Insomnia can literally drive you crazy, as can the drugs used to treat it. Here's how to end insomnia without popping pills
Sylvia Plath, the young American poet, tried to kill herself twice and succeeded the second time around in 1963. Although biographers have blamed these suicide attempts on mental instability, the premature death of her father, an unfaithful husband and even academic overload at the end of her junior year at university, what no one has considered is the possible role of chronic insomnia and the drugs she took to overcome it.
Before her first attempt in 1953, Plath had had a heady junior year at university, racking up a host of academic literary prizes, and securing the much coveted guest editorship for Mademoiselle magazine in New York, the pinnacle of achievement for a young collegiate woman in the Fifties.
In a recently published book called Pain, Parties, Work, which painstakingly details Plath's month in New York during the Mademoiselle editorship, author Elizabeth Winder discloses as an aside,that Sylvia's aunt, a doctor, had given her sleeping pills that spring during her junior year at Smith College. Plath was on them all that year and into the summer, when her aunt saw fit to up the dosage.
Since benzodiazepines like Valium were not invented until the 1970s, Plath was likely to have been given a barbiturate like Nembutal (phenobarbital), the drug she ultimately swallowed to kill herself.
Nembutal's side-effects include agitation, confusion, nightmares, nervousness, psychiatric disturbance, hallucinations, anxiety, thinking abnormalities, confusion, poor judgment and rebound insomnia. The drug is also highly addictive, and can cause depression and suicidal ideation (a desire to commit suicide).
After returning home to Massachusetts that summer before her final year at university, Plath complained that she couldn't concentrate (a known side-effect of barbiturates) on reading or learning shorthand. She couldn't sleep (another side-effect), had paranoid suspicions about her boyfriend (yet another side-effect) and decided that all her talent had suddenly left her (again a side-effect).
One morning her mother discovered her with deep red gashes on her legs under her nightgown (self-harming behaviour, another side-effect) and promptly took her to the family doctor, who prescribed yet more sleeping pills (which would have exacerbated all these side-effects) and electroshock therapy, one well-known side-effect of which is . . . insomnia.
According to Sylvia's personal calendars, says Winder, Plath stayed awake for 21 nights straight. Soon after that, she tried to commit suicide. When she finally successfully did kill herself 10 years later, she was again not sleeping well (most of her best-known poetry was written at predawn) and was taking tricyclic antidepressants. Like barbiturates, these drugs also can encourage suicide.
But new evidence shows that it may even have been the lack of sleep itself that could have pushed her over the edge. Scientists are beginning to acknowledge the connection between disrupted sleep and mood and a host of psychiatric conditions like depression, schizophrenia and bipolar disorder.
Even sleep apnoea, when breathing is disrupted during sleep, has been linked with attention-deficit/hyperactivity disorder (ADHD).
After studying the role of sleep in mental disorders, Elliott Kyung Lee, of the University of Ottawa Department of Psychology and Psychiatry, and Alan B. Douglass, Medical Director of the Sleep Disorders Service of the Royal Ottawa Mental Health Centre, wrote: "The same neurochemistry that controls the sleep-wake cycle has also been implicated in the pathophysiology of numerous psychiatric disorders. Thus it is no surprise that several psychiatric disorders have prominent sleep symptoms."1
Of particular interest to scientists are changes in rapid eye movement (REM) sleep and slow-wave sleep, which they say may have significant roles in memory, cognitive function and regulation of emotions, particularly when it has to do with memories.
But this may be a medical chicken or egg situation-which comes first, sleep disorder or mental disorder? Doctors have long believed that the mental illness itself triggers abnormal sleeping patterns, but new research by Matthew Walker of the University of California at Berkeley, working with researchers at Harvard, concluded the reverse.2 The 'chicken' in the situation is insomnia. Lack of sleep can literally drive us crazy.
Working with the Harvard researchers, Walker demonstrated this by enlisting students aged 24 to 31 and dividing them into two groups, allowing one group to have a good night's sleep while keeping the other group awake for 35 hours straight. The researchers then studied the brain patterns of both groups-using functional magnetic resonance imaging (fMRI), which shows the brain's activity in real time-while viewing a series of photos, which started off as benign (images of a table with a wicker basket), but became increasingly more disturbing (images of burn victims).
In both groups, the amygdala-that part of the midbrain which registers initial emotional responses-reacted similarly to the more benign photos. But with the more disturbing images, amygdala brain activity in the sleep-deprived group registered 60 per cent more activity compared with the other group. In fact, five times more neurons than normal were firing in the emotional centre of their brains.
When Walker looked further, he also saw that the neurons within the amygdalae of the sleep-deprived were not 'talking' as usual to other parts of the brain such as the medial prefrontal cortex, which helps work out the meaning of emotional experience. The neurons were instead 'rewiring' to a portion of the brain stem called the 'locus coeruleus', which secretes noradrenaline (norepinephrine), the precursor of the hormone adrenaline (epinephrine) that put us into fight-or-flight mode.2
"Medial prefrontal cortex is the policeman of the emotional brain. It makes us more rational. That top-down, inhibitory connection is severed in the condition of sleep deprivation," said Walker. "The amygdala seems to be able to run amok."3
Those in this kind of heightened state, says Walker, can experience seesaws of emotion-from huge upset to manic joy-from moment to moment.
Nature's best medicine
Whether or not modern medicine or insomnia contributed to the demons that led to Plath's eventual suicide, there's no question that sleep is one of nature's best medicines. Without a good night's sleep, your body enters a state of 'hyperarousal', raising levels of other stress hormones like cortisol,4 and releasing chemicals like interleukin-6 that promote inflammation.
Over time, such a constant state of high alert can predispose you to osteoporosis, diabetes, heart disease, arthritis and possibly even cancer.5
Dr James Januzzi of the Massachusetts General Hospital reckons a good night's sleep is the best medicine to keep our hearts healthy. He discovered that participants who were deprived of sleep suffered changes in heart rates and heart rate variability, the first signs of a possible heart condition.6
Nevertheless, a good night's sleep eludes the one in seven of us who suffers from chronic insomnia. The standard medical answer to insomnia is a prescription sleeping aid and, currently, one in 10 of us pops a pill to make us sleep. Last year over 15 million prescriptions for sleeping pills were filled just on the NHS in the UK (60 million in the US).
Yet, as the latest evidence shows, people who take sleeping pills just twice a month nearly quadruple their chances of premature death (see box, page 67).
Small wonder then that those with chronic sleep problems are increasingly turning to alternative medicine, as did more than 1.6 million Americans at last count.7 If you do decide to eschew drugs and take an alternative route, it's a good idea to examine what might be causing your wakefulness. A bit of detective work can often sort you out, as can a host of natural sleeping aids.
The drugs don't work
Do benzodiazepines give you a good night's sleep? Researchers analyzing 24 studies involving more than 2,400 insomniacs discovered the short answer is 'no'.
The drugs weren't especially effective for encouraging sleep, but did have devastating effects on daytime activities, increasing the chances of cognitive (mental) problems by almost five times, physical or 'motor' problems by nearly three times and daytime fatigue by nearly four times.1
Sleeping pills and sedatives also increase the risk of pneumonia-a common cause of death among the elderly, the most likely age group to take these drugs-and one in 10 elderly people in the UK is taking a benzodiazepine for anxiety and insomnia. In one study by researchers at the Institute of Cognitive Neuroscience in London, this increased the risk of fatal and non-fatal pneumonia by 54 per cent.2 The benzodiazepines tested included diazepam, chlordiazepoxide, lorazepam and temazepam. The fatal effects are almost immediate, with 22 per cent dying from pneumonia within 30 days of starting the drugs, and 32 per cent dying after three years.
Previous studies have shown that the drugs increase the risk of infection and blood poisoning, or sepsis.
The 'benzos' aren't the only drugs with problems. The so-called Z drugs-the non-benzodiazepine hypnotics, now among the most commonly prescribed sleeping pills-are no better than a placebo, or sugar pill, say researchers. And some 20 per cent of people taking them suffer from side-effects, while 1 per cent of older people have falls, fractures or road traffic accidents while using these drugs.
After reviewing 13 trials involving more than 4,300 people, researchers from the University of Connecticut found that people did fall asleep quicker with a Z drug than with a placebo-but only by 22 minutes.3
1 BMJ, 2005; 331: 1169-73
2 Thorax, 2013; 68: 163-70
3 BMJ, 2012; 345: e8343
Unlikely sleep stealers
Is it hormones? In women, any shift in the balance of sex hormones (testosterone, oestrogen and progesterone) can upset your sleep.8 In fact, the latest thinking is that insomnia and hot flashes are so interlinked that it's difficult to determine which causes the other.
When a researcher interviewed more than 3,200 women aged over 18 in California, the majority-nearly 60 per cent-hadn't reached menopause, while just 22 per cent were going through the menopause and the rest were postmenopausal. Chronic insomnia for at least six months was reported by 80 per cent of the women in the latter two groups who also suffered hot flashes.9
Is it due to drugs you're taking? The following prescription and non-prescription drugs are known to cause insomnia.
o Monoamine oxidase inhibitors (MAOIs)
o Selective serotonin reuptake inhibitors (SSRIs), taken for depression
o Sleeping pills (yes, ironically, they can cause 'rebound' insomnia)
o Calcium-channel blockers
o Chemotherapy drugs
o Theophylline, taken for lung conditions like asthma.
Do you smoke or drink too much coffee? It takes the body about three to seven hours to break down half a single dose of caffeine-say, a cup of coffee-and if you're drinking coffee throughout the day, it will take your body even longer to get rid of all that caffeine.10 As a result, caffeine consumption can affect sleep for many hours. Similarly, the nicotine in cigarettes can cause wakefulness, as can nicotine withdrawal or nicotine replacement therapy if you're trying to break the habit.11
Are you drinking too much booze? Although we think of it as a sedative, booze also has a stimulating effect because it increases the release of dopamine.12 And like cigarettes, giving up drinking can cause insomnia too.
Do you have unidentified food allergies? WDDTY columnist Dr Harald Gaier says that when patients present with insomnia, he looks for a food hypersensitivity that causes no obvious symptoms apart from insomnia. The clue is a delay of some six hours between eating the offending food and feeling 'wide-awake', most likely due to an outpouring of various excitatory neurohormones as well as thyroid hormones.13
Are you deficient in nutrients? The mineral magnesium plays an important role in regulating our circadian (sleep-wake) cycle, as one affects the other.14 The more you suffer from insomnia, the lower the levels of magnesium in your cells.15 If you find yourself waking up often at night because of limb movements during sleep (as in restless legs syndrome) or teeth-grinding, then taking 300 mg/day of magnesium may help significantly, as it did in people suffering from either syndrome after four to six weeks.16
Take these supplements
Zinc. Research shows that magnesium can improve sleep in the elderly when accompanied by zinc and melatonin supplements.17 Women with high levels of zinc and copper sleep longer than those with low levels.18
Suggested daily dosage: 30-50 mg zinc,
1-2 mg copper
Vitamin B12. Insomniacs with a disturbed sleep-wake rhythm cycle often improve when they supplement with B12.19
Suggested daily dosage: 1,500-3,000 mcg
Niacinamide (vitamin B3) can also help you sail off to the land of Nod. In patients with chronic insomnia, Dr Gaier often does a blood test to check niacin status. If it's low, he suggests taking B3 plus magnesium and B6 supplements before bedtime.
Suggested daily dosage: 50 mg niacin or 50 mg vitamin B6
Try these herbs
These herbs all have scientific evidence of effectiveness.
Valerian (Valeriana officinalis). The ancient Greeks found this an effective remedy for insomnia some 2,000 years ago, and it's never gone out of favour as a highly effective sleep aid.20 Pooling the results of 18 studies demonstrated that valerian reduces the time it takes to nod off and improves the quality of sleep too.21 The US Food and Drug Administration (FDA) has given valerian the thumbs up as a GRAS ('generally recognized as safe') herb. Although concerns have been raised about valepotriates-one of its main active ingredients-because of DNA and other toxic effects in laboratory studies, these monoterpenes are generally not found in commercial preparations.22
Suggested daily dosage: 300-600 mg valerian extract, 30 minutes before bedtime
Hops (Humulus lupulus). Although hops can be used on its own, it's usually included in a valerian combo. In one study, a liquid extract of the two improved total sleep time, sleep quality and deep sleep compared with a placebo; another showed that the addition of hops helped patients fall asleep faster than taking valerian on its own.23 Other herbs frequently used in combination with valerian include chamomile, passion flower, American skullcap and catnip.
Suggested daily dosage: 500 mg valerian extract, 120 mg hops extract
Lemon balm (Melissa officinalis). This frequent co-passenger with valerian has also been shown to improve sleep quality.24
Suggested daily dosage: 360 mg valerian,
240 mg lemon balm
Ashwagandha (Withania somnifera). This Indian herb can lower emotional stress and anxiety and improve sleep, at least in animal studies, which may not apply to humans. It's thought to help regulate the activity of GABA (gamma-aminobutyric acid), a neurotransmitter in the brain and central nervous system sensitive to sedatives and involved in sleep.25
Other alternative remedies
Lavender. Lavender oil aromatherapy not only helped female college students with insomnia, but also helped with their depression.26
Acupuncture. High-quality trials are thin on the ground, but there's evidence that it can help, particularly in the elderly, as can acupressure too.27 One randomized placebo-controlled trial of 40 insomniacs showed that acupuncture improved sleep, as evidenced by objective measurements like brain waves, oxygen levels, heart rate, breathing, and eye and leg movements.28 It's even been shown to work significantly better than drugs for sleeplessness in adult insomniac women, while electroacupuncture helped chronic insomniacs improve sleep quality and ability to function during the day.29
Hypnosis can be helpful, as shown by a trial of nearly 40 women.30
Homeopathy. A favourite among European homeopaths is the combination remedy Passiflora GHL, which combines Avena sativa, Passiflora incarnata, Atropa belladonna, Secale cornutum and Valeriana officinalis-all traditional sleep remedies. Pitted against conventional drugs for a month in women suffering from insomnia, this remedy was more effective.31 A.Vogel makes the herbal tincture Passiflora Complex, a combination of Passiflora incarnata and Avena sativa (available from www.avogel.co.uk).
Biofeedback. Two scientific studies showed that electroencephalography (EEG) feedback was more or less helpful for insomnia, depending on whether it was due to muscle tension and anxiety or movement disorders like restless legs syndrome, leg cramps and teeth-grinding.32
Brain music. This novel technology involves recording brain waves and turning them into music that the patient listens to before going to sleep. In one study, this had positive effects in more than 80 per cent of insomnia sufferers.33
Neurofeedback. Initial studies of this feedback technique, which involves monitoring brain activity only, shows that it can improve total sleep time.34
Mellow melatonin and amino acids
Melatonin. This natural hormone, which regulates your body's internal clock, declines with age, one reason that studies have tested supplements of melatonin in seniors. One trial showed that a slow-release version helped older insomniacs fall asleep faster and sleep more regularly, and was safe and effective as a long-term therapy with no serious side-effects.35 But melatonin isn't just for oldies; taking 3-6 mg a few hours before bedtime helped children with ADHD nod off.36
Readily available over the counter in the US, it's available either by prescription in the UK or through the internet (for example, on biovea.net). Watch out for possible side-effects like headache, feeling hung over, stomach discomfort and even depression, and avoid melatonin if you're taking warfarin or other blood-thinners (anticoagulants like apixaban or dabigatran)- the jury's still out concerning the effects of melatonin on seizures and epilepsy.37
l-Tryptophan, which is found naturally in chocolate, oats, bananas, turkey and peanuts.Some three decades of study into supplements of this amino acid and insomnia show that relatively small doses (1 g) can help insomniacs fall asleep quicker, while even lower doses (250 mg) can improve sleep quality. And waking up from an l-tryptophan-induced sleep isn't difficult, as it can be with sleeping pills, nor will it affect your brain power while awake, but be wary of side-effects like stomach irritation and vomiting with high daily doses.38
5-Hydroxytryptophan (5-HTP). This relative of l-tryptophan has been shown in preliminary studies to improve sleep quality by increasing serotonin and REM sleep.39 Dosages used in one study were 200 mg at 9:15 pm and then 400 mg at 11:15 pm.
Change your lifestyle
Limit coffee to one cup in the morning, giving your body enough time to clear it from your system by bedtime.40
Cut out hidden stimulants. When you're investigating the causes of your insomnia, remember that some herbal tonics contain botanical stimulants, while a vast number of over the counter and prescription medicines contain caffeine.
Make your boudoir a 'rest zone'. Make sure you go to sleep at roughly the same time every night and that your bed is comfortable, your room is quiet, the temperature is cool and the room remains dark. If need be, invest in a sleep mask or blackout curtains. Avoid stimulants and large meals near bedtime.
Unplug and turn off your mobile phone, now a recognized major cause of sleep disruption, and turn your Wi-Fi off too.
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6 Presented at the 21st Annual Meeting of the Associated Professional Sleep Societies in Minneapolis, June 9-14, 2007
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Death by sleeping pills
Researchers in Jackson, Wyoming, and La Jolla, California, analyzed the health profiles of over 10,500 people taking a wide variety of sleeping pills, including benzodiazepines like temazepam (Restoril, Normison) and diazepam (Valium), and Z drugs like zolpidem and zaleplon, plus sedative antihistamines and barbiturates. After comparing them with more than 23,000 controls with similar lifestyles and health profiles, but no sleeping-pill prescriptions, the researchers found that the sleeping pill users, even the non-prescription ones, were four or five times more likely to die within two and a half years. In particular:
o those taking either temazepam or zolpidem were up to nearly six times more likely to die within that time; and
o one in every 16 patients taking sleeping pills died compared with one in every 80 non-users.
These were findings after the researchers controlled for other factors like smoking and alcohol use, or preexisting health conditions like heart and lung disease. They also discovered that those taking the highest doses had an increased risk of developing cancer.1
For all these risks, the team found little advantages. Passing his findings on to the US Food and Drug Administration, lead author Dr Daniel Kripke of the Scripps Clinic concluded: "The meagre benefits of hypnotics as critically reviewed by groups without financial interest would not justify substantial risks."
He also confirmed that many doctors and researchers are turning away from drug-based approaches: "A consensus is developing that cognitive behavioural therapy of chronic insomnia may be more successful than hypnotics."
The researchers found that no group of drugs was safer, not even the newer Z drugs. This mirrors earlier research from the Wisconsin Sleep Cohort Study, which followed more than 2,000 patients since 1989 and found a threefold higher risk of death among long-term insomniacs.2
Other studies have suggested some possible causes of the increased death risk. After analyzing 14 years of data from a sample of 14,117 patients, Dr Genevieve Belleville from Universit'e Laval's School of Psychology in Quebec, Canada, concluded that sleeping pills and anxiety drugs may be increasing the risk of early death because it affects motor reactions-so contributing to falls and accidents-and our breathing patterns, which might be disturbed while we sleep.
"These medications aren't candy, and taking them is far from harmless," says Dr Belleville.3
1 BMJ Open, 2012; 2: e000850
2 www.aasmnet.org/Articles.aspx?id =1722
3 Can J Psychiatry, 2010; 55: 558-67