We’ve all been there; lying awake at night in bed begging to be asleep but our mind just won’t switch off. Or waking up in the middle of the night, hours before our alarm. Not being able to nod off is a common problem that most of us go through at some point, but for some it becomes the norm, and affects their day-to-day life. Although lots of people experience sleep problems, not many get the right help.
Lots of things can impact on our shut-eye. Stress and worry are often the culprits here with things like exams, money worries or big life events ruining our chances of counting sheep. Things such as a noisy room, uncomfortable room temperature (either too hot or too cold), physical illness, shift work or drugs and alcohol won’t help either. If you’re using alcohol to help fall asleep, be aware that this actually reduces your quality of sleep and can make the problem worse. Insomnia may also be an indicator of a more serious problem like depression.
Problems aren’t defined by the amount of hours we sleep– different people need different amounts – it’s whether the amount of sleep is normal and enough for you. As a guide most teenagers need 9-10 hours’ sleep whilst adults need around 8 hours (RCPsych). Difficulties can affect both the quality and quantity of your sleep:
- Initial insomnia: you find it difficult to fall asleep and don’t feel alert and refreshed the next day.
- Middle insomnia: you’re ok going to sleep but find it difficult to stay asleep.
- Parasomnias: unusual behaviours during sleep such as sleepwalking, sleep talking /laughing or night terrors; all of which can disturb your sleep.
- Circadian Rhythm disorders: a mismatch of the sleep-wake cycle and wanting to sleep or be awake at the wrong time. Could include jet-lag or shift work.
- Narcolepsey: is day time sleepiness with an uncontrollable urge to sleep wherever you are. You may also get cataplexy (where you suddenly lose control of your muscles when you’re angry, laughing or excited.)
- Sleep apnoea: you’re a loud snorer and stop breathing for short periods throughout the night. Every time you stop breathing, you wake suddenly but then go back to sleep.
You might find it helpful to keep a record of your sleep to identify how much sleep you are actually getting and if there is any pattern in your sleep, if it’s helpful download a sleep diary.
Not getting enough kip will negatively affect your mental and physical health. It can affect your quality of life, put you at risk of depression, stop you achieving what you want to during the day, puts you at risk of high blood pressure and can make you more likely to be absent from work, or involved in work and road accidents.
Proper sleep is essential for all of us so if you’re struggling to drop off, read on and discover what will help. Here are some things you can try yourself:
- Pay attention to your surroundings. If it is noisy, try using earplugs, if it is too bright, get thicker curtains, or use an eye mask.
- Drink milk! It sounds childish but warm milk helps our brain to produce melatonin; the hormone that tells the body it’s time to sleep (this is the same stuff that is in some sleeping tablets).
- Keep bed for sleep and sex. Don't use it for watching television, doing work or using your computer or your brain will associate bed with staying awake.
- Try not to worry about not being able to sleep; this will make you more anxious and more aware of the fact that you are not sleeping!
- Try to get into a routine of getting up at the same time each day. This will lead to you feeling sleepy by a certain time each night. Follow a night-time routine and wind down before going to bed- try having a bath, reading or listening to calming music
- Avoid watching TV or a film as this will wake you up rather than calm you down.
- Avoid stimulants such as tea or coffee before bed as well as heavy meals and spicy foods.
- Exercise; try doing some physical exercise during the day. Even a quick walk will help.
- If you can't sleep, get up and do something like read a magazine or book then try again to sleep
- Do some relaxation techniques before bed. Try the Seven-Eleven technique or Deep Muscle relaxation.
- If your insomnia last more than three weeks, OR sooner if it interferes with your daytime activities or ability to function then you need to contact your GP.
- There are also self-help materials available such as from the Royal College of Psychiatrists who sell audio to listen to, to aid sleep or websites that you can download pod casts from.
If none of the above suggestions seem to be working you can get help from your GP who can refer you for therapy, prescribe some medication short-term or refer you to a regional sleep clinic. If you’re struggling it is fine to ask for a bit of extra help with your wellbeing; especially as it can help prevent more serious problems from developing.
These are sometimes called talking therapies and may involve working with an individual, group of people or families. Depending on your treatment plan you may have psychological therapy as well as taking medication or you may just have therapy.
Therapy is useful because insomnia is often caused by psychological factors such as stress, hyper-arousal and behaviours we have learned that stop us sleeping well. Therapy may look at your sleep routine and behaviours, any distress in your life, use relaxation techniques and help you to learn new sleep behaviours (for example by weakening the link between worry and not sleeping).
The type of therapy used in sleep disorders is often CBT.
Cognitive Behavioural Therapy (CBT)
CBT is an approach based on establishing links between our thoughts, feelings and behaviours and states that how we think about a situation affects how we feel and act. CBT is an effective treatment for insomnia whether therapy is done individually or in small group. In fact CBT has been found to be as effective as prescription medications for short-term treatment of chronic insomnia (Wilson et al 2010). Read more about CBT.
There are several sleep disorder clinics in the UK but you will have to speak to your GP for a referral, you cannot refer yourself.
A drug used to encourage sleep is called a ‘hypnotic’ and this may help you get back into a sleep routine. Although hypnotics may help you sleep they do not treat the underlying cause of why you are struggling to sleep. There are usually two types of medication available if you can’t sleep; which one will depend on your difficulties.
Benzodiazepines may be used to treat insomnia, agitation, irritability and severe anxiety and work by slowing down the central nervous system, helping us to relax. Benzodiazepines should be used to treat insomnia only when it is severe, disabling, or causing the person extreme distress (BNF). Hypnotic Benzodiazepines drugs may go by the brand names of:
- Nitrazepam (Mogadon)
- Triazolam (Halcion)
- Loprazolam (shorter acting)
- Lormetazepam (shorter acting)
- Temazepam (Valium) (shorter acting)
Read more about benzodiazapines
"Z-drugs" (Non-benzodiazepine Hypnotics)
These are not a benzodiazepine but work in a similar way and on similar areas of the brain. They are called Z drugs because their names mostly begin with the letter ‘Z’ The Z-drugs were developed to be a better option than benzodiazepines; as they are less likely to cause next day sedation, dependence and withdrawal (NICE).
Hypnotic Z-drugs drugs may go by the brand names of:
- zaleplon (very short acting, for help falling asleep - half-life = 1hr)
- zolpidem (short acting - half-life = 2.5hrs)
- zopiclone (short acting- half-life = 3.5 – 6.5hrs)
Read more about Z-drugs
Other medication: antidepressants, antipsychotics and melatonin
Z drugs are usually the first medication you will be tried on but some types of antidepressants such as tricyclic’s have been used to treat insomnia for a long time. The side effects of antidepressants can be an increase in the risk of restless leg syndrome and a risk of overdose. Similarly antipsychotics such as Olanzapine and quetiapine are sometimes used to help sleep. Their side-effects may include weight gain, metabolic syndrome, extrapyramidal symptoms and risk of tardive dyskinesia.
Another drug that aids sleep is Melatonin – it’s not a sedative as such as melatonin is a natural hormone produced in our brains that has an important role in regulating our day/night cycles – Melatonin can both change the timing of our biological clock and facilitate sleep directly. This is generally only given to older adults over 55yrs and is sometime used to help disturbed or disrupted sleep in such conditions as ADHD and jet-lag. Side effects can include headache abnormal dream, nausea, dizziness (choice and medication, 2013)
Over-the-counter sleeping medications are usually antihistamines which decrease arousal in the body and sedate us. There is limited evidence that over-the-counter antihistamines work, although there has been more research recently. They are also generally more long-acting and so can cause drowsiness ‘hangover’ the next day.
Some Frequently Asked Questions about Medication (FAQs)
1. Which medication will I have to take?
Which medication you take will depend on your sleep problems and your personal circumstances. Before starting medication your health professional should go through the benefits and side effects of the medication with you. You can compare different medications used to manage insomnia.
2. How long will it take to work?
Some drugs may work very quickly, within an hour, and you might take these before bed if you’re unable to sleep or if you are very agitated and need to relax.
3. How long do I have to take it for?
These type of drugs are only prescribed for a short period as they may create dependence if used for more than 3 weeks.
4. What about side effects?
Any medication may have side effects and while these are not usually common some people may experience one or more. Possible initial side effects of these medications may include: feeling sedated, drowsy, unsteady and experiencing memory problems. Longer term side effects may include, a person becoming addicted if the drug is used for more than 3 weeks or possible withdrawal symptoms if you take them for more than 6 weeks.
If there are problems or concerns about the medication, or unpleasant or worrying side effects it is important that this is raised with the doctor, nurse or health worker. They can discuss the possible outcomes of continuing, changing or stopping the medication. The goal is to promote recovery on the lowest possible dose of medication and so minimising the side effects until you are well enough to stop taking it.