New research from America has found that commonly used sleeping pills, or 'hypnotics', are associated with a dramatically increased risk of death-even among those who take them only once in a while.
The pills have also been linked to a greater risk of cancer.
The study, led by Daniel Kripke from the Scripps Clinic Viterbi Family Sleep Centre in La Jolla, CA, involved 10,500 people who'd been prescribed sleeping pills and another 23,600 who hadn't. The two groups were matched up in terms of age, gender and health to minimize the possibility of other factors affecting the results.
Over a period of two-and-a-half years, the researchers compared death rates between the two groups and found that those in the sleeping-pill group had a more than fourfold greater risk of death. The most commonly prescribed pills were zolpidem, sold as Ambien and Stilnox, and tamazepam, sold as Restoril and Normison.
Most shocking of all, even among patients who were prescribed the lowest number of sleeping pills each year-less than 18-their risk of death was more than three times higher than among similar participants not taking the medications. This increased risk was seen across all age groups.
There are a number of ways that using sleeping pills might be causing death, the researchers said. For one, the pills might be contributing to cancer-which was, in fact, more commonly found in the sleeping-pill group than in the sleeping-pill-free group. Among those taking the highest doses, cancer risk increased by 35 per cent.
Another explanation is that, because hypnotics impair motor and mental-processing skills due to their sedative effects, taking them could lead to hazardous falls and car crashes. Sure enough, zolpidem and other sleeping pills have been asso-ciated with more automobile accidents, and a rise in falls and fractures.
Hypnotics have also been linked to suicide and to potentially dangerous sleep behaviours such as sleep-walking, sleep-driving, sleep-cooking and sleep-eating.
In the end, the Scripps Clinic team concluded that sleeping pills may have been responsible for 320,000 to 507,000 excess deaths in the US in 2010-when 6-10 per cent of adults reportedly took a hypnotic drug because of poor sleep. The team also said that the "meagre benefits" of the drugs-demonstrated by numerous independent trials-did not justify their "substantial risks" (BMJ Open, 2012; 2: e000850).
This new study supports a catalogue of other studies suggesting that hypnotics are hazardous to health. Other risks associated with the drugs include amnesia, compulsive repetitive behaviours, delirium, night-mares, hallucinations, overdose, addiction and life-threatening allergic reactions. All this-and yet, any sleep improvements appear to be "small" (BMJ, 2005; 331: 1169).
Fortunately, a growing number of experts are waking up to the idea that drugs are not the only way to treat sleeplessness, medically known as insomnia. There's now a growing consensus that cognitive behavioural therapy (CBT), or 'talk therapy', may be a better solution to chronic insomnia than drugs. CBT involves teaching patients better sleep habits while trying to change any counter-productive assumptions about sleep.
According to sleep specialist Dr David Plante from the University of Wisconsin, CBT has major advantages over medica-tion, and not just because it's free from dangerous side-effects. "You have long-term benefits, even after the treatment is done, which isn't usually the case for sleeping pills," Plante claims.
In fact, a study that directly compared CBT with drug treatment found that the talk therapy was the superior treatment, resulting in the largest number of normal sleepers afterwards and long-lasting benefits. Interestingly, a combination of CBT and drug treatment had no advantage over CBT alone (Arch Intern Med, 2004; 164: 1888-96).
What's more, CBT has been shown to improve not just insomnia, but also overall well-being and symptoms of depress-ion (J Clin Sleep Med, 2011; 7: 645-52).
CBT isn't for everyone, however. Some people don't have easy access to specialists trained in CBT; others might not have the time to invest. So what else is proving useful for insomnia?
Herbs and supplements
Lots of plant-based remedies and nutritional supplements have a long history of use in treating insomnia and other sleep disorders, many of which have good scientific evidence of success.
- Melatonin, a natural hormone responsible for regulating the human 'body clock', is an increasingly popular treat-ment. It's mostly been tested in the elderly, as melatonin levels are known to decline with age. In one study, slow-release melatonin was found to be a safe and effective long-term therapy for older patients with insomnia. It also significantly reduced sleep latency-the time it took to fall asleep-and had no serious side-effects (BMC Med, 2010; 8: 51). Melatonin may be helpful for young people, too. In a review of children with attention-deficit/hyperactivity disorder (ADHD) and sleep-onset insomnia (difficulty falling asleep), a melatonin dose of 3-6 mg a few hours before bedtime was well tolerated and helped them to doze off (Ann Pharmacother, 2010; 44: 185-91). A word of caution, however: as melatonin is a potent hormone, it should only be taken under medical super-vision. So, although it's freely available in the US, it is only obtained on prescription in the UK. Possible side-effects include headache, feeling 'heavy-headed' or hungover, stomach discomfort and depression. Also, because of the possible interactions, those taking blood-thinning drugs such as warfarin, and those with epilepsy, should avoid melatonin (BMJ, 2003; 326: 296-7).
- l-Tryptophan is another supplement that may help. This amino acid-found naturally in chocolate, oats, bananas, turkey and peanuts-seems to improve sleep latency at doses as low as 1 g and sleep quality at even lower doses (just 250 mg). Also, unlike many of the hypnotics, l-tryptophan doesn't impair mental performance or make it difficult to wake up from sleep. However, there are potential side-effects if you take too much (100 mg/kg/ day, or 7 g/150 lb/day), such as gastric irritation, vomiting and head-twitching (Altern Med Rev, 2006; 11: 52-6).
- 5-Hydroxytryptophan (5-HTP), a compound related to l-tryptophan, is also showing promise for insomnia. Supple-menting with 5-HTP before bedtime (200 mg at around 9 pm and 400 mg two hours later) increased REM (rapid eye movement) sleep, a sign of improved sleep quality, in one trial (Altern Med Rev, 1998; 3: 271-80).
- Valerian (Valeriana officinalis) appears to be a safe and effective herbal sleep aid. A recent pooled analysis of 18 placebo-controlled trials found valerian to successfully reduce the time it takes to fall asleep and improve sleep quality, too (Sleep Med, 2010; 11: 505-11). Although the US Food and Drug Administration (FDA) rates valerian as a GRAS ('generally recognized as safe') herb, choose formulations that are free of ingredients called 'valepotriates', as these are less likely to cause adverse effects (Prescrire Int, 2005; 14: 104-7). A 300-600 mg dose of valerian extract, taken 30 minutes before bedtime, is commonly used.
- Hops (Humulus lupulus) used in combination with valerian may be an effective sleep remedy. One study found that a liquid extract of valerian and hops improved total sleep time, sleep quality and deep sleep (Eur J Med Res, 2008; 13: 200-4).Another trial showed that a standardized valerian and hops combination (containing 500 mg of valerian extract and 120 mg of hops extract) helped insomniacs fall asleep more quickly than did 500 mg of valerian on its own (Phytother Res, 2007; 21: 847-51).
- Lavender is another herbal remedy worth considering. A study of 42 female college students suffering from insomnia and depression found lavender aromatherapy to be beneficial for both conditions (Taehan Kanho Hakhoe Chi, 2006; 36: 136-43).
Other sleep aids
- Acupuncture might be useful for insomnia according to some evidence. In one study of 44 women, acupuncture was better than drug treatment for relieving sleeplessness (Acupunct Electrother Res, 2008; 33: 33-41). Another study found that electroacupuncture, when a small electrical current is passed between pairs of acu-puncture needles, improved sleep quality and daytime social functioning in chronic insomniacs (Chin Med J [Engl], 2009; 122: 2869-73).
- 'Brain music' is gaining in popularity as an alternative insomnia treatment. This novel technology involves recording a person's brain-waves and turning them into music. In one study, this brain music proved to have positive effects in more than 80 per cent of insomnia sufferers (Neurosci Behav Physiol, 1998; 28: 330-5).
- Neurofeedback, which also involves monitoring brain activity, is another promising treatment. It can help you fall asleep quicker and sleep longer, according to the research so far (Appl Psycho-physiol Biofeedback, 2010; 35: 125-34).
- Exercise. Don't forget that something as simple as this can promote relaxation and raise core body temperature in ways that are beneficial for encouraging and maintaining sleep (Cochrane Database Syst Rev, 2002; 4: CD003404). In one trial, moderately intense aerobic exercise not only improved sleep, but also reduced the anxiety felt before sleep in chronic insomniacs (J Clin Sleep Med, 2010; 6: 270-5). However, avoid exercising just before bedtime.
Factfile: What's the cause?
Insomnia-persistent difficulty in falling or staying asleep-can be a symptom of a variety of diseases, conditions, drugs and habits, so try to figure out and fix what's making your sleep suffer. It's probably best to enlist the help of a professional, but here are a few pointers.
- Cut caffeine. The stimulant effects of caffeine can last for up to 20 hours, so even a morning cup of coffee could be affecting your sleep. Besides coffee, watch out for caffeine in black and green teas, cocoa, chocolate, soft drinks and many over-the-counter (OTC) drugs. One study confirmed that avoiding caffeine significantly improved sleep quality (J Clin Nurs, 2009; 18: 13-21).
- Stop smoking. This habit is associated with difficulties in both falling asleep and staying asleep. However, make sure to use natural methods to stop smoking, as drug-based methods can disrupt sleep (Rev Mal Respir, 2006; 23 [3 Suppl]: 6S67-77).
- Fix food allergies. WDDTY columnist Dr Harald Gaier always checks for unidentified food sensitivities that could be causing insomnia. In a study of eight infants, chronic insomnia was traced to cow's milk allergy, and the babies' sleep patterns normalized when milk was cut from their diet (Pediatrics, 1985; 76: 880-4).
- Soothe stress. Stress and anxiety can trigger insomnia, so consider relaxation techniques such as meditation, massage and yoga. A recent trial found that daily yoga practice helped insomniacs fall asleep quicker, sleep longer and generally have a better night's sleep (Appl Psychophysiol Biofeedback, 2004; 29: 269-78).
- Block bright lights. Avoid exposure to bright light before going to bed and during sleep, as it can disrupt the sleep/wake cycle. Use nightlights in the bathroom to avoid turning on bright lights in the middle of the night, and hang thick blinds or curtains to keep your bedroom dark.
WDDTY VOL. 23 NO. 1, APRIL 2012