Insomnia is a very common difficulty which increases with age. About 10% of Americans suffer from chronic insomnia It is sometimes a side-effect of depression, anxiety, or psychosis. In fact, severe insomnia is more closely linked with depression than to any other illness, although various pain conditions are associated with some increase in insomnia. Of patients with insomnia, 40% have some psychiatric disorder, usually depression or anxiety. People with insomnia but without a psychiatric diagnosis are very likely to develop a psychiatric diagnosis over the following year with the odds ratio for new depression being 40 and for new anxiety being 6. This are very high odds. That means that a person with chronic insomnia is 40 times more likely to develop depression than a person without insomnia! (Ford and Kamerow, JAMA 1989). In such cases, the primary disorder should be treated and this will usually eliminate the insomnia. Primary insomnia, i.e., insomnia without any psychiatric disorder, is still very common.
Other conditions associated with insomnia are sleep apnea when individual markedly slow or stop breathing (snoring with a break in breathing due to airway collapse) over 30 times a night, the restless leg syndrome with an irresistible urge to move one's legs, and the periodic limb movement disorder with stereotypic extension of the big toe and dorsiflexion of the foot in non-REM sleep interfering with sleep. Restless leg syndrome is treated with low doses of the same medicines as used for Parkinson's disease.
Insomnia does impair an individual's ability to handle everyday tasks and interpersonal relationships.
Sleep Hygiene: Non-medication techniques should be tried before any medication. Some people suffer from sleep phase disorder mentioned below and need to reset their biological clocks. Psychology studies recommend insomniacs stop using the bed or even bedroom as a place for anything except sleep. Stop reading or watching TV in bed. Don't go to bed unless you are sleepy. If you don't fall asleep after 15 minutes, get up and leave the bedroom until you are sleepy, then try again. I have an occasional night of insomnia and work on adding articles to this website until I get sleepy. At least I haven't wasted any time and it always works in an hour or two.
Exercising during the day has been found to help sleep at night. Avoid alcohol in the evening since it can sometimes worsen insomnia. Avoid coffee after noon if you have insomnia. It may be the cause. A light snack at bedtime may help if a person is hungry. Some people lie in bed for eight hours to sleep only six. The sleep restriction technique allows the patient to lie in bed only six hours a night and their sleep becomes more efficient.
Walking, drinking milk, especially warm milk, and taking acetaminophen (generic Tylenol) have all been reported to be used by large numbers of adults for insomnia (Int J Geriatr Psychiatry. 1999 Oct;14(10):851-7), but none of these strategies has been researched. In view of their popularity, they may well be effective for some people. In view of their lack of side-effects, perhaps they should be the first things tried. Reading this website might be a very educational way of falling asleep and I would heartily recommend it.
Undiagnosed milk intolerance appeared to be causing serious unexplained insomnia in 15 of 17 children (147 had insomnia, but other causes were considered the cause for 130) (Pediatrics. 1989 Oct;84(4):595-603). Milk intolerance insomnia is quite common in infants. I haven't seen any reports for adults, but milk intolerance is common and causes bloating, abdominal pains, gas problems, and other symptoms.
Addiction Prescription Medicines
I strongly prefer to avoid addictive sleeping pills. Virtually all advertised sleeping pills are addictive, even if they claim they aren't. They have no beneficial effects other than sleep. The ones promoted on television are quite expensive with the taxpayer footing the bill. Some older benzodiazepines are available as inexpensive generics. The newer ones are very similar, but are not officially benzodiazepines. The current push is for long-term use, which means long-term profits for the drug companies pushing them. Click on sleeping pills to see this group.
Non-Additive Over-the-Counter Remedies
Melatonin is very inexpensive and available over the counter as 3 mg. tablets. It is my favorite sleep aid. Many studies have found it of value. Most patients have to take two tablets a night and some as many as four. It can increase mental alertness during the daytime, as well as help with sleep at night. Valerian 600 mg. at bedtime is an inexpensive herbal treatment with several good studies showing benefit. Kava is another herb sometimes recommended for insomnia, but it is addictive and can damage the liver resulting in death. Chamomile tea is popular among the herbal crowd, but has no published research.
Diphenhydramine is present in most over-the-counter sleep remedies in the U.S. The most common dose is 50-100 mg at bedtime. It works as well as the benzodiazepines, but patients don't get addicted. However, benefits may less with time, it tends to cause daytime grogginess, and it might even increase the risk of Alzheimer's disease.
Multiple, untested herbal remedies are available and may be worth trying. These include:
Non-Addictive Prescription Medicines
Trazodone is an inexpensive ($10 per month) prescription anti-depressant more commonly used to treat insomnia than depression. The dosage used for insomnia is usually 50-100 mg. at bedtime vs. 300 mg. when treating depression. It doesn't cause weight gain and is usually well tolerated, especially at the insomnia dose.
Clonidine is an inexpensive blood pressure medication which is often used for childhood insomnia and also helps hyperactivity. It frequently causes dizziness and other side-effects, but is usually well tolerated and is not addictive.
For depressed patients needing a sleep-effect in addition to an anti-depressant effect, amitriptyline, doxepin, and mirtazepine (Remeron) also have considerably sleep effects. Mirtazepine is a fair inexpensive generic, but avoid the expensive brandname. Amitriptyline and doxepin and still less expensive. All three cause weight gain in the average patient. Many depressed or anxious patients with insomnia will have an improvement in insomnia with any good anti-depressant and the above mentioned anti-depressants are used primarily as back-up treatments. (Fluoxetine (generic Prozac) relieved insomnia only 3 days slower than trazodone in depressed teens. J Child Adolesc Psychopharmacol. 1997 Summer;7(2):97-107).
Chlorpromazine is an older and inexpensive anti-psychotic with a strong sleep effect which helps an occasional patient not helped by other treatments. It is not a good long-term choice due to potential movement side-effects. Hydroxyzine pamoate (Atarax) 50-100 mg. is an inexpensive, non-addictive medication for itching that also works well for anxiety and has helped for sleep for a few of my patients, although no research is available as a treatment for insomnia. 5-HTP is also sometimes helpful and may have some other health benefits.
6.5-7.5 Hour Sleepers Live Longer: In a study with 6 years of follow-up, those sleeping 6 ˝-7 ˝ lived longer than those sleeping over 8 hours who were 13% more likely to die. Those sleeping an average of 9 hours were 23% more likely to die and those at 5-6 hours 7% more likely. Study with some flaws with self-report, no record for napping, no details on sleepiness, etc. 1.1 million studied via questionnaires in 1982. Corrected for 32 factors including age, smoking, wt, economic status, exercise, and meds. Dan Kripke, UCSD Arch Gen Psych 2/02
7-8 Hours Least Heart Disease: In a Harvard study of nearly 72,000 nurses, who were followed for 10 years, women who averaged five hours or less of sleep a night were 39 percent more likely to develop heart disease than women who got eight hours. Those sleeping six hours a night had an 18 percent higher risk, and seven hours 9% higher risk of developing blocked arteries than the eight-hour sleepers. Nine or more hours of shuteye was associated with a 37 percent higher risk of heart disease. Arch Internal Med 163:205-9, 1/27/03. 37% of US adults are 8 hour sleepers and 31% sleep 6 hours or less.
Ayurvedic Remedy Worked in Small Study: In a DB PC crossover study of 25 adults with sleep onset insomnia, those receiving the Ayurvedic remedy got to sleep 17 minutes more quickly. There were no side-effects. A randomised-controlled trial of the effects of a traditional herbal supplement on sleep onset insomnia. Farag NH, Mills PJ. Complement Ther Med. 2003 Dec;11(4):223-5
Auto Accidents Increased: 3/18/99 NEJM article on Spanish auto crashes. A Univ of Wisconsin study found people with undiagnosed sleep apnea had 7 times more accidents. This study of drivers after accidents found 30% with sleep apnea. 80% of sleep apnea in US undiagnosed.
Depression: Insomniac Elderly More Likely to Become Depressed: In a 1-year follow-up study of 147 men and women over the age of 60 with no history of mental illness, 34 had persistent insomnia, 47 less persistent "indeterminate insomnia," while 66 had no sleep troubles. During the year, 12 developed depression: 6 with persistent insomnia, 4 had indeterminate insomnia and 2 no trouble sleeping. Elderly patients with persistent insomnia were six times more likely to experience serious new-onset depression than individuals who sleep easily. Ten of the 12 depressed patients were women, and all the patients who became depressed while suffering from a persistent form of insomnia were female. Perlis said its unclear why elderly women might be at especially high risk for the insomnia-depression connection. Perlis, M, et al. University of Rochester, J Behavioral Sleep Medicine late 2005. Another study by Perlis of 1,221 elderly treated for depression, those with insomnia were 12 times more likely to still be depressed 6 months later and 10 times more likely to be depressed 1 year later. Ed: This may be a lack of serotonin, which is converted into melatonin to aid sleep. A lack of melatonin causes insomnia, while depression is often caused by a lack of serotonin effect. 5-HTP, a serotonin precursor, has been used for depression. I would hypothesize that it is better for depression with insomnia than depression without insomnia and that it might prevent depression in elderly with insomnia.
Diabetic Insomnia: When compared with nondiabetics, patients with diabetes report higher rates of insomnia (71%), excessive daytime sleepiness, and unpleasant sensations in the legs that disturb sleep In type 1 diabetes, rapid changes in glucose levels during sleep have been postulated to cause awakenings. In type 2 diabetes, sleep disturbances may be related to obesity or obesity-associated sleep disorders, such as sleep apnea. A strong association also exists between obesity, impaired glucose tolerance, insulin resistance, and sleep-disordered breathing. Also, central-type apneas and periodic breathing have been reported in patients with autonomic diabetic neuropathy. Patients with diabetes, particularly those with peripheral neuropathy, have restless legs syndrome and periodic limb movements that can cause sleep-onset and maintenance insomnia.
Gaboxadol GABA(A) Receptor Agonist Helps Sleep: Gaboxadol, a selective GABA(A) receptor agonist, was used in the DB PC crossover study of 10 healthy elderly given 15 mg gaboxadol hydrochloride on three consecutive nights vs. placebo. Gaboxadol significantly shortened subjective sleep onset latency and increased self-rated sleep intensity and quality without side effects. Next-day cognitive performance was not affected by gaboxadol. Effect of Repeated Gaboxadol Administration on Night Sleep and Next-Day Performance in Healthy Elderly Subjects. Mathias S, Zihl J, et al. Max-Planck-Institute of Psychiatry, Munich, Germany. Neuropsychopharmacology. 2004 Dec 15. Ed: Gaboxadol is a new medication under development.
Nasal Dilator Strip Might Help: In a 4-week randomized study of 80 nonobese, adults with a primary chronic sleep-maintenance insomnia and mild to moderate sleep disordered breathing (SDB), the treatment group had (p=.0001) large improvements in insomnia and sleep quality, as well as some improvement in life satisfaction. Nasal dilator strip therapy for chronic sleep-maintenance insomnia and symptoms of sleep-disordered breathing: a randomized controlled trial. Krakow B, et al. Albuquerque, NM. Sleep Breath 2006 Feb 23. Strips cost $8-10 for one that lasts a month.
Sleep Phase Disorder: Many teenagers have problems with insomnia. In 8% it is severe enough to be a medical disorder. 90% of these are reportedly due to getting in the habit of staying up too late and the body being unable to force itself to fall asleep at an earlier hour. An old treatment for this has been rediscovered. The teenager is instructed to make his sleep and awaking time 3 hours later each day for six or seven days until the sleep time has been shifted to what is needed. Clinicians report great success with this approach. Phillip Pearl, George Washington Univ., AAP 2002 National Conference. Presented Oct. 23, 2002.
Snoring Common, Especially in Males: A cross-sectional, epidemiological study of 1245 adults found that habitual snoring was reported in 8.9% of females and 29.5% of males. Male sex, age over 40 years, obesity, smoking, and the use of alcohol were significant risk factors. Hypertension and coronary heart disease were statistically more common with habitual snoring. The severity was high enough in 2.1% of females and in 9.4% of males to force their roommates to leave the room, making 1.1% of females and 3.4% of males to show willingness to receive medical attention. The prevalence of snoring in adult population. Kara CO, et al. Pamukkale University, Denizli, Turkey. . Kulak Burun Bogaz Ihtis Derg. 2005 Jan-Feb;14(1-2):18-24.
Snoring Linked to Hyperactive, Inattentiveness, Tiredness, Emotionality: In 1144 children, habitual snoring (HS; snoring frequently or always) and impaired behavior were assessed using parental questionnaires. Intermittent hypoxia was determined by pulse oximetry. HS was significantly associated with hyperactive (OR: 2.4) and inattentive behavior (OR: 4.0), daytime tiredness (OR: 7.1), and sleepiness (OR: 2.6-4.8). These associations were independent of intermittent hypoxia. HS was also significantly associated with bad conduct (OR: 2.8), emotional symptoms (OR: 5.5), and peer problems (OR: 9.7). At follow-up, hyperactive and inattentive behavior but not academic success had significantly improved in children in whom HS had ceased. Habitual snoring, intermittent hypoxia, and impaired behavior in primary school children. Urschitz MS, Eitner S, et al. University Children's Hospital, Tuebingen, Germany. Pediatrics. 2004 Oct;114(4):1041-8
Snoring Again Linked to ADHD in Children: In a study of 2147 children, 151 children with habitual snoring (HS) were compared to 302 controls. Children with ADHD were excluded. Of the remaining 96 habitual snorers and 190 control subjects (mean age: 9.4), HS had more symptoms of hyperactivity (Conners-ADHD index) (P: 0.033), attentional (P: 0.019), and conduct and oppositional defiant in subscales (P: 0.001) of Conners' Parent (Conners-P) and inattention hyperactivity scale (IHS)-Parents. A pooled score of Conners-P ADHD Index > 60 and IHS-Parent score > 1.25 showed considerable difference in HS when compared with controls (5.1% vs. 1.4%) (P < 0.0001). Daytime hyperactivity and excessive daytime sleepiness reported by parents correlated with scores of Conners-P and IHS-P (P < 0.01). Teachers' observations showed significant correlations with learning disability and the level of academic performance in HS (P < 0.01). Symptoms of inattention and hyperactivity in children with habitual snoring: evidence from a community-based study in Istanbul. Arman AR, et al. Marmara University, Istanbul, Turkey. Child Care Health Dev. 2005 Nov;31(6):707-17.
Trazodone Helped SSRI, Bupropion, MAOI Insomnia: Twelve depressed patients on SSRI anti-depressants and suffering from insomnia due to the anti-depressants were given either 100 mg trazodone or placebo for 7 days in a double-blind crossover design with a 7-day washout period. Trazodone significantly increased total sleep time, percentage of stages 3+4, sleep efficiency index, sleep continuity index and decreased percentage of stage 1, number of awakenings, and stage shifts. This improvement was also obtained after 7 days of treatment. Hamilton depression scores were reduced to 11.5+/-4.5 with trazodone and to 12.2+/-3 with placebo. The effects of trazodone on sleep in patients treated with stimulant antidepressants. University of Istanbul. Sleep Med. 2004 Jan;5(1):15-20. Similar DB PC results for fluoxetine or bupropion insomnia. Yale. Am J Psychiatry. 1994 Jul;151(7):1069-72. Also, helped insomnia on MAO inhibitors without complications in an open trial. J Clin Psychiatry. 1990 Jul;51(7):298-302
Trazodone Helped Post Alcohol Withdrawal, PTSD Insomnia: In a 16-patient DB PC 4-week study of alcoholics just after detox, patients given trazodone had fewer sleep problems as well as less depression and better global clinical scores. Double-blind, placebo-controlled study of the efficacy of trazodone in alcohol post-withdrawal syndrome: polysomnographic and clinical evaluations. Le Bon O, Murphy JR, Staner L, Hoffmann G, Kormoss N, Kentos M, Dupont P, Lion K, Pelc I, Verbanck P. J Clin Psychopharmacol. 2003 Aug;23(4):377-83. Trazodone is also reportedly helpful for insomnia in PTSD patients in a 74 patient open trial study, but no double-blind trials are available. Pharmacopsychiatry. 2001 Jul;34(4):128-31
Neither Valerian Nor Kava Helped Anxiety or Insomnia in Large Internet Study: It had to happen. In the first internet-based, 4-week DB PC study of 391 adults with anxiety disorders from all across the U.S.,
Valerian As Good as a Benzodiazepine in Large DB Study: In a 6-week, 202-patient DB study comparing 600 mg/die valerian extract (Sedonium) or 10 mg/day oxazepam, valerian was at least as effective as oxazepam with markedly increased sleep quality compared with baseline (p <0.01) including feeling of refreshment after sleep, psychic stability in the evening, psychic exhaustion in the evening, psychosomatic symptoms in the sleep phase, dream recall, and duration of sleep confirmed similar effects of both treatments. Most patients assessed their respective treatment as very good (83% for valerian, 73% for oxazepam). Efficacy and tolerability of valerian extract LI 156 compared with oxazepam in the treatment of non-organic insomnia--a randomized, double-blind, comparative clinical study. Ziegler G, Ploch M, Miettinen-Baumann A, Collet W. Stuttgart, Germany. Eur J Med Res. 2002 Nov 25;7(11):480-6
Valerian Mild Benefit in DBs for Sleep: GABA affinity. Mild sedative. Reported anxiolytic. 2-3 g root TID or HS. Wong. JAMA 11/11/98 280:1566-7 report on cardiac diff and delirium from valerian root withdrawal. Als delayed effects assoc with OD. In a DB study of a benzodiazepine vs. a valerian-hops combination, both were equal for sleep for 2 weeks although the benzodiazepine caused withdrawal symptoms with aggravated insomnia. Patients had improved during treatment on both and sleep deteriorated after stopping on both. Schmitz, Vienna, Wien Med Wochenschr ’98;148:291; Five other very small earlier DB in German areas or Sweden. Two found no impact on sleep, one of which didn’t find a benzodiazepine to have any impact either. Valerian has been used since times of ancient Greeks and in U.S. until the 1950’s when it was replaced by benzodiazepines. From root. Far less sedating than benzodiazepines in 1993 German mouse study. 150-300mg am and 300-500 hs. recommended by Kathryn Connor. U. Gerhard’s 1996 German study DB 60 pts valerian vs. flurazepam or placebo found valerian equally effective with flurazepam and only 10% vs. 50% of those on flurazepam had side-effects.
Valerian Helped Sleep as Well as Benzodiazepine: In a DB study of 75 patient for 28 day, clear improvement occurred in both oxazepam and valerian 600 mg 30 min before bedtime groups. Forsch Komplementarmed Klass Naturheilkd 2000 Apr;7(2):79-84. No negative impact was found for valerian on reaction time, alertness, or concentration vs. placebo after 14 days. Pharmacopsychiatry 1999 Nov;32(6):235-41; One odd report of treating 23 patients in "n-of-1 studies" for insomnia found valerian of no value. Univ. Sydney. Complement Ther Med. 2003 Dec;11(4):215-22
Valeriana was Better than Salvia Miltiorrhiza for Angina: Valeriana officinalis var latifolia VOL was superior to SMCo on matter in the remission of symptoms, decreasing the attack frequency and shortening the duration of angina, or in restoring the blood supply to ischemic myocardium. In addition, it was discovered that VOL could lower plasma lipids as well. Zhongguo Zhong Xi Yi Jie He Za Zhi. 1994 Sep;14(9):540-2.