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Insomnia

MagazineDecember 2010 (Vol. 21 Issue 9)Insomnia

Having persistent difficulty in falling or staying asleep is a common sleep disorder that often has no obvious cause

Having persistent difficulty in falling or staying asleep is a common sleep disorder that often has no obvious cause. Research has linked it with a host of medical, psychological and social problems-including, most recently, an increased risk of death-so it's vital that the condition not go ignored.

People who suffer from chronic insomnia have a dramatically greater risk of death, accord-ing to alarming new research from the United States.

The long-term study, presented in Texas at SLEEP 2010, the 24th Annual Meeting of the Associated Professional Sleep Societies LLC, revealed that chronic insomnia sufferers are three times more likely to die from any cause compared with people without the sleep disorder.

The study involved more than 2000 participants from the Wiscon-sin Sleep Cohort Study, all of whom had self-completed a number of questionnaires on their sleep habits in 1989, 1994 and 2000. The group was followed for up to 19 years, during which time 128 participants had died. After analyzing the available data, the researchers found that those with long-term insomnia had a threefold increased risk of death-even after controlling for age, BMI (body mass index) and other variable factors.

Laurel Finn, a biostatistician at the University of Wisconsin-Madison and lead author of the study, declared that the results emphasize the need for physicians to provide effective treatments for insomnia, even when no other health conditions are evident (www.aasmnet. org/Articles.aspx?id =1722).

Conventional treatments

Sadly, the conventional treatment of insomnia usually involves the use of sleep-inducing (hypnotic) drugs which are often totally inadequate and, sometimes, downright dangerous. Indeed, according to one review of the scientific literature, most of the drugs prescribed for insomnia involve some risk of overdose, tolerance, habituation and addiction (Altern Med Rev, 2000; 5: 249-59). Even zolpidem, considered to be among the safer pharmaceutical options, has been associated with significant side-effects, including amnesia and compulsive repetitive behaviours (Clin Toxicol [Phila], 2007; 45: 179-81), delirium, nightmares and hallucinations (Clin Neuropharmacol, 2000; 23: 54-8), anaphylaxis (severe allergic reaction) and angioedema (severe facial swelling) (Drug Saf, 2009; 32: 735-48). It may even increase the risk of skin cancer (J Sleep Res, 2008; 17: 245-50).

Ironically, zolpidem also appears to actually cause sleep problems such as sleepwalking, sleep-related eating and, most worrying, sleep-driving (J Clin Sleep Med, 2009; 5: 471-6). Indeed, one study found that people taking hypnotic drugs such as zolpidem were at least twice as likely to be involved in a road-traffic accident (Sleep Med, 2008; 9: 818-22).
Not surprisingly, a growing number of insomniacs are turning to alternative medicine in their efforts to solve their sleeplessness. A recent analysis of national survey data in the US revealed that over 1.6 million American adults use some form of complementary and alternative medicine to treat insomnia or other sleep difficulties (Arch Intern Med, 2006; 166: 1775-82). Of the wide variety of options available, the following appear to have the most promise.

Alternative sleep therapies

o Supplements. A variety of supplements are available for insomnia, many of which have good evidence of success.

o Melatonin. This natural hormone, which regulates the human 'body clock', is an increas-ingly popular treatment for insomnia. It has mostly been tested in the elderly, as melatonin levels are known to decline with age. In one randomized controlled trial, slow-release melatonin was found to be a safe and effective long-term therapy for older patients with insomnia. It also significantly reduced sleep latency-the time it took patients to fall asleep-and had no serious side-effects (BMC Med, 2010; 8: 51).

Some studies suggest that melatonin may be useful for young people, too. In a review of children with attention-deficit/hyper-activity disorder (ADHD) and sleep-onset insomnia, a melatonin dose of 3-6 mg a few hours before bedtime was well tolerated and helped them to fall asleep (Ann Pharmacother, 2010; 44: 185-91).

However, as melatonin is a potent hormone, it should only be taken under medical supervision. For this reason, although it is freely available in the US, it is only obtained on prescription in the UK. Possible side-effects include headache, feeling 'heavy-headed' or hungover, stomach discomfort and depression. Also, because of the possible interactions, those taking warfarin or other oral anticoagulants (blood-thinners) and those with epilepsy would do well to avoid melatonin (BMJ, 2003; 326: 296-7).

o l-Tryptophan. This amino acid-found naturally in chocolate, oats, bananas, turkey and peanuts-has been researched for sleep dis-orders for more than 30 years. Improvement in sleep latency with it has been noted, even at doses as low as 1 g, and even lower doses-just 250 mg-have improved sleep quality. Also, unlike many of the hypnotics, l-tryptophan doesn't limit cognitive (mental) perfor-mance or impede arousal from sleep. However, there are potential side-effects at high doses (100 mg/kg/day, or 7 g/150 lb/day), such as gastric irritation, vomiting and head-twitching (Altern Med Rev, 2006; 11: 52-6).

o 5-Hydroxytryptophan (5-HTP). A compound related to l-trypto-phan, 5-HTP is a promising treatment for a variety of condi-tions, including insomnia. Supple-menting with 5-HTP (200 mg at 9:15pm and 400 mg at 11:15pm) increased REM (rapid eye move-ment) sleep, a sign suggestive of improved sleep quality (Altern Med Rev, 1998; 3: 271-80). However, more research is needed to determine its true usefulness in this context.

o Magnesium. If your insomnia is due to periodic limb movements during sleep (PLMS) or restless legs syndrome (RLS), then mag-nesium supplements may prove helpful. In people suffering from RLS- or PLMS-related insomnia, taking around 300 mg of mag-nesium every evening for four to six weeks significantly improved the quality of their sleep, with fewer arousals (Sleep, 1998; 21: 501-5).

o Vitamin B12. Research suggests that people with insomnia resulting from disorders of their sleep-wake rhythm cycle may benefit from taking B12 at doses of 1500 to 3000 mcg/day (Sleep, 1990; 13: 15-23; Sleep, 1991; 14: 414-8).

o Herbs. Plant-based remedies have a long history of use for insomnia and other sleep disorders. The following have been tested in clinical trials.

o Valerian (Valeriana officinalis). Recognized by the ancient Greeks more than 2000 years ago as an effective treatment for nervous unrest, stress and sleep disorders, valerian is now a top-selling natural sleep aid (Aust Fam Physician, 2010; 39: 433-7). A recent meta-analysis, which pooled the results of 18 randomized controlled trials, found valerian to be effective for reducing the time it takes to fall asleep as well as improving the quality of sleep itself (Sleep Med, 2010; 11: 505-11).

In addition, the US Food and Drug Administration (FDA) rates valerian as a GRAS ('generally recognized as safe') herb. Valepotriate-free formulations, water-based exracts and low water-alcohol extracts are prefer-able, as these are more likely to have no adverse effects (Prescrire Int, 2005; 14: 104-7). A 300-600 mg dose of valerian extract, taken 30 minutes before bedtime, is commonly used.

Other herbs are frequently used in combination with valerian, including hops and lemon balm (see below), as well as chamomile, passion flower, American skullcap and catnip.

o Hops (Humulus lupulus). This herb may be useful on its own, but it's more often used in combina-tion with valerian. In one study, researchers found that a liquid extract of valerian and hops improved total sleep time, sleep quality and deep sleep, according to both objective and subjective evaluations (Eur J Med Res, 2008; 13: 200-4).

Another trial showed that a standardized valerian plus hops combination (containing 500 mg of valerian extract and 120 mg of hops extract) reduced the time to fall asleep more than did 500 mg of valerian on its own (Phytother Res, 2007; 21: 847-51).

o Lemon balm (Melissa officinalis). Also used in conjunction with valerian, this herb helped to improve sleep quality in healthy volunteers (Fitoterapia, 1999; 70: 221-8). However, further research involving insomnia sufferers is needed.

o Lavender. Well known for its calming scent, lavender oil may also be an effective insomnia remedy. A study of 42 female college students suffering from insomnia and depression found lavender aromatherapy to be beneficial for both conditions (Taehan Kanho Hakhoe Chi, 2006; 36: 136-43).

o Acupuncture. Although high-quality trials are lacking, acupuncture may be useful for insomnia. In a study of 44 women aged 22-56 years, abdominal acupuncture was superior to drug treatment for relieving sleep-lessness (Acupunct Electrother Res, 2008; 33: 33-41). In addition, electroacupuncture considerably improved sleep quality and day-time social functioning in chronic insomniacs (Chin Med J [Engl], 2009; 122: 2869-73).

o Brain music. A novel technology that involves recording a persons brainwaves and turning them into music is showing promise as a treatment for insomnia. In one study, such so-called 'brain music' proved to have positive effects in more than 80 per cent of insomnia sufferers (Neurosci Behav Physiol, 1998; 28: 330-5).

o Neurofeedback. This technique, which also involves monitoring brain activity, can improve sleep latency and total sleep time, although more studies are needed to clarify its true effectiveness (Appl Psychophysiol Biofeedback, 2010; 35: 125-34).
Joanna Evans

WDDTY VOL. 21 ISSUE 7


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