There are many causes of insomnia. It should be noted that as annoying as insomnia can be, it is not lethal and does not create mental illness. In fact the body will enforce sleep when it becomes necessary for health. However it can be an uncomfortable experience, and hence there are various approaches to treating it, particularly when it is chronic or long-term.


Medication is not usually effective for long-term treatment of insomnia. The best chance for long term help with medicines comes when the doses are kept low. Increasing doses usually leads to unsuccessful outcome due to the likelihood that the pattern of escalating doses continues and eventually the dose gets in to the range where the individual faces unacceptable side effects, risks, or other problems.

Different types of medication have different advantages and disadvantages. All have risks, and for some, these can be quite significant.

Medications like Ambien, Lunesta, and the benzodiazepines work very well at first but may cause a chemical dependency (i.e., habit forming). This is due to the occurrence of rebound insomnia with an inability to sleep if a dose is missed. In addition, there is often a pattern of finding they work less well with time and need increasing doses (i.e., tolerance). Other medicines without chemical dependency such as trazadone, Vistaril, or Doxepin do not seem to have this rebound insomnia. All of the medicines, regardless of type, have the best long-term effectiveness and fewest problems and risks if the dose is kept as low as possible.

Seroquel (quetiapine) is sometimes prescribed for sleep but patients who use this must understand that it carries the rather significant risk of causing diabetes and elevating cholesterol, as well as stimulating weight gain. Although the numbers are not high, diabetes is a serious illness and some cases of medication-induced diabetes do not go away even if the medication is stopped.

Behavioral Strategies

Behavioral approaches actually have the best long-term success, often when accompanied by low doses of non-habit-forming medications. Many of these approaches are common sense but some are not so obvious.

  1. One important strategy is not to let the sleep cycle become “reversed” where one sleeps during the day and is awake at night. Medications will not fix this, but setting an alarm clock, two if needed, and getting up and out of bed in the morning and not getting back into bed is far and away the most effective. The sleepiness that is felt during the day which may build up will in fact eventually increase the ease of falling asleep at night. This reversal of sleep cycle is often particularly challenging for those who do not have a fixed daily schedule such as the unemployed or retired. However, for someone who is prone to insomnia and does have a daily schedule on weekdays, this approach may be necessary on the weekends also.
  2. A second fairly obvious strategy related to the one above is not to nap during the day. For people experiencing insomnia, even a short nap may extensively prolong the time necessary to fall asleep at night. Some people can get away with naps and some cannot. It is important to know which category you fall into and act accordingly.
  3. A third approach is to try to ensure that there are adequate daily activities. A day without mental or physical activities allows the brain to operate at a slower rate and will, for some people, make it more difficult to become tired enough to go to sleep at a reasonable time.
  4. A fourth approach is to identify if there are any chemicals that are interfering with sleep. Alcohol is not identified as a problem as readily as, say, caffeine, but alcohol is notorious for putting a person to sleep but then having them awaken early, often very anxious (which is a rebound anxiety from alcohol intoxication). Stimulants such as caffeine may have surprisingly long-lasting effects and may need to be limited to early in the day. As with other things, dose also makes a difference.
  5. This strategy relies on common sense: reduce things that may interrupt sleep. Utilizing a fan or sound machine to create white noise and/or the use of ear plugs, as well as reducing light and noise such as late night TV, all are strategies which may help.
  6. A sixth approach is to develop a ritual, or following the same set of routine activities before going to bed each night. It really doesn’t matter what activities are in the ritual as long as they are relaxing and not contrary to the strategies listed above. The idea is to create a predictable experience around the act of going to sleep. This is both relaxing and increases sleep readiness.
  7. Finally if all of the above behaviors are incorporated and you are still experiencing sleep latency (time to fall asleep) which is too long, then it is time to determine if you are one of those people who just may not need as much sleep. Studies have shown there is considerable variation in how much sleep different people need, and also that the amount of sleep needed changes at different ages. There is a technique that can help determine this and it requires only some diligence and a willingness to temporarily tolerate some daytime tiredness. It involves reducing sleep until the increasing tiredness makes falling asleep adequately easy. It goes as follows:

First, one sets a reasonable wake-up time, and as many alarms as necessary may be used to ensure this is the get-out-of-bed time and that it this time is maintained seven days a week. And, of course, there is no daytime napping. Then, one determines an initial “bedtime”. This is the time that you do actually succeed at falling asleep. It does not matter whether it is 11 PM or 3 AM. Maintain this for at least a few days. In time, you will become increasing tired during the day and at night. When the desire to fall asleep becomes strong, set the “bedtime” one hour earlier. Continue this. If daytime and evening tiredness starts to build up, set it one hour earlier again. Continue this process as many times as needed to reach the point where you are falling asleep within about a half hour or less, sleeping most of the night, able to get out of bed at the appointed morning hour, and are not excessively sleeping during the day. This schedule is what your body needs – and it may or may not be eight hours!

This article is a summary of approaches to insomnia. It is extremely likely that a combination of low-dose medication together with the application of some, if not all, of the seven behavioral approaches described above will result in adequate sleep.

Oct 21, 2014 | Blog

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