An Expert’s Perspective on Treating Chronic Insomnia
Dr. Susheel Patil is a board-certified sleep medicine specialist with University Hospitals in Cleveland and practices at the Cleveland Medical Center. He shares common questions he receives from patients about living with insomnia and finding the right treatment.
A: With insomnia, an individual has difficulty falling and/or staying asleep, which can affect daytime function, mood, and quality of life. Insomnia can either be short-term or long-term (chronic). Even if their insomnia is short-term–typically less than three months–a person will have at least several nights per week where their sleep is affected. Beyond the three-month mark, most clinicians will consider these persistent symptoms to be chronic insomnia.
A: When someone with insomnia says they’re tired, this may convey many meanings. They may have low energy and feel physically exhausted. They may feel sleepy all day. They may experience mood changes; insomnia can worsen anxiety and it’s a risk factor for developing depression. People with insomnia can have impaired short-term memory and gastrointestinal disturbances, as well. And of course, it can impact a person’s ability to perform well or safely at their job, at school, or at home. Insomnia can take a huge toll on an individual, so when someone comes in to see me, I work intently with them together with our sleep medicine team to find solutions.
A: There are two main ways we approach insomnia treatment, and they’re often complementary. There is the behavioral aspect, which includes behavioral changes and lots of education. And there is also medication, which we turn to if behavioral techniques aren’t enough. The evidence shows us that cognitive behavioral therapy (CBT) is enormously effective in improving insomnia. CBT is a type of psychotherapy that involves examining a patient’s sleep habits and their feelings about sleep, and educating them on proper sleep hygiene. There are a lot of misconceptions about sleep, so we make sure we’re on the same page about basic sleep biology and healthy routines. We’ll work together to establish a routine that promotes good sleep, which means waking up and going to bed at the same time every day, avoiding afternoon caffeine, setting up their bedroom for proper sleep, and more. Committing to these behavioral changes is extremely important because sleep requires consistency. CBT also addresses the emotional aspect of sleep. People can get into a self-defeating cycle when it comes to sleep, and CBT can help interrupt and examine their mindsets and thought processes to build a better relationship with sleep. A sleep psychologist, also called a behavioral sleep medicine specialist, is best equipped to guide someone in this technique, although many sleep medicine specialists can help with that as well.
A: If behavioral changes aren’t doing enough, sometimes we’ll turn to medications. Over-the-counter (OTC) medicines can be helpful, but they shouldn’t be used indefinitely. They are most effective and safest for patients when taken on a short-term basis, for no more than several weeks. If you’ve been taking OTC sleep medications on a regular basis for a long time, that should be a sign to talk to your doctor. The most common OTC sleep medications are actually meant to treat other conditions; for example, diphenhydramine (Benadryl) is an antihistamine– an allergy medication–that many people take to help them sleep because it causes drowsiness. Antihistamines are helpful, especially in younger patients, but I don’t recommend them to older people, as they can lead to problems with urination or constipation. Melatonin is also a commonly used OTC treatment. It’s a supplement your body produces naturally, and it can help to standardize your internal sleep clock to make it easier to fall and stay asleep. There are lots of different brands selling melatonin, in a variety of doses, so it’s important to talk to a professional about your melatonin use. What’s written on the bottle may not always be the right strategy for you. And of course we also have a number of herbal products out there, like Valerian root; they can help, but I encourage people to talk to their doctors before taking any supplements. Many products combine different ingredients and we don’t always understand very well what they’re all doing.
In some cases, prescription medication is needed. It’s an evolving field and there are a number of different medications available today. Patients may try a class of drugs called sedative-hypnotics; this class includes zolpidem (Ambien) and zopiclone (Lunesta). If someone has depression or anxiety along with insomnia, we may prescribe them certain antidepressant medications that also carry the benefit of improving sleep, like trazodone (Desyrel) or mirtazapine (Remeron). And then there is a newer class of medications called orexin agonists that target specific parts of the brain that help with sleepiness; lemborexant (Dayvigo) and suvorexant (Belsomra) are two available drugs in this class.
We want to avoid long-term use of any sleeping medications, because they can cause a physical dependence, become less effective over time, and sometimes lead to other side effects like long-term memory problems. Newer drugs are less likely to create a dependence, but ultimately we think of medications as a temporary bridge towards other methods of insomnia management, like CBT and behavioral changes.