Insomnia—difficulty falling or staying asleep—can wreak havoc on people's lives. And with the coroner's finding that Michael Jackson died from a lethal dose of the anesthesia medication propofol (Diprivan), which the pop star reportedly received routinely because of his chronic inability to sleep, it's a good time to revisit safe ways to help cure insomnia.
About 30 percent of adults experience some degree of insomnia at some point in their lives, and about 10 percent have problems that are severe enough that their waking hours are affected, according to the American Academy of Sleep Medicine, which published guidelines for the treatment of insomnia last year in the Journal of Clinical Sleep Medicine. "Almost everyone who walks the face of the Earth will have at least a very transient period of sleep disturbance at some point in their lives," due to stress, pressure, worry, or even medical problems that cause pain and distress, says Michael Sateia, a coauthor of the AASM's insomnia guidelines and chief of sleep medicine at Dartmouth-Hitchcock Medical Center in Lebanon, N.H. For most people, sleep problems are short term and go away on their own. But about 10 percent of adults have chronic insomnia, defined by sleep interruptions at least three times per week for a month or more. Some people experience the problem for years or even decades.
At least eight out of 10 people with insomnia have what's called secondary insomnia, meaning their sleep disturbances are caused by health problems, medications, sleep disorders, or certain substances. But others have primary insomnia, meaning their sleep problems don't have these triggers and may instead result from prolonged stress or emotional upset, according to the National Heart, Lung and Blood Institute. A small study presented at the annual meeting of the Associated Professional Sleep Societies in June suggests another possible cause of primary insomnia: It showed that some sufferers have a neurochemical abnormality that makes it hard for the mind to shut down and allow the body to sleep at night. Researchers looked at the 16 insomniacs' levels of gamma-aminobutyric acid, also known as GABA (which slows activity in many areas of the brain), and then at the GABA levels of 16 normal sleepers. Study participants who'd had primary insomnia for at least six months had lower GABA levels. The study's lead investigator, John Winkelman of Brigham and Women's Hospital in Boston, said the research suggests that insomnia may affect the brain.
Insomniacs don't have to suffer and simply live with their condition, however. "There are a lot of things that individuals can do to improve their ability to sleep or allow themselves to sleep better," says Neil Kline, a Philadelphia-based sleep physician and spokesperson for the American Sleep Association. Here are 9 things you can do if you're battling insomnia:
Consider cognitive behavioral therapy, which attempts to change the thoughts and actions that interrupt your body's ability to get a good night's rest. Because research shows that psychological and behavioral issues factor into insomnia, CBT can be used to help improve sleep, and the benefits last over time, research shows; even a year after therapy, most people report continuing to sleep well, according to the Mayo Clinic. A study published in June in the journal Sleep found that online cognitive behavioral therapy is also an effective treatment for chronic insomnia.
During CBT, you're taught to pinpoint false notions that may affect your sleep—for example, you may think you need eight hours of sleep when your body can actually get by on seven. You're also taught to deal with negative thoughts or concerns that may keep you awake at night and to change certain behaviors, such as caffeine consumption (more on that below). CBT typically includes between four and eight half-hour sessions led by a sleep therapist, and may also include meditation, muscle relaxation, biofeedback, or hypnosis.
Avoid taking daytime naps, which decrease your nighttime sleep needs, Kline says. Of course, being an insomniac can make you sleepy during the day, experts acknowledge. So if you must nap, Sateia says, limit the duration, and make it as early in the day as possible.
Avoid caffeine or nicotine close to bedtime. The Food and Drug Administration recommends not having caffeine or nicotine for four to six hours before bedtime. Sateia goes farther, advising insomniacs to restrict caffeine to small amounts in the morning. That means no more than a cup or two of coffee per day, and nothing after midday, he says.
Skip the glass of wine at bedtime. Alcohol can actually interfere with sleep—not improve it, as many people assume. Although it's sedating, Sateia says, it's also very short-acting. "What happens is it gets metabolized quickly, he says, and "sleep becomes lighter and more fragmented." That means you may wake up in the middle of the night and have trouble getting back to sleep.
Exercise and eat early. It's best to avoid exercising and eating large meals within two hours of bedtime, according to the FDA. And try to prepare yourself for bed by listening to music or reading in the half-hour just before bedtime. In addition, sleep experts advise that insomniacs use their beds only for sleep and sex.
Get out of bed. If you can't fall asleep quickly, get up. "If you're not able to get to sleep within about 20 minutes, remove yourself from bed and do something else relaxing until you're prepared to go back and try it again," advises Sateia. The same advice applies if you awaken in the middle of the night.
Create a supportive sleeping environment. Experts suggest having a bedroom environment that's conducive to sleep: dark and quiet, with a comfortable temperature, and preferably free of noisy pets, beeping cellphones or pagers, television, radio, and computers. "It's easy to get carried away with all of the technology we have available to us," Kline says, but he says it's a must to limit tech use close to bedtime if you want a good night's rest.
Restrict your "sleep window," which is the amount of time that you spend in bed. "So if you're only sleeping five hours a day, the rules of sleep restriction say you start out with the allotted five hours in bed," Sateia says. Gradually lengthen your time in bed, but only after you've trained yourself to actually sleep for 90 percent or more of the initially restricted sleep window.
The average sleep time is about seven hours for adults (eight hours is ideal), yet people with chronic insomnia "will spend 10, 12, 16 hours in bed because they haven't gotten enough sleep," Sateia says.
Maintain a sleeping routine. "We're creatures of habit, and every cell in our body has a rhythm," Kline says. "Generally speaking, it's a good idea to keep a regular sleep routine: going to bed at the same time, waking up at the same time. Keep it within 15 to 30 minutes of that routine." And that includes not sleeping in on the weekends.
Consider medication, but be careful with over-the-counter sleep aids, most of which contain antihistamines, which make you drowsy but may interact with certain other types of medications. The options for OTC sleep aids include various pills that contain diphenhydramine, a sleep-aiding ingredient. Among these are Benadryl, Tylenol PM (which contains acetaminophen plus diphenhydramine), Advil PM (ibuprofen plus diphenhydramine), Sominex and Nytol (both contain diphenhydramine as their primary active ingredient). Unisom (doxylamine) is another option, as are dietary supplements, including melatonin and valerian, but not much is known about the safety and effectiveness of these supplements, according to the Mayo Clinic.
If you are or were recently taking a prescription monoamine oxidase inhibitor (an antidepressant known as an MAOI), you should ask your doctor before taking OTC sleep aids or supplements. The same goes for anyone taking any medications for Parkinson's disease, depression, or any psychiatric or emotional problems. And be careful with the combination sleep aide Tylenol PM because it contains acetaminophen, which can be dangerous if consumed in high-enough doses and is also found in many pain relievers and combination cold, allergy, and sinus medications. And Advil PM, in a class of drugs called nonsteroidal anti-inflammatory medications, or NSAIDs, carries its own risks. Also, there's no evidence that OTC sleep aids are helpful to people when taken over long periods of time for insomnia, Sateia says.
If OTC medications and nondrug approaches like CBT aren't enough, there are also prescription drugs that can help improve sleep and may be appropriate for people with acute insomnia, says Sateia. Newer-generation sleep aids include zolpidem (Ambien), eszopiclone (Lunesta), zaleplon (Sonata), temazepam (Restoril), and ramelteon (Rozerem), which Sateia says are generally safe. They're recommended for short-term use, but some research suggests people may be able to use them over a longer period of time without suffering harmful side effects or becoming dependent. Takeda Pharmaceuticals North America, which makes Rozerem, says that there is no scientific evidence that the drug causes dependence or abuse. Ongoing use of certain other sleep aids, however, can lead to chemical dependence.
Nevertheless, anyone taking these medications should be followed closely by a doctor, especially since some of the medications have been linked to rare episodes of strange behavior, including sleep eating, sleep driving, and making phone calls or having sex while asleep.
And as for taking propofol—the anesthesia medication implicated in Michael Jackson's death: No way, says Sateia. It's not a recommended treatment for insomnia and should never be used outside of a hospital.