11:46 PM. It's Bedtime.

Strategies to avoid insomnia - both obvious and overlooked.

You stare at the bed in front of you. With fluffy pillows and flannel sheets it certainly looks inviting. But as of late that bed has become a place of frustration, self-loathing, and restless despair. You’ve been watching the clock advance each night, sleepless, waiting hours sometimes for unconsciousness to arrive. And when it finally arrives it leaves you awake again much too soon. You ruminate in the anxious dark about all the damage being done to your body. You’ve read about how important good sleep is for health, and all the miserable diseases that are associated with chronic insomnia. You’ve read even more about how to sleep well. Yet all that knowledge isn’t helping right now. The damn lavender scented noise machine next to your head does not make this struggle easier. Insomnia starts to feel like a kind of torture, and before you’ve counted your 635th sheep, the dreaded first light of dawn is cutting through the window curtains. It’s what you feared the most, and now the whole day is at risk of a fatigued failure. And yes, that is the sound of gleeful sparrows chirping as they wake from their restful night. And yes, they slept well, perched upright on tree branches blowing in the wind on a 20-degree frigid night, with not even a bed, pillow, or drop of chamomile tea.

Perhaps tonight, if you make it through the day, you will join the sparrows outside in the tree branches.

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Trouble falling asleep, staying asleep, and restless sleep are some of the most common complaints discussed on a daily basis in primary care. No one ever comes in happy about it, or even neutral. The concerns are usually communicated with a grim sense of alarm, frustration, and defeat. Implicit in the grievance is a sense that this insomnia is not just maddening, but that it will lead to health problems. Catastrophic health problems. We seek quick solutions.

It is very important to acknowledge from the outset that poor sleep can be a symptom of an underlying problem such as anxiety, depression, obsessive thinking, chronic pain, cognitive problems, and now even post-Covid conditions. We should step back and look at the big picture, and hopefully a primary care doctor can be part of our initial assessment and plan. But to narrowly refocus back on the problem of insomnia as isolated from our unique circumstances, and for the purposes of examination:

Reframe the problem

Trouble sleeping is not usually the imminent, desperate situation it might seem. There are simple techniques and behaviors we can practice and learn. Some will help immediately; others will take some time. Like weeks. Or even months to perfect. And so, at the outset, it is important to reframe this as more of a challenge to be overcome, rather than a shameful failure to quickly erase.

Often it helps to think more positively of rest. An obsession with total unconscious sleep time can lead us to watch the clock, to continually survey our brains asking am I asleep yet? Many sleep studies show brainwaves consistent with light sleep when patients are sure they have not slept a wink. Even when we are not completely asleep, it’s true that rest is still restorative. It’s built right there into the word. Therefore, a first way to disarm insomnia is to deny it the destructive power we give it. Try to relax and think: this rest is still good. Unconsciousness is just a bonus.

Indeed, restructuring our negative patterns of thought surrounding insomnia is at the core of the most effective treatment: Cognitive Behavioral Therapy for Insomnia. CBT-I has been proven to be the best, safest, and most durable approach to helping with sleep problems. It focuses on dysfunctional thoughts, emotions, and behaviors that interfere with sleep. The basic framework centers around:

• Education about sleep and sleep hygiene.

• Identifying and challenging negative thoughts and beliefs about sleep.

• Stimulus control techniques that help associate the bed with sleep and relaxation rather than wakefulness and anxiety.

• Possible sleep restriction techniques to limit the amount of time spent in bed to match the amount of time spent asleep, and gradually increasing the time spent in bed as sleep efficiency improves.

• Good old-fashioned relaxation techniques like progressive muscle relaxation, deep breathing, and mindfulness meditation.

• Cognitive restructuring to identify and challenge negative thought patterns like catastrophic thinking about the consequences of not getting enough sleep.

We can do CBT-I programs online. Studies have actually shown that this can be as effective as seeing a real-life counselor trained in CBT-I. Some of the more commonly used websites for this include Somryst, CBT for Insomnia, and Sleepio, but there are certainly many others with different price points.

For those preferring a human being to guide, tailor, and help motivate, a list of providers can be found using the search box on Psychology Today. Try putting in a zip code, and then sort by “Issues,” and select “Sleep or Insomnia.” Follow this up with an inquiry to the provider as to whether they are trained specifically in CBT-I.

And finally, telemedicine can also open the door to CBT-I with a trained professional through sites like Better Help and Talk Space.

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Go through this checklist

There are so many websites, articles, and admonitions out there telling us how to sleep. It can be mind numbing and almost cliched. But here is a homemade tip sheet, written by hand. I hope that its amateurish appearance will lend it sincerity… and help us relax into better sleep, insomnia or not.

This image should be printable. Notice the darkening gray gradient as you progress down the tip sheet. You are getting sleepy. Very sleepy.

Consider printing this list out and checking off the boxes that you already succeed with. Then perhaps focus on those boxes that are unchecked if you’re having troubles, or just want to improve your restful time.

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Medications for insomnia have their place.

In general doctors try to avoid prescribing sleeping pills. Short term they can be great, like when used to break a repetitive cycle of anxiety-driven misery. But most sedatives can be addictive. They can lead to falls, memory problems, accidents, daytime fatigue, and rebound anxiety as they wear off. They usually stop working as well with prolonged use. Meds do not address the underlying drivers of poor sleep. But given the maddening torture insomnia can become, and with the limited time we have to get through ever-lengthening lists of problems in 20 minutes - a prescription for Ambien or lorazepam becomes a merciful and rational act. It’s easy. Too easy. We should try to use sleeping pills rarely if at all, and think of them as a short term, infrequent crutch.

Ramelteon (Rozerem) is only modestly effective compared with placebo, but it has few adverse effects. In fact, after trying CBT-I, the American Academy of Sleep Medicine concedes 8 mg of ramelteon as an evidence-based treatment for chronic sleep-onset insomnia.

Doxepin is a tricyclic antidepressant that is not frequently used, but perhaps should be considered more often. According to an article in American Family Physician:

Compared with placebo, doxepin at doses of 3 and 6 mg improves sleep efficiency and total sleep time, and a 6-mg dose improves sleep latency.³⁶ The adverse effect profile of both doses is favorable in older adults and similar to placebo, even when used long term.^18,37 Doxepin is also available in a much less expensive generic formulation in 10-mg capsules. Although safe, this dosage has not been approved by the FDA for the treatment of insomnia.

Over the counter sleeping aids have issues, too. Most of the “PM” formulations contain diphenhydramine (Benadryl) as the active ingredient. Antihistamines can make us tired as a side effect, ergo they can help with falling and staying asleep. Yet long term antihistamine use has recently been associated with memory problems, and in the short term can depress our moods, constipate our bowels, and dry our mouths.

Melatonin can help for some people, and is generally safe. Melatonin preparations reduce sleep-onset latency, increase total sleep time, and slightly improve sleep efficiency.

Here is an algorithm, the gist of which might be spinning inside your doctor’s head as they listen to your story:

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Deprescribing benzodiazepines

No one likes to be stuck taking sleeping pills. But when they have been used on most nights for months, it can be really frustrating to get off these medications. Especially benzodiazepines like Ativan, or Ambien and Lunesta. And even worse, these medications can stop working, requiring higher doses and more frequent administration. That’s a hallmark of an addictive medication. A practice guideline from American Family Physician sums this up quite well:

Benzodiazepine receptor agonists (BZRAs), which include benzodiazepines and drugs such as zolpidem (Ambien), are often used to treat insomnia. Although they are beneficial for short-term improvement in sleep onset latency and duration, they also have associated harms, including problems with dependence. Evidence suggests that the benefits of BZRAs for insomnia wane after four weeks, whereas harms can continue, especially for older persons, including a greater risk of falls, motor vehicle collisions, problems with memory, and daytime sedation.

Unwinding someone from the tangle of dependence can be tricky. It involves anticipating and accepting that the landing is going to be somewhat bumpy. Expect some degree of turbulence as the plane lands, but take the descent nice and slow as this graph illustrates:

And most importantly, if we are stuck on medications, we shouldn’t feel ashamed, embarrassed, or angry. We usually end up cornered in the labyrinth for good reasons. We just need to turn around sometimes.

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You stare at the bed in front of you. With fluffy pillows and flannel sheets it certainly looks inviting. And as of late that bed has become a place of solace, rest, and gratitude. You stopped watching the clock advance each night, and you’re no longer obsessed with waiting for unconsciousness to arrive. You’re still resting regardless, and that’s good. And when true sleep finally arrives it stays longer. You peacefully slumber as repairs are being done in your body. You’ve read about how important good sleep is for health, and all the miserable diseases that are associated with chronic insomnia. You’ve read even more about how to sleep well. You finally invested in cognitive behavioral therapy for insomnia, maybe for the second time, and all that knowledge is helping now. You rarely need that half of a pill. The lavender scented noise machine next to your head helps sometimes, but often you forget to turn it on. Lavender is a bit much every night. Insomnia starts to feel like a kind of occasional nuisance, and counting sheep never really helped anyway. The first light of dawn is cutting through the window curtains. It’s what you hoped for the most, another day in the world to be alive, tired or not. And yes, that is the sound of gleeful sparrows chirping as they wake from their restful night. And yes, they slept well, perched upright on tree branches blowing in the wind on a 20-degree frigid night, with not even a bed, pillow, or drop of chamomile tea.

Perhaps tonight you will join the sparrows outside in the tree branches, and gently shoot one. But you love animals, so that’s just the dark humor talking.

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I hope this has been helpful. I’d like to hear your stories. What troubles have you had with sleep? What solutions have worked for you? As a state of being that constitutes up to a third of our finite lives, it is no wonder that we seek to do it well.

Goodnight, and sleep tight.