Dreaming of Sleep

woman laying in bed
Photograph courtesy of Wiros via a Creative Commons license.

You lay in bed, tossing and turning. Your body is exhausted, but your mind is racing with the day’s activities. Or worse yet, you’re stressing out about all the things on your to-do list for tomorrow.

Insomnia has become a major health concern worldwide with about 15% of the global population seeking relief with sleeping pills or tranquilizers. In the US, 60 million prescriptions for sleeping pills are issued each year. The most commonly prescribed type of sleeping pill is non-benzodiazepines, also called z-drugs — zaleplon (Sonata), zolpidem (Ambien), zopiclone (Imovane), and eszopiclone (Lunesta). However, a recent scientific journal article has raised some concerns about using these drugs.

Researchers from Harvard Medical School, the University of Connecticut and the University of London performed a quantitative statistical analysis of 13 studies on the effectiveness of z-drugs and their associated placebo response. They selected only randomized double-blind placebo-controlled trials, which means that neither the 4378 participants nor the researchers knew who was given the drug and who the placebo. They obtained the data from the US Food and Drug Administration, using both published and unpublished trials in order to avoid “publication bias.”  Their research results were published in the British Medical Journal on December 17, 2012.

This large, well-designed study found that the z-drugs helped participants fall asleep more quickly, as measured subjectively by the participants and by equipment in a sleep lab. However, half the effect of the drug was found to be due to a placebo response. Specifically, participants on average fell asleep in the lab only 22 minutes faster if taking the z-drug compared to the placebo. This has raised concern on whether the benefits of taking z-drugs are worth the risk of adverse side effects, which include daytime fatigue, memory loss, problems with balance, dependency, and an associated risk of an earlier death.

Of course, how quickly you fall asleep is only one symptom of insomnia. Other important measures are the total sleep time, number of awakenings, sleep quality, and time spent awake after sleep onset. Although the study looked at these other outcomes, unfortunately there was insufficient data to make firm conclusions on these factors.

Hopefully there will be further research to analyze the effectiveness of z-drugs on all aspects affecting sleep quality. In addition, the demonstrated importance of the placebo response suggests that more attention should be directed at psychological interventions for insomnia.

For more information about z-drugs, check out my KQED Quest blog.

Jet Lag? Sleepless Nights?

woman laying on bed awake
Courtesy of Wiros via Creative Commons

A while back I used melatonin supplements in order to help with jet lag, since I was traveling for work to Germany. A friend that travels a lot had recommend melatonin to me, and it did seem to help me re-establish a normal sleep cycle when dealing with a large time shift.

Occasionally I have trouble sleeping through the night at home also. I usually fall asleep right away, but I wake up in the middle of the night and sometimes have trouble falling back to sleep. I have allergies and regularly take antihistamines, so the popular over-the-counter sleep aids like Tylenol PM (which has the same active ingredient as Benadryl as the sleep aid) don’t really work for me. So I wondered if I should take melatonin instead. Although melatonin is an herbal supplement, I did a little research to determine if I think it is safe to take as a normal sleep aid. This is what I found.

Melatonin is a hormone naturally produced by your pineal gland, which is a small pea-sized structure located deep inside your brain between the two hemispheres. Melatonin regulates your circadian rhythm, or basically your 24-hour internal clock. When the sun sets and darkness falls, you begin to naturally secrete increased levels of melatonin.  As the melatonin levels rise in your blood, you start to feel sleepier. This hormone level is highest in your blood around bedtime and stays elevated for about 12 hours, then it falls back to the low daytime level around 9 am. Although nighttime melatonin levels remain at least an order of magnitude higher than at daytime throughout your life span, the concentration of melatonin continually decreases as you age. This helps explain why many older adults have problems with frequent insomnia.

Melatonin supplements have been shown to help “reset” the body’s internal clock in those suffering from jet lag, shift workers who work nights and sleep during the day, and blind people. There have been many studies on melatonin use, including studies on its effect to reduce insomnia for older adults. One such research study was performed by Richard Wurtman at the Department of Brain and Cognitive Sciences at MIT. He studied two groups of elderly subjects; one group had frequent insomnia and the other slept normally. Each subject received either a placebo or a melatonin dose about 30 minutes prior to bedtime, and those who received the melatonin were given a dose of either 0.1, 0.3, or 3.0 mg. Each subject was medicated for 7 days, followed by a “washout” period of 7 days. Wurton found that taking the hormone significantly improved the quality of sleep for the older adults. More importantly, he found that they were able to sleep through the night best when taking the 0.3 mg dose. Now perhaps this shouldn’t be surprising, because the body naturally produces melatonin at this “physiological” level. However, the typical over-the-counter melatonin dose is 3 mg and this was determined to be less effective in helping insomnia.

Despite the many studies that have demonstrated melatonin to be an effective sleep aid, there is still controversy about melatonin use though. Some doctors consider it harmless and others potentially harmful. This is true, in part, because the function of the melatonin hormone may not be fully understood. What is understood is that melatonin does more than just regulate the internal clock, such as affecting the onset of puberty. It is also clear that melatonin is only available as a prescription in many European countries and Canada (although this seems to be due more to ingredient regulatory issues than medical concerns), whereas in the US it is an herbal supplement that isn’t regulated by the FDA.

So what does this all mean? Mostly it means that the human body is a complicated system that we don’t entirely understand. But from what I’ve read, I’ve concluded that melatonin is probably a safe and effective sleep aid for adults (at least those over age 50). Of course, I’m a scientist and not a medical doctor. All in all, it is probably best to speak with your physician before taking it regularly as a sleep aid. If you consider taking melatonin, you do need to remember that it is a sleep regulator rather than a sleep inducer. It isn’t the same as taking something like Ambien or Tylenol PM. You also probably want to somehow chop up the over-the-counter pills into smaller pieces (doses) without getting a crumbled mess. For now, I’m just going to stick with daily exercise, relaxing before bedtime, Advil for sore muscles, and the World Finest Ear Plugs for peace and quiet. Sweet dreams.