CCF Sleep

Info about prescription medication and OTCs for insomnia

With today’s fast-paced lifestyles and overbooked days, insomnia strikes nearly everyone at some point. It’s normal to have some nights that aren’t as restful as others, but when it happens in a string of nights, you might want to try an over-the-counter sleep aid.

Here are 4 tips to using over-the-counter sleep aids safely:

• Allow enough time for a full night’s sleep: Set aside a full eight hours for sleep. You want the aid to help you fall asleep, but not make you groggy when you wake up.
• Be on the lookout for side effects: If you have a history of depression, sleep aids can temporarily make it worse. These medications reduce anxiety and relax your muscles, but they can also lead to abnormal thinking, hallucinations, or sleep-drunkenness. Headaches and nausea are also possible.
• Only take pills for a short time: Use sleep aids for no longer than two to four weeks. If insomnia persists, talk with your doctor as long term use of sleep aids can perpetuate chronic insomnia and potentially lead to memory impairment and incoordination.
• Don’t stop taking a sleep aid suddenly: Quitting abruptly can cause rebound insomnia – three to four days of more severe insomnia than usual. Patients can even experience rebound insomnia after only brief use. If you take a sleep aid nightly, gradually reduce the dose until you no longer need the medication.

However, if over-the-counter sleep aids aren’t cutting it, a prescription sleep aid may be warranted. Prescription sleeping pills, also known as sedative hypnotics, promote sleep through different brain mechanisms. Talk to your doctor to find out which medication is best for you.

Complementary, natural approaches to aid medical methods

Already seeing a physician for help with your sleeping problems? You might want to try complementary therapies as another way to help you get back to restful slumber.

Complementary medicine refers to forms of non-invasive therapies that a patient can use alongside conventional medicine. Nearly 40% of Americans use these approaches, says the National Institutes of Health, and they have been scientifically shown to be safe and effective.

Here’s a rundown of complementary therapies for insomnia and how you can leverage them to get back to sleep:

Mind-body therapies

The mind is a key player when it comes to how easily you fall asleep and stay asleep, so people should try mind-body techniques first when they experience insomnia. Examples of mind-body techniques include meditation, hypnosis, guided imagery, tai chi and yoga. These practices can help to calm people’s thoughts and help them to relax. They are particularly helpful for older adults.

Body-based therapies

Body-based therapies can relax the body enough so that it is ready for sleep. Massage and acupuncture enhance sleep quality, especially if you’re feeling pain. Energy techniques are used for stress reduction and include reiki, healing touch, and therapeutic touch.

Biologically-based therapies

Biological supplements aren’t sleeping pills. They help to balance your body’s chemistry and rhythm naturally, and may make it easier to fall asleep.

Some of the most popular biological treatments are:

• Magnesium, a mineral supplement
• Melatonin, a hormone that plays a role in sleep
• Chamomile tea
• I-theanine, a naturally occurring amino acid
• Valerian, an herb

Cognitive-behavioral therapy for insomnia

Cognitive behavioral therapy for insomnia (CBT-I) is a group of strategies that can help you to fall asleep faster, stay asleep and improve your sleep quality. CBT-I is effective in both the short- and long-term, and has minimal side effects.

Understanding the link between insomnia and depression

Getting no sleep is no fun, but with insomnia, the effects can be even more severe. Depression, a mental health disorder characterized by a consistently depressed mood and/or lack of interest in activities previously found to be enjoyable, is commonly accompanied by or caused by insomnia.

Depression can affect all areas of your life, including:

• Appetite
• Concentration
• Energy level
• Motivation

People with major depression report feelings of helplessness, hopelessness, worthlessness, and may have suicidal thoughts. However, the majority of all people with depression experience symptoms of insomnia, consisting of:

• Difficulty in falling asleep
• Difficulty staying asleep
• Early morning awakening
• Non-refreshing sleep

What the evidence shows us

Studies of depressed patients show prolonged sleep latency (time to fall asleep), lack of slow wave sleep (also known as deep sleep), reduced REM sleep latency (time to REM sleep from sleep onset), and increased amount of REM sleep (dreaming sleep).

There is much evidence linking depression with sleep disorders, and it has been shown that insomnia increases the risk of depression and that depression can cause insomnia. Studies have shown that the risk of developing depression among people with insomnia is twice that of those without insomnia. Of all the symptoms of depression, insomnia is often the last to respond to medications, and untreated insomnia increases the risk of a depression relapse. Talk to your healthcare provider about options for treating your insomnia along with a co-occurring condition like depression.

How insomnia can affect more than your nighttime routine

Insomnia can negatively affect a person’s health, work, social relationships and quality of life. The economic burden of insomnia due to these factors is estimated to be more than $100 billion annually, with average indirect costs of insomnia of over $1,200 to the individual with insomnia.

Some of the most frequent consequences associated with chronic insomnia are:

• Fatigue
• Irritability
• Depressed mood
• Difficulty concentrating 

With chronic insomnia, people may experience greater risks for:

• Chronic nausea
• Obesity
• Drug or alcohol abuse
• Major depression
• Suicidal thoughts
• Stroke 

Research also suggests that untreated insomnia may have a role in the onset and/or progression of chronic diseases such as cardiovascular disease, chronic pain, and diabetes. Additionally, people with short sleep duration insomnia (less than five hours per night) are at increased risk for heart and neurological issues as compared to insomniacs with longer sleep duration (greater than five hours per night). 

The cost of insomnia on individuals and the population

People with untreated insomnia not only have greater social and health costs, but they have greater monetary costs too, as insomnia places a significant financial burden on both the individual and society. Insomnia contributes to:

• Increased rates of absenteeism
• Increased healthcare utilization
• Decreased work productivity
• Increased automotive accidents 

Treating insomnia is well worth it as it can negatively impact your social relationships, work productivity and mental and physical health.

Chronic insomnia affects 10-15% of adult Americans, but few actually seek help. Many are unaware of the long-term consequences of sleep loss or assume that sleeping pills are the only solution.

But there’s good news. When insomnia is not due primarily to an underlying health condition like depression, medications are usually not recommended at all. Rather, sleep experts use cognitive behavioral therapy for insomnia, or CBT-I, to treat chronic insomnia sufferers. CBT-I is highly effective in improving insomnia, has long-lasting benefits and does not have the side effects of many medications.

What experts say about CBT-I

“CBT-I is a proven method to help people return to more normal sleep patterns,” says psychologist Michelle Drerup, PsyD. Behavioral treatments are more effective and longer lasting than sedative hypnotic medications.

“Cognitive behavioral therapy for insomnia is our treatment of choice,” Dr. Drerup says. “It’s really effective – about 70 percent to 80 percent of people who go through treatment have improvements in sleep without medications.”

Some of the goals of CBT-I are to change sleep habits, schedules and behaviors. For example, you may need to change your habit of using your bed for activities such as watching television or working on your laptop.

CBT-I techniques and strategies for a better night’s rest

CBT-I techniques include many strategies such as stimulus control (conditioning yourself to sleep in the bedroom), sleep restriction, sleep hygiene, and relaxation therapy that provides you with tools to deal with worrisome thoughts and daily stressors. CBT-I also includes regular follow-up visits with a behavioral sleep medicine specialist or skilled psychologist to examine your sleep/wake habits and pinpoint the actions that may be preventing you from sleeping soundly.

Dr. Drerup says the best thing you can do to quiet your brain for sleep is to stay consistent. “We need to be more mindful of our sleep routines,” she says. “Your brain likes routine.”

Insomnia warning signs, red flags and consequences

Insomnia can really ruin your day. But what is it? Chronic Insomnia is a sleep disorder that causes difficulty falling asleep, problems getting continuous sleep and/or waking up earlier than you would like occurring for more than three months. Insomnia results despite having adequate opportunity to sleep, and therefore differs from sleep deprivation in that it is more of a “can’t sleep” situation than a “won’t sleep” one.

Prevalence of insomnia

Insomnia is incredibly common—in fact, according to the Centers for Disease Control and Prevention, up to a quarter of the population suffers from insomnia! About 50% of those with insomnia have a long-term case with symptoms for more than three months. Although insomnia is more common in women, particularly post-menopausal women, men are also at risk. Many factors, such as medical illness, psychiatric disorders, and medications, can precipitate or perpetuate insomnia.

Common symptoms of insomnia include:

• Tiredness
• Reduced concentration
• Negative effect on family/social relationships
• Compromised work or school productivity and performance
• Mood disturbances and increased irritability

Sadly, the vast majority of people who suffer from these sleep difficulties do not seek help from their physician. A possible reason for this may include feeling that symptoms are not important enough and can just be “powered” through. There also may be the perception that effective treatments are not available, however, this is not the case!

Insomnia screening and treatment

Screening instruments are oftentimes used to determine whether you have insomnia, and if you do, to gauge the severity of the insomnia. For example, the Insomnia Severity Index is a seven-item survey focused on assessing insomnia in the following ways:

1. Difficulty falling asleep
2. Difficulty staying asleep
3. Problems waking up too early
4. Level of satisfaction or dissatisfaction with your current sleep
5. Noticeability of your sleep problem to others
6. Level of worry or distress about your sleep problem
7. Extent of your sleep problem on daily functioning (daytime fatigue, mood, ability to function)

Behavioral treatments for insomnia are preferred given their low-risk profile and high degree of effectiveness, but pharmacologic treatment can also be considered. However, over the counter sleep aids can have many side effects such as daytime grogginess and glaucoma, particularly in elderly individuals. And of course, one of the most important aspects of treatment is good sleep hygiene, i.e. engaging in habits that are conducive to obtain good sleep.

How to tell if you have shift work sleep disorder

So now that you know what SWSD is, you need to figure out if it applies to you and what to do next. Fortunately, not every shift worker suffers from SWSD. It’s estimated that 10-40% of shift workers have SWSD, so if you’re in the 60-90% that don’t, then you’re in luck! But it’s important to see if you have any symptoms to know if you have SWSD and what kind of treatment you’ll need.

10-40% of shift workers have SWSD

Here are some of the most common effects of SWSD:

• Excessive sleepiness
• Difficulty sleeping when desired
• Difficulty concentrating
• Headaches
• Lack of energy
• Irritability
• New health concerns, like stomach irritability, heart disease, and even cancer

What to do if you think you might have SWSD

If you’re having any of these symptoms and you think SWSD could be the culprit, talk to your healthcare provider. They will likely first run some tests to rule out other underlying sleep disorders, such as sleep apnea or narcolepsy.

Also, it’s a good idea to keep a sleep diary of which shifts you worked and what hours you slept. That way, your doctor can use your diary to help identify the problem and monitor its progression over time. Click here to see what a sample diary looks like and learn how you too can help take control of SWSD.

9 effective SWSD management tips and tricks

So you have SWSD and want to get rid of its effects, but it seems like a never-ending cycle. Don’t worry – you can help reset your circadian clock and get back to making the most out of your days with some simple lifestyle changes.

Sunlight and shifting schedules can make sleep a chore for shift workers, so here are some tips to help you get to sleep and get the most out of your sleep time:

1. Wear sunglasses on your way home from your shift to keep morning sunlight from activating the internal “daytime clock”

2. Keep a regular sleep schedule, even on weekends and days off

3. Ask your family to help create a dark and quiet setting during sleep time by avoiding vacuuming, loud TV, or other disturbances.

These tips can help you get to sleep easier and have more restful sleep, but here are some additional tips to decrease the effects of SWSD:

4. Keep a sleep diary to help identify the problem and monitor its progression over time.

5. Decrease the number of night shifts worked in a row to five or less with days off in between.

6. Avoid extended work hours and long commutes to have time to sleep and participate in family and social activities.

7. Avoid frequently rotating shifts, since these lead to erratic sleep-wake schedules and more wake-time impairment.

8. Plan a nap or get some light exposure before or during the night shift to help you stay alert.

9. Caffeine can help you stay awake during your shift, but make sure not to take it within four hours of your bedtime.

Talk with your doctor if shift work is getting you down. Prescription-strength wake promoting medications are available.

Underlying causes of shift work sleep disorder

Many things can impact our ability to sleep. Too much noise and too much caffeine are common culprits, but light can keep you from getting adequate rest, too. Too much light at the wrong times can impact your quality of sleep by interfering with your natural circadian rhythm.

Impact of light on your circadian rhythm

Your circadian rhythm causes you to feel more alert or sleepy, depending on the time of the day. Your levels of melatonin, a sleep-promoting hormone, rise in the evening, but light exposure delays the release of that hormone.

We take cues from the intensity and timing of light, and that’s what helps us sleep and stay wake. But if you’re working the night shift, the bright light of the morning when you’re trying to sleep sends your body mixed messages. That’s called shift work sleep disorder (SWSD).

Negative impact of SWSD on your general health

Because of how SWSD disrupts your body’s internal circadian clock, you may be more likely to experience these adverse health effects:

• Cardiovascular system
• Metabolism, appetite and food intake
• Digestion
• Immune system
• Hormone balance

Because circadian shifts can impact so many areas of your health, night shift workers have to be extra careful to avoid bright light when it’s time to sleep and actively seek bright light when it’s time to stay awake. Here are some tips to get the rhythm on your side:

• Wear sunglasses on your way home from work after a night shift
• Use blackout shades to cover your windows in the room where you sleep
• Use a sleep mask to block out extra, unwanted light 
• Get some bright light exposure before your shift to keep you alert
• Consider a light therapy lamp, which safely mimics natural daylight

Before you schedule an appointment

Before you schedule a sleep center appointment, consider the following:

• Do you have a general sleep question you’d like answered? If so, you can call 216-636-ZZZZ (216-636-9999) to be connected to a Cleveland Clinic Sleep Center caregiver
• Have you talked to your primary physician about your sleep problems? They may be able to help you with your sleep or give you a referral to a sleep center
• Check to make sure your insurance doesn’t need a pre-authorization to see a sleep provider if you don’t have a referral

Scheduling your sleep center appointment

It takes less than 10 minutes to schedule a Cleveland Clinic Sleep Center appointment at one of our many locations (or as a virtual visit), and here’s how:

• Online:  Use the Online Appointment Scheduler or sign in to MyChart
• By phone:  Call 216-636-5860 for the Neurological Institute scheduling center or call 1-866-320-4573 for the 24 hour scheduling center, answer the three prompts, and then wait to be connected to schedule your appointment