January 21, 2020

Is Melatonin Right for You?

If you or a loved one are affected by restless legs syndrome (RLS), then you likely suffer from disrupted sleep. In fact, a person with moderate to severe RLS averages less than five hours of sleep per night, according to experts. Sleep deprivation is linked to many negative health effects, including depression, which can have a profound impact on a person’s day-to-day life.* Therefore, it makes sense to seek an intervention that may improve quality of life.

Many people who have difficulty sleeping turn to an over-the-counter supplement: melatonin. Melatonin is a naturally occurring hormone that is produced by the pineal gland in the brain to regulate the circadian rhythm, or the body’s internal clock. The release of melatonin is controlled by light. As daylight fades, usually one to three hours before bedtime, melatonin levels increase, which helps promote sleep. In the morning, the increase in daylight signals to the brain to halt melatonin production, aiding the transition to wakefulness.

More than 3 million adults take melatonin as a sleep aid, according to the National Center for Health Statistics. However, the effects of melatonin seem to vary; its effectiveness largely depends on the dose and timing of the supplement, as well as the sleep disorder being addressed.

Research on circadian rhythm sleep-wake disorders sheds light on the use of melatonin to improve sleep. According to the clinical guideline for treating these disorders (Auger, et al., 2015), studies have shown mixed results when administering melatonin to people whose circadian rhythm sleep-wake disorders stem from external alterations to their sleep cycles, such as shift work or jet lag. In one study, melatonin improved the length and quality of daytime sleep for people with shift work disorder in some, but not all participants. In another study of people with jet lag disorder, melatonin was more effective than the placebo for the first three days after traveling, but then lost its advantage. For circadian rhythm sleep-wake disorders that fall under the category of internal alterations in the timing of sleep, such as irregular sleep-wake rhythm, current data does not support the use of melatonin as a treatment. This may be relevant to RLS, since RLS follows a circadian pattern – that is, with most intense symptoms in the evening and nighttime hours. More research with a greater number of participants is necessary to determine the usefulness of melatonin across the board.

Nevertheless, melatonin may help one’s sleep schedule if taken at the right time and at the right dose. Typical doses of melatonin range from 0.5 mg to 5 mg. Higher doses should be avoided, even though there are many over-the-counter products available in doses as high as 10 mg. The best timing for most people is one to three hours before bedtime. It makes sense to consider melatonin as a potential option for a good night’s rest – but not necessarily for individuals with RLS; melatonin has been shown to trigger symptoms of RLS for some people. In a small study, researchers found a significant increase of sensory and motor symptoms of RLS when participants took melatonin compared to those who did not (Whittom, et al., 2010). Why is this?

Although RLS follows a circadian pattern, RLS is believed to be a sensorimotor disorder of the central nervous system. Research has shown that brain iron deficiency contributes to RLS, particularly within brain cells that contain the neurotransmitter dopamine. In terms of the sleep-wake cycle, dopamine is associated with wakefulness because it hinders the neurotransmitter norepinephrine, which then blocks melatonin release from the pineal gland. Because the human body operates under a system of checks and balances, melatonin also hinders release of dopamine in the central nervous system, thus creating a feedback loop. Since melatonin contributes to lower levels of dopamine, and lower levels of dopamine are associated with worsening RLS symptoms, some scientists suggest that melatonin may play a role in exacerbating RLS symptoms.

Another characteristic to note is that melatonin is serotonergic, which means that it is made from the same starting molecule (or building block) as serotonin – a neurotransmitter produced by the body that contributes to feelings of well-being and happiness. While serotonin’s role in regulating the sleep-wake cycle is complex, studies show that increases in serotonin reduce rapid eye movement sleep (REM sleep, the stage in sleep generally associated with dreaming) and can aggravate periodic leg movements of sleep. This is consistent with the fact that a common class of antidepressant medications that increase serotonin called selective serotonin reuptake inhibitors, or SSRIs, cause a worsening of RLS symptoms.

The bottom line is that melatonin may or may not help individuals sleep depending on many different factors. For people with RLS, it is important to know that taking melatonin comes at a risk of potentially aggravating symptoms. As always, you should to talk to your doctor before starting or stopping any treatment, even when they are marketed as naturally produced supplements.

*See Depression and RLS, available in the member portal at www.rls.org or by request.

August 1, 2019

CBT-I Just Might Help

By Régis Langelier, PhD

As many of you know, those of us who are “NightWalkers” have not only RLS, but also the insomnia that comes with it. All who endure RLS have some learned coping expertise; however, we also need new ways of thinking and strategizing for revitalization!

Now there is something proven to help: cognitive behavioral therapy for insomnia (CBT-I) – a treatment primarily given by specialized, doctoral-level psychologists. In 2016, the American College of Physicians finally recommended CBT-I as a first-line therapy for chronic insomnia,¹ officially endorsing the combined finding of data from multiple studies (meta-analysis).² CBT-I is proven to be the best treatment for chronic insomnia disorder, works as well as sleep medications and has the added benefit of fewer or no adverse effects. I use CBT-I every day, and so can you.

RLS and insomnia pose daily challenges to well-being

RLS is a complex, neurological and torturous affliction. Just by itself, it creates fragmented and diminished sleep; constant fatigue (often an RLS trigger); sometimes an inability to relax during the day; disruption of life’s pleasurable activities; impaired behavioral, emotional and cognitive functioning; and trouble with common activities such as driving, or attending a play or movie.

Insomnia is associated with one or more of the following symptoms: difficulty initiating sleep; difficulty maintaining sleep (characterized by frequent awakenings, or problems returning to sleep after awakenings); and early morning awakening with the inability to return to sleep. In chronic insomnia, sleep disturbance causes clinically significant distress or impairment in important areas of functioning, occurs at least three nights per week, and is present for at least three months. Chronic insomnia is linked to an increased risk of developing a number of physical and mental disorders, including but not limited to high blood pressure, heart disease, diabetes, chronic pain, work-related accidents, major depression, alcohol and substance abuse, and trouble with memory, concentration and performance.

Population-based estimates indicate that in general, about one-third of adults report insomnia symptoms³; in comparison, the prevalence in people with RLS is much higher (48–60 percent).⁴ Regardless of whether their RLS symptoms are relieved by medication, many patients continue to have sleep issues and other health problems. They also may be plagued by anxiety and depression, plus suffer from a sense of despair. RLS is invisible to our friends and others, as is insomnia. Often such unseen maladies contribute to feelings of isolation, to overwhelming stress, to chronic relaxation problems and to unique or quaint (soap under your pillow as a placebo?) coping strategies. Medications are not proven to be a universal answer. Coping and improvement are usually best achieved by medical evaluation and creating an individually tailored strategy that may include drug and/or nondrug treatments.

Poor sleep is partly learned and partly inherited. Factors known to contribute to sleep issues are age, pain, medical conditions, drugs, substance abuse, fear, financial insecurity, difficult work/living conditions, trauma, poverty and relationship problems –to name just a few common culprits. RLS and insomnia combined pose a much greater daily challenge to living well, and to achieving happiness!

Something proven to help: CBT-I

CBT-I is a set of strategies that helps modify thoughts, beliefs and behaviors that interfere with sleep and life. Although this therapy doesn’t work as quickly as sleep aids (which remain the most popular treatment for insomnia, despite publicized concerns about safety and efficacy), CBT-I is an evidence-based therapy that can be effective and enduring, especially by increasing shuteye time in stages 3 and 4 of sleep (slow wave sleep, and deep sleep). CBT-I improves mood and is particularly effective in mitigating excessive sleep effort – the common tendency to try too hard to make sleep happen. (Who hasn’t experienced this?)

CBT-I typically involves a sequence of eight or fewer sessions with a trained psychologist, and includes the following elements:

Sleep Assessment. The provider conducts a comprehensive evaluation and history of sleep problems, physical and mental health issues, substance use (including caffeine), daily sleep diary profiles, the Insomnia Severity Index score (mild to severe), and the Sleep Efficiency Index result (total time in bed actually spent asleep).

Sleep Education and Sleep Hygiene. This part of CBT-I addresses normal sleep and its stages, sleep regulators such as circadian processes, arousals from sleep, environmental conditions, and sleep hygiene recommendations. Screen time, Starbucks stops, and the nightly wine or beer are also added up on the “sleep trouble” scale.

Stimulus Control and Sleep Restriction Therapy.⁵ These strategies aim to strengthen cues for sleep, reduce cues that interfere with sleep, reduce the amount of time spent awake in bed each night, and associate one’s bed with falling asleep quickly. Stimulus control instructions are:

• Lie down intending to go to sleep only when you are sleepy.
• Do not use your bed for anything except sleep and intimacy.
• If you are unable to fall asleep within 20 minutes, then get up, go to another room and return to the bedroom when you are sleepy again. Do this as often as necessary throughout the night.
• Get up at the same time every morning, regardless of how much sleep you had during the night. This will help the body acquire a consistent sleep rhythm.
• Keep active during the day and avoid naps (except for a limit of 30 minutes when sleepiness might cause harm).

Sleep restriction is designed to increase the drive for sleep (i.e., tiredness) and is used in combination with stimulus control instructions and cognitive therapy. If you never fall asleep before midnight, but your bedtime is 10 pm, then go to sleep at 11:45 pm. This will limit or restrict the time you are “trying” to fall asleep. Also set up a wake-up time. This is typically seven to eight hours after your bedtime, even if you have a terrible night’s sleep.

Relaxation Training. This training reduces physical arousal and muscle tension, slows down the heart rate and breathing, and slows a racing mind. Approaches might include diaphragmatic breathing, visual imagery, and mindfulness-based stress reduction.

Cognitive Techniques, or cognitive restructuring. This therapy addresses misconceptions about the causes and consequences of insomnia, unrealistic sleep expectations, and negative automatic and sometimes catastrophic thoughts about sleep. It is important to challenge those thoughts and beliefs by identifying more realistic substitutes for them. In this therapy, negative thoughts (make your own list) such as “I am never going to fall asleep” or “I won’t cope tomorrow” or “I have no control over this racing mind” are treated, challenged and restructured by realistic thoughts: “I always fall asleep eventually” or “I will be tired tomorrow but will get through it as always” or “I am not alone – at least two in five people with RLS have sleep trouble.” Time is scheduled during the day to address anticipated worrisome bedtime thoughts and to practice relaxation. CBT-I providers typically provide handouts on cognitive techniques for patients to take home with them.

CBT-I considerations

A combination of CBT-I and RLS medication might be necessary to address the sleep disturbances and severe RLS symptoms. This combination can make the difference between frustrating torture, and some measure of success. With conditions such as depression, studies2 show that compared with antidepressant medication alone, CBT-I in conjunction with these medications can significantly reduce depressive symptoms and increase insomnia remission rates.

Sleep restriction therapy has been found effective for older adults (not for children) but is contraindicated for specific types of depression (e.g., bipolar disorder) and may at first increase anxiety. For this reason, sleep restriction therapy is optional for individuals who have post-traumatic stress disorder. Skip sleep restriction therapy if it doesn’t seem right for you.

Finally, although CBT-I can be conducted in groups or online, research to date on CBT-I outcomes has focused on in-person treatment.² However, time demands, health issues and transportation issues encourage remote consults (telepsychology) by specialized psychologists to treat RLS and insomnia.

In summary, CBT-I offers an effective, evidence-based protocol to improve sleep profiles for children and adults who have RLS. If you would like to explore this therapy, talk with your health care provider about whether this treatment may be right for you.

_________________________________________________

Régis Langelier, PhD, is a practicing, licensed psychologist in southern Maine offering CBT-I in-person and by remote consults. He is a behavioral medicine specialist, and a past clinical associate professor of psychiatry at the University of Vermont, Burlington. Langelier formerly served as treasurer of the RLS Foundation Board of Directors, was a support group leader for 10 years, and currently volunteers as an RLS support contact.

¹ Qaseem A. “Management of Chronic Insomnia Disorder in Adults: A Clinical Practice Guideline from the American College of Physicians.” Annals of Internal Medicine, July 19, 2016.
² DeAngelis T. “Behavioral Therapy Works Best for Insomnia.” Monitor in Psychology Vol 47, No 9, October 2016.
³ DSM-5 Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, American Psychiatric Association, Washington, DC, 2013.
⁴ Lee HB, Buchfurer MJ, Allen R, Hening WA. Clinical Management of Restless Legs Syndrome, Second Edition, Professional Communications, Inc., NY, 2013.
⁵ Bootzin RR, Epstein DR. “Understanding and Treating Insomnia.” Annual Review of Clinical Psychology 7, 11.1–11.24, 2011.

Both Conditions Have Serious Consequences on Sleep Cycles

Like restless legs syndrome, migraines can be horribly debilitating. According to the Mayo Clinic , "a migraine can cause severe throbbing pain or a pulsing sensation, usually on just one side of the head. It's often accompanied by nausea, vomiting, and extreme sensitivity to light and sound."

In fact, two-thirds of individuals that participated in the Migraine in America 2016 survey , reported that their symptoms lasted five days or more. That's more than five days of excruciating pain, sometimes enough to be disabling.

To make matters worse, one in six reported that they also experience restless legs syndrome during a migraine attack. These are two serious conditions that interfere with sleep, potentially resulting in a decreased quality of life.

In fact, 66 percent of survey respondents said that lack of sleep could bring on a migraine. The irony is that migraines make it nearly impossible to fall into a restful sleep, yet sleep is one of the best tactics at soothing a migraine.

Read more about migraines and their adverse affects on various aspects of life in Reader's Digest.

Insufficient Sleep Cited as Public Health Problem

According to the Centers for Disease Control and Prevention (CDC), more than one third of adults in the United States fail to get a sufficient amount of sleep on a regular basis. In fact, many of these people are actually suffering from sleep disorders.

A sleep disorder is defined by any change in the way you normally sleep. Some of the more common examples include insomnia, sleep apnea, narcolepsy and restless legs syndrome (RLS) .

Symptoms of a sleep disorder involve irritability upon awakening and problems concentrating, and can lead to an overall decreased quality of life. Specifically, restless legs syndrome can prevent falling and staying asleep, resulting in unrefreshed sleep cycles and serious daytime fatigue.

Read the full article from Oklahoma Magazine here .