|Photo: Inger Anne Hulbaekda; Agency: Dreamstime.com.|
NEW YORK, NY—Chronic sleep problems are so common, many people simply accept them as inevitable, but they should be considered medical emergencies, said Anne McClenon, ND, at the annual meeting of the New York Association of Naturopathic Physicians.
Disordered sleep and chronic sleep deprivation confer significant morbidity and mortality, and physicians need to take the issue much more seriously, said Dr. McClenon, a naturopathic physician in Plymouth, Mass. Sleep problems are associated with a 40% increased risk of metabolic syndrome, and they double the risk of stroke and myocardial infarction. They are strongly associated with depression, anxiety and inflammatory disorders.
Lack of sleep leads to fatigue, which can be deadly. While roughly half of all auto accidents are alcohol-related, most of the other half involves drivers falling asleep at the wheel. In one national survey, 60% of all adult drivers reported falling asleep at the wheel at some point in their lives.
If sleep problems promote illness, good sleep is one of the strongest and most versatile of medicines, provided that it is not drug-induced. Thorough sleep is anti-inflammatory, restores the adrenal glands, and helps balance hormones. Helping patients to sleep better is a great way to build your practice, said Dr. McClenon.
Ask the Right Questions
A very simple question: “When was the last time you woke up feeling rested?” can yield an astonishing amount of information about a patient’s overall physical and emotional health. Dr. McClenon strongly recommended asking this of every patient, and making it part of your routine evaluation. Other helpful questions include:
- What time do you typically go to bed, and how long does it take to fall asleep?
- How often do you wake up feeling rested?
- At what time of day do you feel you have your best energy?
- What is most bothersome to you about this sleep problem?
- What, if anything, has helped you sleep in the past?
Combined, a patient’s answers will give you a good picture of what his or her days are like, as well as insight into overall functional status and personal concerns. Further, the questions will engage patients in their own healing; many have never been asked about sleep before, and they’re usually relieved to know you care.
Whenever working with a patient who has significant sleep problems, make sure to evaluate for depression, anxiety, bipolar disorder, thyroid problems, and menopausal symtoms. All of these are associated with sleep disturbances, and tend to be worsened by chronic sleep loss.
Healthy Sleep Cycles
|“A very simple question: “When was the last time you woke up feeling rested?” can yield an astonishing amount of information about a patient’s overall physical and emotional health.|
Speaking generally, Dr. McClenon said that a healthy night’s sleep progresses through predictable and ordered sub-cycles, beginning with a light doze with vague awareness of surroundings, into a light and easily disrupted sleep, followed by deeper delta-wave sleep. During these serotonergic, GABAergic, non-REM states, the brain is using less glucose.
This non-REM induction phase lasts roughly 45 minutes or so, and then shifts into REM sleep, which is a hypermetabolic, cholinergic state during which growth hormone (GH) is released. REM states generally run about 90 minutes before cycling back into lighter sleep states. People who sleep well and wake up rested usually go through about 4–5 total cycles per night.
The deep sleep states are especially important for overall health, and if someone misses a full night’s sleep, the following night’s sleep will be almost exclusively spent in deep sleep.
A host of hormonal and neurotransmitter changes occur during the various sleep cycles. Histamine, which promotes waking, needs to drop in order for someone to fall asleep. GABA, which is released during the early non-REM stages, slows nervous system activity, enabling a person to fall into deeper sleep states.
The growth hormone surge as one transitions from non-REM to REM sleep, is in itself deep-sleep promoting, which is why people who nap will often feel refreshed after 20 minutes, but will wake up groggy if woken at 45–60 minutes. At that point, they’re in the middle of the GH surge. GH release is strongest in younger people and drops with age, which is why elderly people often have difficulty obtaining deep sleep.
Melatonin, naturally released during the early light-sleep phases, also promotes progression to deeper sleep states by slightly lowering body temperature. Like GH, it too tends to drop off with age. In women, progesterone is sedating, while estrogen tends to be stimulating. Dr. McClenon says she is convinced that disordered sleep plays a big role in both the premenstrual syndrome and in menopausal symptoms.
The Case Against Rx Sleep Drugs
Many prescription sleep medications are good for inducing the lighter sleep states, but they disrupt deep sleep, which is why patients on these drugs tend not to wake rested, though they may reliably fall asleep after taking their meds.
Benzodiazepines, commonly prescribed to treat anxiety and panic symptoms, attach to specific GABA receptors. While they do induce non-REM sleep patterns, they block the transition to stage 4 REM sleep. “This is the form of sleep you most try to make up if you are sleep-deprived,” Dr. McClenon explained. So patients routinely taking benzodiazepines actually perpetuate their sleep deprivation, even though they fall asleep after dosing.
Ambien (zolpidem), also very popular for sleep induction, attaches to a smaller subset of GABA receptors than the benzodiazepines. It does not interfere with deep sleep. Theoretically, it should be a better choice than benzodiazepines. But Dr. McClenon has found that patients typically require higher and higher doses over time, and it can be very difficult to get patients off this drug. “Whether it’s a habituation or a true addiction or an emotional attachment has been argued over for some time now. I’m not sure what it is, but I know that it is harder for people to get off Ambien.” It can also interfere with appetite and libido.
Lunesta (eszopiclone) has the longest follow-up data (12 months), and it does help people sleep. However, it can cause significant taste-disturbances (metallic taste in the mouth) that many patients find extremely unpleasant. Some find that if they stop Lunesta, their sleep problems are worse than prior to starting the drug. “Be very careful with this one.”
The newest player in the sleep aid arena is Rozerem (ramelteon), which binds to melatonin receptors, and can induce sleep quickly. It’s manufacturer claims it is non-addictive and non-habit-forming. While this is generally true, be aware that Rozerem can induce apnea, so it should not be used in patients at risk for sleep apnea. It can also raise prolactin levels, and interfere with normal hormone cycling. There is no evidence that Rozerem is any more effective than melatonin itself, which can be obtained without prescription at a fraction of the cost.
Melatonin, taken orally, is an excellent remedy for inducing sleep. It does not interfere with natural sleep architecture, it has a very short half-life of 1 hour or less, it raises endorphins, reduces circulating cortisol, inibits release of dopamine, and usually works at low doses. “Melatonin helps to jump-start the sleep process,” said Dr. McClenon.
In her experience, melatonin is really effective for patients with insomnia and irritable bowel syndrome, as well as those who have migraines. “Give it to migraine patients and they’ll think you walk on the water! I’ve seen this in two of my patients—20 years of migraine headaches gone!”
She recommends beginning with 0.5 mg before bedtime for five days. If that does not help, increase the dose by 0.5 mg for another five days. Go as high as 3 mg per day. If that doesn’t work for a particular patient, then melatonin is not the right therapy. There’s no reason to go higher than 3 mg.
Side effects are few; some patients experience drowsiness, stomach upset, headaches or unusually vivid dreams after taking melatonin, but these are rare. Melatonin is not a good choice for women who want to become pregnant, or their mates. Routine use interferes with ovulation in women and lowers sperm count in men. “In Europe, they use high dose melatonin (90–100 mg), as birth control.”
It is contraindicated for patients with severe mental illnesses, severe allergies, autoimmune disorders, leukemias and other immune system cancers. It is not the best choice for children with ADHD and insomnia. But for many otherwise healthy adults, melatonin is a safe and inexpensive ticket to healthier sleep.
Valerian & Other Herbal Helpers
|Extract of Valerian (Valeriana officinalis) deepens stage 4 “deep” sleep. For many patients, it is effective at very low doses. Photo: Marilyn Barbone/Agency: Dreamstime.com.|
Valerian (Valeriana officinalis), a flowering plant native to Europe and parts of Asia, but found widely now across the US, is Dr. McClenon’s herb of choice for patients with insomnia. Extracts of the roots of this plant have been used medicinally since the time of Galen, and it’s name derives from the Latin word valere, meaning “strong” or “healthy”.
As a sleep aid, liquid extracts of Valerian deepen stage 4 sleep, which so many people desperately need to restore. “I find it incredibly effective at low doses,” she said. “Manufacturers often recommend that people take 300–400 mg before bedtime as a standard recommended dose. But I don’t really use it like that. I tell my patients to take just 5 drops before bed, and then another 5 if they wake up in the middle of the night. Valerian builds up in one’s system, and the more you take the groggier you end up feeling. So you really don’t need much.”
Patients usually find that their sleep is greatly improved within one week after starting Valerian. She added that she has had many patients respond well to a Valerian-based multi-herb formula made by Wise Woman Herbals (www.wisewomanherbals.com). The compound formula includes Skullcap (Scutellaria), Passionflower (Passiflora), Kava (Piper methysticum), and Oat (Avena sativa) in addition to Valerian. She estimated that this formula is effective for roughly 70% of the patients who try it.
Again, she stressed that low doses of 1–5 drops no more than 4 times per day, usually does the trick. “You really don’t need to take droppers-full. I’ve seen patients get as much effect from a few drops as from 2 droppers full.”
Other herbs she has found helpful include St. John’s Wort (Hypericum perforatum), which tends to help tight-lipped patients with depression; and Viburnum or Dioscorea both of which are anti-spasmodics and good for people with chronic pain in addition to insomnia.
Diet & Nutritional Factors
A patient’s diet can play an important supporting role in establishing healthy sleep cycles. Dr. McClenon advises patients to avoid heavy meals three hours before going to bed. She has found that certain foods like turkey, nut butters, dates, figs, rice, tuna and bananas tend to induce sleep, presumably because they contain tryptophan. Others, like spinach, potatoes, tomatoes, and soft cheeses tend to disrupt sleep, possibly owing to their tyramine content.
Generally, people who have trouble sleeping should eliminate or at least cut down on caffeinated beverages and alcohol. While the latter may induce drowsiness, heavy consumption tends to interfere with healthy sleep architecture.
Supplemental magnesium can be a big help for insomniacs, especially those who have chronic anxiety. Doses in the range of 400 mg are usually effective, and Dr. McClenon said she has not seen any major advantage or disadvantage to any particular form of magnesium, though glycinate forms are the best option for patients who develop diarrhea on other forms.
Supplementation with a good vitamin B complex also supports healthy sleep, especially in anxious or emotionally fragile patients. The vitamins should be taken in the morning, not before bed.
Some patients respond very well to supplemental 5-HTP, and the effect is usually observable within 5 days. Be aware, however, that gut dysbiosis which is common in these patients, can alter metabolism of 5-HTP. In these cases, it makes sense to also give a good acidophilus-based probiotic.
The ubiquitous presence of electric lighting, TVs, computers and other bright, flashing modern gizmos in our lives has created a situation in which many people seldom experience true darkness. This has been very disruptive to sleep cycles. Dr. McClenon strongly advises patients to avoid bright lights for at least an hour before bed. That means no pre-sleep email checks, or late night TV. They should also try to do whatever they can to make their bedrooms as dark as possible, and to only use their bedrooms for sleep and love-making. That means no taking work to bed, and did we mention no late night TV?
She also advises patients against turning on lights should they wake up in the middle of the night; that will only make it even more difficult to fall back to sleep.
Many patients will benefit from establishing a consistent bedtime and sticking to that schedule. Early morning exercise also helps—it gives energy during the day and promotes sleep at night. For those with seasonal affective disorder, 15 minutes of early morning light therapy with a full-spectrum lighting system, three days per week, can make a big difference.
Restoring healthy sleep is a process, and it sometimes takes time. Though insomnia can be incredibly frustrating and the desire for quick fixes is understandable, Dr. McClenon is not a fan of drugging patients to sleep.
She noted that our culture has little tolerance for empty, quiet, emotionally unclear states—precisely the sort of state in which people with sleep problems find themselves. But these states can be very helpful for self reflection, for processing difficult emotions like grief, sadness, or unspoken fears. Encourage patients to accept and explore these states rather than trying to dose them into a sleep that offers neither full rest nor opportunity for psychoemotional integration.
“I tell my patients that quiet wakefulness at night can be a real gift. Take advantage of that time. Don’t just tranquilize yourself because you feel you have to sleep.”