Sleep – All living creatures need it, and we will die without it. Yet for many humans in our modern, fast-paced and technologically advanced society, sleep seems like an elusive task that gets in the way of life and productivity. At a fairly young age, we learn and believe that the need for sleep can be suppressed by the use of stimulants like coffee, tea, herbal supplements, and even prescription stimulants. In college we learn to drink coffee, despite it’s bitter, off-putting taste. By graduation, we’re hooked on the luscious nectar and can’t fathom giving it up. We might start a new job, attend graduate school, get married, start a family, deal with a crisis, or experience chronic emotional stress. While many of life’s stressors are positive, or “eustress” meaning they benefit the individual, the absence of lifestyle habits known to help cope with stress, coupled with poor diet and lack of exercise can greatly diminish our chances for restorative, quality sleep.
It is estimated that 30% Americans suffer from insomnia, and at least 10% suffer from chronic insomnia, or long-standing difficulties with sleep (1). Insomnia can mean any of the following:
- Difficulty falling asleep
- Difficulty maintaining sleep
- Waking up too early
- Not feeling rested after a full night’s sleep
- Sleep-disordered breathing (obstructive sleep apnea, obesity hypoventilation syndrome)
Insomnia is thought to be caused by a state of hyper-arousal, with stress being the leading culprit in activating the HPA (hypothalamic-pituitary-adrenal) axis. One study found that individuals with chronic insomnia had higher levels of cortisol and ACTH when compared to normal sleepers (2). When cortisol is high, melatonin tends to be low. Thus chronic elevations in cortisol are thought to contribute to insomnia by impairing melatonin, the hormone that drives sleep and wakefulness. Other factors include the behavioral conditioning that can result from constant worry or rumination (i.e. worry or rumination about life stressors causes insomnia which causes worry and rumination about insomnia). Further, exposure to artificial light or lack of natural sunlight are major contributors to insomnia, particularly in regions where daylight is limited for part of the year, or when an individual works long hours in artificial light (2).
The risk factors for insomnia include:
- Female sex
- Older age
- Night shift work
- Psychiatric conditions
- Chronic medical conditions
Interestingly, psychiatric conditions often co-exist with insomnia and are prevalent in up to 40% of cases, most commonly depression and anxiety disorders (1). Historically it was thought that insomnia was a symptom or result of a psychiatric disorder, however recent evidence suggests that in many cases the insomnia itself may actually cause mental illnesses like depression and anxiety (1). Obstructive sleep apnea and restless leg syndrome (disorders associated with obesity and metabolic syndrome) are often associated with poor sleep, thus it is important to talk with your healthcare provider if you are experiencing insomnia so that medical causes can be ruled out.
Insomnia can have serious consequences. Studies show that workers who experience insomnia are more likely to have serious accidents on the job. Insomnia can also lead to absenteeism, decreased concentration, lower productivity, decreased quality of life, and increased health costs for the individual. Driving while sleep-deprived leads to deadly motor-vehicle accidents, and is especially prevalent amongst shift workers.
Research also suggests that sleeping less than 7 hours per night increases one’s risk for high blood pressure, heart disease and heart attack, diabetes, obesity, depression, anxiety, and alcohol use (2). Further, it is estimated that 80-90% of sleep disordered breathing cases (i.e. sleep apnea) are undiagnosed. Untreated sleep apnea increases the risk for metabolic syndrome, obesity, diabetes, heart disease, heart attack, stroke, and heart failure (2).
Once medical causes for insomnia are ruled out, treatments in the standard medical model typically include over the counter supplements like melatonin, prescription medications ranging from hypnotics, to anti-anxiety drugs, and antidepressants. There are currently no specific guidelines for the management of sleep loss, and if you’re lucky enough to find a doctor who asks you about your sleep, you may find yourself receiving a prescription and a referral for psychotherapy. Don’t let that discourage you, as Cognitive Behavioral Therapy for Insomnia (CBT-I) is emerging as one of the most effective non-pharmacologic treatments for insomnia. However, if your healthcare provider doesn’t ask you about your sleep, and you forget to mention it in your 10-12 minute visit, you may be left struggling with a potentially serious problem for longer than necessary.
I believe there is massive room for improvement for how healthcare providers address sleep loss with their patients. We know that drug therapies for insomnia are incapable of reproducing quality, physiologic sleep. Behavioral therapies are thought to be as effective and longer-lasting than drug therapies, however many clinicians are not trained in behavioral treatments and thus rely on the use of drug therapies which are not likely to get to the root cause sleep loss. Below we will discuss behavioral and lifestyle interventions which may be helpful for sleep loss. Remember, if you’re experiencing insomnia, it’s important to get checked out by your healthcare provider to rule out medical causes of poor sleep.
Sleep hygiene techniques are simple lifestyle changes that, over time, can have a significant positive impact on your sleep quality.
- Avoid stimulants after lunchtime. Many experts say 6 hours is long enough to avoid stimulants before bed, but I believe some of us may need to be more cautious. 99% of the caffeine may be out of our bodies within 6 hours, but that doesn’t necessarily mean the effects on our HPA axis have ceased. Caffeine intensifies the stress response, so if you’re prone to stress in the afternoon/evening, it may be best to avoid caffeine after 1 or 2pm. If you enjoy a warm beverage in the afternoon, try decaf or herbal tea.
- Turn your bedroom in to a welcoming sleep cave. Creating a relaxing and quiet sleep environment can help facilitate quality sleep. Keep the lights dim, and consider bulbs that can change color to remove blue rays. Diffusing essential oils like lavender can help to facilitate sleepiness. A cooler room is better than a warm room for inducing sleep, as our bodies need to drop in temperature before we call fall asleep. The bedroom should be reserved for sleep and sex, nothing else!
- Minimize blue light exposure. Do you watch TV in bed? This exposure to blue light late in the evening confuses the brain into thinking you should stay awake. Turn off the TV, and put down your phone. Use “night mode” if you must be on the phone after dark. If you must use the computer late in the evening, consider downloading an app that filters out blue light, or purchase a pair of blue-light filtering glasses.
- Go to sleep and wake up around the same time every day. Sleep drive is determined by our internal clock, or circadian rhythm (3). Light exposure is one way our internal clocks regulate, but we can improve sleep by creating habits that our internal clock will rely on. Setting an alarm at the same time each day, and setting a reminder to get ready for bed each night can be helpful. Try to maintain this on the weekends, too!
- Avoid eating 2 hours before bedtime. Many of us eat our heaviest meal in the evening. Consuming a large meal before bed can hinder sleep by causing indigestion.
- Avoid drinking excessive fluids before bed. Water intake is important, but avoid drinking too much before bed as this may lead to unwanted bathroom trips in the middle of the night.
- Avoid alcohol if you have insomnia. Despite popular belief, alcohol does not help us sleep. It actually prevents us from entering deeper phases of sleep and thus leads to poor quality, non-restorative sleep.
- Move your body every day. Try to make time for exercise on a daily basis. It doesn’t have to strenuous every day, but even taking a walk in nature can do wonders for our stress level. Since stress and worry are big contributors to anxiety, its no surprise exercise can help. Exercise is also an effective, evidence-based medicine for anxiety and depression, and can be used alone, or as adjunct to drug therapies (10).
- Exercise early in the day. Not only does this have beneficial effects on mood, energy level, productivity, and perceived stress, but exercising late in the evening can make it more difficult to fall asleep. Exercise stimulates the release of cortisol, which is helpful earlier in the day, but potentially detrimental to sleep if done within 3 hours of bedtime.
- Spend time outdoors. The Japanese practice of Shinrin-Yoku, or forest-bathing, is a time tested and evidence-based practice for reducing stress, lowering blood pressure, improving mood, boosting immune health, and improving sleep (11).
- Stretch and breathe before bed. Yoga, yogic breathing, and meditation are all useful tools to promote sleep. Practicing gentle floor stretches in a dim-lit room, perhaps with gentle music in the background, is a simple and relaxing way to prepare for sleep. While you stretch, focus on your breath. Inhale and exhale slowly and deeply through your nose. Let your breath fill the pit of the belly and expand the ribcage and chest. The combination of breathing and stretching helps to slow the heart rate, activates the parasympathetic nervous system (rest and digest), and encourages more restful sleep. Yoga Poses for Sleep
- Meditate for 5-20 minutes before bed. There are many wonderful meditation apps you can download for free. Meditations may be categorized by time or effect desired. You could practice a 5 minute seated meditation, or a 20 minute meditation for sleep while lying in bed. You may find yourself falling asleep before the meditation is over! Meditation Studio and Insight Timer are two of my favorite meditation apps.
Many supplements have been touted for sleep-inducing benefits. Below is a short list of some popular herbs and supplements, their potential mechanism of action, and safety considerations. ***Please consult with your healthcare provider before taking supplements, as many herbal supplements may be contraindicated in certain conditions, or may interact with medications. The below information is not intended as, or to be used in place of, medical advice***
- Melatonin is probably the most commonly known over-the-counter sleep aide. Melatonin is a synthetic version of the hormone our body uses to regulate our internal clock. It can be helpful for circadian rhythm disorders, jet lag, and for helping those with blindness establish a sleep-wake cycle. Despite popular belief that melatonin can help anyone fall asleep, most research does not support this. According to sleep expert Matthew Walker, it is more likely that the placebo effect is to blame for these subjective reports. Further, supplements containing melatonin are unregulated and may contain very little of the actual substance (8).
- Valerian Root is an herb for promoting sleep, especially in the menopausal woman (6). More studies are needed to determine effectiveness in other groups as well as safety and adverse effects, but preliminary evidence is promising (7). Valerian is probably safe for short term use (up to 28 days), but data for long-term safety is lacking. Safety during pregnancy/lactation is unknown.
- Passionflower is an herb used for insomnia or anxiety, and is thought to work by modulating GABA receptors, though exact mechanisms are unknown. An Australian study of 41 healthy adults showed that drinking 1 cup of passionflower tea before bed significantly improved sleep quality compared to placebo (5). Do not take if pregnant or breastfeeding. Do not combine with other sedatives.
- Chamomile is an herbal sleep inducer with many other potential health benefits. Steeped as a tea in warm water, tends to induce sleep within 90 minutes. The sedating effects may be due to the flavanoid apigenin, which binds to benzodiazepine receptors in the brain. Chamomile may also inhibit the stress hormone ACTH (4). Buy organic, and avoid if you have a severe ragweed allergy. Has not been studied in pregnancy or breastfeeding. May interact with medications Tamoxifen, Warfarin, or medications metabolized by the CYP3A4 pathway.
- Lemon Balm has been used for centuries for sleep difficulties, anxiety, and restlessness. Steep in tea with chamomile or lavender. Avoid taking with alcohol or other sedatives. Buy organic from a reputable herbal shop. Limited data on long term safety or safety during pregnancy/lactation.
- Kava is an extract made from Piper methysticum, a plant native to the western Pacific islands. It is thought to help ease stress and promote sleep, but there have been major safety concerns due to cases of liver damage and death from liver failure. Unsafe for long term use, and possibly unsafe for short term use. More studies are needed to determine safe doses and adverse effects (9).
The bottom line regarding the use of herbs, supplements, and prescription drugs for sleep is that we really cannot be sure a sleep-inducing substance is actually inducing the same quality sleep nature intended. Supplements and sleep aids may have a benefit for short term use or for periodic sleeplessness, but long term data on safety and effectiveness is lacking. This creates a barrier for healthcare providers who most certainly want to offer safe and effective sleep aids, but need to make recommendations backed by scientific literature and safety data. The safest and most effective way to promote healthy, natural sleep is to implement the above sleep hygiene techniques on a regular basis, manage stress through exercise, meditation, yoga, or enjoyable hobbies, eat a diet plentiful in whole plant foods and healthy fats, avoid alcohol or recreational drugs, and seek help from a professional if you are struggling with mental illness (1 in 5 of us are). If you are still struggling with insomnia despite implementing sleep hygiene techniques and you’ve seen your healthcare provider to rule out medical conditions, it may be helpful to see a professional counselor trained in Cognitive Behavioral Therapy for Insomnia (CBT-I). I hope that you’ve gained some insight on safe and simple strategies to promote quality, restful sleep.
- J Clin Sleep Med. 2007 Aug 15; 3(5 Suppl): S7–S10. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1978319/
- Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Chapter 3. https://www.ncbi.nlm.nih.gov/books/NBK19961/
- Twelve Simple Steps to Improve Your Sleep. http://healthysleep.med.harvard.edu/healthy/getting/overcoming/tips
- Chamomile: A herbal medicine of the past with a bright future. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2995283/
- A double-blind, placebo-controlled investigation of the effects of Passiflora incarnata (passionflower) herbal tea on subjective sleep quality.https://www.ncbi.nlm.nih.gov/pubmed/21294203
- Effect of valerian on sleep quality in postmenopausal women: a randomized placebo-controlled clinical trial.https://www.ncbi.nlm.nih.gov/pubmed/21775910
- Effectiveness of Valerian on insomnia: a meta-analysis of randomized placebo-controlled trials.https://www.ncbi.nlm.nih.gov/pubmed/20347389
- 14 of the biggest sleep myths debunked. https://www.independent.co.uk/life-style/health-and-families/sleep-myths-debunked-coffee-tips-snoring-tired-dreams-a8240456.html
- Kava. https://www.webmd.com/vitamins/ai/ingredientmono-872/kava
Is the Comparison between Exercise and Pharmacologic Treatment of Depression in the Clinical Practice Guideline of the American College of Physicians Evidence-Based? https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5430071/
Shinrin-Yoku (Forest Bathing) and Nature Therapy: A State-of-the-Art Review. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5580555/
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