HAMBURG — To sleep like a baby. It’s a paradoxical idiom: babies regularly wake up in the night to drink or to check that they are safe. When falling asleep, they often need physical contact, a constant background noise like the hum of a vacuum cleaner, or they want to be rocked or carried. All of this is necessary for them to relax, which is the basic prerequisite for falling asleep.
Get On This Day In History delivered straight to your inbox ✉️ each day! Sign up here.
This is true for adults, too: no relaxation, no sleep. The search for relaxation is difficult for many. One in three people worldwide knows the feeling of lying wide awake in bed, at least occasionally. Around 10% of people in industrialized countries like Germany suffer from chronic insomnia. This means that they have not been able to sleep well for at least three months, and at least three nights a week: They keep waking up or do not feel rested even after a full night’s sleep. This makes them irritable, depressed, moody and tired.
But it’s rather easy to artificially induce sleep. “That’s why the prospect of a miracle pill or a miracle herb that helps you fall asleep and sleep through the night has always been tempting,” says Dieter Riemann, a psychologist who has dedicated his entire professional life to sleep research.
For almost 30 years, Riemann has been working in a special consultation unit for sleep disorders at the University Hospital in Freiburg. “Sleep problems are extremely complex and still puzzle researchers,” he says.
This may seem confusing at first. It seems fairly easy to describe sleep. As a state of consciousness that, unlike wakefulness, is characterized by a kind of isolation: closed eyes, a pause in conscious thought.
“But it’s not that simple because sleep changes throughout the night,” Riemann explains, there is not one defined area of the brain or one neurotransmitter that regulates whether and how well we sleep. Rather, sleep and thus sleep problems are regulated by a hodgepodge of biological and social factors.
Some people, however, are particularly susceptible to sleep disorders. Researchers have identified certain gene variants that are associated with insomnia. In addition, people who are particularly anxious or perfectionistic are more likely to develop occasional or chronic sleep problems. The triggers can be a wide variety of psychological and social factors, such as relationship crises or stress at work.
The promise of pills
Once sleep disorders have set in, they become a great burden for those affected. Various sleeping pills promise to help. The most effective drugs all target a specific neurotransmitter: gamma-aminobutyric acid, or GABA for short.
This neurotransmitter is the most important inhibitory force in the human nervous system. When GABA binds to the receptors of a cell, it reduces its ability to be activated by other stimulating neurotransmitters. A number of brain structures that normally drive the body are shut down — the cerebral cortex, but above all areas of the brain stem from the so-called ascending reticular activating system, which crucially regulates wakefulness. The result: the person relaxes and falls asleep.
The medicinal substances that act in the GABA system make it easier for people to fall asleep faster and also extend the length of sleep by about an hour. But although they are very effective, they are not the miracle cure for insomnia that we had hoped for. They often have severe side effects: headaches, dizziness, diarrhea, and dry mouth. They are not the safest, and they have never been.
The first drugs that impacted the GABA system were introduced as sleep medication around 1900: barbiturates. We don’t use them anymore, because they’re too dangerous: their dosage range is so narrow that many patients accidentally overdose and die.
“Mommy’s little helper”
In the 1960s, barbiturates were replaced by benzodiazepines. But even “mommy’s little helper,” as The Rolling Stones called one of the drugs so popular (and disproportionately used) among older women, has now fallen into disrepute for several reasons.
First, a small but substantial group of users experience parasomnias, meaning they get out of bed in their sleep without noticing. In the most harmless cases, they only go to the refrigerator, for example, but from time to time people get into the car, putting themselves or others in danger.
Second, the drugs only seem to help users reach a certain phase of sleep, namely light sleep, that does not bring about restful sleep. Studies suggest that for this reason, and because benzodiazepines take a long time to break down in the body, many users do not feel fit the next day. This is called a spillover effect. People become less concentrated, less productive and, for example, more often involved in traffic accidents.
Benzodiazepine habits are one of the most serious disorders in addiction medicine today.
But another effect of benzodiazepines is particularly problematic: They reduce anxiety and provide a pleasant feeling of euphoria that can lead to psychological addiction. Then, the body quickly gets used to the increased GABA effect and begins to adapt. That’s when the physical addiction kicks in.
Those affected need an increasingly higher dose of sleeping pills to achieve the desired effects. They experience withdrawal symptoms when they stop taking them: feelings of anxiety, restlessness, sweating, tremors, muscle pain, seizures, and even psychosis.
Benzodiazepine habits are one of the most serious disorders in addiction medicine today. Around 1 million people in Germany alone suffer from benzodiazepine dependence — despite the numerous awareness campaigns.
New pills, same side effects
The worrying part is that all of these side effects have now also been reported for the newest class of GABA-associated sleeping pills: the so-called Z-substances. The three drugs, zolpidem, zaleplon and zopiclone, are currently the most popular sleeping pills.
When they were introduced in the early 1990s they promised deep sleep without overhang or addiction. This is because the Z-substances work on the GABA system in a different way than benzodiazepines or barbiturates do. They do not increase the effect of the body’s own GABA, but rather bind to a class of GABA receptors and inhibit the excitability of cells.
“At first, this seemed promising,” Riemann says. The psychological dependence did somewhat lower as a result, as the Z-substances specifically improve sleep and do not produce the anxiety-free high that makes benzodiazepines so attractive. Nevertheless, recent studies show that they are just as addictive to the body.
But GABA drugs are not the only option.
GABA sleeping pills are a crutch, says Riemann. They can only help for a short time, during an emergency. They should not be taken for longer than four weeks and only under close medical supervision. Riemann only considers them appropriate for exceptional situations: acute pain, as part of a temporary illness, after surgery, or during a serious psychological crisis. They ensure that sleep itself does not become a further problem and allow those affected to deal with their actual crisis after a good night’s sleep.
But GABA drugs are not the only option. Many other depressant drugs are less effective but also have fewer side effects. Many of them block cell receptors to which activating messenger substances dock, thereby making the user more tired.
In Germany, these include, for example, daridorexant and the antidepressant doxepin. However, small doses of other antidepressants are also prescribed, and occasionally a neuroleptic, such as that used to treat psychoses. But these are still unofficial, off-label applications.
The drugs have been approved for the treatment of mental illnesses for years, but not for use in sleep problems. There have been no approved studies about the correlation between these drugs and insomnia, as they were not profitable for the pharmaceutical companies: they are already patented. Nevertheless, psychiatrists routinely prescribe them for insomnia. And with good reason: “Experience has shown that they can help some patients,” Riemann explains.
Natural remedies
Another pharmacological approach that raised hopes in recent years is the body’s own hormone: melatonin. It is a kind of clock that synchronizes our sleep-wake rhythm with the change between day and night. In the dark, melatonin is released from our pineal gland in the brain into the blood; light suppresses the release.
Many researchers hoped that taking melatonin, which is available in every supermarket in Germany, or the antidepressant agomelatine, which enhances the signaling effect of melatonin, would help with falling asleep. But scientific research shows that this might not be the case.
Agomelatine is currently only approved for the treatment of insomnia in the context of depression. Melatonin is particularly helpful when the sleep rhythm is completely out of control — for example, in the case of jet lag — but in the case of classic insomnia, melatonin doesn’t really do much, Riemann says.
Many people, especially those with mild sleep problems, try herbal remedies that are available over the counter, such as valerian root, passion flower, lemon balm leaves. There are only a few high-quality studies on their effectiveness to date, and they seem to show that herbal remedies have only a marginal effect on sleep — if any.
Looking at root causes
Riemann generally advises against taking sleeping pills unless there is an acute crisis such as pain or severe psychological stress. Insomnia should only be treated in severe cases, he says. And it makes more sense to look for the causes of the sleep problems than to treat the symptoms with medication. “Insomnia usually occurs when we are stressed,” Riemann says.
People are evolutionarily trained to stay awake when stressed so that they can react to danger. This is still evident today when brooding over a conflict, for example, or fear of an important task prevents you from falling asleep or sleeping through the night. People can cope with this for a few nights without any big problems. But if the stress does not subside — and insomnia makes it worse — people get trapped in a vicious circle.
In the case of insomnia, says Riemann, psychotherapy or a short counseling session can be used to try and understand what keeps the patient awake and how they can deal with stress differently. The connection between sleep and stress is weakened by dissolving a certain type of sleep anxiety: “Patients need to become aware, for example, that one bad night, or even five bad nights, are always followed by a better one,” Riemann says.
In this way, sleep loses its role as a central concern. “After a few counseling sessions, I often point out to my patients that we didn’t talk about sleep once in an entire therapy session.”
Long-term investement
If you compare the effects of psychotherapy and medication, the results seem comparable; it takes less time to fall asleep and you sleep through the night better. Yet the effects of psychotherapy seem to be more lasting.
Studies have shown that subjects still benefit from it one year after the end of psychotherapy. For example, they fall asleep faster and wake up less often. Riemann estimates that with psychotherapy or counseling, he can help around eight out of 10 patients who visit his unit at the University Hospital in Freiburg. And these are usually patients who have been suffering from insomnia for years, he says.
Medication can be a short-term and very useful help, but psychotherapy is an investment in one’s own abilities. People can learn to sleep on their own — even if sometimes they need a little help.
