A Basic Guide to Insomnia: Part III:
Psychotherapeutic and Non-prescription Approaches to Treatment of Insomnia
by Ernest J. Bordini, Ph.D.1, Farinde, Abimbola, Pharm.D., MS2 and Mattie President, B.S.3
1 Clinical Psychology Associates of North Central Florida, Gainesville Florida
2 Walden University, Minneapolis, MN
3 California School of Professional Psychology at Alliant International University, California
Published 2/9/13 in the Articles and Archives of Clinical Psychology Associates of North Central Florida All rights reserved
2121 NW 40th Terrace Suite B, Gainesville, FL 32605 Phone: (352) 336-2888
Behavioral and Cognitive-Behavioral Therapy Approaches to Insomnia Treatment
Once proper medical, psychiatric and/or clinical psychological assessment has been made to diagnose, rule out and otherwise treat conditions that may be producing insomnia, treatment focus proceeds to the direct treatment of insomnia as a primary disorder or persisting symptom.
First Steps:There are many good and bad habits people fall into in terms of their daily lives and sleep habits.Individuals vary about how sensitive their sleep is to disruption by such habits and patterns.In any event, it is important that people who suffer intermittent, persistent, or severe insomnia practice good habits. This is often referred to as “Sleep Hygiene”. A sample Sleep Hygiene Handout with some basic tips used in our clinic is available on the www.cpancf.com website.
Good sleep hygiene include 1) setting a regular time to go to bed and a regular time to wake up, 2) engaging in regular, late afternoon or early evening aerobic exercise. Consult with a physician when starting and before working up to a goal of 30-40 minutes of aerobic exercise, 3) avoiding daytime naps, 4) eating no more than a light snack or beverage before bedtime if hungry, 5) avoiding or minimizing caffeine, nicotine and other stimulants, and 6) making the bedroom as comfortable and as secure as possible (Glovinsky et al., 2008).
The use of behavioral or psychotherapeutic approaches to treat insomnia or other sleep disturbances is generally recommended before considerations of drug treatment for primary insomnia (Lande & Gragnani, 2010).
CBT (Cognitive-behavioral therapy) patients are typically instructed by a clinical psychologist on proper sleep habits, relaxation techniques, and ways to divert counter-productive thoughts or anxieties regarding sleep in weekly individual psychotherapy sessions. Some studies have demonstrated CBT (Cognitive-behavioral therapy) as more effective than medication, in up to 80% of patients with persistent insomnia (Morin et al., 2009). A Harvard Medical School study found treatment of insomnia with CBT in combination with proper sleep hygiene and relaxation training remained effective for a year or more after treatment and was superior to sleep medication.CBT also minimizes risks of medication side-effects and risks of medication dependence or abuse. CBT can also be initiated and continued in conjunction with drug therapy.
Yoga, Tai-chi, other exercises and activities can also play a part or be incorporated into cognitive-behavior therapy or other psychotherapeutic approaches to treatment and management of sleep disorders.
Effects: High Efficacy, Minimizes risk of addiction, somnambulism, and morning grogginess or “medicine head”. Cons: Insurance coverage may vary.Access to well-qualified clinical psychologists varies by location. Mental health insurance benefits can be restrictive, well-qualified providers may not participate in your insurance plan, and/ or managed care plans create obstacles.
Over-the-Counter Medications, Herbals, and Supplements
When considering over-the-counter, herbal, supplement, or alternative medicines for sleep difficulty it is still important to consult with your medical doctor to rule out underlying causes for the sleep disorder and how these OTC and other supplements can interact with your medical history and other medication or supplements.While many can be effective in the short-run, brief or occasional use, some, like prescription medication, can cause tolerance, dependence, and can actually cause mask other disorders or make sleep problems worse in the long run.Though a prescription is not required, some can produce severe, even toxic, side effect. These can produce drug interaction, and can produce drug dependency and withdrawal if they are suddenly stopped.
Many OTC, herbal preparations and supplements can impact the central nervous system and produce lingering daytime effects such as dizziness, trouble with fine motor coordination or daytime sleepiness.Thus, as with prescription medication avoidance or care about driving or working with dangerous machinery is well-advised.
DISCLAIMER – The following discussion about OTC, herbal or supplement approaches to insomnia is for educational purposes only. It is not intended to provide medical or other advice, or a list of all possible negative consequences or side effects.Any approach an individual uses should be reviewed with a medical doctor in the context of medical history and other medications and supplements.
Antihistamines such as diphenhydramine (H1 receptor agonists) are the most commonly used OTC medications and syrups for insomnia. Diphenhydramine can often be found in OTC Compoz, Sominex, Nytol, etc.Antihistamines have been shown to be effective for transient insomnia. As a result of the anticholinergic properties of such agents as diphenhydramine, some adverse side effects include) or sedation. Doxylamine (found in preparations such a Unisom) is another antihistamine which has anticholinergic properties similar to diphenhydramine, but warnings indicate it should not be used for longer than 10 days due to tolerance to the hypnotic effects. Other more potent antihistamines such as promethazine and hydroxyzine have much longer half-lives, are available only by prescription and may be more problematic due to persisting daytime effects or “hangover”.
Side Effects: Significant side effects also may include urinary retention, confusion, dry mouth, blurred vision, constipation, dizziness and clumsiness. There is a risk for increased intraocular pressure in patients with narrow angle glaucoma. Consultation with a doctor is always advised before taking antihistamines. Particular warnings are warranted if you have an enlarged prostate, have breathing problems such as bronchitis, COPD, or emphysema, if you take an MAO inhibitor, take medicine for Parkinson’s disease or depression or if you take other medications for sleep.Women who are nursing should avoid antihistamines.
Melatonin is a natural hormone produced by the pineal gland that has a role in circadian rhythm control. It may be considered in patients with circadian rhythm disorders (e.g. jet lag), low endogenous melatonin level, or delayed sleep syndrome (Herxheimer & Petrie, 2002).I t also sometimes appears effective for teenagers. Typical doses range from 0.5 mg to 10 mg at night.It can help to decrease sleep latency in children or adults. Except for the recently FDA-approved Ramelton (Rozerem), melatonin compounds don’t have the quality control regulations and proven efficacy of medications approved by the FDA. There are warnings about more than short-term use (more than two months).
Effects: Possibly helpful for reducing symptoms of jet lag, and for treating adolescent onset insomnia and nightmares, but minimal evidence of general efficacy for insomnia. Other studies have questioned safety for individuals under age 20.
Side effects: Melatonin appears to be non-addictive for short-term use for sleep onset difficulties, but long-term safety is unknown and there are concerns it can worsen depression, and warnings about use in individuals with liver problems or in women who are pregnant or nursing. Warnings about interactions with anticoagulants (blood-thinners), immunosuppressant medication, birth control pills and diabetes medications have been issued. There are also some reports of hallucinatory dreams or hallucinations.
Many supplements are not entirely benign or without controversy as they can be toxic. Tryptophan and L-tryptophan are amino acids which impact the serotonin system which is involved in sleep, depression and other functions. 5-hydroxytryptophan (5-HTP) is a melatonin precursor and also has serotonergic effects. While some studies have found shorter sleep onset, at this point, the evidence of efficacy for treatment of insomnia is inconsistent at best. Since it impacts the serotonin neurotransmitter system, there are concerns about toxic interaction effects with some psychiatric medications.
Valerian is derived from the valeriana plant root and sometimes marketed as a non-FDA approved supplement to promote sleep. It appears to act on the central GABA system. Current research suggests some, but inconsistent support for treatment of insomnia, but concerns about hepatotoxicity and serious side effects such as headaches, vivid dreams or nightmares, potential for restlessness and excitability, and even changes in heart rhythm likely make it a poor choice as a sleep supplement.
Kava is sometimes promoted as a sleep aid for sleep onset due to some anxiolytic properties. It is derived from the root of Piper Methysticum, a shrub called the pepper plant. It tends to act on the GABA-A receptors and produce inhibition of monoamine oxidase B (MAO-B). It has some anesthetic, sedative and anxiolytic properties, but can also cause feelings of sadness or dysphoria and excess does can cause psychiatric and mental status changes as well as neurological side effects such as ataxia. Proponents warn it should not be used more than a couple of times per week, and though some argue that it may depend on the preparation, there are concerns about hepatotoxicity (liver toxicity) and even proponents warn against use in children, adolescents, or women who are pregnant or nursing. FDA warnings state people who have liver disease or liver problems, or people who are taking medicines that can affect the liver should consult a doctor or pharmacist before using kava products. Concerns about liver damage have caused it to be banned as a supplement in some European countries and patchy rashes and yellowing of skin and eyes have been reported. Risk is even higher with alcohol use and likely due to it’s metabolism in the liver, it can interact with anti-seizure medications, levodopa, benzodiazepines, other psychoactive medications, and certain blood pressure medications. Some concern about abuse and addiction potential has also been raised.
Alcohol. The sedative properties of alcohol and easy availability make this tempting as a sleep aid. However, as with many medications, while a little may help, more can actually produce middle insomnia, with a typical pattern of early morning wakening around 3:00 a.m. – 5:00 a.m.While usually not recommended, a small amount of alcohol (probably ½ a standard drink) for many adults who do not have high tolerance based on regular alcohol use, can often reduce sleep-onset latency. Side Effects: Can result in poorer quality sleep and nighttime awakening or middle insomnia (awaking at 3 or 4am). Alcohol also is clearly not appropriate for someone with a risk for alcohol abuse, dependency or addictions. Alcohol can interact with other medications and depress respiratory function due to synergistic effects and cause death. Ask your doctor about interactions of alcohol with your medication. Regular use may also result in dependency. Some OTC preparations combine antihistamines, pain relievers (i.e. Tylenol P.M) and/or alcohol (i.e. Nyquil).
Lemon Balm and chamomile tea are commonly chosen herbal medications for their mildly tranquilizing properties. For many people they are relatively harmless, but some people experience allergic reactions to those who have plant or pollen allergies and there is a concern that these can interfere with other medications, or that they may interact with other OTC or prescribed sleep medications. St. John’s Wart has an even higher reported potential to interact with antidepressant medication, blood thinners and even birth control pills. As always, consultation with a doctor is advised.
Part III Summary
Once a medical consultation has been conducted to rule out or determine medical causes of insomnia, and psychiatric and/or clinical psychological evaluation has been conducted to rule out or determine psychiatric causes of insomnia then, along with appropriate treatment of medical and psychiatric conditions, additional approaches to insomnia may be considered.
Clearly, Cognitive Behavioral Therapy in combination with good sleep hygiene habits and interventions, and relaxation techniques are safe and have demonstrated long-term efficacy without risk of medication side-effects, drug interactions, or daytime grogginess, drug abuse or dependency issues, or safety concerns. For some people, short-term use of OTC medications or supplements is sometimes effective though safety concerns and consultation about risks in the context of your medical condition and other medication is strongly advised, since many have medical and psychiatric side effects and can even be toxic.
Clinical Psychology Associates of North Central Florida offers a structured time-limited assessment and Cognitive Behavioral Therapy treatment approach to insomnia. While no referral is necessary, discussing your sleep problem with your medical doctor to rule out medical causes of insomnia or medication-induced insomnia is advised before starting the program.Call (352) 336-2888 for an intake appointment.
Other Articles in this Series:
A Basic Guide to Insomnia:Part I: Insomnia the Basics
A Basic Guide to Insomnia:Part II:Sleep Hygiene Handout
A Basic Guide to Insomnia Part IV: Prescription Medication Considerations in the Treatment of Insomnia
A Basic Guide to Insomnia Part V: Sleep Disorder Classification
Glovinsky, P.B., Yang, C-M., Dubrovsky, B., Spielman , A.J. (2008). Nonpharmacologic strategies in the management of insomnia-rationale and implementation. Journal of Clinical Sleep Medicine, 3,189-204.
Herxheimer, A. & Petrie, K.J.(2002). Melatonin for the prevention and treatment of jet lag. Cochrane Database System Review, 2, CD001520.
Lande, R.G., Gragnani, C. (2010). Nonpharmacologic approaches to the management of insomnia. The Journal of the American Osteopathic Association,110 (12),695-701.
Morin, C.M., Vallieres, A., Guay, B., Savard, J., Merette, C., Bastien, C., et al., (2009). Cognitive Behavioral Therapy, Singly and Combined With Medication, for Persistent Insomnia A Randomized Controlled Trial. Journal of the American Medical Association, 301(19), 2005-2015.
Riley, W. T. (2005). Manifestations and management of chronic insomnia: NIH state-of-the-science conference findings and implications.
last update 4/27/14 EJB