Jessica Peeling was a 4th year medical student from UNECOM in Biddeford, Maine on rotation at the Falcon Clinic in Utica, NY. She gave a presentation on “Insomnia” during a luncheon at the office.
Jessica Peeling, OMS IV
The Holistic Approach to Insomnia
Insomnia is defined as “impaired daytime function due to difficulty initiating sleep, difficulty maintaining sleep, or waking up early in the morning without ability to return to sleep”. 2 The American Academy of Sleep Medicine states that in order to be diagnosed with insomnia, patients need to fit the aforementioned definition, as well as to have both the criteria of impairment in daytime functioning and difficulty with sleep, despite having an adequate opportunity and circumstance for sleep. Per the International Classification of Sleep Disorders, Third Edition, there are three major types of insomnia: short-term, chronic, and other. Short-term insomnia persists for less than three months, and is usually caused by a specific stressor. Chronic insomnia lasts for greater than three months, and tends to have longer-lasting effects on patient health and well-being. Patients that fall in the category of “other” do not meet all the criteria for short-term or chronic insomnia.
Insomnia is incredibly prevalent in the general population, and remains one of the leading diagnoses in primary care offices worldwide; over five million visits occur per year, in the United States alone. Approximately 69% of patients from a study of primary care clinics in California and Hawaii suffered from some form of insomnia. 2 This costs the healthcare system more than $240 billion annually. There is a positive correlation of diagnosis of insomnia with poor socioeconomic status and comorbid psychiatric and substance abuse disorders. The National Sleep Foundation has a recommendation of sleep, in hours per night, that decreases with increasing age, from approximately 14-17 hours for newborns, to 7-8 hours for adults over the age of 65. Nearly half of all patients ages 20-59 report sleeping less than the currently recommended time per night, and this number is slowly increasing annually. Why is this so important? The effects of chronic insomnia are often overlooked as major contributions to the degradation of mind, body, and soul.
Patients with insomnia often have a decreased quality of life, and report symptoms of excessive daytime sleepiness and fatigue. They also suffer from behavioral changes, memory lapse, and mood disorders. Patients with chronic insomnia subjectively report a negative effect on performance of day-to-day activities, however, studies have found that these effects may be overestimated. There was evidence to support a deficiency of overall balance as well as a 20% reduction in tasks involving memory retention.2 Insomnia has also been linked to serious health issues, including: obesity, diabetes/impaired glucose tolerance, increased risk of fatal heart attacks, substance abuse, and an increase in general mortality. Interestingly, the relationship between a patient’s BMI and average nightly sleep has been shown to be curvilinear; patients receiving less than seven hours of sleep per night show an increase in BMI, however, patients with greater than nine hours of sleep per night also showed an increase in BMI. One specific study comparing BMI and average nightly sleep (showing this curvilinear relationship) looked at patients who ages fell within the recommended range of 7-8 hours of sleep. This further suggests that following the recommendations has a positive effect on general health. The impact of insomnia on BMI and obesity is thought to be secondary to lower levels of leptin (a hormone that suppresses appetite) and higher levels of ghrelin (a peptide that stimulates appetite). The correlation between impaired glucose tolerance and risk of diabetes also follows a curvilinear relationship.6
One study found that five hours of sleep or less per night was associated with a 45% increase in risk of fatal heart attacks, after adjustments were made for BMI, age, and history of tobacco use. The overall risk of increased mortality from all causes, in patients with chronic insomnia, was found to be approximately 15% when compared to the general population. In terms of mental health, there is a significant risk of depression and anxiety in chronic insomniacs, as well as an elevated risk of suicide attempt.6 Patients often resort to alcohol, abuse of over-the-counter medications as sleep aids, or overuse of medications such as benzodiazepines and hypnotics to try and help decrease sleep latency. This, in turn, leads to dependency and substance abuse and may foster addiction to other illicit substances.
What can health care providers do to combat insomnia, as it becomes increasingly commonplace in patients worldwide? We can start simply by spending quality time with our patients, and not forgetting the importance of a well-detailed history. As providers struggle to meet specific time constraints, they often forget to ask simple questions such as, “How many hours are you sleeping at night?” or, “What is your sleep environment like?” Therefore, many patients may not mention difficulties falling asleep or maintaining sleep, especially if it is not one of their primary concerns. Often, we hear patients say that their sleep is inadequate secondary to pain or mental health concerns, but we rarely elaborate as we should, given that insomnia is an underlying component of and contributor to many disease states. During stage three sleep, which is considered deep sleep, characterized by delta waves, our bodies take the time to undergo restoration of immune system functions and repair of muscles and tissues. If patients with chronic insomnia spend little time in stage three sleep, they are unable to fully access the inherent self-healing and self-regulating mechanisms of the body.10
As part of the holistic approach to insomnia, providers should include questions in their history that are fully descriptive of the patient’s sleep, once an issue has been identified. These include concepts such as: duration of problem, total hours of sleep per night, number of nighttime awakenings, number and length of naps, duration until sleep onset, bedtime routine, structure of bedtime environment, and assessment of common symptoms of insomnia. Patients should be encouraged to fill out a daily sleep log to bring to their subsequent appointment, and can also keep a sleep diary with specific thoughts or concerns that are keeping them awake, or pattern of dreams. The Epworth Sleepiness Scale can elicit symptoms of insomnia or other sleep disorders. Since mood disorders and anxiety are common comorbidities, it is also a good idea to have patients fill out scales such as the Beck Depression Scale or the Hamilton Anxiety Rating Scale. Actigraphy, which is a way of monitoring human activity and rest, is also an affordable option for assessment of insomnia, and can be interpreted alongside the patient’s sleep log. The actigraph is a small machine containing a piezoelectric accelerometer, usually worn on the wrist for one-two weeks; this unit collects information about sleep and transmits to a USB device.1
Many of the standard treatments available for insomnia have poor side-effect profiles and some have limited long-term efficacy. Benzodiazepines such as Temazepam, Flurazepam, and Estazolam are common agents used for treatment for insomnia; they bind to gamma-aminobutyric acid (GABA) type A receptors and promote sedation. Nonbenzodiazepine hypnotic medications with a similar mechanism of action include Zolpidem, Zaleplon, and Ezopiclone. These medications have common short-term side-effects such as excessive daytime sleepiness, dizziness, lightheadedness, and cognitive impairment. Many of these agents can cause respiratory depression when misused. Though they are sometimes efficacious for the treatment of short-term insomnia, long-term use of these medications may cause dependency and worsen sleep architecture and the symptoms of insomnia. Other adverse effects include aggression, anterograde amnesia and complex sleep-related behaviors, including sleep walking and sleep driving. They can cause rebound insomnia when discontinued. Over-the-counter medications that are often used as sleep aids, such as Benadryl and Tylenol PM, have anticholinergic side-effects such as dry mouth, blurry vision, constipation, increased intraocular pressure, and urinary retention. Antidepressant medications such as Trazodone, Amitriptyline, and Remeron, as well as atypical antipsychotics such as Quetiapine and Olanzapine can be used in smaller dosages for the promotion of sleep with less of a side-effect profile, but still have the potential for many drug-drug interactions.1
Arguably, the first and most important holistic treatment for insomnia is the implementation of sleep hygiene. Sleep hygiene is defined as the “promotion of healthy, regular sleep”. There are a variety of components for the basic tenants of sleep hygiene. The National Sleep Foundation recommends that patients maintain a similar sleep schedule each night, to promote a healthy circadian rhythm. They also recommend that sleep environment should be comfortable in every aspect – from temperature, to lighting, to level of noise. In all senses, there should be a reduction in external stimuli. If patients have computers or televisions, providers should recommend that these not be placed in the bedroom. Also, patients should limit the use of electronic devices around the time that they go to bed, and should make sure that LED screens are turned away to decrease the emission of light. The National Sleep Foundation also recommends using the bed for only sleeping, and not other activities. Other components of sleep hygiene include avoiding large meals before bedtime, and the avoidance of caffeine, cigarettes, and large amounts of alcohol after dinner. Patients should try to avoid napping throughout the day, as this increases sleep debt (the idea that there is a cumulative effect of one not having sufficient day-to-day sleep). Other ideas include taking warm baths or meditating before bed, and using white noise sound machines to further decrease external stimuli. It is also very important to exercise regularly, at least twenty minutes a day, 4-5 times per week.10
Dietary and herbal supplements are an often overlooked, adjunctive therapy for reducing sleep latency. Many supplements lack FDA approval and regulation, but have years of research indicating efficacy for use in insomnia. The supplements that are highly recommended for use in clinical practice are: Kava, Chamomile, Lemon Balm, Valerian, Melatonin and Tryptophan. As with all supplements and medications, there are still side-effects and interactions to be cautious of, however, the side-effect profiles are generally more well-tolerated than with standard treatment for insomnia. Rosick, a DO from Michigan State University College of Osteopathic Medicine, recently reviewed these supplements in his article entitled “The Use of Supplements, Herbs, and Alternative Therapies in the Treatment of Insomnia”. Kava, or piper methysticum, is plant that is native to the Pacific Islands. Its mechanism of action is hypothesized to be similar to that of benzodiazepines, having some GABA-binding potential with sedative properties. The root, rhizome, and stem are the most used portions of the plant, which contain the active ingredient in most supplements, called kavalactones.10 A recent study showed that a dose of 200 mg/day of standardized kava extract, taken for four weeks, caused significant, subjective increase in quality of sleep in 61 subjects. 9 Kava should be avoided in patients with liver disease, Parkinson’s, history of medication-induced extrapyramidal effects, or chronic lung disease.
Lemon balm, or Melissa officinalis, is a perennial herb native to Europe, which is a member of the mint family. The usable portions of the herb are the leaf, and the oil from the leaf, which contain active compounds such as citronellal, neral, and geranial monoterpenoid aldehydes, flavonoids and polyphenol.8 There have been very few studies on the efficacy of lemon balm on insomnia alone, but it has been studied in combination with Valerian. One study recently conducted showed that 20 participants, ages 18-70 years, took 600 mg of a lemon-balm extract for fifteen days, two times daily. Seventeen out of the twenty patients reported almost full improvement in symptoms of insomnia.9 The common dose of lemon balm is 500-1000 mg/day; its mechanism of action is unknown, but it does have sedative properties. It does have the potential for interaction with standard medications used to treat insomnia, as well as thyroid medications.
Chamomile, or Matricaria recutita, is an herb that is native to Germany. The usable potion of this herb is the flowerhead, which contains apigenin, with sedative properties. Its mechanism of action is also unknown, but it has been suggested that apigenin can bind to the GABA receptors.8 A study conducted in 2011 showed that 34 participants, ages 18-65 years taking 270 mg of chamomile extract daily, showed a small to moderate decrease in nighttime awakenings and sleep latency. The Fatigue Severity Schedule was used to interpret the data from this research. Of note, chamomile may have estrogenic effects and has the ability to reduce creatinine output. A typical dose would be 200-300 mg/day.9
Valerian, or Valeriana officinalis, is a perennial herb that is native to Asia and Europe and is useful in the treatment of insomnia. The applicable portion of this herb is the root, which contains up to 150 active compounds, including valepotriates, volatile oils, and valerenic acid. The mechanism of action of these compounds may include potentiation and inhibition of GABA-A and Adenosine A receptors.8 The common dose is 200-600 mg/day. There have been many studies looking at the efficacy of valerian for sleep, including a meta-analysis of 1,093 patients. A newer study conducted in 2002 compared 600 mg/day of valerian root extract versus 10 mg/day of oxazepam among 202 participants, ages 18-73; this six-week study found that both agents showed similar efficacy.9
L-tryptophan is an essential alpha amino acid which is present in concentrations of 1-2% in plant and animal proteins, and can help combat insomnia. In the body, it follows a conversion pathway to 5-HTP, then to serotonin, and eventually melatonin. Tryptophan can also cross the blood brain barrier and cause sedative effects.8 The common dose is 2-5 g/day. Limited studies show improvement in total sleep time and decreased sleep latency; one study looked at 17 participants taking 2 g of tryptophan per day with this result.9 Tryptophan can exacerbate eosinophilia, as well as kidney or liver dysfunction, so it should be used in caution with certain patient populations.
Melatonin is the most widely studied supplements for use in insomnia. It is a hormone that is produced in the pineal gland, and is also the end-product of the biosynthetic pathway mentioned above. The suprachiasmatic nucleus in the hypothalamus controls melatonin production and, thus, our circadian rhythm. Production of melatonin naturally increases with decreasing light, and production decreases with age. Numerous studies have been conducted on the efficacy of melatonin on sleep – one conducted in 2010 included 791 participants, ages 18-80 years, with primary insomnia. These patients took 2 mg/day of melatonin, and it was shown that they had a significant decrease in sleep latency over an eight-month period.8 Interestingly, it has also been shown that very low doses of melatonin (.1-1 mg/day) are strong enough to cause a decrease in symptoms of insomnia. This relates to the fact that our body’s physiologic production of melatonin is actually only 2-200 pg/ml; .1-1 mg/day of melatonin gives the patient a physiologic equivalent of melatonin. With higher doses, concentrations of melatonin can reach 3-60 times their normal physiologic peak, which can contribute to sleepiness, hyperprolactinemia, hypothermia, and cognitive impairment.11
Osteopathic cranial manipulation is another approach that has been shown to decrease rates of insomnia by decreasing sleep latency and altering sympathetic nerve activity. On osteopathic structural examination, patients with insomnia may present with decreased cranial rhythmic impulse, cranial dysfunction, increased sympathetic tone, or sacral dysfunction. Many osteopathic treatments can help reduce sympathetic activity and increase parasympathetic activity. One technique that has been shown to be useful with insomnia is the CV4 cranial technique; the compression of the fourth ventricle is a technique “in which the lateral angles of the occipital squama are manually approximated, taking the cranium into sustained extension and obtaining a still point”. Recently, a study was conducted at the University of North Texas Health Science Center, in which 20 participants, ages 22-35 were placed into three groups: treatment with the CV4 technique, “sham” treatment, or placebo. Sleep latency was tested with the standard Multiple Sleep Latency Test protocol, and direct recording of efferent muscle sympathetic nerve activity; a statistically significant decrease in both was recorded.9
Cognitive behavioral therapy is an important component of treatment of chronic insomnia, especially in patients with comorbid psychiatric illnesses. Cognitive behavioral therapy for insomnia is also referred to as “CBTi”. It includes a structured approach to insomnia, including: psychoeducation, sleep restriction therapy, stimulus control, relaxation training, and relapse prevention. Psychoeducation teaches patients about the importance of sleep hygiene and the basic tenants of CBT. Sleep restriction is based upon the concepts of time spent in bed, total sleep time, and sleep efficiency. Sleep efficiency is the total sleep time divided by the time in bed. At the beginning of CBTi, patients’ time in bed is restricted to total sleep time. Sleep restriction is based upon the fact that the bed is a source of mental frustration and association with insomnia, and therapy seeks to break this association. Stimulus control is a portion of CBTi where patients are given specific instructions to identify and modify sleep-interfering behaviors and thoughts. Patients are encouraged to keep sleep logs and diaries, and to avoid planning until they are no longer in bed. Relaxation training involves the education of breathing techniques and meditation to promote decreased sleep latency. Relapse prevention gives patients specific exercises to keep them in a holding pattern. In one study, over 70% of patients were shown to have a lasting benefit in reduction of insomnia using CBTi, and another study showed that patients undergoing CBTi spend more time in stages 3 and 4 sleep – moreso than those who take hypnotic medications. Patients are encouraged to use online CBTi programs if they are in an area where mental health resources are lacking.5
Acupuncture and acupressure are concepts derived from Eastern medicine that have been shown to be efficacious in decreasing symptoms of insomnia and increasing restful sleep. Acupuncture relies on the regulation of yin and yang to reinforce health, and increases biological concentrations of y-amino butyric acid. In 2009, a meta-analysis of 46 randomized trials of 3,811 participants showed a statistically significant benefit in patients with insomnia. Another study suggested that acupuncture alone was more efficacious than the use of benzodiazepines and acupuncture together. Acupressure points are another concept that patients can be instructed to use at home; the points K 6 and B 62 are located between the heel and malleoli. The concept of acupressure treatment includes pressing these points together by placing the thumb on one side and the fingertips on the other side of the ankle and holding for several seconds; this helps patients relax and decreases sleep latency.4
Aromatherapy is the practice of using natural, essential oils to improve physiologic and psychological well-being. Two of the most widely studied essential oils for the treatment of insomnia are lavender and sandalwood oil. These oils can be used during massage therapy, or utilized at home, by the patient, via a diffuser. Lavender contains an active compound called linalool, which has been shown to increase parasympathetic nervous system activity and inhibit sympathetic nervous system activity. One study evaluated 60 coronary ICU patients, who were treated with the inhalation of 2% lavender essential oil for 15 days. The Pittsburgh Sleep Quality Index and Beck Anxiety Inventory were used to assess improvement in sleep and found a statistically significant difference in the intervention group versus the control group. Sandalwood is an essential oil with an active compound called santalol, which has shown increased NREM sleep and decreased early awakenings in animal studies.3
Alterations in diet are also an important factor in the holistic treatment of insomnia. Many food groups have been studied and implicated in increasing sedation and decreasing sleep latency. Patients can be instructed to include these foods with dinner to promote healthy sleep hygiene. Foods that are rich in melatonin or tryptophan will promote the biosynthetic pathway with induction of circadian rhythm – some of these foods include cherries, walnuts, and almonds. Similarly, foods that are abundant in Vitamin B6, which is a co-factor in the production of melatonin, help stimulate this pathway. These foods include many types of fish, especially tuna, and bananas. Any food that contains magnesium can help with the relaxation of muscles and the promotion of sleep; this includes foods such as almonds and whole grains. Other foods such as lettuce contain special compounds with sedative properties – lettuce contains one called lactucarium. Honey contains a mixture of fructose and glucose, which help your liver produce glycogen. If the body has enough glycogen, frequent awakenings will decrease.7
- Arand, DL, Bonnet MH. Clinical Features and Diagnosis of Insomnia in Adults. UpToDate. 2017.
- Arand, DL, Bonnet MH. Overview of Insomnia in Adults. UpToDate. 2017.
- Bakir, E et al. Effects of Aromatherapy on Sleep Quality and Anxiety of Patients. Nurs Crit Care. 2017 Mar;22(2):105-112.
- “Insomnia & Sleep Disorders Acupressure Points and Tips” Acupressure Points. April 2017.
- “Insomnia Treatment: Cognitive behavioral therapy instead of sleeping pills”. Mayo Clinic. April 2017.
- Institute of Medicine (US) Committee on Sleep Medicine and Research; Colten HR, Altevogt BM, editors. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Washington (DC): National Academies Press (US); 2006. 3, Extent and Health Consequences of Chronic Sleep Loss and Sleep Disorders.
- Korpela, R et al. Dietary factors and fluctuating levels of melatonin. Food Nutr Res. 2012; 56: 10.
- “Natural Medicines Database” Natural Medicines. TRC. April 2017.
- Rosick, Edward. The Use of Supplements, Herbs, and Alternative Therapies in the Treatment of Insomnia. Osteopathic Family Physician (2014)2, 14-18.
- “Sleep & Sleep Disorder Information.” American Sleep Association. April 2017.
- Wurtman, R. Physiology and available preparations of melatonin. UpToDate. 2017.