Insomnia

According to recent reports, many people today have a serious problem getting a good nights sleep. Our lives are simply too busy for us to get the 8 hours we really need. To make matters worse, many of us suffer from insomnia. When we do get to bed, we may stay awake thinking for hours. Sleep itself may be restless instead of refreshing.

Most people who sleep substantially less than 8 hours a night experience a variety of unpleasant symptoms. The most common are headaches, mental confusion, irritability, malaise, immune deficiencies, depression, and fatigue. Complete sleep deprivation can lead to hallucinations and mental collapse.

The best ways to improve sleep are lifestyle changes: eliminating caffeine and sugar from your diet, avoiding stimulating activities before bed, adopting a regular sleeping time, and gradually turning down the lights.

Many drugs can also help with sleep. Such medications as Ambien, Restoril, Ativan, Valium, Xanax, and chloral hydrate are widely used for sleep problems. However, these medications tend to promote tolerance and dependency on the drug, and can even cause addiction.

Recently, physicians have come to regard some forms of insomnia as a variation of depression. This conclusion comes from a kind of reverse reasoning: We know that depression almost always disturbs sleep, and that antidepressants frequently help insomnia. Therefore, maybe some cases of insomnia really are depression in disguise.

Antidepressants can be used in two ways to correct sleep problems. Low doses of certain antidepressants immediately bring on sleep because their side effects include drowsiness. However, this effect tends to wear off with repeated use.

For chronic sleeping problems, full doses of antidepressants may be necessary. Antidepressants are believed to work by actually altering brain chemistry, which produces a beneficial effect on sleep. Desyrel (trazodone) and Serzone (nefazodone) are two of the most commonly prescribed antidepressants when improved sleep is desired, but most other antidepressants can be helpful as well.

Principal Proposed Treatments for Insomnia:

Although the scientific evidence isnt yet definitive, the herb valerian and the hormone melatonin are widely accepted as treatments for certain forms of insomnia.

Valerian: Appears to Improve Sleep Gradually

Over 200 plant species belong to the genus Valeriana, but the species used for insomnia is Valeriana officinalis. This perennial grows abundantly in moist woodlands in Europe and North America and is under extensive cultivation to meet market demands. The root is used for medicinal purposes.

Valerian has a long traditional use for insomnia. Galen recommended valerian for insomnia in the second century A.D. The herb became popular in Europe from the sixteenth century onward as a sedative and was widely used in the United States as well until the 1950s. Rumors have it that Valium was named to imitate the sound of valerian, although there is no chemical similarity between the two.

Scientific studies of valerian in humans did not begin until the 1970s. The results ultimately led to its approval by Germanys Commission E in 1985. Presently, valerian is an accepted over-the-counter drug for insomnia in Germany, Belgium, France, Switzerland, and Italy.

Valerian is commonly recommended as an aid for occasional insomnia. However, the results of a recent study suggest that it may be more useful for long-term improvement of sleep.

What Is the Scientific Evidence for Valerian?

Constituents of valerian as well as whole-valerian extracts have been shown to act as sedatives in laboratory animals. Studies in humans have also found that valerian is an effective sleeping aid.

A recent 28-day double-blind placebo-controlled study followed 121 people with histories of significant sleep disturbance. This study looked at the effectiveness of 600 mg of an alcohol-based valerian extract taken 1 hour before bedtime.

Valerian didnt work right away. For the first couple of weeks, valerian and placebo were running neck and neck. However, by day 28 valerian had pulled far ahead. Effectiveness was rated as good or very good by participant evaluation in 66% of the valerian group and in 61% by doctor evaluation, whereas in the placebo group, only 29% were so rated by participants and doctors.

This study provides good evidence that valerian is effective for insomnia. However, it has one confusing aspect: the 4-week delay before effects were seen. In another large study, valerian produced an immediately noticeable effect on sleep,and that is what most practitioners believe to be typical. Why valerian took so long to work in this one study has not been explained.

Additional evidence for valerians effectiveness comes from a double-blind placebo-controlled study of 78 elderly patients. In this case, sleep improved by the end of the study, at 14 days.

Finally, a 28-day double-blind trial of 75 individuals with insomnia compared valerian (600 mg at bedtime) with the standard drug oxazepam (10 mg at bedtime). The results showed no differences in effectiveness.

The combination of valerian and lemon balm, also known as melissa, has been tried for insomnia. A rather poorly designed, 30-day, double-blind, placebo-controlled study of 98 individuals without insomnia found marginal evidence that a valerian–lemon balm combination improved sleep quality as compared to placebo. However, a double-blind crossover study of 20 people with insomnia that compared the benefits of the sleeping drug Halcion (0.125 mg) against placebo and a combination of valerian and lemon balm, failed to find the herb effective. Finally, a study compared a mixture of hops and valerian against the standard European sleeping medication bromazepam, and found them equally effective.

We dont really know how valerian acts to induce sleep. Research suggests that the neurotransmitter GABA may be involved, although this has been disputed. Conventional sleeping pills affect GABA as well.

For more information, including dosage and safety issues, see the full valerian article.

Melatonin: Rapid Effect on Sleep

The body uses melatonin as part of its normal control of the sleep-wake cycle. The pineal gland makes serotonin and then turns it into melatonin when exposure to light decreases. Strong light (such as sunlight) slows melatonin production more than weak light does, and a completely dark room increases the amount of melatonin made more than a partially darkened room does.

Taking melatonin as a supplement seems to stimulate sleep when the natural cycle is disturbed. It has been most studied as a treatment for jet lag. In addition, it may be helpful for individuals who work the night shift and want to change sleeping time on the weekends, as well as for those with ordinary insomnia. Melatonin may also help blind people adjust to a sleep schedule.

What Is the Scientific Evidence for Melatonin?

There is reasonably good evidence that melatonin can help you fall asleep when your bedtime rhythm has been disturbed, although there have been negative studies as well.

One double-blind placebo-controlled study enrolled 320 people and followed them for 4 days after plane travel. The participants were divided into four groups and given a daily dose of 5 mg of standard melatonin, 5 mg of slow-release melatonin, 0.5 mg of standard melatonin, or placebo. The group that received 5 mg of standard melatonin slept better, took less time to fall asleep, and felt more energetic and awake during the day than the other three groups.

According to one review of the literature, melatonin treatment for jet lag is most effective for those who have crossed a significant number of time zones, perhaps eight. One sizeable study on travelers found no benefit, but it has been suggested that the change in time zones experienced by these travelers wasnt great enough to require melatonin. However, a small double-blind trial found no benefit even with travel over many time zones.

Mixed results have been seen in other studies involving the use of melatonin for swing-shift workers and for elderly individuals with insomnia.

A 4-week double-blind trial evaluated the benefits of melatonin for children with difficulty falling asleep. A total of 40 children who had experienced this type of sleep problem for at least a year were given either placebo or melatonin at a dose of 5 mg. The results showed that use of melatonin significantly helped participants fall asleep more easily. Benefits were also seen in a study of 20 developmentally disabled children with sleep problems.

Note: The long-term safety of melatonin usage has not been established. Do not give your child melatonin except under physician supervision.

Many individuals stay up late on Friday and Saturday nights, and then find it difficult to go to sleep at a reasonable hour on Sunday. A small double-blind placebo-controlled study found evidence that use of melatonin 5.5 hours before the desired Sunday bedtime improved the ability of participants to fall asleep.

Benefits were seen in a small double-blind trial of patients in a pulmonary intensive care unit. It is famously difficult to sleep in an ICU, and the resulting sleep deprivation is not helpful for those recovering from disease or surgery. In this study of 8 hospitalized individuals, 3 mg of controlled-release melatonin "dramatically improved" sleep quality and duration.

A double-blind placebo-controlled trial of 38 individuals with insomnia and diabetes found significant benefits in sleep quality. In addition, a study of 19 individuals with schizophrenia who had disturbed sleep patterns found that 2 mg of controlled-release melatonin improved sleep.

Blind people often have trouble sleeping on any particular schedule, because there are no "light cues" available to help them get tired at night. A small double-blind placebo-controlled crossover trial found that the use of melatonin at a dose of 10 mg per day was able to resynchronize participants sleep schedules.

Some individuals find it impossible to fall asleep until early morning, a condition called delayed sleep phase syndrome (DSPS). Melatonin may be beneficial for this syndrome.

In addition, people trying to quit using sleeping pills in the benzodiazepine family may find melatonin helpful. A double-blind placebo-controlled study of 34 individuals who regularly used such medications found that melatonin at a dose of 2 mg nightly (controlled-release formulation) could help them discontinue the use of the drugs.

Note: There can be risks in discontinuing benzodiazepine drugs. Consult your physician for advice.

For more information, including dosage and safety issues, see the full melatonin article.

Other Proposed Treatments for Insomnia:

Tryptophan and 5-Hydroxytryptophan

For many years, people used tryptophan as a sleeping aid. However, an accidental poisonous contaminant in one batch caused many cases of a terrible illness called eosinophilic myalgia. Tryptophan has since been taken off the shelves.

The substance 5-HTP (5-hydroxytryptophan) has recently become widely available as a substitute. Because it is made by a completely different manufacturing process (starting from a plant rather than bacteria), one would not expect the same contaminant to appear. Surprisingly, however, in September 1998 the FDA released a report stating that there was some evidence that commercial 5-HTP preparations might contain a similar contaminant. Because this is late-breaking news, we suggest you check with your physician for the most recent information.

For other dosage and safety issues, see the full 5-HTP article.

Acupressure

A single-blind placebo-controlled study involving 84 nursing home residents found that real acupressure (5 minutes of acupressure, 5 times weekly for 3 weeks) was superior to sham acupressure for improving sleep quality. Treated participants fell asleep faster and slept more soundly.

Other Herbs and Supplements

The antianxiety herb kava might be helpful for insomnia, although there is no direct evidence that it works.

Because prescription antidepressants can help you sleep, it has been suggested that the herb St. Johns wort may be useful in the same way. A double-blind trial of 12 non-insomniacs found no sleep-promoting benefit, but this says little about its effectiveness in individuals with sleep problems.

Many other herbs are reputed to offer sedative or relaxant benefits, including ashwagandha, astragalus, chamomile, He shou wu, hops, ladys slipper, passionflower, and skullcap. Vitamin C is also sometimes recommended. However, there is as yet little scientific evidence that these treatments really work.