Insomnia

<< Back to Disease Index

* Please note that most treatment modalities listed below are based on conventional medicine. PreventDisease.com does not advocate the use of any pharmaceutical drug treatments. Long-term drug therapy is detrimental to human health. All drug information is for your reference only and readers are strongly encouraged to research healthier alternatives to any drug therapies listed.

Insomnia

WHAT IS INSOMNIA?

Sufficient and restful sleep is a human need as basic as food, vital to emotional and physical well being. In recent years, scientists have made great strides in identifying patterns and functions of brain activity in sleep. [ See Box Healthy Sleep.]

Insomnia is not a disease but the sensation of daytime fatigue and impaired performance caused by insufficient sleep. In general, people with insomnia experience one of the following:

An inability to sleep despite being tired.
A light, fitful sleep that leaves one fatigued upon awakening.
Waking up too early.

Definition of Chronic Insomnia

Insomnia, usually temporary, is often categorized by how long it lasts:

Transient insomnia lasts for a few days.

Short-term insomnia for no more than three weeks.

Chronic insomnia occurs when the following characteristics are present:

When a person has difficulty falling asleep, maintaining sleep, or has nonrestorative sleep for at least three nights a week for one month or longer.
In addition, the patient is distressed and believes that normal daily functioning is impaired because of sleep loss.

Chronic insomnia may also be primary or secondary, depending on the cause:

Primary chronic insomnia occurs when it is the sole complaint of a patient.
Secondary chronic insomnia is caused by medical or psychiatric conditions, drugs, or emotional or psychiatric disorders.

HEALTHY SLEEP

Circadian Rhythm

In sleep studies, subjects spend about one-third of their time asleep, suggesting that most people need about eight hours of sleep each day. Individual adults differ in the amount of sleep they need to feel well rested, however. (Infants may sleep as many as 16 hours a day.)

The daily cycle of life, which includes sleeping and waking, is called a circadian (meaning "about a day") rhythm, commonly referred to as the biologic clock. Hundreds of bodily functions follow biologic clocks, but sleeping and waking comprise the most prominent circadian rhythm. The sleeping and waking cycle is approximately 24 hours. (If confined to windowless apartments, with no clocks or other time cues, sleeping and waking as their bodies dictate, humans typically live on slightly longer than 24-hour cycles.) It usually takes the following daily patterns:

Humans are designed for daytime activity and nighttime rest.
Additionally, there is a natural peak in sleepiness at mid-day, the traditional siesta time.

In addition, daily rhythms intermesh with other factors that may interfere or change individual patterns:

The fraction-of-a-second-firing of nerve cells in the brain may be faster or slower in different individuals.
The monthly menstrual cycle in women can shift the pattern.
Light signals coming through the eyes reset the circadian cycles each day, so changes in season or various exposures to light and dark may unsettle the pattern. The importance of sunlight as a cue for circadian rhythms is dramatized by the problems experienced by people who are totally blind: they commonly suffer trouble sleeping and other rhythm disruptions.

The Response in the Brain to Light Signals

The response to light signals in the brain is an important key factor in sleep:

Light signals travel to a tiny cluster of nerves in the hypothalamus in the center of the brain, the body's master clock, which is called the supra chiasmatic nucleus or SCN.
This nerve cluster takes its name from its location, which is just above ( supra) the optic chiasm. The optic chiasm is a major junction for nerves transmitting information about light from the eyes.
The approach of dusk each day prompts the SCN to signal the nearby pineal gland (named so because it resembles a pine-cone) to produce the hormone melatonin.
Melatonin is thought to act as the body's time-setting hormone. The longer a person is in darkness the longer the duration of melatonin secretion. Secretion can be diminished by staying in bright light. Melatonin also appears to serve as a trigger for the need to sleep.

Sleep Cycles

Sleep consists of two distinct states that alternate in cycles and reflect differing levels of brain nerve cell activity. During a normal night's sleep, one progresses through these stages about five or six times:

Non-Rapid Eye Movement Sleep (NonREM). NonREM sleep is also termed quiet sleep. NonREM is further subdivided into three stages of progression:

Stage 1 (light sleep).
Stage 2 (so-called true sleep).
Stage 3 to 4 (deep "slow-wave"; or delta sleep).

With each descending stage, awakening becomes more difficult. It is not known what governs NonREM sleep in the brain. A balance between certain hormones, particularly growth and stress hormones, may be important for deep sleep.

Rapid Eye-Movement Sleep (REM). REM sleep is termed active sleep and is believed by some experts to be regulated by the circadian clock in the hypothalamus. Most vivid dreams occur in REM sleep. REM-sleep brain activity is comparable to that in waking, but the muscles are virtually paralyzed, possibly preventing people from acting out their dreams. In fact, except for vital organs like lungs and heart, the only muscles not paralyzed during REM are the eye muscles. REM sleep may be critical for learning and for day-to-day mood regulation. When people are sleep-deprived, their brains must work harder than when they are well rested.

The REM/NREM Cycle. The cycle between quiet (NREM) and active (REM) sleep generally follows this pattern:

After about 90 minutes of NonREM sleep, eyes move rapidly behind closed lids, giving rise to REM sleep.
As sleep progresses the NonREM/REM cycle repeats.
With each cycle, NonREM sleep becomes progressively lighter, and REM sleep becomes progressively longer, lasting from a few minutes early in sleep to perhaps an hour at the end of the sleep episode.

WHAT ARE THE CAUSES OF TRANSIENT OR SHORT-TERM INSOMNIA?

Response to Change or Stress

A reaction to change or stress is one of the most common causes of short-term and transient insomnia. This condition is sometimes referred to as adjustment sleep disorder .

The precipitating factor could be a major or traumatic event such as the following:

An acute illness.
Injury or surgery.
The loss of a loved one.
Job loss.

Temporary insomnia could also develop after a relatively minor event, including the following:

Extremes in weather.
An exam.
Traveling.
Trouble at work.

In such cases, normal sleep almost always returns when the condition resolves, the individual recovers from the event, or the person becomes acclimated to the new situation. Treatment is needed if sleepiness interferes with functioning or if it continues for more than a few weeks.

Female Hormonal Fluctuations

Fluctuations in female hormones play a major role in insomnia in women over their lifetimes. Such insomnia is most often temporary.

During Menstruation. Progesterone promotes sleep, and levels of this hormone plunge during menstruation, causing insomnia. (When they rise during ovulation, women may become sleepier than usual.)
During Pregnancy. The effects of changes in progesterone levels in the first and last trimester can disrupt normal sleep patterns.
Menopause. Insomnia can be a major problem in the first phases of menopause, when hormones are fluctuating intensely. Insomnia during this period may be due to different factors that occur. In some women, hot flashes, sweating, and a sense of anxiety can awaken women suddenly and frequently at night during the first months of menopause. In such women, hormone replacement therapy may be beneficial. Insomnia may also be perpetuated by psychologic distress provoked by this life passage. In most cases, insomnia is temporary. Cases of chronic insomnia in women after 50 are more likely to be due to other causes. [ See What Causes Chronic Insomnia?]

Jet Lag

Air travel across time zones often causes insomnia. After long plane trips, one day of adjustment is usually needed for each time zone crossed. Traveling west to earlier times seems to be less traumatic than going east to a later time because it is easier to lengthen a circadian phase than to shorten it.

Working Conditions

Working conditions can cause insomnia, as indicated by the following studies:

In one study, people on night shifts or on schedules of two- and three-shifts tended to suffer more from sleep-related problems, including insomnia, than those on day shifts.
Another study found that 53% of night-shift workers fall asleep on the job at least once a week, implying that their internal clocks do not adjust to unusual work times. (They are also at much higher risk than other workers for automobile accidents due to their drowsiness.)
A Japanese study reporting on different aspects of insomnia found that excessive computer work was associated with all forms of insomnia. People who were over-involved with their work tended to have trouble falling asleep and they tended to awaken earlier than average.

Caffeine and Nicotine

Certain lifestyle habits can lead to sleeplessness.

Caffeine. Caffeine most commonly disrupts sleep.

Nicotine. Nicotine can cause wakefulness. Quitting smoking can also cause transient insomnia. In fact, it has been suggested that if sleeping could be improved during withdrawal from smoking, then perhaps it would be easier to quit smoking.

Partner's Sleep Habits

In one 1999 survey, 17% of women and 5% of men reported that their partner's sleep habits impaired their own sleep. Snoring can certainly be a factor in a partner's insomnia. In fact, in the same survey 44% of men and 36% of women reported snoring a few nights a week and of those who snored, 19% could be heard through a closed door.

Medications

Insomnia is a side effect of many common medications, including over-the-counter preparations that contain caffeine. People who suspect their medications are causing them to lose sleep should check with a physician or pharmacist.

Noise and Other Disruptions

In one study, 20% of adults reported that light, noise, and uncomfortable temperatures caused their sleeplessness.

Effect of Light

Excessive Light at Night. It is well known that a person's biologic circadian clock is triggered by sunlight and very bright artificial light to maintain wakefulness. One study indicated that even dim artificial light may disrupt sleep.

Insufficient Light During the Day. Insufficient exposure to light during the day, as occurs in some disabled elderly patients who rarely venture outside, may also be linked with sleep disturbances. One study suggests that exposure to bright daylight results in higher melatonin levels in response to darkness, which aids sleep.

WHAT CAUSES CHRONIC INSOMNIA?

Psychophysiologic Insomnia after Transient Insomnia

Psychophysiologic insomnia is the revolving door of sleeplessness:

An episode of transient insomnia disrupts the person's circadian rhythm.
The patient begins to associate the bed not with rest and relaxation but with a struggle to sleep. A pattern of sleep failure emerges.
Overtime, this event repeats, and bedtime becomes a source of anxiety. Once in bed, the patient broods over sleeplessness and all attempts to sleep fail.
After such a cycle is established, insomnia becomes a self-fulfilling prophecy that can persist indefinitely.

Sometimes anxiety and the inability to sleep dates back to childhood when parents used various threats to force their children into sleep for which they may not have been ready. In general, this problem is easily treated within a short period of time with relaxation techniques and cognitive therapy.

Medical Conditions and Treatments

In a 1999 survey, 22% of adults reported that health conditions, pain or discomfort impaired their sleep.

Medical Problems. Among the many medical problems (and some of the drugs that treat them) that can cause insomnia are allergies, arthritis, cancer, fibromyalgia, heart disease, gastroesophageal reflux disease (GERD), hypertension, asthma, rheumatologic conditions, Alzheimer's disease, Parkinson's disease, hyperthyroidism, and attention deficit hyperactivity disorder.

Medications. Among the many medications that can cause insomnia are nicotine, certain antidepressants (eg, fluoxetine, bupropion), theophylline, lamotrigine, felbamate, beta-blockers, and beta-agonists.

Emotional Disorders

A large percentage of chronic insomnia cases prove to have a psychologic or even psychiatric basis. The disorders that most often cause insomnia are the following:

Anxiety.
Depression.
Bipolar disorder.

Some researchers have even observed that 90% of depressed patients show evidence of disrupted sleep on electroencephalogram (in which electrodes placed on the head measure the activity of nerve cells). It should be noted, however, that insomnia may also cause emotional problems, and it is often unclear which condition has triggered the other, or if the two conditions, in fact, have a common source. [ See Effects on Emotions under How Serious is Insomnia?]

Alcohol as a Cause of Insomnia

An estimated 10% to 15% of chronic insomnia cases result from substance abuse, especially alcohol, cocaine, and sedatives. One or two alcoholic drinks at dinner, for most people, poses little danger of alcoholism and may help reduce stress and initiate sleep. Excess alcohol or alcohol used to promote sleep, however, tends to fragment sleep and cause wakefulness a few hours later. It also increases the risk for other sleep disorders, including sleep apnea and restless legs. Alcoholics often suffer insomnia during withdrawal and, in some cases, for several years during recovery.

Hormonal Fluctuations Associated with Aging

An imbalance in specific hormones important in sleep has been associated with aging and may be partly responsible for the higher incidence of insomnia in older people.

Normal aging is associated with a blunting of regular, cyclical surges of growth hormone. This hormone, which is normally secreted in the late night, is associated not only with growth but with deep, slow-wave sleep. (Older people generally have less slow-wave sleep.)
Older people experience higher levels of major stress hormones (cortisol and adrenocroticotropin) during the night. High levels of cortisol reduce REM sleep.
Melatonin levels, the hormone secreted by the pineal gland are lower, in older people. Some experts believe that the pineal gland may harden as people age and so release less melatonin. Some research suggests that elderly people may have lower levels in general because many stay mostly indoors, and out of normal sunlight.

Genetic Factors

Sleep problems seem to run in families, with approximately 35% of people with insomnia having a positive family history, with the mother being the most commonly affected family member.

Circadian Rhythm Disorders

Circadian rhythm disorders are defined as those that are characterized by the inability to sleep at conventional times.

Delayed Sleep-Phase Syndrome. Delayed sleep-phase syndrome is the term for a circadian clock that runs late but reliably. People who have this condition (usually adolescents) fall asleep very late at night or in early morning hours, but then they sleep normally.

Advanced Sleep Syndrome. This syndrome tends to develop in older people; it produces excessive sleepiness in the morning and undesired awakening early in the morning.

Nightly Leg Problems

Leg disorders that occur at night, such as restless legs syndrome or leg cramps, are common cause of insomnia, particularly in older people. [For more information, see the Report #95, Leg Disorders. ]

WHO HAS INSOMNIA?

In general, studies estimate that about one-third of American adults experience some insomnia each year, with between 10% and 20% of them suffering severe sleeplessness. European studies suggest similar rates. A 1999 survey conducted by the National Sleep Foundation reported even worse statistics on sleeplessness in the US:

Only 35% of American adults reported sleeping eight hours or more per night during the work week.
56% had one or more symptoms of insomnia a few nights a week or more.
Over half of the elderly took an hour's nap during the work week and nearly half of 18 to 29 year olds napped.
60% of children, particularly teenagers, complained of being tired during the day.

In spite of this widespread problem, however, studies suggest that only about 30% of American adults who visit their doctor ever discuss sleep problems. Conversely, physicians seem rarely to ask patients about their sleep habits or problems.

Gender

Overall, insomnia is more common in women than men, although men are not immune from insomnia. Sleep efficiency deteriorates equally in men and women as they get older.

Men. One major study suggested that as men go from age 16 to 50, they lose about 80% of their deep sleep. During that period, light sleep increases and REM sleep remains unchanged. (The study did not use women as subjects, and there is some evidence to suggest they are not as affected.) After age 44 REM and total sleep diminish and awakenings increase.

Women. Younger adult women suffer from insomnia because of both cultural and biologic factors.

In women, a number of hormonal events can disturb sleep, including premenstrual syndrome, menstruation, pregnancy, and menopause. All these conditions are natural, and in most cases the wakefulness associated with them is temporary and can be ameliorated with sleep hygiene and time.
After childbirth, most women develop a high sensitivity to the sounds of their children, which causes them to wake easily. Women who have had children sleep less efficiently than women who have not had children. It is possible that many women never unlearn this sensitivity and continue to wake easily long after the children have grown.

Older women who are not bothered by sleeplessness tend to have longer and better sleep than men their own age.

Aging

Complaints of insomnia are remarkably higher in people over the age of 65 than in those aged 18 to 34. As people grow older, sleep changes:

In most older people, about 15% of their sleeping time is in stage 1, light sleep. (In infancy, only 5% is spent in light sleep.) According to one study, on average, a 60-year old awakens 22 times, compared to a young person who awakens about 10 times a night.

A number of factors affect sleep in the elderly:

Older people are more sensitive to environmental disruptions, such as light, noise, or jet lag.
Elderly people are more likely to be sedentary.
Medical conditions that cause pain or nighttime distress are common in the elderly. They include arthritis, gastrointestinal distress, urination problems, and heart conditions.
Neurologic diseases in the elderly, such as Parkinson's, Alzheimer's, and other forms of dementia, can cause nighttime disorientation, confused wandering, and delirium.
Subtle and dramatic hormonal shifts also occur, including reductions in melatonin and growth hormone and increases in stress hormones, creating an imbalance that may reduce all stages of sleep. (It should be noted, however, that some studies suggest that older adults with healthy life style factors have the same risk for insomnia as younger adults.)
Older people often take a number of prescription drugs whose side effects include insomnia.
The elderly are also prone to grief, depression, and anxiety, the handmaidens of sleeplessness. One study found, in fact, that in healthy older adults, psychologic factors, such as anxiety and depression, were more likely to be the cause of insomnia than illness, medications, or living conditions.

Sleep loss among the elderly is not inevitable, however. While older people are more susceptible to many physiologic conditions that can cause insomnia, treatments and a healthy lifestyle, particularly regular exercises, are as useful in providing relief to the elderly as to the young.

Shift-Workers

Shift workers are at considerable risk for insomnia. In one major 1999 survey, 65% of shift workers reported one or more symptoms of insomnia at least a few nights a week. Workers over 50 and those whose shifts are always changing are particularly susceptible to insomnia, although night-shift workers also have a high rate of sleeplessness.

Other Risk Factors

The following people are also at risk for insomnia:

People who travel frequently and cross time lines are at increased risk for insomnia.
Insomnia is also linked to relatively low social and economic status.
People with tinnitus (ringing in the ears).

HOW SERIOUS IS INSOMNIA?

Sleep deprivation, and the daytime sleepiness that follows, is increasingly recognized as a cause of mood disruption and contributor to industrial errors and motor vehicle crashes. Insomnia costs the US approximately $13.9 billion each year in direct medical costs and unknown billions from decreased productivity and consequences of accidents.

Increased Risk for Accidents

As many as 200,000 automobile accidents in the US and 1,500 deaths from such accidents are caused by sleepiness. Studies continue to report that drowsy driving is as risky as drunk driving. The following are some examples:

Estimates on fatigue as a cause of automobile crashes range from 1% to 56%, depending on the study.
A large 1997 survey indicated that accidents involving motor vehicles or machine tools occurred twice as often in persons with moderate or severe daytime sleepiness, compared with those without daytime sleepiness.
In a major 1995 poll, 33% of those surveyed said they had fallen asleep while driving, and 10% of these people had had accidents because of this.
An Australian study reported that 17 hours of sleep deprivation cause impaired performance levels comparable to those found in people who have blood alcohol levels of 0.10%, a level that defines intoxication in many states.

Negative Effect on Thinking and Performance

Studies suggest that insomnia worsens many waking behaviors including the following:

Reduced concentration. Some experts report that deep sleep deprivation impairs the brain's ability to process information.
Impaired task performance . One study reported that missing only two to three hours of sleep every night for a week significantly impaired performance and mood. An Australian study reported that 17 hours of sleep deprivation causes impaired performance levels comparable to those found in people who have blood alcohol levels of 0.10%, a level that defines intoxication in many US states.
Effect on learning. One study indicated that healthy sleep is important for learning certain perceptual skills related to visual patterns as well as repetitive skills, such as typing. Some studies reported no difference in test scores between people with temporary sleep loss and those with full sleep, although a Canadian study found that students who slept after cramming for an exam did better than those who stayed awake.

Effects on Emotions

One study reported that 20% of people with insomnia suffer from major depression. Although stress and depression are major causes of insomnia, insomnia may also increase the activity of the hormones and pathways in the brain that can produce these emotional problems. Even modest alterations in waking and sleeping patterns can have significant effects on a person's mood. Persistent insomnia may actually be a symptom of later emotional disorders in some cases. Some evidence suggesting that insomnia may contribute to emotional problems include the following:

One 1997 study reported that young adults with stress-related insomnia were at an increased risk of developing depression later in life. (Sleeplessness unrelated to stress did not appear to be associated with later depression.)
Another study of male medical students found that young men who experienced insomnia were twice as likely to suffer from depression at middle age as those who slept normally. Genetic factors may play a role in the association between sleep disorders and depression.
In one study of patients diagnosed with depression, family members with certain sleep abnormalities were found to be at greater risk for depression than those with normal sleep patterns.
Individuals with normal sleep patterns who are from families with abnormal sleep habits also appear to have an increased risk for mood disorders.
Some investigators, in fact, are exploring the possibility of preventing psychiatric disorders by early recognition and treatment of insomnia. (On the other hand, people with co-existing depression and insomnia may find relief from both conditions by treating depression first.) [See also Emotional Disorders under What Causes Insomnia?]

Cause of 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 the Heart and Mortality Rates

Studies have not found any evidence that insomnia increases mortality rates. Studies on the effects between heart disease and insomnia are weak but indicate a need for further research:

Some studies have associated a higher risk of heart disease with shift work. This has been reported in only two studies, however, and more research is needed to confirm this finding.
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 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, a risk factor for heart attacks in elderly people.

Headaches

Headaches that occur during the night or early in the morning may be caused by sleep disorders. In one study, patients who had these complaints were treated for the sleep disorder only and over 65% reported that their headaches were cured.

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 people who said they were insomniacs and people who said they weren't actually had the same sleep behavior, including sleepiness during the day and the time it took to fall asleep. People with insomnia may have frequent brief awakenings during sleep that appear to be a continual state of wakefulness, which they perceive as taking longer to actually fall asleep. Some experts believe that anyone who reports that they believe they have insomnia and are suffering daytime fatigue, less concentration, and impaired memory should be treated aggressively.

Taking a Sleep History

In general, the recommended approach is first to take a sleep and personal history. The physician may begin an interview that may include 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.

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 (Indicate a score of 0 to 3) 0 = no chance of dozing, 1 = slight chance of dozing, 2 = moderate chance of dozing, 3 = high chance of dozing
Sitting and reading
Watching TV
Sitting inactive in a public place (eg a theater or a meeting)
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon when circumstances permit
Sitting and talking to someone
Sitting quietly after a lunch without alcohol
In a car, while stopped for a few minutes in traffic
Score Results 1-6 Getting enough sleep 4-8 Tends to be sleepy but is average. 9 and over Very sleepy and suggestive of sleep-disorder breathing. Patient should seek medical advice.

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 therefore their ability to fall asleep. It 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.

Polysomnography. Polysomnography may be used to rule out other sleep disorders. It is not useful for routine screening of insomnia. The patient arrives about two hours before bedtime without having made any changes in daily habits. The polysomnopraph instrument electronically monitors the patient during sleep. It tracks the following:

Brain waves.
Body movements.
Breathing.
Heartbeats.

Actigraph. A new device, the actigraph, can be worn on the wrist. It records body movements during wakefulness and sleep. It can be used at home and therefore is reflects more natural conditions than tests in a laboratory. It can also keep a record over several nights rather than a single session. However, it cannot distinguish whether the patient is awake or asleep.

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

Behavioral or psychologic techniques can actually cure chronic insomnia and studies report their effectiveness in nearly all patients with primary chronic insomnia. (Medications cannot cure this condition and prolonged use frequently results in dependency.) Treatment goals for behavioral methods are typically the following:

To reduce the time it takes to go to sleep to below 30 minutes.
Reduce wake-up periods during the night.
The more severe the insomnia the more aggressive the treatment. If proper sleep hygiene does not relieve sleeplessness, a number of behavioral approaches are available that should be tried before taking medications.

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 methods are effective and work better than drugs in all age groups, including elderly patients. 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.

Experts currently recommend the following methods in order of effectiveness for patients with chronic primary insomnia:

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 also be helpful for 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).
Multicomponent cognitive behavioral therapy (evidence inconclusive on its value, although a 2001 study reported that it was significantly more effective that progressive muscle relaxation and offered persistent benefits).
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 may stay in bed, but they should do something relatively arousing, such as reading.)
Maintain a regular wake-up time no matter how few hours are spent sleeping.
Avoid naps.

Progressive Muscle Relaxation. Progressive muscle relaxation is another effective technique for inducing sleep. (One 2000 study of college students reported, however, that although it helped increase sleep time it did not improve functioning during the day.)

It takes about 10 minutes a day and involves the following:

Focus on a specific muscle group (for example the muscle in the right foot).
Inhale and tense the muscle group for about eight second until the muscles start to shake and there is some mild muscle pain. (Do this gently. It is not intended to cause any severe muscles contraction pain.)
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. (Typically start with the muscles in one foot and 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 two weeks.
Dividing actual average nightly sleep time by hours in bed. The answer, given as a percentage, is the sleep efficiency number. (For example, if a patient sleeps five hours out of seven hours in bed the calculation result is .714 and the sleep efficiency percentage is 71%.)
The patient's goal is to achieve a sleep efficiency percentage 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 somewhere between 75% to 85%.)

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

Begin by going to bed fifteen minutes later than usual the first week.
If 85% sleep efficiency isn't reached by the end of the week, another fifteen minutes is added to staying up until bedtime.
The patient must limit time in bed even when tired. (The time in bed should not be reduced below five hours, however.)
Once efficiency reaches 90% or more, the time allowed in bed is increased by 15 minutes per week.

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. In one study comparing those who used sleep restriction therapy and those who used relaxation techniques, the improvement for sleep restriction subjects was approximately twice that of those who used relaxation methods alone.

Cognitive-Behavioral Therapy. Cognitive behavioral therapy (CBT) is a form of therapy that emphasizes observing and changing negative thoughts (such as, "I'll never fall asleep";). It also employs actions intended to change behavior. Studies have been mixed on its effectiveness. One reported that it helped people with insomnia, even when it was caused by pain disorders, which are commonly thought to require sleeping medications and be resistant to therapeutic maneuvers.

Sleep Hygiene. The term sleep hygiene is used to describe simple behaviors that may help everyone improve their sleep. [ See Box Sleep Hygiene Tips.]

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.
A light snack before bedtime can help sleep, but a large meal may have the opposite effect.
Eat light meals and schedule dinner four to five hours before bedtime.
Spend a half hour in the sun each day. (Take precautions against overexposure to sunlight by wearing protective clothing and sunscreen. The best times are early or late in the day.)
Avoid fluids just before bedtime so that sleep is not disturbed by the need to urinate.
Avoid caffeine in the hours before sleep.
Quitting smoking not only brings many health benefits to any smoker, it eliminates the effects of nicotine that contribute to sleep loss.
Patients who cannot sleep after 15 or 20 minutes should get up and go into another room, read or do a quiet activity using dim lighting until they are sleepy again. (Don't watch television, for it emits too bright a light.)
One study showed that sleeping alone is more restful than sleeping with another person. If a person with insomnia is distracted by a sleeping bed partner, moving to the couch for a couple of nights might be useful.

Exercise

Exercise may be one of the best ways to achieve healthy sleep. One study found that exercise is as good for promoting sleep as the use of benzodiazepines, a prescription sleep aid.

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. A light-box can be purchased for about $300. [For some suppliers, see Where Else Can Help be Obtained for Insomnia?]

In general people using the light box should do the following:

Sit a few feet away from a light box that emits very bright fluorescent light (over 2000 lux) for about 30 minutes every morning.
Avoid bright light in the evening.

The following people might benefit from light therapy in specific ways.

Shift workers. Light 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.
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 their 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.

Psychotherapy

Many people are reluctant to consult with a psychologist or psychiatrist, yet insomnia is commonly caused by emotional disorders that can be successfully treated. In a study of chronic insomniacs who were referred to therapists, only one-third followed through with appointments, but of those who did, about three-fourths benefited from psychotherapy. It might be useful when sleep loss is associated with unconscious conflicts, such as those that involve loss of control, injury, self-exposure, aggression, and sexuality.

Unconventional Therapies

Chewing Gum. One interesting study reported that people who chewed gum from midnight until morning reported less sleepiness than those who also stayed up and didn't chew. Although not a remedy for insomnia, it may help people who have lost sleep the night before to stay alert.

Low-Energy Emission Therapy. A novel approach called low energy emission therapy (LEET), uses radio waves transmitted through a spoon-like device that a person with insomnia inserts into the mouth before sleep. Very early studies suggest that it may have actual benefit for some people.

Other Methods. Other approaches that may be helpful for some patients include hypnosis, meditation, guided imagery and other imagery methods, and acupuncture.

WHAT ARE DRUG TREATMENTS FOR INSOMNIA?

Guidelines for Drug Treatments for Insomnia

According to a 1999 survey, about 30% of American women and 20% of men report taking a medication to help them sleep at some time during the course of a year. Over half of these drugs are over the counter medications. 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. Most sleeping pills become less effective over time and require higher doses. Many can cause rebound insomnia if withdrawn rapidly.

Sleep medication 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. In addition, the following precautions are important in taking sleeping pills:

Drugs used specifically for improving sleeping are called hypnotics. Start with non-prescription medication. If using prescription hypnotics, start with as low a dose as possible.
In general, 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.

Note: Sleeping pills 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 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.

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.

Natural Remedies

Melatonin. Although melatonin is now commonly taken for insomnia, its actual effects are still 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. Different studies on its effects in specific groups have reported the following:

Shift-workers. In a study of emergency medicine personnel who worked night shifts, 1 mg of melatonin was no more effective than placebo in improving sleep quality.
Elderly people. It appears to help some older people with insomnia. (Although all older people experience a drop in melatonin levels, melatonin supplements do not appear to make people sleepy who do not already experience insomnia.)
In blindness. 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. The studies on benefits of melatonin for jet lag are mixed. It is unclear, for instance, if certain dosages and timing may be beneficial while others are not.
During Withdrawal from Other Sleeping Pills. One 1999 study suggested that melatonin might help people withdraw from benzodiazepines, the more potent class of prescription sleeping-drugs, while maintaining good quality sleep.
Delayed Sleep Syndrome. A 2001 study indicated that it might be somewhat helpful for people with delayed sleep phase syndrome.

One difficulty in assessing study results is that there are no consistent standards on melatonin dosages or when it should be taken. Some studies suggest that 0.3 mg may be the most effective dosage in many people with insomnia. In fact, higher doses (3 to 5 mg) may have an opposite effect. (A study on blind people, however, suggested that much higher doses may be needed for this group, at least at the beginning of treatment.)

High doses of melatonin have been associated with the following adverse events:

Mental impairment.
Drowsiness.
Severe headaches.
Nightmares.
It may increase the risk for seizures in children with existing neurologic disorders.
Of note, melatonin is structurally similar to L-tryptophan, another natural agent that has been used for insomnia. Contaminants in L-tryptophan have been linked with a rare, sometimes fatal illness. No cases of this illness have been linked to melatonin, however. [ See Box Warnings on Alternative and So-Called Natural Remedies.]
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 State is the only developed nation that does not regulate this agent.) Melatonin is a powerful hormone that can have major effects, many still unknown, on all parts of the body. The bottom line is that there is little evidence yet that this agent has any major benefits and its long-term safety is unknown. At this time, people who take melatonin are experimenting on themselves.

Other Herbal Remedies. Many people attempt to combat insomnia by using herbal medicines, including the following:

Valerian root. Some studies suggest that valerian may be helpful but evidence is inconclusive. It should be noted that high doses of valerian can cause blurred vision, excitability, and changes in heart rhythm.
Kava kava may help alleviate anxiety and promote sleep in some people. Allergic reactions have been reported.
Chamomile.
Lemon balm.

Although these herbs are generally safe, it is important to note that, as with melatonin, they have not been well tested, their benefits are not proven, and they can sometimes be harmful. [ See Box Warnings on Alternative and So-Called Natural Remedies.]

Warnings on Alternative and So-Called Natural Remedies

It should be strongly noted that 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. 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. Most problems reported occur in herbal remedies imported from Asia, with one study reporting a significant percentage of such remedies containing toxic metals. Even if studies report positive benefits, most, to date, are very small. In addition, the substances used in such studies are, in most cases, not what are being marketed to the public.

The following are of particular importance for people with insomnia.

Jin Bu Huan. 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.
Sleeping Buddha. The herbal remedy Sleeping Buddha actually contains a benzodiazepine, the major ingredient in many prescription sleeping pills and therefore has the same side effects and risks for dependency.
Tryptophan and 5-HTP. Structurally similar to melatonin, tryptophan, an amino acid used in the formation of the neurotransmitter serotonin, was formerly employed as a self-remedy for insomnia. In 1989, contaminated batch of tryptophan supplements was responsible for an outbreak of a rare disorder called eosinophilia myalgia syndrome (a systemic illness that leads to severe muscle pain and can be fatal). Tryptophan was withdrawn from the market, but 5-http, a byproduct of tryptophan, is available as a supplement. Some of these supplements may also contain dangerous impurities. 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 available yet. http://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).

Hypnotics: Benzodiazepines

Drugs used specifically for improving sleeping are called hypnotics. Benzodiazepines are the ones most commonly prescribed, but others are available that may be better tolerated and have less risk of dependency. All sleeping pills should be taken at the lowest dose possible, and with the guidance of a doctor. 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.
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.

Short-Acting Nonbenzodiazepine Hypnotics

Brands. Newer short-acting nonbenzodiazepines are available that can induce sleep with fewer side effects than the benzodiazepines. These hypnotics include zolpidem (Ambien), zaleplon (Sonata), and zopiclone (Imovane).

Benefits. 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). 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. Ambien may be useful for people who take it as soon as they go to bed, since it is longer-acting than Sonata. These agents may be particularly helpful for jet lag and for the elderly and the depressed. They may even be safe for older patients with chronic lung problems, but research is needed to confirm this.

Side Effects. Adverse side effects of these drugs are mild but can include the following:

Nausea.
Dizziness.
Nightmares.
Agitation or antagonistic mood in the morning.
Amnesia (in high doses).
Headache.
Rare fatal overdoses have been reported.

Interactions. As with any hypnotics, alcohol poses a danger with these drugs.

Dependency, Withdrawal Symptoms, and Rebound . The risk for rebound, dependence, and tolerance is lower with these agents than with benzodiazapine. In one study, people who took Sonata 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.

Other Prescription Drugs

Chloral Hydrate. Chloral hydrate is relatively reliable, and many physicians prescribe it for short-term use if other hypnotics cannot be used. It does not appear to be effective in the elderly. This drug has an unpleasant taste and odor when taken as a syrup, but capsules or rectal suppositories are available. Chloral hydrate use can result in abuse and dependency. 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.

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.

TREATMENT OF SPECIFIC GROUPS

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 Tourettes 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. S hift 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.

Treating People with 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), nefazodone (Serzone), and trazodone (Desyrel) which 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. (Trazodone may have unique side effects, including a risk for disturbed heart rhythms and, in men, priapism, a prolonged and unwanted erection.) [For more information on depressants, see the Report #8, Depression.]

WHERE ELSE CAN HELP FOR INSOMNIA BE OBTAINED?

American Academy of Sleep Medicine, 6301 Bandel Road, Suite 101, Rochester, MN 55901
Call (507-287-6006) or (http://www.aasmnet.org/)

Gives all accredited sleep disorders centers. This is a professional organization, but they will provide people with a full list of accredited Sleep Disorder Clinics. They publish the journal Sleep.

National Sleep Foundation, 1522 K Street, NW, Suite 500, Washington, D.C. 20005.
Call (202-347-3471) or (http://www.sleepfoundation.org) Will supply names of sleep disorders clinics and information to the public.

The Sleep Well (http://www.sleepquest.com/)

This is a very good site from Stanford University filled with information

National Center for Sleep Disorders Research, National Heart, Lung, Blood Institute
PO Box 30105, Bethesda, MD 20824-0105.
Call (301-251-1222) or (http://www.nhlbi.nih.gov/nhlbi/sleep/sleep.htm) or (http://www.nlm.nih.gov/medlineplus/sleepdisorders.html)

Society for Light Treatment and Biological Rhythms, 842 Howard Avenue, New Haven, CT 06519, USA.
Fax: (203-764-4324) or on the Internet (http://www.sltbr.org)

The following sites offer light boxes. This a random selection and they have not been reviewed for either price or quality.

http://www.sunboxco.com/

http://www.lighttherapyproducts.com/

http://www.alaskanorthernlights.com/

Useful Internet Sites

UCLA Sleep Home Page (http://www.sleephomepages.org/) Has a searchable database with articles on all sleep topics.

Good site (http://www.websciences.org/bibliosleep/NAPS/)

Sleep Research Online (http://www.sro.org/)

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

Excellent mental health site (http://mentalhelp.net/)

Circadian Technologies. A consulting and research company that helps find solutions for shift workers (http://www.circadian.com/)