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Before going to bed every night, Ruth Danoff, 47, a small-business owner in Germantown, Maryland, turns on a white-noise machine (to muffle night sounds), blocks the entrance to her bedroom with a baby gate (to prevent her Labrador-poodle mix from jumping into bed), reads or listens to a CD for about 20 minutes (to help her unwind), and takes the sleep medicine Lunesta (she has tried others, but this helps her fall asleep and stay asleep). Sure, it's a lot of preparation just to get some zzz's, but, explains Danoff, "I'm a very light sleeper, and I need the help of my routines, as well as medicine."
"There's a growing recognition that using pharmaceutical sleep aids as you work on improving sleep habits can help nip insomnia in the bud so it doesn't bloom and become an ongoing issue," says Mary S. Esther, MD, president of the American Academy of Sleep Medicine. "Short-term use is the ideal, but we also know that for people with chronic sleep problems, taking a medication for a longer period of time can make a huge difference in their ability to enjoy life and function well."
Today's sleep medications are less likely to cause next-day drowsiness or addiction than older remedies. Some are safe enough to take intermittently over long periods. This is good news for women, who not only report more sleep problems than men but also take sleep aids 58 percent more often.
Sleeping soundly requires finding the lifestyle solution -- and, if needed, medicine -- geared to your specific type of sleep problem. Read on to see where you fit.
Lifestyle changes: Avoid caffeine for at least six hours before bedtime and cut out stimulating activities, such as answering e-mails, housecleaning, or watching TV, a habit shared by 90 percent of people who report sleep problems, according to a poll by the National Sleep Foundation. (The bright flashing images and sounds from TVs and computers actually wake up your brain, notes Marcel Hungs, MD, PhD, director of the Center for Sleep Medicine at the University of California, Irvine.) Instead, shift gears and slow down for about 20 minutes before bed: Take a warm bath, write in a journal, or listen to soothing music. A ritual of relaxing pre-bedtime activities is an automatic cue to become sleepy, making it more likely you'll fall asleep, says Helene A. Emsellem, MD, medical director of the Center for Sleep and Wake Disorders, in Chevy Chase, Maryland.
Prescription help: Zolpidem tartrate (the generic form of Ambien) acts quickly to put you to sleep within 15 to 30 minutes on average and, as a benefit, may help you sleep longer and awaken less, according to a recent University of Rochester study of almost 200 men and women. And because it doesn't appear to cause rebound insomnia, it shouldn't prevent you from falling asleep on the nights you don't take it. Since it lasts only four to six hours, there's a low risk of next-day drowsiness.
Side effects can include headaches and dizziness, but what is more worrying are reports that this drug can cause sleepwalking, sleep-driving, night eating, and short-term amnesia. It turns out that these can be problems with other prescription sleep medications as well, "especially if not taken as directed," says Dr. Emsellem. Many side effects occur because people take extra doses or mix the drug with alcohol. Report any unusual reactions to your doctor.
Lifestyle changes: Eliminate dead-of-night disturbances that rouse you: Shut the bedroom door so the cat can't jump on you or place twin-size top sheets and blankets side by side so your husband takes only his covers when he rolls over. Also, avoid alcohol before bed: It may help you fall asleep faster but will likely make you wake up a few hours later and have problems going back to sleep.
Prescription help: Zaleplon (the generic form of Sonata) works in less than half an hour, then lasts less than four. A study from St. Luke's Hospital in Chesterfield, Missouri, found zaleplon didn't cause daytime sleepiness in patients given it in the middle of the night, then awakened three and a half hours later.
The downside of zaleplon is that if you wake up in the wee hours, you then have to decide whether to take the pill and wait for it to work. If you awaken almost nightly, a low dose of trazodone (the generic form of the brand drug Desyrel) may be better. This antidepressant is rarely used to treat mood disorders today (other drugs are more efficient), but it is the most-often prescribed drug for problems falling and staying asleep. "People do not have to be depressed for it to work," explains Dr. Esther, who says trazodone is safe for most healthy adults to take, even for years. Side effects of the low doses used to promote sleep may include dizziness, next-day drowsiness, headache, and weight gain. If hot flashes are what's waking you in the middle of the night, discuss the pros and cons of hormone therapy with your doctor, including whether it might help you sleep.
Lifestyle changes: Try all the tactics already mentioned, and then some. First, turn in and get up at roughly the same hour every day to help synchronize your biological clock into a regular schedule of feeling sleepy and awake. Don't stay up past your normal bedtime or sleep in for more than an extra hour on weekends.
Turn a critical eye to your sleep environment, too, advises Carol Ash, MD, medical director of Sleep for Life, in Hillsborough, New Jersey. She says your bedroom should be quiet and cool (ideally in the mid-60s F.) and your pillow should be no more than one or two years old (after that it will start to break down and stop providing good support). Your mattress may need rethinking, too; instead of a firm model, many experts now recommend medium-firm. According to an Oklahoma State University study supported in part by the International Sleep Products Association and similar groups in Europe and Canada, switching to a medium-firm mattress can result in better sleep quality, comfort, and quantity, plus less back and shoulder pain.
Prescription help: Lunesta or Ambien CR (controlled release) puts you to sleep in 30 minutes or less, then helps you stay asleep for seven to eight hours. Studies of Lunesta and Ambien CR show these drugs significantly improve sleep quality and quantity when used nightly or intermittently. Long-term studies show they're generally safe to use for extended periods and you don't need to keep raising the dosage for them to continue to work. Patients over 65 may be more sensitive to the drugs.
Lifestyle changes: You need to readjust your body's internal clock so that you get sleepy earlier in the evening. Start by exposing yourself to early-morning sun. Pull the blinds up as soon as your alarm goes off or, if your room lacks early sun, turn on bright lighting. Early-morning exposure to daylight can shift your body clock forward, so you naturally feel tired earlier at night.
In addition, at least half an hour before your ideal bedtime, get into a low-light environment to trigger your body's production of the sleep-promoting hormone melatonin. Close the blinds and read by the light of a single lamp; avoid flashing computer or TV lights. Finally, make your bedroom as dark as possible. If curtains and shades don't completely block out light, consider wearing an eye mask. And cover clocks with lighted faces or turn them to the wall.
Prescription help: Ramelteon (brand name: Rozerem) targets the brain part involved in the sleep- wake cycle and helps reset your biological clock so that going to bed earlier and waking earlier become more natural, though this may take a week or two. Ramelteon puts you to sleep in less than an hour.
Lifestyle changes: Exercise. Working out boosts your brain's feel-good chemicals, easing stress, lifting a low mood and contributing to better sleep. A study of more than 170 women from the Seattle area found that those who followed a moderate-intensity walking program for 45 minutes, five mornings a week, were less likely to have trouble falling asleep than those who exercised less or in the evening (working out too close to bedtime may rev you up rather than relax you). Other studies found that practices such as yoga, tai chi, and stretching also cut stress and help sleep, so your workout choice may be less important than simply establishing some type of morning routine.
Prescription help: Consider benzodiazepines, such as Valium, Xanax, or Halcion. These anti-anxiety drugs are commonly prescribed for short-term insomnia (the kind you might have due to an illness in the family). They can put you to sleep in as little as 15 minutes and help you stay asleep, though daytime sleepiness is a common side effect. Benzodiazepines can be addicting, so use only for one or two nights a week or less than two weeks continuously. If stress and sleeplessness linger, a daily sedating antidepressant, such as Elavil, Remeron, or Sinequan, can be used safely long-term and is especially effective if you also have mild depression. Common side effects: next-day drowsiness, constipation, and dry mouth. Weight gain, heart arrhythmias, and forms of extreme restlessness may rarely occur at the low dose used to aid sleep.
YES: Antihistamines. Over-the-counter sleep aids and allergy medicines with the antihistamines diphenhydramine HCI or doxylamine can make you fall asleep. And most experts say it's okay to use them two to four times a month. Since they do cause next-day drowsiness, don't plan on driving early in the morning. People can quickly develop a tolerance to their effects, so they're less helpful the more often you use them.
NO: Valerian. This herb did no better than a placebo to help sleep in a University of Washington study and may cause dizziness, nausea, upset stomach, and headache, says Stacy Passarella, clinical pharmacist at Tampa General Hospital.
L-tryptophan. The amino acid has never been conclusively found effective for sleep. The FDA warns that many who took it got a life-risking muscle-pain condition called eosinophilia-myalgia syndrome.
MAYBE: Melatonin. Some studies have found that taking a dietary supplement of melatonin, a natural hormone, helps with symptoms of jet lag, cutting daytime drowsiness and upping alertness. There is conflicting information on how and when to take it, so consult with a sleep expert first. Still, compared with other natural remedies, says Passarella, "melatonin appears to be safe when used short term and has few reported adverse effects."
Some sleep complaints aren't a sign of trouble -- they're a mistaken perception about what a good night's rest should be.
Complaint: I sleep less than 7 to 8 hours a night.
When it's normal: If you're not sleepy the next day, it's okay. There is no magic number of sleep hours people need to feel rested.
Complaint: I wake up at 4 or 5 a.m.
When it's normal: If you went to bed at 9 p.m., you've probably gotten enough sleep; just delay bedtime by two hours so you naturally wake up later.
Complaint: It takes me longer than five minutes to fall asleep.
When it's normal: It takes many people an average of 20 minutes to fall asleep once their head hits the pillow.
Complaint: I wake up one or two times a night.
When it's normal: Night-waking (to visit the bathroom, for example) isn't considered unhealthy if you can go back to sleep fast and wake up refreshed.
Originally published in Ladies' Home Journal, December 2008.