The first step you and your doctor must take before deciding on the right treatment for your insomnia is to identify the cause as precisely as possible. In many cases, insomnia is a symptom of an underlying health problem, such as depression, chronic stress, sleep apnea, or other breathing disorders.

Treating insomnia involves changing behaviors that are affecting your sleep and possibly adding a prescription or over-the-counter sleep medication. In general, sleep medications produce faster short-term results; the behavioral interventions are required for the long-term. Most sleep medications are habit-forming and all of them lose their effectiveness with prolonged use, except perhaps melatonin.

This conclusion is supported by a study published in the Journal of the American Medical Association. The study, which included 78 patients with insomnia with an average age of 65, compared eight weeks of drug treatment, cognitive/behavioral therapy or a combination of the two. All three interventions improved sleep over the short-term. But when the patients were followed up two years later, the researchers found that the cognitive and behavioral therapy was the most effective way to maintain the improvement in sleep.

Keep in mind that the treatments outlined below are based on general medical guidelines for insomnia and may not be appropriate for any particular person. The right medication or therapy for a given individual can be determined only through a medical examination.

Behavioral interventions

When doctors prescribe “behavioral interventions” to treat insomnia, they are recommending changes in behaviors that may be causing or reinforcing poor sleep. Below are several behavioral interventions that your doctor may recommend for insomnia.

Stimulus control

Stimulus control involves eliminating activities or circumstances that “trigger” or stimulate you to stay awake. The goal is to help you form a psychological connection between the bedroom and sleeping. Here are a few examples of stimulus control:

  • Use the bedroom only for sleep and sex. The bedroom should not be used for watching TV, reading, eating, or working, since each of these activities stimulates wakefulness.
  • Go to bed only when you are sleepy.
  • If you are unable to fall asleep in 15 or 20 minutes, get out of bed and go into another room until you become sleepy. (Avoid bright lighting or other factors that stimulate wakefulness.)
  • Practice good “sleep hygiene” — the habits that help ensure good sleep.

Relaxation techniques

Relaxation techniques include deep-breathing exercises, meditation and light stretching. These methods, ued before bedtime, help calm the mind, relax your muscles and ease the day’s tension.
Stabilizing the sleep-wake cycle

This approach is meant to help you regain the right balance of sleep and wakefulness. It also aims to improve your “sleep efficiency” so that the time you are in bed is spent sleeping (rather than staring at the ceiling). Examples include the following:

  • On most days, get out of bed the same time each morning regardless of how long you slept or how late you went to bed. This helps you establish a more predictable pattern for going to sleep.
  • Minimize daytime napping. If you must nap, medical experts recommend napping in the early afternoon for no more than 30 minutes.

Sleep restriction therapy

At first, this approach might sound counter-productive. However, the purpose behind this behavioral therapy is to increase your need for sleep by temporarily shortening the amount of sleep per night. This creates a “sleep debt.” You then gradually lengthen the amount of sleep until you are getting an adequate amount. For example, a person with chronic insomnia may initially limit his or her time in bed to five or six hours for a few days, then increase it by 15 minutes or more each day.

Cognitive therapy

This form of counseling or “talk therapy” is used when a person with insomnia needs to “work through” any thoughts or attitudes that may be leading to sleep disturbances. It consists of identifying distorted thinking or attitudes that are making you feel anxious or “stressed,” and then replacing these thoughts with more realistic or rational ones.

Medications for insomnia

Prescription drugs

In addition to lifestyle and behavior changes, a prescription sleep medication may be required. One type (or class) of drugs used for insomnia is the hypnotic such as zaleplon (Sonata®), zolpidem (Ambien®, Ambien CR®), eszopiclone (Lunesta®) and certain benzodiazepines. These medications usually are recommended for short-term use; however Ambien CR and Lunesta is approved for long-term use.

The FDA has also approved ramelteon (Rozerem®) for the treatment of insomnia characterized by difficulty with sleep onset. Ramelteon acts through melatonin receptors which help regulate the sleep-wake cycle. There is no time restriction on how long ramelteon may be taken.

Doctors also prescribe antidepressants to treat insomnia. Antidepressants have been shown to improve sleep in people with depression and can be used long-term.

by David N. Neubauer, M.D, originally posted at

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