Insomnia

Insomnia is essentially displeasure with sleep quality or quantity. Insomnia may lead to irritability, difficulty concentrating, lack of productivity, accidents, daytime fatigue, decline of overall health, and many other issues. Insomnia is frequently diagnosed with other psychiatric disorders such as anxiety or depression, which may be the underlying cause. Someone with an anxiety disorder may have difficulty unwinding or shutting down racing or ruminating thoughts or fears. Depressed individuals often wake up earlier than intended and are not able to return to sleep. Insomnia itself can also lead to, or exacerbate, anxiety, depression, or other mental health disorders. The potential causes of insomnia are numerous. Underlying causes could be medical in origin or psychiatric in origin and are often “idiopathic” (unknown). 

How we can help

At this practice we primarily treat insomnia that exists with, or is caused by, other psychiatric disorders, such as depression or anxiety. By treating the underlying psychiatric disorder, sleep often improves on its own over time. In the short-term we may also treat the insomnia directly while working on resolving the primary disorder. As always, we start by obtaining a thorough medical and family history to rule out medical disorders or medications as an underlying cause. Usually, it is not that difficult or complicated to treat the insomnia. In some cases, we may order lab work, recommend a physical exam, recommend a sleep study, or refer to a sleep specialist if insomnia is treatment-resistant or a medical cause is suspected.

What we can not help with

We are not able to treat severe insomnia where an individual is non-functional or poses a serious safety risk due to lack of sleep, treatment-resistant insomnia (non-responsive to 2+ medication trials specifically for insomnia), or insomnia that requires controlled substances to manage. If insomnia has an underlying medical origin or suspected medical origin, we may refer to relevant outside sources.

Medication Options for Insomnia:

Antidepressants: Antidepressants are first-line medications for depression and anxiety and by treating these disorders sleep can improve as well. However, certain antidepressants are known to help individuals begin sleeping immediately.

Prescription antihistamine: There is a particular antihistamine medication that may aid with sleep in addition to providing short-term and fast-acting anxiety relief.

Sedative hypnotics & benzodiazepines: These medications can be effective for short-term relief of insomnia. However, they are usually not good options, even for short-term use. They are not believed to work long-term, can worsen numerous psychiatric symptoms, and cause serious issues such as increased risk of motor vehicle accidents. They are highly addictive and have the ability to cause a very serious physical dependence, that can even be fatal if medication is stopped abruptly. These classes of medications typically create far more problems than they solve. Baltimore Psychiatry does not prescribe these medications for new patients. In the very limited instances we do prescribe them, use is limited to 1 to 2 weeks.

Natural remedies: There are a couple natural remedies which may be helpful with mild to moderate insomnia. However, due to a lack of regulatory oversight many alternative medications or supplements are often not available in a reliable, standardized dosage free of contaminants. Mixing alternative medications with prescription medications may also present unknown risk of interactions. Some natural or alternative medications may be a viable treatment option in some cases and can be discussed with your provider.

Before beginning any medication to treat insomnia we believe strongly in adopting good “sleep hygiene.”

Sleep Hygiene

While many of us think of the term “hygiene” in relation to cleanliness, the term is also used to refer to a beneficial set of practices. Sleep hygiene is an invaluable set of practices that can rival the power of medication without any of the downsides.

During the day

  1. Avoid caffeine, nicotine, alcohol, and use of any other substances that may interfere with sleep. If they are used, limit their use and avoid any use for at least a few hours prior to bedtime.
  2. Stay hydrated, but don’t drink large amounts of fluid immediately before bed.
  3. Avoid large late night meals.
  4. Exercise is great for your physical and mental health, including the ability to get good sleep. However, exercising within a few hours prior to bedtime can make it more difficult to sleep, so time exercise routines accordingly.
  5. If you are going to nap during the day make the naps brief and early in the day, not in the evenings or close to bedtime.

Prior to bed

  1. Give yourself some time to wind down physically and mentally prior to bedtime. Avoid strenuous mental or physical activity and find a relaxing activity or hobby that accentuates this. A warm bath or shower in a cool environment can also help induce sleep. Eventually it is ideal to go to sleep at the same time every day but when first starting, only go to bed when you are genuinely tired. Try to get up at the same time every day, even from the start.
  2. Establishing a set schedule for sleep and wake times will help set your internal clock. Know that if you’ve adopted unhealthy sleeping patterns or times, you may feel a little worse while your body resets its internal clock, but you will feel better once it has reset and you become adjusted to the new times.

Preparing the bedroom and sleeping

  1. Invest in a good mattress, pillows, sheets, and blankets and maintain them well. There are many different mattress types on the market and finding a mattress that meets your personal preferences is important. We spend around 1/3 of our lives in bed and good sleep is critical to our health, happiness, and longevity.
  2. Ideally, the bedroom should be used for sleep, sex, or peaceful, relaxing activities only. TV’s, computers, smartphones, disruptive pets, clocks (if you are a clock-watcher), even stimulating books, or any unnecessary devices or stimuli should be off or out of the room. You want your brain to associate the bedroom with sleep and relaxation.
  3. Limit noise. Earplugs may be helpful for some but others may find them painful or disrupting if used for long periods of time. White noise from a fan or other machine that you find acceptable can be very helpful.
  4. Make the room as dark as possible and your brain will secrete the hormone melatonin naturally.  This powerful hormone tells your brain it is time to sleep. In order for this work well the room must be made very dark. A sleep mask can also be of use if you do not find it uncomfortable or disruptive. If the room is truly darkened and you then find it hard to wake up in the morning with lack of sunlight, you may want to purchase a sunlight alarm. This is an alarm that has a light that slowly mimics the sunrise.
  5. Personal preferences can vary, but we generally sleep best in cool environments. 60’s to low 70’s F is ideal. Proper ventilation is important as well, so make sure the air can circulate.

Summary

Adopting these practices with genuine effort can be immensely helpful and may even be more beneficial than medication, without any of the downsides. These practices cost nothing and can be performed, at least to some extent, virtually anywhere. However, when these practices alone are not enough you may need a professional evaluation or medication to help you sleep.

Therapy?

Cognitive Behavioral Therapy-Insomnia or “CBT-I” is a type of short-term cognitive behavioral therapy specifically focused on improving sleep. It may be beneficial for individuals suffering from insomnia that has not responded well to other treatments. Regular CBT or other forms of therapy may also be indirectly helpful for improving sleep by reducing overall levels of depression and anxiety, when applicable.