use of Computers Cause Insomnia?

I spend most workdays at the computer. Then I spend an hour or more of leisure time surfing the web and answering emails later in the day. And I wonder: does my heavy computer use—mostly work related—increase my susceptibility to insomnia?

A recent article on the relationship between sleep problems and computer use at work and during leisure time offers insight into that. Here’s the scoop:

Insomnia can be the result of heavy computer use at nightI spend most workdays at the computer. I start at 6:30 in the morning and finish about 7 hours later when my brain runs out of steam. It’s not unusual to spend some or most of the workday on the computer, according to statistics from the Organisation for Economic Cooperation and Development. In 2012, some 64% of working Americans were using computers at work.

In addition to my work-related computer use, I spend an hour or more of leisure time surfing the web and answering emails later in the day. And I wonder: does my heavy computer use increase my susceptibility to insomnia?

A recent article on the relationship between sleep problems and computer use at work and during leisure time offers insight into that. Here’s the scoop:

A Relationship Between Computer Use and Sleep

The researchers took their data from the 2010 Danish Work Environment Cohort Study, a series of questionnaires used to assess the work environment and health and habits of the general working population of Denmark every 5 years. Respondents included 7,883 currently employed wage earners in every major occupation. All worked during the daytime.

The researchers analyzed information about workers’ average weekly computer use at work and their use of computers during leisure time, presumed to occur in the evening. They also used information about workers’ sleep, assessed with questions taken from the Bergen Insomnia Scale. In addition, they took into account several factors that can affect people’s sleep: body mass index and chronic health conditions, for example; work conditions, such as demands made of workers and their influence at work; and workers’ level of physical activity on the job and during leisure time.

Sleep Effects of Computer Use at Work

Even after investigators controlled for all the variables, their results showed no relationship between work-related use of the computer in the daytime and the soundness and quality of workers’ sleep at night. So I guess I can’t blame my insomnia on my 7 or 8 hours of screen time!

(Take note, though: excessive screen time is known to have other harmful effects, including eye strain, dry eyes, and blurred vision. Also, the heavy use of blue light-emitting devices with screens may have more serious long-term effects such as the earlier formation of cataracts and macular degeneration.)

Sleep Effects of Computer Use During Leisure Time

Light or moderate use of the computer during leisure time had no effect on workers’ sleep at night. But workers who spent 30 or more hours a week (that’s an average of between 4 and 5 hours a day) on the computer in their free time were almost twice as likely to have severe sleep problems as those whose leisure-time computer use was more limited—even after adjusting for all the confounders listed above.

Other studies have shown that, used at night, computers and other devices with screens interfere with sleep. The usual explanation is that the light they emit blocks secretion of the hormone melatonin, thereby delaying sleep onset. The psychological arousal associated computer gaming, use of social media, and/or working at night to meet tight deadlines might also contribute to the sleep problems of those who spend lots of time on the computer at night.

But the take-away here, the authors conclude, is that any negative effect of light from the computer screen on sleep is relatively short lasting. It’s heavy use of computers at night that might cause you to experience insomnia—not being married to the computer during the day.

How many hours a day do you spend on the computer? Have you noticed it affects your sleep?

Sleeping Pill Update: The Orexin Blockers

Blog posts I’ve written about sleeping pills get a lot of traffic. Among people with sleep problems, interest in drugs to relieve insomnia is high.

Pharmaceutical companies don’t seem to share this interest, though. A quick survey suggests that few companies are actively working on new drugs for the treatment of insomnia. Those with sleeping pills in the pipeline are developing drugs similar to suvorexant (Belsomra). Here’s more about this relatively new class of insomnia drugs.

new sleeping pills few and far betweenBlog posts I’ve written about sleeping pills get a lot of traffic. Among people with sleep problems, interest in drugs to relieve insomnia is high.

Pharmaceutical companies don’t seem to share this interest, though. A quick survey suggests that few companies are actively working on new drugs for the treatment of insomnia. Those with sleeping pills in the pipeline are developing drugs similar to suvorexant (Belsomra). Here’s more about this relatively new class of insomnia drugs.

Calming the Orexin System

Suvorexant and other similar medications achieve their soporific effects by blocking the activity of neurons that produce two neuropeptides called orexin A and orexin B. These orexin-producing neurons, located in the hypothalamus and numbering about 70,000 in all, project to neurons that regulate wakefulness, arousal, attention, and motivation.

When the orexin neurons are firing in full force, we’re up and alert and doing things. But the orexin neurons are mostly quiet during sleep.

Studies have shown that an overabundance of orexin in mice and zebrafish results in insomnia-like states. The problem of insomnia might have to do with the overexpression of orexin, researchers reasoned, and drugs that could counteract the expression of orexin at night might help insomniacs sleep. In fact, studies subsequently showed that drugs that blocked orexin activity in mice, rats, dogs, and humans helped to promote sleep.

Development of Orexin Drugs

There are two types of orexin receptors in the human brain: OX1 and OX2. Early testing determined that arousal was mainly governed by OX2 receptor signaling, and that OX2 receptors had a more important role in maintaining a balance between sleep and waking than OX1 receptors. Blockade of OX2 receptors was also more effective at promoting sleep. Blockade of both receptors appeared to be even more effective.

So pharmaceutical companies starting formulating and testing drugs called “dual orexin receptor antagonists” (DORAs) that blocked both OX1 and OX2. Research on the first of these drugs, almorexant, was discontinued due to safety concerns. But the second DORA, suvorexant (Belsomra), made it through stage III testing and was approved for the treatment of insomnia by the FDA in 2014. Merck’s launch of Belsomra on the U.S. market occurred near the end of the year.

During the first half of 2015 (according to the most recent information I can find), sales of Belsomra were brisk. As the first insomnia drug in its class—and purportedly carrying fewer risks than other insomnia drugs—it was bound to have face appeal.

But people with sleep problems have offered different opinions on the drug’s effectiveness. Some reviewers have praised the drug on this website (see my blog post on Belsomra’s benefits and risks). More have complained about side effects and a lack of effectiveness. Among 170 reviewers weighing in on Drugs.com, Belsomra gets an average of 3.7 points out of 10.

Orexin Drugs in the Pipeline

Despite what looks like a rather lackluster start, as of the end of May 2016, two drug companies—Eisai Inc. and Minerva Neurosciences—were developing sleeping pills that would act on the orexin system. Eisai’s drug, a DORA, was to enter Phase III testing (the final round of testing a drug must go through before its maker can apply for approval from the FDA) near the end of 2015.

Minerva’s drug is a “selective orexin-2 receptor antagonist,” or SORA, that blocks only OX2 receptors. Results of lab experiments suggest it increases sleep time in rodents while preserving normal sleep staging. It was undergoing Phase II clinical trials as of December 2015.

Whether these insomnia drugs will ever come to market—and whether they’ll be better than Belsomra—is anybody’s guess. For now, insomniacs will have to look elsewhere in the quest for a better night’s rest. Check out CBT for insomnia if you haven’t tried it yet.

Sleep Problems Following a Stressful Childhood

Only a minority of the insomnia sufferers I interviewed for The Savvy Insomniac said their insomnia began in childhood. But regardless of when their sleep problem began, a number reported having had stressful and/or abusive experiences in childhood.

Is there a relationship between adverse childhood experiences and insomnia later in life? Anecdotal and scientific evidence suggests there is.

insomnia can occur following a stressful childhoodOnly a minority of the insomnia sufferers I interviewed for The Savvy Insomniac said their insomnia began in childhood. But regardless of when their sleep problem began, a number reported having had stressful and/or abusive experiences in childhood.

Is there a relationship between adverse childhood experiences and insomnia later in life? Anecdotal and scientific evidence suggests there is.

Difficult Childhoods

Liz’s insomnia started in adulthood, worsening around the time of menopause. But she remembered being “a very, very nervous, anxious child”:

I have my suspicions that my trouble sleeping goes back a long, long way. My mother and father had difficulties and they fought a lot, and that made me anxious. I don’t think I feared for myself so much as I felt a general anxiousness about the disruption. Then I had a brother who was 6 years older than me and was always getting into trouble. He grew up with his father away in Egypt during the war. All of sudden he was 6 years old and he had a father and there were major problems between them. That was another disruption, another source of anxiety for me.

Keith thought it was the pattern of abuse he experienced at the hands of a family member that set him up for trouble sleeping:

I experienced severe childhood abuse—physical, emotional, and sexual abuse. It started when I was young and continued a long, long time. It happened early in the morning. When I wake up early now, and I often do, there’s frustration that I’m not able to sleep because I’m vigilant, I’m unable to relax. I’m pretty sure the childhood abuse is the source of my sleep difficulties.

What the Research Shows

Adverse childhood experiences (ACEs) increase people’s susceptibility to health problems later in life. The relationship between ACEs and mental illness, substance abuse, and heart disease is well documented. A recent literature review conducted by Harvard researchers shows that children who experience trauma are also more vulnerable to sleep disorders as adults.

In a majority of studies documenting this relationship, sleep problems were assessed subjectively, by the patients or participants themselves:

  • In a retrospective study of data collected from 17,337 HMO members, trouble falling and staying asleep was significantly associated with several types of childhood trauma: (1) physical abuse, (2) sexual abuse, (3) emotional abuse, (4) witnessing domestic violence, (5) household substance abuse, (6) household mental illness, (7)parental separation or divorce, and (8) household member imprisonment.
  • In a subsequent study, the authors found these same ACEs to be associated with frequent insufficient sleep.
  • In a longitudinal study, children who experienced family conflict between the ages of 7 and 15 were more likely to report insomnia at age 18.
  • Among women overall, there was a strong association between childhood sexual abuse and sleep disturbances reported in adulthood.

In two studies, sleep problems were assessed objectively using a wristwatch-type device:

  • Among 39 insomnia patients, a history of abuse and neglect explained a moderate amount of variance in sleep onset latency (39%), sleep efficiency (37%), number of body movements (40%) and moving time in bed (36%).
  • Among 48 psychiatric outpatients, childhood stress load was a correlate of total sleep time, sleep latency, sleep efficiency, and number of body movements.

Finally, the more traumatic childhood events people reported, the poorer was their quality of sleep:

  • People who experienced 1 to 2 ACEs were twice as likely to report poor sleep quality as people with no ACEs. People who experienced 3 to 6 ACEs were 3.5 times as likely to experience poor quality sleep as people with no ACEs.
  • As the number of ACEs went up, so did the prevalence of insufficient sleep.

Clearly adverse childhood experiences make it more likely that people will develop chronic insomnia or insomnia symptoms in adulthood. I did not experience familial abuse or neglect. I’m guessing, though, that the bullying I experienced one year at school increased my susceptibility to insomnia . . . but that’s a topic for another blog post.

How about you? Do you think there’s a link between your trouble sleeping and adversity you experienced in your youth?