***INSOMNIA***

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Alcohol and Substance Abuse

Although alcohol and substance abuse can cause insomnia, the conditions may be reversed. For example, a 1999 survey reported that 14% of American adults use alcohol within a month to help them sleep, with 2.5% reporting frequent use of alcohol to reduce sleep.

Effects on Physical Health

Effects on the Heart. Although there has been some concern that insomnia may increase the risk for heart problems, little evidence has supported any significant dangers. One study reported signs of heart and nervous system activity in people with chronic insomnia that might place such individuals at risk for coronary heart disease. If it exists, however, this increased danger is very modest compared with other risk factors for heart disease. Yet another report suggested that sleep complaints in elderly people without coronary artery disease predicted a first heart attack. Sleep disorders in such cases may have been a marker for depression, however, which is a risk factor for heart attacks in elderly people.

Effects on the Immune System.A 2003 study reported significant differences in immune factors among sleepers, with higher levels of certain infection-fighters observed in good sleepers than in people with chronic insomnia. The significance of these findings is still unknown, however.

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HOW IS INSOMNIA DIAGNOSED?

General Approach to Diagnosing Insomnia

Diagnosing sleep disturbance and its cause is the most important step in restoring healthy sleep. There is little agreement, even among experts, however, on the best methods for effectively assessing a patient's insomnia. A major difficulty in diagnosing this problem is its subjective nature. One study showed that there was no difference in sleep behaviors between people who said they were insomniacs and people who said they weren't. People who believe they have insomnia may have actually had frequent brief awakenings during sleep that they perceive as being continuously awake. Some experts recommend, however that any individual should be treated aggressively if he or she believes they have insomnia and also is suffering daytime fatigue and impaired concentration and memory.

Sleep Questionnaires

A number of questionnaires are available for determining whether a patient has insomnia or other sleep disorders. For example, the physician may ask the following questions:

• How would the sleep problem be described?
• How long has the sleep problem been experienced?
• How long does it take to fall asleep?
• How many times a week does it occur?
• How restful is sleep?
• Does the difficulty lie in getting to sleep or in waking up early?
• What is the sleep environment like (Noisy? Not dark enough?)?
• How does insomnia affect daytime functioning?
• What medications are being taken (including the use of self-medications for insomnia, such as herbs, alcohol, and over-the-counter or prescription drugs)?
• Is the patient taking or withdrawing from stimulants, such as coffee or tobacco?
• How much alcohol is consumed per day?
• What stresses or emotional factors may be present?
• Has the patient experienced any significant life changes?
• Does the patients snore or gasp during sleep (an indication of sleep apnea)?
• Does the patient have leg problems (cramps, twitching, crawling feelings)?
• If there is a bed partner, is his or her behavior distressing or disturbing?
• Is the patient a shift worker?

Sleep Diary. If the patient cannot answer these questions, keeping a sleep diary is a helpful diagnostic tool. Every day for two weeks, the patient should record all sleep-related information, including responses to questions listed above described on a daily basis. A bed partner can help by adding his or her observations of the patient's sleep behavior.

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Measuring Sleepiness

The Epworth Sleepiness Scale. The Epworth sleepiness scale (ESS) uses a simple questionnaire to measure excessive sleepiness during eight situations. [ See Box The Epworth Sleepiness Scale.]

THE EPWORTH SLEEPINESS SCALE
SITUATION	CHANCE OF DOZING 0 = no chance of dozing 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing
Sitting and reading.	(Indicate a score of 0 to 3)
Watching TV.	(Indicate a score of 0 to 3)
Sitting inactive in a public place (e.g., a theater or a meeting).	(Indicate a score of 0 to 3)
As a passenger in a car for an hour without a break.	(Indicate a score of 0 to 3)
Lying down to rest in the afternoon when circumstances permit.	(Indicate a score of 0 to 3)
Sitting and talking to someone.	(Indicate a score of 0 to 3)
Sitting quietly after a lunch without alcohol.	(Indicate a score of 0 to 3)
In a car, while stopped for a few minutes in traffic.	(Indicate a score of 0 to 3)
SCORE RESULTS	1-6: Getting enough sleep 4-8: Tends to be sleepy but is average. 9-15: Very sleepy and should seek medical advice. Over 16: Dangerously sleepy

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Multiple Sleep Latency Test. The multiple sleep latency test (MSLT) employs a machine that measures the time it takes to fall asleep lying in a quiet room during the day:

• The patient takes four or five scheduled naps two hours apart.
• People with healthy sleep habits fall asleep in about 10 to 20 minutes.
• The test can detect changes in sleepiness associated with sleep deprivation in patients with insomnia.

It has limitations, however, and does not take into consideration any situations that may affect the patients' mental state and the actual home situation. The test is used mainly after other sleep disorders have been ruled out and the doctor is uncertain whether or not insomnia is a correct diagnosis.

Sleep Disorders Centers

If unexplained insomnia persists after treatment or there is evidence of a primary sleep disorder, such as sleep apnea or narcolepsy, the physician may recommend a sleep specialist or a sleep disorders center. Centers are accredited by the American Academy of Sleep Medicine. Patients should investigate centers carefully, being sure that they offer full sleep studies. [ See Where Else Can Help for Insomnia Be Obtained? below.]

Among the signs that may indicate a need for a sleep disorders center are the following:

• Insomnia due to psychologic disorders.
• Sleeping problems due to substance abuse.
• Snoring and sudden awakening with gasping for breath (possible sleep apnea).
• Severe restless legs syndrome.
• Persistent daytime sleepiness.
• Sudden episodes of falling asleep during the day (possible narcolepsy).

At most, sleep disorders centers patients undergo an in-depth analysis, usually supervised by a multidisciplinary team of consultants who can provide both physical and psychiatric evaluations.

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WHAT ARE BEHAVIORAL AND OTHER NON-DRUG TREATMENTS FOR INSOMNIA?

Behavioral Approaches

Prevention of sleeplessness is very much dependent upon the patient's ability to relax and learn the art of sleeping well. A number of behavioral methods are aimed at achieving these goals. Behavioral techniques can actually cure chronic insomnia and studies report their effectiveness in nearly all patients with primary chronic insomnia. Although medications are equally effective for helping people with insomnia to sleep, behavioral methods act faster. Behavioral methods are effective in all age groups, including elderly patients. In addition, medications cannot cure this condition and prolonged use frequently results in dependency.

Studies have reported that between 70% and 80% of those who are treated with non-drug methods experience improved sleep with an average treatment duration of only five hours over a four-week period. Furthermore, studies report that 75% of those who have been taking drugs are able to stop or reduce their use.

Specific Behavioral Methods. Proper sleep hygiene is the first step and should accompany any behavioral method. [ See Box Sleep Hygiene Tips.] A number of approaches are available, but all have the same basic goals:

• To reduce the time it takes to go to sleep to below 30 minutes.
• Reduce wake-up periods during the night.

Some experts currently list the following behavioral methods in order of effectiveness:

• Stimulus control (standard treatment, which receives a high degree of physician support). It may also be helpful for some patients with secondary insomnia caused by a medical or psychiatric condition.
• Progressive muscle relaxation (studies and physician reports reflect a moderate degree of confidence in its effectiveness). It may be helpful for older individuals and some patients with secondary insomnia caused by a medical or psychiatric condition.
• Paradoxical intention (studies and physician reports reflect a moderate degree of certainty in its effectiveness).
• Biofeedback (studies and physician reports reflect a moderate degree of certainty in its effectiveness).
• Sleep restriction (evidence inconclusive on its value).
• Cognitive behavioral therapy (evidence inconclusive although studies are increasingly reporting benefits not only for improving sleep in the short term, but in help maintain healthy sleep).
• Sleep hygiene, imagery training, and cognitive training only (experts unable to recommend these approaches as sole therapy).

Stimulus Control. Stimulus control is now considered the standard treatment for primary chronic insomnia and may be helpful for some patients with secondary insomnia as well. The primary goal of stimulus control is to regain the idea that the bed is for sleeping. It involves the following:

• Go to bed only when ready to sleep or for sex.
• If unable to sleep within fifteen to twenty minutes, get up and go into another room. (People who find it physically difficult to get out of bed should sit up and do something relatively arousing, such as read.)
• Maintain a regular wake-up time no matter how few hours are spent sleeping.
• Avoid naps.

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Progressive Muscle Relaxation. Progressive muscle relaxation is another technique for inducing sleep that is effective for many people. In one study, it was as effective as anxiety management training, a short-term behavioral technique. It takes about 10 minutes and involves the following:

• Focus first on a specific muscle group, typically with the muscles in one foot. Inhale and tense the muscle group for about eight second until the muscles start to shake and be mildly painful. (Do this gently. It is not intended to cause severe muscles contractions.)
• Release the muscles quickly and let them become loose and limp. Stay relaxed for 15 seconds and then repeat the same muscle group.
• Focus on the next muscle group and repeat the sequence. Move progressively from each foot and leg up through the abdomen, chest, then to each hand and arm and then to the neck and shoulders and face.

Paradoxical Intention. Paradoxical intention is a psychological approach that is based on doing the opposite of what one wants or fears and take it to extreme. The first step is to make a plan to take such a paradoxical approach to insomnia.

• Instead of going through activities leading to sleep, the patient prepares for staying awake and doing something energetic.
• In some cases, people may take specific psychological barriers to sleep to an extreme limit. For example, if worry is a factor in insomnia, the patient intensifies the worries.

Biofeedback. Biofeedback is also effective, but requires being monitored with an electroencephalogram (EEG), a device that measures brain waves. Patients are given feedback to recognize certain states of tension or sleep stages so that they can either avoid or repeat them voluntarily.

Sleep Restriction Therapy. Sleep restriction therapy may be effective, although evidence is inconclusive. In one 2001 study, patients practiced sleep hygiene and sleep restriction. Sleep hygiene was very helpful during the first two months while sleep restriction led to sustained benefits and deeper sleep. The approach is a systematic method for achieving sleep and restricting the time spent in bed.

The first step is to calculate a person's sleep efficiency number:

• Keep a sleep diary for 14 days. Then calculate the average hours of actual sleep and hours in bed. Then divide the average hours slept by the hours in bed. The result, given as a percentage, is the sleep efficiency number. (For example, if a patient sleeps an average of five hours out of seven hours in bed then the result is .714 and the sleep efficiency percentage is 71%.)
• The patient's goal is to achieve sleep efficiencies of between 85% and 90%, which means only 10% to 15% of the time is spent staying awake in bed. (Sleep efficiency in older people may fall normally somewhere between 75% to 85%.)

To achieve this goal, the patient takes the following actions:

• Begin by going to bed 15 minutes later than usual the first week.
• If 85% sleep efficiency isn't reached by the end of the week, add another 15 minutes before going to bed. Refrain from going to bed even if tired, although bedtime should not be reduced below five hours.
• Once efficiency reaches 90% or more, then begin to go to bed 15 minutes earlier each week.

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Other parts of the program include stopping any sleep medications and following good sleep hygiene. [ See Box Sleep Hygiene Tips.] People using this treatment have reported lasting improvements after just eight weeks and studies report that it is significantly more successful than relaxation techniques.

Cognitive-Behavioral Therapy. Cognitive behavioral therapy (CBT) is a form of therapy that emphasizes observing and changing negative thoughts about sleep (such as, "I'll never fall asleep"). It also employs actions intended to change behavior. Studies have been mixed on its effectiveness, although a major 2003 analysis of six trials suggested that it might be helpful for older adults. As another example, a 2002 study reported that CBT used alone or in combination with medications resulted in improved sleep efficiency and better on-going maintenance of healthy sleep compared to medication alone or sham treatment. In other studies, CBT has even helped post-traumatic stress victims and people with insomnia caused by chronic pain, who are all commonly resistant to most therapeutic maneuvers. The success of this approach rests strongly on the skill of the therapist. The long-term benefits of CBT are not known, and refresher sessions may be needed.

Using Imagery. A 2002 study enrolled people whose chronic insomnia was associated with unwanted thoughts and worries. They were given specific positive mental tasks that gave them a sense of positive control (as opposed to their real life concerns, which felt out of their control.) Those images distracted them and allowed them to fall asleep faster. In support of this approach, a 2002 study evaluated patients with insomnia who were given a problem before sleep. One group was asked to think of the problem in images and the other in words. The group who used imagery fell asleep more quickly and woke up with less anxiety.

Sleep Hygiene. The term sleep hygiene is used to describe simple behaviors that may help everyone improve their sleep.

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Sleep Hygiene Tips

• Establish a regular time for going to bed and getting up in the morning and stick to it even on weekends and during vacations.
• Use the bed for sleep and sexual relations only, not for reading, watching television, or working; excessive time in bed seems to fragment sleep.
• Avoid naps, especially in the evening.
• Exercise before dinner. A low point in energy occurs a few hours after exercise; sleep will then come more easily. Exercising close to bedtime, however, may increase alertness.
• Take a hot bath about an hour and a half to two hours before bedtime. This alters the body's core temperature rhythm and helps people fall asleep more easily and more continuously. (Taking a bath shortly before bed increases alertness.)
• Do something relaxing in the half-hour before bedtime. Reading, meditation, and a leisurely walk are all appropriate activities.
• Keep the bedroom relatively cool and well ventilated.
• Do not look at the clock. Obsessing over time will just make it more difficult to sleep.
• Eat light meals and schedule dinner four to five hours before bedtime. A light snack before bedtime can help sleep, but a large meal may have the opposite effect.
• Spend a half hour in the sun each day. The best time is early in the day. (Take precautions against overexposure to sunlight by wearing protective clothing and sunscreen.)
• Avoid fluids just before bedtime so that sleep is not disturbed by the need to urinate.
• Avoid caffeine in the hours before sleep.
• If one is still awake after 15 or 20 minutes go into another room, read or do a quiet activity using dim lighting until feeling very sleepy. (Don't watch television or use bright lights.)
• If distracted by a sleeping bed partner, moving to the couch or a spare bed for a couple of nights might be helpful.
• If a specific worry is keeping one awake, thinking of the problem in terms of images rather than in words may allow a person to fall asleep more quickly and to wake up with less anxiety.

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Exercise

Exercise may be one of the best ways to promote healthy sleep, including in adults over 60 who are not precluded from exercise for medical reasons. One study found that exercise is as good for inducing sleep as the use of benzodiazepines, a prescription sleep aid. Some research has found that yoga practice may have specific benefits on sleep health. Yoga uses meditation, deep breathing techniques, and movements that emphasize stretching and balance. A government-sponsored clinical trial is underway to determine if yoga helps people with insomnia.

Light Therapy

The circadian rhythm is more a function of darkness and light rather than actual time of day. Bright light can discourage drowsiness, and darkness can cause sleepiness, day or night. The use of a special light box may be helpful.

The procedure is noninvasive and simple. The patient sits a few feet away from a box-like device that emits very bright fluorescent light (over 4,000 lux) for about 30 minutes every day. The following people might benefit from light therapy in specific ways.

• Shift workers. Light therapy should be maximized during hours they are at work and minimized when they need to sleep.
• Frequent travelers. Light therapy may be useful for adjusting to new time zones and reducing jet lag.
• Nursing home patients.
• People with delayed sleep-phase syndrome. (These people have a natural tendency to fall asleep very late at night or in early morning hours, but then sleep normally.)

Everyone should check with his or her physician before using light therapy. The following people should avoid it or use it only under a physician's direction:

• Anyone with eyes or skin that are highly sensitive to light.
• Anyone taking medications that increase the risk for photosensitivity.
• People with bipolar disorder.

Timing of the therapy depends on the type of insomnia or sleep schedule of the individual. For example, in people who cannot get to sleep at night, light therapy in the morning and restricting bright light at night may be helpful. People who wake up early in the morning may benefit from light therapy performed in the evening, although a 2002 study reported that it had no effect in this group. Some light boxes have dawn/dusk simulators that help determine the correct brightness.

Alternative Techniques

Some alternative approaches that may be helpful for some patients include hypnosis, meditation, guided imagery and other imagery methods, and acupuncture. One study reported some benefits from pulses of weak electromagnetic fields applied to the brain.

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WHAT ARE DRUG TREATMENTS FOR INSOMNIA?

General Guidelines for Drugs Used in Insomnia

According to a major 2003 survey, about 20% of American older adults use some form of sleep aid--including prescription or over-the-counter drugs, alcohol, or some combination. Furthermore 15% use such aids every night.

It should be stressed that only behavioral or psychologic techniques can actually cure insomnia, whereas prolonged use of sleeping pills can only result in dependency. In addition, a 2002 study reported lower survival rates in people who took sleeping pills, although more research is needed to clarify this association.

In general, the following precautions are important in taking sleeping pills:

• Start with non-prescription medication.
• Drugs used specifically for improving sleeping are called hypnotics. If prescription hypnotics are required, start with as low a dose as possible. Discuss with the physician the benefits and risks of benzodiazapines versus non-benzodiazepines. Until recently benzodiazepines were most commonly prescribed, but newer non-benzodiazepines a may be better tolerated and have less risk of dependency. In general, hypnotics should generally be used only to prevent the vicious cycle of psychophysiologic insomnia in people with transient or short-term insomnia when non-medical treatments have failed.
• As a general rule, do not take either prescription nor non-prescription sleeping pills on consecutive days or for more than two to four days a week.
• If insomnia is still a problem after stopping the drug and continuing with good sleep hygiene, this pattern can be repeated again, but for no longer than four weeks.
• Medication should be withdrawn gradually and the patient should be aware of the possibility of rebound insomnia when stopping medication.
• Alcohol intensifies the side effects of all sleeping medication and should be avoided.
• If chronic insomnia is a companion to depression or anxiety, treating these problems first may be the best approach. Some newer antidepressants, such as nefazodone (Serzone), may be effective at treating both depression and insomnia at once.

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Common Non-Prescription Drugs

Over-the-counter and prescription sleeping medications are very commonly used medications.

Brands with Antihistamines. Antihistamines cause drowsiness and many over-the-counter preparations are available that might help transient insomnia.

• Most over the counter sleep aids use antihistamines ingredients, most commonly diphenhydramine. They may simply contain diphenhydramine alone (Nytol, Sleep-Eez, Sominex) or contain combinations of diphenhydramine with pain relievers (Anacin P.M., Exedrin P.M., Tylenol P.M.).
• Doxylamine (Unison) is another antihistamine used in sleep medications.
• Certain antihistamines indicated only for allergies, such as chlorpheniramine (Chlor-Trimeton), diphenhydramine (Benadryl), or hydroxyzine (Atarax or Vistaril) may also be used as mild sleep-inducers.

Unfortunately, most of these drugs can leave patients drowsy the next day and may not be very effective in providing restful sleep. Side effects include the following:

• Daytime sleepiness.
• Dizziness.
• Drunken movements.
• Blurred vision.
• Dry mouth and throat.

In general, they should be avoided by people with angina, heart arrhythmias, glaucoma, problems urinating, or while taking medications to prevent nausea or motion sickness. Some, such as those containing doxylamine should also be avoided by patients with chronic lung disease.

Common Pain Relievers. When sleeplessness is caused by minor pain, simply taking an acetaminophen (Tylenol) or an NSAID, such as ibuprofen (Advil, Motrin) can be very helpful without causing any daytime sleepiness. The extra "P.M." antihistamine found in combination products is simply an extra, needless chemical in these situations.

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Natural Remedies

Many people with insomnia choose herbal remedies for treating their insomnia. Some such as chamomile tea or lemon balm are harmless for most people. It should be strongly noted that a being labeled "natural" is neither equal to being safe or necessarily to even being natural. Herbal remedies are not regulated. Some even contain conventional medicines. [ See Box Warnings on Alternative and So-Called Natural Remedies.]

Melatonin. Melatonin is the best studied natural remedy for insomnia, although in the US it remains unregulated. Evidence on its effects remains unclear. Some studies have found that although many people fall asleep faster with melatonin, it has no effect on total sleep time or daytime feeling of sleepiness or fatigue. One difficulty in assessing study results is that there are no consistent standards on melatonin dosages or usage. Some research suggests that 0.3 mg may be the most effective dosage in many people with insomnia. Of note, however, a 2003 study reported no benefits for people with chronic insomnia from either 0.3 mg or 1.0 mg of melatonin. Higher doses (3 to 5 mg) may even keep some people awake.

Although it may not have many benefits for most people with chronic insomnia, studies suggest that it may help specific individuals, such as the following:

• Elderly people. It may help certain older people with insomnia, such as those with evidence of low melatonin levels and those dependent on prescription sleeping medications. It is not clear, however, how significant the benefits are.
• People without sight. A 2000 study reported that melatonin can help people without sight retrain their circadian cycle so that they can sleep at regular hours. The best dosages and timing, however, need to be clarified. High doses (10 mg) may be needed to start with, but can probably be reduced over time.
• Travelers and jet lag. Some studies have reported that melatonin may help prevent jet lag in some travelers. The optimal dosages or timing for preventing jet lag are still unclear, however.
• During withdrawal from prescription sleep medication. Melatonin may help people who are dependent on sleeping medications withdraw from these agents and maintain good quality sleep.
• People with delayed sleep syndrome. It might be somewhat helpful for people with who fall asleep very late at night or in early morning hours but then they sleep normally.
• Children. Melatonin may be effective and safe for children with chronic insomnia. In one small study, or example, melatonin was specifically helpful for children with Asperger's syndrome, who are at risk for sleep disturbances. More research is warranted, however. At this time, no one should give their child melatonin, which is a potent hormone and not regulated in the US, without a doctor's recommendation.

Melatonin is a powerful hormone that can have major effects on all parts of the body. Doses of melatonin over 0.3 can disrupt the circadian system in the brain and long-term consequences are unknown. High doses have been associated with the following adverse events:

• Mental impairment.
• Severe headaches.
• Nightmares.

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Interactions with other drugs are not completely known. It should be stressed that melatonin is currently classified as a dietary supplement and not as a drug, so its quality and effectiveness is uncontrolled in the US. (The United States is the only developed nation that does not regulate this agent.) The bottom line is that at this time, people who take melatonin are experimenting on themselves.

Valerian root. Valerian is an herb that has sedative qualities and has been helpful in people with insomnia. One study reported that it was also useful for helping patients withdraw from benzodiazepines--the standard prescription sleeping pills. In another study, 82.8% patients rated the effects of valerian (Sedonium) on sleep as very good. In the same study, valerian was as effective as oxazepam, a standard prescription sleeping medication. This herb is listed on the FDA's list of generally safe products. Side effects include vivid dreams. It should be noted that high doses of valerian can cause blurred vision, excitability, and changes in heart rhythm. Of note, however, its effects could be dangerously increased if it is used with standard sedatives. Other interactions and long-term side effects are unknown. As with all herbal remedies, the quality of individual brands is unregulated.

Chamomile. Many people drink chamomile tea for its sedative properties. Although it appears to be safe, it may cause allergic reactions in people who have plant or pollen allergies. Also, as with any agent that affects the nervous system, it should not be used with if a person is taking sleeping agents or drugs that are used for neurologic or psychiatric problems or otherwise affect the central nervous system.

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Warnings on Alternative and So-Called Natural Remedies

Alternative or natural remedies are not regulated and their quality is not publicly controlled. In addition, any substance that can affect the body's chemistry can, like any drug, produce side effects that may be harmful. Even if studies report positive benefits from herbal remedies, the compounds used in such studies are, in most cases, not what are being marketed to the public. There have been a number of reported cases of serious and even lethal side effects from herbal products. In addition, some so-called natural remedies were found to contain standard prescription medication.

The following warnings are of particular importance for people with insomnia:

Chinese Herbal Remedies. Studies suggest that up to 30% of herbal patent remedies imported from China having been laced with potent pharmaceuticals such as phenacetin and steroids. And one study reported a significant percentage of such remedies containing toxic metals. For example, the herbal remedy Sleeping Buddha was recalled in 1998 because it actually contains a benzodiazepine, the major ingredient in many prescription sleeping pills, and also appeared to increase the risk for birth defects in pregnant women. Reports of a few cases of acute hepatitis have occurred from Jin Bu Huan, a Chinese herbal remedy sold as treatment for pain and insomnia.

Kava. Kava has been used to relieve anxiety and improve sleep. It is not generally considered safe, however, after reports of liver failure and death from this medication, with highest risk in those with liver disease. Other side effects include itchy, scaly skin, muscle weakness, and problems with coordination. It also interacts dangerously with certain medications, including alprazolam, an anti-anxiety drug. And it increases the potency of certain other drugs, including other sleep medications, alcohol, and antidepressants.

Tryptophan and 5-L-5-hydroxytryptophan (HTP). Tryptophan is an amino acid used in the formation of the neurotransmitter serotonin, which is known to promote well-being and has been associated with healthy sleep. L-tryptophan was marked for insomnia and other disorders but was withdrawn from the market after contaminated batches caused a rare and even fatal disorder called eosinophilia myalgia syndrome. 5-htp, a byproduct of tryptophan, is still available as a supplement. There have been reports that some brands contain a substance called Peak X, which some evidence suggests may be harmful. To date, no serious adverse effects have been reported and reliable brands are available. Evidence that 5-HTP alleviates insomnia is scant.

The following website is building a database of natural remedy brands that it tests and rates. Not all are yet available and the information requires a paid subscription (www.consumerlab.com).

The Food and Drug Administration has a program called MEDWATCH for people to report adverse reactions to untested substances, such as herbal remedies and vitamins (call 800-332-1088).

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Hypnotics: Benzodiazepines

Benzodiazepines are the ones most commonly prescribed hypnotics. Originally developed to treat anxiety, these drugs reinforce a chemical in the brain that inhibits neuron excitability.

Brands. Commonly prescribed benzodiazepines include the following:

• Long acting benzodiazepines include flurazepam (Dalmane) and clonazepam (Klonopin), quazepam (Doral).
• Medium- to short-acting benzodiazepines include triazolam (Halcion), lorazepam (Ativan), alprazolam (Xanax), temazepam (Restoril), oxazepam (Serax), prazepam (Centrax), estazolam (ProSom), and flunitrazepam (Rohypnol). Short-acting benzodiazepines are particularly useful for air travelers who want to reduce the effects of jet lag.

Side Effects. Elderly people are more susceptible to side effects and should usually start at half the dose prescribed for younger people and should not take long-acting forms. Side effects may differ depending on whether the benzodiazepine is long- or shorting acting. They include the following:

• The drugs may increase depression, a common co-condition in any case in many people with insomnia.
• Respiratory depression may occur with overuse or with people with pre-existing respiratory illness.
• Long-acting agents have a very high rate of residual daytime drowsiness compared to others. They have been associated with a significantly increased risk for automobile accidents and falls in the elderly particularly in the first week after taking them. Shorter-acting benzodiazepines do not appear to pose as high a risk.
• Memory loss (so-called traveler's amnesia), sleepwalking, and odd mood states have been reported after taking Halcion and other short-acting benzodiazepines. These effects are rare and probably enhanced by alcohol.
• Incontinence. (In one 2002 study, 33% of patients experienced incontinence at least twice a week. The risk is highest in the elderly and with older, long-acting agents.)
• Because these drugs cross the placenta and enter breast milk, pregnant women or nursing mothers should not use them. An association was reported between the use of benzodiazepines in the first trimester of pregnancy and the development of cleft lip in newborns.
• In rare cases, overdoses have been fatal.

Interactions. Benzodiazepines are potentially dangerous when used in combination with alcohol, and some medications, like the ulcer medication cimetidine, can slow the metabolism of the benzodiazepine.

Withdrawal Symptoms. Withdrawal symptoms usually occur after prolonged use and indicate dependence. They can last one to three weeks after stopping the drug and may include the following:

• Gastrointestinal distress.
• Sweating.
• Disturbed heart rhythm.
• In severe cases, patients might hallucinate or experience seizures, even a week or more after the drug has been stopped.

Rebound Insomnia. Rebound insomnia, which often occurs after withdrawal, typically includes one to two nights of sleep disturbance, daytime sleepiness, and anxiety. In some cases patients may experience the return of original severe insomnia. The chances for rebound are higher with the short-acting benzodiazepines than with the longer-acting ones.

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Short-Acting Non-benzodiazepine Hypnotics

Newer short-acting non-benzodiazepines also referred to as benzodiazepine receptor agonists (BZRAs), can induce sleep with fewer side effects than the benzodiazepines. They are increasingly prescribed and are becoming the hypnotics of choice for many physicians. As of the date of this report, however, there have been no randomized controlled studies comparing benzodiazepines with these newer agents that provide sound evidence of any specific advantages.

Brands and Benefits. These hypnotics include zolpidem (Ambien), zaleplon (Sonata), and zopiclone (Imovane). The brands have some differences, such as the following:

• Zaleplon (Sonata) is the shortest-acting hypnotic available. It can be taken even in the middle of the night and if a patient needs to awaken in only four hours. In such cases, the medication is effective and still does not leave the person overly sedated in the morning. It appears to have a better safety record than other hypnotics and may be particularly useful for patients in the younger and older age groups.
• Zolpidem (Ambien) may be useful for people who take it as soon as they go to bed, since it is longer acting than Sonata. A 2002 study suggested that the drug might be used on an as-needed basis, with up to five tablets taken a week. After three weeks, two-thirds of the patients taking zolpidem in this way were able to reduce their tablet intake by more than 25% without losing improvements in sleep.
• Zopiclone (Imovane) is the longest acting agent of this group. It still carries a low risk for daytime drowsiness, however.

These agents can be particularly helpful for preventing jet lag. They also may be beneficial for people who also have accompanying mood disorders, such as depression or post-traumatic stress disorder. Because they are short-acting, zaleplon and zolpidem may pose fewer risks for falls and memory loss in elderly patients. They may even be safe for elderly patients with chronic lung problems, but research is needed to confirm this. They are expensive, however.

Side Effects. All of these agents have fewer morning side effects than the benzodiazepines, including morning sedation and memory loss (although they can occur to some degree). Ambien's record of adverse effects is similar to that of triazolam (Halcion), the short-acting benzodiazepine. Sonata appears to have less severe side effects. In general, the side effects are mild but can include the following for one or all of these agents:

• Nausea.
• Dizziness.
• Nightmares.
• Agitation or antagonistic mood in the morning.
• Amnesia (in high doses).
• Headache.
• Visual distortion
• Rare reports of kidney injury.
• Rare fatal overdoses have been reported.

Interactions. As with any hypnotics, alcohol increases the sedative affects of these drugs. These hypnotics also interact with other agents, including rifampin, ketoconazole, erythromycin, and cimetidine. They may also interfere or be interfered by other agents. Patients should report all medications to their physicians.

Dependency, Withdrawal Symptoms, and Rebound. The risk for rebound, dependence, and tolerance is lower with these agents than with benzodiazepine, particularly with Sonata. In one study, people who took this hypnotic every night for one year had no evidence of dependency or withdrawal symptoms, but more large studies are needed to confirm long-term safety. These agents are still subject to abuse. In any case, no hypnotic should be taken for more than a few days or at higher than the recommended dose.

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Other Drugs Used or Investigated for Insomnia

Designer Antidepressants. A combination of newer antidepressants and structured psychotherapy is proving to be very effective for improving both depression and insomnia in patients with both conditions. Researchers are particularly interested in investigating nefazodone (Serzone), a newer antidepressant that appears to improve sleep efficiency. Studies report it is very effective for treating both insomnia and depression, particularly in combination with cognitive-behavioral therapy. It may even help patients whose sleep disturbances are associated with posttraumatic stress disorder, which is very difficult to treat.

Eszopiclone. Eszopiclone (Estorra) is a new hypnotic currently in late trials that is proving to improve both sleep and daytime alertness and functioning. In one study, patients took the medication for a year without suffering loss of effect.

Indiplon. Indiplon is another new agent in late clinical trials. It is a non-benzodiazepine that acts on a receptor in the brain called GABA-A, which helps promote sleep. Early studies suggest it is effective and does not cause a rebound effect during withdrawal.

Older Agents Rarely Used

Chloral Hydrate. Chloral hydrate has been in use since 1832. It has significant adverse effects, however, and most experts believe it no longer has a role in the treatment of insomnia. In any case it does not appear to be effective in the elderly. Chloral hydrate poses a risk for addiction and it can be fatal in overdose. It also has carcinogenic properties and can harm genetic material. Potential side effects also include irritation of the skin, mucous membranes, and stomach. People with stomach, heart, kidney, or liver disorders should not take this drug at all. If a child is given it (usually for minor surgery), then that child should never be given chloral hydrate again in his or her lifetime.

Barbiturates. Barbiturates (Seconal, Nembutal) were the standard sleeping medication before the introduction of benzodiazepines. Overdose is dangerous and frequent; addiction and abuse are common. At present these drugs should rarely or never be prescribed for insomnia.

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Treating Children with Insomnia

There are few studies on the appropriate treatment for children with severe insomnia. The physician should first rule out any treatable causes or situations. Behavioral treatments are the first-line therapies for children. Some medications are thought to be safe by some experts and have been used in certain cases, but none have been approved by the FDA for children. Such medications include the long-acting benzodiazepine flurazepam (Dalmane) and certain antihistamines, such as trimeprazine (Temaril). Short-acting benzodiazepines may have some use for brief treatment of children with insomnia related to mood disorders or medication. Long-term use of any sleeping medication is rarely, if ever, warranted.

Treating Insomnia in the Elderly

Long-acting benzodiazepine hypnotics are often used in nursing homes, where the institutional setting, nighttime light and noise, and the underlying medical problems of older patients worsen sleeplessness. It is in the staff's interest to have sleeping times as regimented as possible, so as to promote good sleep.

The chronic use of the older sleeping pills in the elderly, however, can produce side effects, such as impaired memory and alertness, urinary incontinence, daytime sleepiness, and imbalance, that can make care even more difficult in the long run. The newer short acting benzodiazepines and the hypnotic non-benzodiazepines may not pose such risks, but studies are needed to confirm this. Zolpidem (Ambien) may be especially safe and effective in this group. In the meantime, behavioral therapy is proving to be useful even in older adults and, as in younger people, should be tried first. Light therapy may be particularly beneficial for nursing home residents.

Treating Insomnia During Menopause

Hormone Replacement Therapy. Hormone replacement therapy may be useful for women with insomnia associated with hot flashes and sweating. (There are both risks and benefits to this therapy, which a woman should discuss with her physician.)

Clonidine (Catapres), a drug known as an alpha-2 agonist, is used for Tourette's syndrome and hypertension. Some evidence suggests it may be useful for hormone-related symptoms of menopause.

Behavioral Techniques. Nonmedical treatments are recommended for women whose insomnia is related to stress and emotional distress. If insomnia continues in spite of strong efforts, hypnotics or antidepressants may be useful.

Treating Insomnia in Shift Workers

Shift workers should sleep in a completely darkened room and wear dark glasses during the day.

Light Therapy. Shift workers may benefit from sitting in front of a light box before starting a night shift. One study indicated that even moderate light was effective with this method.

 

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Treating People with both Depression and Insomnia

When insomnia appears to be caused by depression, the use of antidepressants should be considered as a first option. Often, the insomnia will clear up along with symptoms of depression. It should be noted that many doctors appear to be prescribing antidepressants even to insomnia patients who may not be clinically depressed, a strategy for which there is little evidence.

Of notable benefit for depressed patients with insomnia appear to be newer antidepressants that affect serotonin and other brain chemicals. Of note are mirtazapine (Remeron) or nefazodone (Serzone) may be specifically helpful for patients who suffer from both depression and insomnia.

It should be noted that many common antidepressants, such as fluoxetine (Prozac), paroxetine (Paxil), and other so-called SSRIs, can cause insomnia. Some research suggests that the newer hypnotics, notably zolpidem (Ambien), may be useful for insomnia experienced by people taking these agents.

All antidepressants have side effects and interactions with other medications that should be discussed with the physician. [For more information on depressants, see, Depression.]

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WHERE ELSE CAN HELP FOR INSOMNIA BE OBTAINED?

American Academy of Sleep Medicine (www.aasmnet.org). Call (708-492-0930).

National Sleep Foundation (www.sleepfoundation.org ). Call (202-347-3471).

The Sleep Well (www.sleepquest.com ). Call (650-365-6492).

National Center for Sleep Disorders Research (www.nhlbi.nih.gov/health/public/sleep/index.htm ). Call (301-251-1222).

Society for Light Treatment and Biological Rhythms (www.sltbr.org ).

The following sites offer light boxes. This is a random selection and they have not been reviewed for either price or quality: (www.sunboxco.com ), (www.lighttherapyproducts.com ), (www.alaskanorthernlights.com ).

UCLA Sleep Home Page (www.sleephomepages.org ).

Sleep Research Online (www.sro.org) .

World Federation of Sleep Research Societies (www.wfsrs.org/newsletter.html) .

Circadian Technologies is a consulting and research company that helps find solutions for shift workers (www.circadian.com) .