Dr IMRAN SAJID | June 2022
Watch the explainer videos for the full information, or scan the highlights below.
Links to self-help resources are listed at end.
Poor sleep is common.
Around a THIRD of all adults may have one bad night of sleep per week and around ONE in TEN of us fulfill the criteria for 'insomnia'.
Possibly less than 1% of those with persistent sleep difficulties are directed to the recommended first-line treatment.
Sometimes insomnia isn’t related to other health issues, but it can often be driven by underlying emotional difficulties, or conditions such as restless legs, chronic pain, parasomnias, or medical disorders, such as sleep apnoea.
We all have completely different sleep requirements, eight hours is not scientific target. Anywhere from four to eleven hours could be considered 'normal'; it’s about what works for you. If you’re generally feeling fine and functioning during the day; try not to agonise over exactly how many hours of sleep you may or may not be getting at night.
Drugs for sedation generally boost inhibitory pathways (’off switches') in the nervous system, or block excitatory pathways (’on switches') in the nervous system.
Common prescriptions for sleep include benzodiazepines (such as Valium / diazepam, Xanax / alprazolam etc) or Z-drugs, also called Hypnotics (such as Stillnoct / zopiclone or Ambien / zolpidem). These potentiate GABA neuroreceptors ('off switches') in the nervous system, to produce sedation.
Research shows that, compared to placebo, these sedatives broadly help you fall asleep around 15 minutes quicker and sleep around 30 minutes longer in total. Results do vary between studies and drugs vary in their onset and duration of action.
We're inaccurate in judging our time asleep, so those objectively measured changes in sleep metrics may subjectively feel very different to us.
Low-dose sedating anti-depressants are often also used for sleep. These have their own side effects and risks, with often very limited research for insomnia. Many provide sedation, at least partly, through anti-histamine effects.
Anti-histamine (allergy medicine) sleeping aids can be obtained over the counter without prescription; these may be less effective than prescription sedatives and you can potentially become tolerant to their effects, finding them less effective following continuous use. They tend to have longer half-lives, meaning they can leave some hangover drowsiness the following morning (similar to many of the sedating anti-depressants). They do however have a lower risk of dependence/addiction.
Melatonin is a chrono-biology drug which may help for those with a circadian rhythm (internal clock) problem, such as jet lag, although studies suggest the effect is very minimal.
Other over-counter supplements (eg magnesium or Valerian) are available, although have very limited supportive evidence.
Medication is best discussed with a professional, tailored depending on the specific pattern of insomnia, any contributing underlying conditions, other medical history and your preferences.
A package of interventions, cognitive behavioural therapy for insomnia (CBTi) is the recommended first-line gold standard treatment, shown to be as effective as medication in the short-term, and more effective in the long-term.
Benefits persist even after completing the therapy.
Consistent bed time and waking time.
Daily exercise and outdoor light.
Moderate caffeine, alchohol & smoking.
No waking activities in bed.
Bed should be associated with only sleep/sex.
If you're unable to sleep for what feels like twenty minutes or more, get out of bed, do something quiet for a while and then return to the bedroom to try again only when you're feeling sleepy, perhaps 45-60min, or more, later.
You can't force yourself to fall asleep, but you can control staying awake and when you wake up in the morning.
Gauge how many hours you're currently sleeping, then reduce the amount of time you're spending in bed.
This should enable you to fall asleep easier, in a less stressful manner, achieving more consolidated and restorative sleep.
Fewer hours in bed, but better quality, 'deeper' sleep.
The total time you're asleep should be around 85% of the time you give yourself in bed.
Excess negative thoughts about insomnia can ramp up our hyperarousal to the issue and worsen the problem. It is within our control to re-frame such thoughts to reduce the noise they create. For example. reassuring ourselves that we typically can get through difficult days following a night of insomnia.
Yoga, meditation, prayer, spirituality, or simple breathing techniques can all be helpful to reduce our levels of arousability. A very simple method is 7-11 breathing (inhaling over 7 seconds, followed by a slow exhale over 11 seconds, through pursed lips). Relaxation techniques require practice, so may be useful to deploy both during the day and night.
If you suffer any daytime fatigue when starting these techniques, consider morning caffeine, or physical activity breaks during the day to increase energy levels.
CBTi can be delivered through a sleep coach/therapist but can also be self-managed, for example through digital tools (listed below) which have been shown to be effective.
Somryst (For US-based individuals)