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Sleep Therapy

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  • The American College of Physicians (ACP) has released new guidelines on the management of chronic insomnia
  • ACP recommended a form of psychotherapy known as cognitive behavioral therapy for insomnia (CBT-I), which helps people to change their thoughts and behaviors regarding sleep
  • CBT-I helped most people to relieve insomnia with minimal side effects, as opposed to insomnia medications, which carried sometimes-severe risks
 

The Benefits of Sleep Therapy Over Drugs

May 19, 2016 | 47,238 views

By Dr. Mercola

Lack of sleep is detrimental to your health, and in the case of chronic insomnia, it can even be deadly. People with chronic insomnia have a three times greater risk of death from all causes compared to those who sleep normally.1

Sleep is also intricately tied to important hormone levels, including melatonin, production of which is disturbed by lack of sleep. This is extremely problematic, as melatonin inhibits the proliferation of a wide range of cancer cell types, as well as triggers cancer cell apoptosis (self-destruction).

Lack of sleep also decreases levels of your fat-regulating hormone leptin while increasing the hunger hormone ghrelin. The resulting increase in hunger and appetite can easily lead to overeating and weight gain.

Considering the steep physical risks — and the mental and emotional toll chronic insomnia can take — you may be willing to try anything, even sleeping pills, to get some sound sleep. Experts suggest, however, that there's a safer option that can relieve insomnia — psychotherapy.

Therapy Relieves Chronic Insomnia, Is Safer Than Drugs

The American College of Physicians (ACP) has released new guidelines on the management of chronic insomnia. Drugs like Ambien and Lunesta should take a backseat to psychotherapy because, while both options may improve sleep, the latter does so with far less risk and at a lower cost.

In particular, ACP recommended a form of psychotherapy known as cognitive behavioral therapy for insomnia (CBT-I), which helps people to change their thoughts and behaviors regarding sleep. Each person's CBT-I treatment plan is tailored to his or her individual needs.

The therapy has been shown to help most people improve their sleep quality and duration. The new guidelines were released after two ACP-commissioned reviews of insomnia treatments, one focusing on medications and the other on psychological and behavioral treatments.

CBT-I was the clear winner, helping to relieve insomnia with minimal side effects, as opposed to insomnia medications, which carried sometimes-severe risks. The American Academy of Sleep Medicine (AASM) also recommends psychotherapy as a first-line treatment for insomnia.

While not all large cities (or even all U.S. states) have therapists trained in CBT-I, online and phone-based options are available, as are self-help books. If you're wondering what a course of CBT-I therapy entails, STAT News reported one patient's story:2

"John Cormier, 56, started receiving CBT-I last year after 25 years of sleeping problems and a desire to give up medications. During the treatment, he would give himself 30 minutes to fall asleep.

If he was still awake, he made himself get up and go do something else for 30 minutes before trying again. He repeated the pattern if sleep didn't come.

'I had a few nights of almost sleepless nights,' he said. 'It brought me back to my days in college.' After some time, however, Cormier started to see progress. He can now typically get more than six and one-half hours of quality sleep and hasn't taken sleep medication since last summer."

Insomnia Is Common and Causes Significant Distress

If you're wondering whether your sleep difficulties are actually chronic insomnia, the condition is defined as dissatisfaction with sleep quantity or quality. It's associated with difficulty initiating or maintaining sleep and early-morning waking with an inability to return to sleep.

To be classified as chronic, the symptoms must cause significant distress or impairment in your ability to function, and the symptoms must be present for at least three nights per week for at least three months.3

Up to 10 percent of U.S. adults have insomnia, which results in more than $63 billion in lost productivity each year.4 Unfortunately, many people resort to taking medications to help them sleep, which is risky at best and downright dangerous at worst.

After a systematic review of randomized, controlled trials published from 2004 through September 2015, the ACP concluded:5

"Cognitive behavioral therapy for insomnia is an effective therapy for chronic insomnia disorder and can be performed and prescribed in the primary care setting.

Evidence showed that CBT-I was effective in treating the general population of adults as well as older adults with chronic insomnia disorder.

There is insufficient evidence to directly compare CBT-I and pharmacologic treatment. However, because CBT-I is noninvasive, it is likely to have fewer harms, whereas pharmacologic therapy can be associated with serious adverse events."

Hypnotic drugs, for instance, may be associated with dementia and fractures, while the U.S. Food and Drug Administration (FDA) warns that such drugs may lead to cognitive and behavioral changes, driving impairment, motor vehicles accidents and other adverse effects.

Insomnia Medications Linked to Premature Death, Alzheimer's and Cancer

Up to 43 percent of older adults use benzodiazepines (Valium, Xanax, Ativan, etc.) for insomnia (as well as for anxiety) often chronically, even though their long-term effectiveness and safety remains unproven.6

International guidelines recommend short-term use of benzodiazepines, because they cause withdrawal symptoms that make discontinuation problematic. Despite this, many seniors take them for years instead of a few weeks, as is recommended.

Older adults who used benzodiazepines for three months or more had a 51 percent greater risk of Alzheimer's disease than those who did not.7 Benzodiazepines, common side effects of which include dizziness, unsteady gait and falling, are also known to cause hip fractures, impairment of thinking and memory loss.

Further, people who received drugs for poor sleep (including benzodiazepines) showed that "as predicted, patients prescribed any hypnotic had substantially elevated hazards of dying compared to those prescribed no hypnotics."8

The association held true even when patients with poor health were taken into account — and even if the patients took fewer than 18 pills in a year.

The study suggested that those who take such medications are not only at higher risk for certain cancers but are nearly four times more likely to die than people who don't take them. In "The Dark Side of Sleeping Pills," an e-book by one of the study's researchers, Dr. Daniel Kripke, it's explained:9

"It seems quite likely that the sleeping pills were causing early death for many of the patients. In addition, those who averaged over 132 sleeping pills per year were 35 percent more likely to develop a new cancer …

Theoretically, there could be confounding factors or biases in the selection of patients which caused these deaths without involving sleeping pills.

We can only say that we found almost no evidence of such biases … If sleeping pills cause even a small portion of the excess deaths and cancers associated with their use, they are too dangerous to use."

Lack of Vitamin D May Increase Your Risk of Sleep Apnea

While chronic insomnia must, technically speaking, not be linked to other sleep, medical, or mental disorders, obstructive sleep apnea syndrome can also interfere with your sleep. Obstructive apnea relates to an obstruction of your airway that begins in your nose and ends in your lungs.

The frequent collapse of your airway during sleep makes it difficult to breathe for periods lasting as long as 10 seconds. Those with a severe form of the disorder have at least 30 disruptions per hour. Obstructive sleep apnea, or OSA, arises from what is basically a mechanical problem.

During sleep your tongue falls back against your soft palate, and the soft palate and uvula fall back against the back of your throat, effectively closing your airway.

Breathing usually resumes with a large gasp, snort or body jerk. These movements interfere with sound sleep. They can also reduce the flow of oxygen to vital organs and cause irregular heart rhythms.

If you have obstructive sleep apnea, you should be sure to have your vitamin D levels checked and optimize them if necessary. Recent research published in the journal Sleep found a significant inverse relationship between vitamin D and the severity of OSA.10 That is, people with lower vitamin D levels had more severe disease. Further, vitamin D levels tended to be significantly lower in people with OSA compared to those without.

Are You Using Electronics Before Bed? Turn Them Off!

You can certainly try CBT-I if you struggle with insomnia, but I'd also suggest making some changes to your sleep hygiene and bedtime routine, especially if it involves watching TV or using your computer or tablet. Even your cell phone screen could be problematic. This is because one of the greatest plights of modern-day sleep is the introduction of light-emitting electronic devices to the bedroom.

Research shows that 90 percent of Americans use an electronic device within an hour of going to bed, and this is associated with poor sleep.11 A study also compared the use of an iPad for four hours before bed (for five consecutive nights) to reading a print book for the same period.12 There were significant biological effects of iPad use before bed, including:13

  • Reduced secretion of melatonin, a hormone that induces sleepiness
  • Delayed circadian rhythm of more than an hour
  • Feeling less sleepy before bedtime
  • Feeling sleepier and less alert the following morning, even after eight hours of sleep
  • Spending less time in REM sleep

The blue light emitted from electronics such as cell phones, tablets, TVs and computers suppresses your melatonin production, thereby preventing you from feeling sleepy. What you may not realize is that even if you don't feel sleepy, you need sleep. You've simply artificially disrupted your body clock; you have not in any way altered your body's biological needs.

I previously interviewed Dan Pardi on the topic of how to get restorative, health-promoting sleep. Pardi is a researcher who works with the Behavioral Sciences department at Stanford University and the departments of Neurology and Endocrinology at Leiden University in the Netherlands. In addition to avoiding blue light at night, be careful with turning on bright lights in the bathroom if you're brushing your teeth before bed or using the bathroom in the middle of the night.

Pardi also recommends getting at least 30 to 60 minutes of outdoor light exposure during daylight hours in order to "anchor" your master clock rhythm. The ideal time to go outdoors is right around solar noon, but any time during daylight hours, including first thing in the morning, is useful. If you can't get outdoors in the morning, try turning on your indoor lighting, which should have a similar ambient brightness to a sunrise.14

Once the sun has set, the converse applies. After sunset, you want to avoid light as much as possible in order for your body to secrete melatonin, which helps you feel sleepy.

Are You Having Trouble Sleeping?

I suggest reading my "Guide to a Good Night's Sleep for 33 simple tips" on improving your sleep before even considering sleeping pills. Small adjustments to your daily routine and sleeping area can go a long way to ensure uninterrupted, restful sleep. To start, consider implementing the following changes. No. 1 on my list? As mentioned, turn off your electronic gadgets well before bedtime and keep them out of your bedroom:

  • Avoid watching TV or using your computer/smartphone or tablet in the evening, at least an hour or so before going to bed.
  • Make sure you get BRIGHT sun exposure regularly. Your pineal gland produces melatonin roughly in approximation to the contrast of bright sun exposure in the day and complete darkness at night. If you are in darkness all day long, it can't appreciate the difference and will not optimize your melatonin production.
  • Get some sun in the morning. Your circadian system needs bright light to reset itself. Ten to 15 minutes of morning sunlight will send a strong message to your internal clock that day has arrived, making it less likely to be confused by weaker light signals during the night.
  • Sleep in complete darkness, or as close to it as possible. Even the tiniest glow from your clock radio could be interfering with your sleep, so cover your clock radio up at night or get rid of it altogether. Move all electrical devices at least three feet away from your bed. You may want to cover your windows with drapes or blackout shades, or wear an eye mask when you sleep.
  • Install a low-wattage yellow, orange, or red light bulb if you need a source of light for navigation at night. Light in these bandwidths does not shut down melatonin production in the way that white and blue bandwidth light does. Salt lamps are handy for this purpose.
  • Keep the temperature in your bedroom no higher than 70 degrees F. Many people keep their homes too warm (particularly their upstairs bedrooms). Studies show that the optimal room temperature for sleep is between 60 to 68 degrees F.
  • Take a hot bath 90 to 120 minutes before bedtime. This increases your core body temperature, and when you get out of the bath it abruptly drops, signaling your body that you are ready to sleep.
  • Avoid using loud alarm clocks. Being jolted awake each morning can be very stressful. If you are regularly getting enough sleep, you might not even need an alarm, as you'll wake up naturally.
  • Be mindful of electromagnetic fields (EMFs) in your bedroom. EMFs can disrupt your pineal gland and its melatonin production, and may have other negative biological effects as well. A gauss meter is required if you want to measure EMF levels in various areas of your home. If possible, install a kill switch to turn off all electricity to your bedroom. If you need a clock, use a battery-operated one.

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