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How is insomnia treated?

When a person has primary insomnia, in which the inability to sleep is not caused by other health problems, the two key treatments are medication and cognitive behavioral therapy (CBT), according to Alon Avidan, MD, PhD, associate director of the Sleep Disorders Program at UCLA.

He says that some people initially attempt to address insomnia on their own by taking over-the-counter medications with a sedative effect or by using herbal compounds or dietary supplements. These drugs may help with temporary insomnia in some people but should be used only intermittently and only for a short duration. "We also have newer prescription medications that can safely and effectively treat both short-term and chronic insomnia, including new, non-habit-forming compounds that do not cause drowsiness the next day," he says. “Patients should always solicit the assistance of their physicians for help addressing sleep problems. Likewise, primary care physicians should include sleep disorders in their review of system inventory.”

Sarosh Motivala, PhD, a clinical psychologist specializing in sleep disorders at the Jane and Terry Semel Institute for Neuroscience and Human Behavior at UCLA, says cognitive behavioral therapy (CBT) is often more effective than medications for treating insomnia, without adverse side effects, and some patients may begin to see improvements after only a few therapy sessions. “CBT addresses the stress-related and behavioral aspects of insomnia and provides long-term benefits by helping the patient change the thoughts and actions that interfere with the ability to get restful sleep,” Dr. Motivala explains. Nighttime anxieties, dealing with day-to-day stresses and spending excessive amounts of time in bed awake are all behaviors that can be targeted with CBT.

When insomnia is caused by other conditions that interfere with sleep, such as depression or anxiety, chronic pain, periodic leg movements or, more commonly, sleep apnea, designing a treatment strategy can be more complicated.

Sleep is strongly interconnected with many chronic diseases. It is important that people raise the issue with their doctors because there are serious consequences of prolonged sleep disorders.

Studies suggest that treatments that help you modify the behaviors and thoughts that interfere with sleep are more effective in the long run than sleep medications. Here are four common approaches:

Relaxation therapy uses methods such as progressive muscle relaxation, deep-breathing exercises, biofeedback, and meditation or another attention-focusing activity to help you relax your mind and body.

Sleep-restriction therapy involves limiting the time you spend in bed to the average number of hours you actually sleep each night over a 2-week period. That does not include the time you spend tossing and turning. If you typically get only 5 hours of good shut-eye and feel tired and out of sorts the next day, you'll begin by being in bed for only 5 hours. Eventually, as your sleep improves, you'll increase your time in bed by 30-minute increments until you're getting enough of the high quality sleep you need to feel rested.

Sleep hygiene involves practicing healthy sleep habits, including limiting bedroom activities to sleep and sex—not working, not watching TV, not reading in bed—to retrain yourself to associate the bed only with those two activities. For many people, reconditioning by following the principles of good sleep hygiene allows them to fall asleep more quickly.

Cognitive-behavioral therapy (CBT) is done with a therapist in order to help you learn to overcome the stressful attitudes or specific beliefs that undermine your efforts to get to sleep. CBT often accompanies another approach, such as sleep-restriction therapy.

Good "sleep hygiene" or our personal sleep habits are essential to getting a good night’s sleep. I frequently counsel patients as to how to get a good night’s sleep. These are some pointers that I give to patients, and that I try to follow myself. 

  • Keep a fixed time for going to bed and waking up, even on the weekends. Avoid napping during the day.
  • Avoid excessive alcohol or caffeine in general, and especially avoid or limit these beverages 4-6 hours before bedtime.  
  • Try to get regular exercise, ideally in the afternoon.
  • Keep the temperature in your bedroom at a comfortable setting. Keeping your bedroom too hot or cold may keep you awake.
  • Keep your bedroom free of noise or excessive light.
  • Reserve your bed for just sleep and sex. Do not use the bed for watching TV, doing work, or as a recreation area. You need to associate the bed with sleeping only. In addition do not keep a TV in your bedroom.

If you find that you wake up in the middle of the night and cannot get back to sleep, do not remain in bed tossing and turning, or staring at the clock. Get out of bed and perform a quiet activity such as reading, do NOT perform stimulating activity such as work, housework, and do not watch TV. 

If these measures are not effective, consult your doctor.

Dr. Mehmet Oz, MD
Cardiologist (Heart Specialist)

If you have insomnia, remember to start your day with some exposure to sunlight or a bright light. Get some exercise throughout the day, and avoid napping and caffeine after 3 p.m. Hide the clocks in the bedroom, and if you toss and turn for more than 20 minutes, get out of bed and read or listen to music until you feel sleepy.

Remember that alternative sleep remedies like cognitive behavioral therapy, acupuncture and yoga have been shown to be just as effective as medications. These therapies also help reduce stress and anxiety.

Concerns about insomnia should be discussed with a doctor. Help for an ongoing sleep problem is available from the sleep team at an accredited sleep center.

This content originally appeared on the American Academy of Sleep Medicine website.

If you are having problems with insomnia, there are several things you can do to help reset your sleep cycle:

  • Do not watch TV or work on the computer later than 9 p.m. (ideally 8 p.m.). Both of these activities are stimulating to the mind and significantly impair the secretion of melatonin due to the strong light they emit.
  • Remove the TV from your bedroom. The environment of the bedroom should reflect the activities taking place there—sleep, relaxation and sexual intercourse. Having a TV in the bedroom is counterproductive to all of these activities. Although many people look to television as a way of relaxing, from a neurochemical standpoint, it has a stimulating effect.
  • Watch the sunset daily. Even if you are able to only take a 10-minute walk as the sun is setting, this is a very powerful way to enhance melatonin secretion. Once you are waking up earlier, also watch the first 10 minutes of the sunrise. Your brain is able to differentiate between the setting and rising rays of the sun and initiates a chain of biochemical reactions to support your natural daily cycles. An easy way to prevent jet lag is to watch the sunset and sunrise for the first 24-48 hours in your new destination.
  • Stop drinking caffeine. Caffeine disrupts your natural sleep cycle. Even drinking caffeine in the morning interrupts your sleep because, over time, it causes a chemical shift towards a state of excitation. Caffeine taken in the second half of the day is an even bigger obstacle to deep sleep during the night. Stopping caffeine abruptly can be quite stressful to the nervous system so slowly taper off your caffeine gradually over 4-8 weeks.
  • Eat a small dinner. You now know that your digestion gets weaker as the day progresses. Eating a large dinner interrupts your ability to fall asleep because your body is contending between two different processes -- preparing for sleep and restoration versus managing the undigested food in your stomach.
  • Avoid naps during the day until you are able to fall asleep before 10 p.m. If you still need a nap during the day even though you have adjusted your bedtime to before 10 p.m., then a brief nap is okay. If this is predominantly happening after meals, then you need to work on strengthening your digestion. Once your digestion is stronger, you will not feel tired after meals.
Dr. Ruth White, MPH
Social Work Specialist

The main treatments for insomnia include behavioral programs, medications (over-the-counter, prescription, and herbal), and improved sleep hygiene. Without going into detail, some of the behavioral programs include cognitive behavioral therapy (CBT) and relaxation and meditation strategies. Medications used for sleep include the family of drugs related to benzodiazepines, such as Ambien (zolpidem), Halcion (triazolam), Sonata (zaleplon), and Lunesta (eszopiclone); antidepressants, such as Desyrel (trazodone) or Remeron (mirtazapine); and some antipsychotic medications, such as Seroquel (quetiapine), because of their sedating qualities.

The easiest place to start treating insomnia is to change your sleep-related behavior. If your strategies don't work, discuss other interventions with your provider.

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Dr. Marina Johnson
Endocrinologist

I’m an endocrinologist—a hormone specialist—and it’s important to emphasize that insomnia can result from endocrine problems in both men and women. Disorders of thyroid hormone, testosterone, cortisol, and growth hormone can all cause sleep disorders. Detecting a subtle endocrine imbalance may sometimes be difficult requiring the expertise of an endocrinologist.

Sleep is a mysterious bodily process that is absolutely essential to good health. We should not have to rely on a drug to make us sleep! We do not have to be taught how to sleep. Every member of the animal kingdom has an obligatory need for sleep. If humans go much more than 18 hours without sleep, they start experiencing microsleep where they zone out from a few seconds to minutes. 

People can also develop insomnia from poor lifestyle choices. Overzealous Americans intent on squeezing more work, more fun, more family time and more sheer activity into their lives often short-change their sleep. What are ways to promote a good night sleep? Try going to bed at the same time each night and getting up at the same time. The body likes a regular schedule. Sleep in a cool, dark room use nightshades, white noise or a sleep mask if necessary. Avoid spicy food or caffeine-containing foods in the evening. Finish eating at least 3 hours before bedtime. Many individuals find that heavy intake of sugar or alcohol at dinner leads to restless sleep. Start winding down in the evening. Do not engage in heavy exercise late at night. Don’t watch the 10 o’clock news or read grisly books which cause mental over-stimulation. Individuals who can’t function without a large dose of coffee in the morning are usually sleep-deprived.

Establishing hormone balance can lead to normal, refreshing sleep which is the body’s own way of healing a myriad of health problems. Read more in my guidebook for women, “Outliving Your Ovaries:  An Endocrinologists Reviews and Risks and Rewards of Treating Menopause with Hormone Replacement. www.drmarinajohnson.com.

Insomnia can be caused by numerous things, so treatments vary based on the cause. In this video, Jamie Fernandez, MD, of Memorial Hospital of Tampa, describes some of the therapies and medications to treat primary and secondary insomnia.

There are several treatment options for short-term insomnia. If the cause of your insomnia is an underlying medical condition, a doctor might be able to treat the condition and get rid of the insomnia by doing so. If the cause is stress or anxiety, cognitive-behavioral therapy might help offer relief. Lifestyle changes such as keeping regular hours or not drinking caffeine may also help. Your doctor may also prescribe sleep medication.

The treatment for insomnia depends on the cause(s). If the person with insomnia has mood or anxiety problems, getting treatment for those conditions improves sleep. If a person's schedule for getting to sleep and waking up is irregular, a more consistent schedule may help. Avoiding stressful or exciting tasks or vigorous exercise in the evening and having a routine for winding down with quiet, pleasant or restful activities may help.

If anxiety or mood problems are treated, the sleep and waking schedule is consistent, a relaxing bedtime routine is established and alcohol and caffeine are limited but the insomnia continues, then other approaches may be necessary. Learning relaxation techniques may help. Using prescription sleep medications for short-term relief or on an intermittent basis is an option, but using many sleeping pills for longer than that or chronically may cause addiction.

What are some tips on getting a good night's sleep?

  • Keep to a schedule where you go to sleep and get up at the same times every day. This will put your body into a good sleep-wake rhythm.
  • For several hours before bedtime, avoid alcohol, drinks that contain caffeine, chocolate, heavy, sugary or spicy foods and smoking.
  • Try to get regular exercise in the morning or afternoon. Avoid exercising in the evening.
  • Make the place you sleep as comfortable as possible. Buy a firm, comfortable mattress, make sure your bedroom is a comfortable temperature for sleeping and well ventilated. Block out all distracting noise and darken the room as much as possible.
  • Use your bed for sleep and sex only. Do not use your bed as an office or recreation room.

If insomnia is caused by a short-term change in the sleep/wake schedule, as with jet lag, your sleep schedule may return to normal on its own.

If your insomnia makes it hard for you to function during the day, talk to your doctor.

Treatment for chronic insomnia includes:
Finding and treating any medical conditions or mental health problems. Looking for routines or behaviors, like drinking alcohol at night, that may lead to the insomnia or make it worse, and stopping (or reducing) them. Possibly using sleeping pills, although controversy surrounds the long-term use of sleeping pills. You should talk to your doctor about the risks and side-effects. Trying one or more methods to improve sleep, such as relaxation therapy, sleep restriction therapy, and reconditioning.

Relaxation Therapy: This type of therapy aims to reduce stress and body tension. As a result, your mind is able to stop "racing," the muscles can relax, and restful sleep can occur. Sleep Restriction: Some women suffering from insomnia spend too much time in bed trying to fall asleep. They may be helped by a sleep restriction program under the guidance of their doctor. The goal is to sleep continuously and get out of bed at the desired wake time. This treatment involves, for example, going to bed later or getting up earlier and slowly increasing the amount of time in bed until the person is able to sleep normally throughout the night. Reconditioning: This means using your bed only at bedtime when sleepy or for sex. Avoid other activities in your bed, such as reading or watching TV. Over time, your body will relate bed and bedtime with sleep.

This answer is based on source information from the National Women's Health Information Center.

Dr. Lisa Medalie, CBSM, PsyD
Psychology Specialist

The main treatment options for alleviating insomnia symptoms are 1. Cognitive Behavioral Treatment for Insomnia (CBT-I), 2. Medication, or 3. Combined CBT-I and Medication. Head-to-head studies comparing CBT-I to medication show that both work equally well in the short run but in the long run CBT-I works best because you stop taking medication and it stops working! Also, many patients complain about side effects for medications commonly used for insomnia.

To elaborate on CBT-I, it is typically a 5-8 week treatment administered by a trained Behavioral Sleep Medicine Specialist. The work involves filling out weekly sleep logs, making changes to your sleep schedule and learning strategies for dealing with thoughts, behaviors and emotions interfering with sleep. Research shows this treatment is effective in 75 percent of those who follow treatment guidelines. In clinic, almost all patients see at least some alleviation of insomnia symptoms. Patients with moderate to severe psychological or medical comorbidities may not respond as well to treatment as those who have "pure" insomnia. However, even patients with secondary insomnia (i.e., insomnia caused by mental or medical issues) can benefit from CBT-I.

Dr. Michael Breus, PhD
Psychology Specialist

Diagnosing and treating insomnia are critically important to your health and your safety. Fortunately, there's been tremendous progress in the treatment of insomnia, both in pharmacological and non-pharmacological therapies.

Pharmacological therapies include new drugs that work as an entirely new type of sleep medication, by blocking the brain receptor for a hormone called orexin that promotes wakefulness and alertness. Unlike other sleep medications that play with the brain’s “sleep” switch, this new form of medication changes the brain’s “wake-up” switch.

Other important therapies, like cognitive behavioral therapy (CBT), exist to help reduce or eliminate the difficult symptoms of insomnia. CBT has been shown tremendously effective in reducing the symptoms of insomnia and works by changing behaviors, attitudes and feelings about sleep. In a series of structured sessions with a therapist or counselor, people reflect on how things they think or do could affect their sleep. They then work to replace those behaviors with habits that promote good sleep.

This content originally appeared on doctoroz.com.

Transient and intermittent insomnia may not require treatment because episodes only last a few days. Some people who experience daytime sleepiness and impaired performance from transient insomnia can find relief with short-acting sleeping pills. However, over-the-counter sleep medicines, if used at all, should be used on a short-term basis and are not recommended for chronic insomnia.

Lifestyle changes and consultation with a healthcare professional are your best options for persistent insomnia. These include identifying and treating any underlying medical or psychological problems, and reducing sleep-impairing activities, such as limiting caffeine consumption or managing stress. Behavioral modification can also be undertaken through special behavioral techniques, such as:

  • Relaxation therapy. Specific techniques to reduce or eliminate anxiety and body tension, such as yoga, meditation or guided imagery. Ideally, your mind is able to stop racing, your muscles can relax, and you can get some restful sleep. You typically have to practice these techniques for a few weeks before they're effective.
  • Sleep restriction. Some people suffering from insomnia spend too much time in bed trying to sleep. They may benefit from a program that initially allows only a few hours of sleep during the night, gradually increasing sleep time until a more normal night's sleep is achieved.
  • Reconditioning. Another treatment is to recondition yourself so you learn to associate the bed and bedtime with sleep. For most people, this means not using the bed or bedroom for any activities other than sleep and sex; this is also referred to as stimulus control. As part of the reconditioning process, you should only go to bed when you're sleepy. If you're not able to fall asleep, get up, stay up until you're sleepy and then return to bed. Throughout this process, you should avoid naps, and wake up and go to bed at the same time each day. Eventually your body and mind begin to associate the bed and bedtime with sleep.
  • Using medications that aid in insomnia treatment. These include zaleplon (Sonata), eszopiclone (Lunesta), zolpidem (Ambien), ramelteon (Rozerem), hypnotic medications, antidepressants and antihistamines. Don't drink alcohol if you're taking any sleep medications because it can intensify their effects.

There are several approaches to treating insomnia. If insomnia may be attributed to a particular underlying cause, it is important to address this, but insomnia is increasingly viewed as a separate disorder requiring appropriate attention and treatment. Approaches consist primarily of behavioral intervention and/or medication.

Behavioral intervention may include sleep hygiene and stimulus control, in which the bedroom is associated with sleep and sex only and stimuli such as television and other activities are restricted. Avoiding caffeine, food, alcohol or exercise before bed, setting up a regular sleep schedule and avoiding sleeping in during the mornings may also help with insomnia. Relaxation techniques and cognitive behavioral therapy have also been proved to be effective for many people who suffer from insomnia.

Medications such as benzodiazepines and other sedatives may also be used in the treatment of insomnia. Medications may vary in strength, duration and side effects and may not be safe to take in certain populations. If you suffer from insomnia, speak with your physician to find the right approach for you.

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Important: This content reflects information from various individuals and organizations and may offer alternative or opposing points of view. It should not be used for medical advice, diagnosis or treatment. As always, you should consult with your healthcare provider about your specific health needs.