Dr. Donna Arand is a Diplomate of the American Board of Sleep Medicine and is President of the American Insomnia Association. She is the Clinical Director of the Kettering Medical Center Sleep Disorders Center in Ohio. Dr. Arand also is an Assistant Professor of Neurology at the Wright State University Boonshoft School of Medicine.
Here are answers she provided to some common questions about insomnia and how it is treated.
Q. Everyone has trouble sleeping at times. How do I know when my insomnia is severe enough that I should seek help?
A. You should seek help when these three statements all describe your insomnia:
- The insomnia has lasted more than three weeks.
- It is not improving.
- It is interfering with your ability to function during the day.
Insomnia is often a typical response to a stressful situation. It should disappear as the stress decreases. But bad sleep habits can develop during the period of stress. This prolongs and establishes the insomnia. It is easier for you to re-establish good sleep if you eliminate these habits early.
Q. Is insomnia just “in my head,” or is there a physical or medical cause for it?
A. Insomnia can be caused by psychological, physiological or medical problems. It also can occur without an obvious cause. It can co-exist with many medical and psychological problems. To treat insomnia, it is important to determine if there is any underlying cause. Effective treatment requires treating any underlying causes as well as the insomnia.
Q. I only have insomnia when it is the night before an important meeting or event. How can I sleep better in these situations?
A. Insomnia is a common response to a stressful situation. Anticipating the next day’s activity can make you tense. You “turn on” your mind, flooding it with various thoughts about the upcoming event. This hinders you from being able to fall asleep. Activities to reduce physical tension and mental stress help you “turn off” your mind so you can sleep.
A useful technique is to set aside time after dinner to think about the next day’s events. Mentally review all of your concerns or issues about the next day and complete any unfinished business. You may want to make a list of things you need to do the next day. Then choose to release yourself from your worries. Tell yourself, “I’ve made all my preparations, and my materials are ready for tomorrow.” This will help remove the worry and stress of these thoughts at bedtime.
Then engage in relaxing activities until bedtime. After you get in bed, try muscle relaxation. Begin with your feet by tensing your left foot. Hold that position for about 20 seconds. Then release it. Focus on how relaxed and limp that foot feels. Repeat this with the other foot. Continue this process with each leg, hand and arm. End with your face.
If intrusive thoughts of tomorrow’s events still occur, focus on something else. The use of guided imagery will help prevent the unwanted thoughts. For example, imagine yourself floating down an endless river. Any image will work as long as it is relaxing and endless. These techniques should help for your situational insomnia.
Q. Instead of seeing a doctor, can’t I simply treat my insomnia with products that I can buy at my local drugstore?
A. If you have chronic or recurring insomnia it is better to seek professional help. Over-the-counter medications are only helpful for some people. Tolerance or other problems can occur with long-term use. You should never use alcohol to treat insomnia. It can cause severe sleep problems.
Also, there may be underlying physical causes for your insomnia. These causes also would need to be treated. A doctor or sleep specialist can determine the best course of treatment. For an infrequent night of insomnia, consider the cause. If it is related to pain or physical discomfort, treat that instead. Also, that glass of milk that your grandmother told you to drink before bed may help. Milk actually contains an ingredient that can help you fall asleep.
Q. How does a doctor decide whether cognitive behavioral therapy (CBT) or a medication is the best treatment option for me?
A. The decision to use CBT or medication depends on many factors. CBT is preferred when the insomnia is chronic or recurring. CBT has no side effects and has long-term benefits. But it does require some effort on the part of the patient to get started. Medication acts quickly, so generally it is used for acute or short-term insomnia. Some of the newer sleeping medications allow longer term use.
But with any of these treatments it is important to know that there is no other medical problem causing the insomnia. These are some other factors that your doctor will consider:
- Interactions with other medications
- Other medical or sleep problems
- Your previous response to any sleep medications
Q. Where do I find a doctor who specializes in CBT?
A. The American Academy of Sleep Medicine certifies doctors who are experts in behavioral sleep medicine. Their Web site has a list of the doctors who have passed the certification exam. If you are unable to find a specialist near you, then contact an accredited sleep center for help.
Q. I see a lot of commercials on TV for new sleep medications. Are these drugs safer and more effective than older sleeping pills?
A. The new sleeping medications being advertised are generally less addictive. They also have few side effects compared to older sleeping medications. All FDA-approved sleep medications have been shown to be effective in improving sleep. But it is not possible to say that newer drugs are more effective than older sleep medications. The effectiveness of sleeping pills varies. So a medication that is effective for one person may not be effective for another.
Q. There are a lot of different sleeping pills on the market. How do you choose which one to prescribe for your patients?
A. The choice depends on a number of factors. Sleeping pills that have a short "half-life" act quickly and are processed quickly by your body. They likely would be used to treat a primary complaint of difficulty falling asleep. Other medications have a long half-life and are processed slowly. They would be preferred for problems that include staying asleep or early-morning awakenings. Your doctor also will consider interactions with other medications. Your history of previous medication use is another important factor.
Q. About how much more sleep will a sleeping pill help me to get each night?
A. Individual responses vary. All FDA-approved sleep medications have been tested and shown to improve sleep. These results are based on EEG measurements of your brain activity. Actual increases in sleep time are typically less than an hour. But EEG measures do not always match your perception of your sleep time.
When you have insomnia, your perception of the amount and quality of your sleep is probably more important than actual EEG-measured sleep. This is because insomnia is a complaint about inadequate sleep or non-restorative sleep. This does not mean that insomnia is not a real problem. Rather it means that the EEG may not be the best thing to measure in insomnia.
Current drug research includes many subjective measures of the amount and quality of sleep. New medications show improvement in these measures. But the response to sleeping pills can vary between individuals. A medication that works well for one person may not work for another.
Q. Will I become addicted to sleeping pills if I take them for more than a few nights?
A. The newer sleep medications have a very low addiction potential. A few of them are no longer limited to short-term use. It is unlikely that you will become addicted to these medications. You also should have no withdrawal symptoms.
Some people are more sensitive to medications. Perhaps you have a history of problems with alcohol or other drugs. You may have had trouble withdrawing from other medications. If so, then make sure your doctor is aware of this. There is one new sleeping medication that may be better for you. It works on a different site in the brain. The FDA has classified it as not having any addiction potential. This means that it can be used without a time limit.
Q. What side effects are most common when taking sleeping pills?
A. Side effects tend to be uncommon with the new sleeping medications. These are some of the most common side effects of the current sleeping medications:
- Daytime sleepiness
- Nausea
- Headache
- Vomiting
- Dizziness
Each of these side effects occurs in less than 1% of people. Only a small number of these people will discontinue the medication because of a side effect. Side effects tend to increase with higher doses of medication.
Daytime sleepiness may be the most worrisome side effect. It can impair your ability to function safely. This is critical if you are driving, operating machinery or working in any risk-associated occupation. Daytime sleepiness represents a “drug hangover.” It occurs when the medication is still active in your body when you get out of bed. This is common when you do not allow enough time for sleep.
Q. Is it safe to take a sleeping pill if I’m pregnant?
A. Sleeping pills should not be used during pregnancy. There have been no reports of adverse affects on the fetus. But sleeping pills have not been studied scientifically in pregnant women.
Keep in mind that sleep problems are common during pregnancy. They generally change with each trimester as a result of changes in hormones. They also may be related to discomfort caused by the growing fetus. Thus sleep problems are considered a common “side effect” of pregnancy. Carefully discuss sleep medications with your obstetrician before taking them during pregnancy.
Q. Is it more dangerous for older people to take sleeping pills?
A. Older people have a higher rate of medical problems that are associated with poor sleep. A common example is sleep apnea. It is important to rule these out or treat them first before prescribing sleeping pills.
Sleeping pills have been tested in older people. Their bodies process some of these pills slower than young adults. As a result, their recommended dose is lower. Some sleeping pills can occasionally cause confusion, unusual behavior, difficulty with coordination, and an increased risk of falls. These effects are less common at lower doses.
However, all sleep aids need to be used with caution in older patients. These patients should be observed for the occurrence of any side effects. In general, sleep medications are considered safe and effective at lower doses when untreated sleep-related breathing problems are absent.
Q. Do you have one “secret” for a good night of sleep that you can share with me?
A. I do not have one secret for a good night of sleep. My prescription for a good night of sleep is a day that includes these ingredients:
- Some outdoor activity
- A little exercise
- No caffeine or alcohol
- A positive mental outlook
More Information
Guidelines for Taking Sleep Medications
Insomnia: Questions to Ask Your Doctor
Finding a Cure for Insomnia: A Review of Common Treatments
AASM-Certified Behavioral Sleep Medicine Specialists
Updated July 20, 2007
