There are new treatments for insomnia
Miranda Can’t Sleep at Night, Until Late 7:30 AM: Implications for Sleep and Other Treatments of Insomnia
Miranda can’t remember when she didn’t have insomnia. The 23 year old, who asked for her last name to be withheld, started struggling with sleep when she was a child. As she’s grown older, it’s only become worse. She takes “a myriad of medications” each night, she says, but usually still cannot fall asleep until the early hours of the morning. “I can’t get up and be functional until halfway through the day,” she says. She dropped out of university because she was not able to attend classes and hold on to her job. Her insomnia exacerbates other medical conditions as well, including migraines and the pain condition fibromyalgia. She says it is hugely disabling. It affects everything.
Some studies suggest that insomnia can stem from a high level of underlying brain activity during sleep. According to Ruth Benca, a psychiatrist at the Wake Forest School of Medicine in North Carolina, this raises the question of whether reducing this activity can be used to treat insomnia. Companies and academic research groups are beginning to test this proposition with wearable devices that use auditory tones or mild electrical stimulation to increase slow-wave activity in the brain. Evidence suggests that some of the devices on the market can increase the duration of deep sleep. Last June, researchers at Elemind Technologies in Cambridge, Massachusetts confirmed that sound waves in sync with brain-wave rhythms of people who struggle to fall asleep for more than 30 minutes allow them to shave about 10 minutes off that time.
On the Use of Digital Platforms for Delivering CBT-I in Clinical Trials: A Study of Cannabinol, a Candidate from the Cleveland Clinic and the Veterans Affairs
There has been a slow increase in the number of physicians. He says he can see a world where digital care is your first stop if that isn’t successful, and if you see a therapist.
The Cleveland Clinic in Ohio, and the US Department of Veterans Affairs are two of the companies or health systems that have created digital platforms for delivering CBT-I. SleepioRx, for example, is a 90-day digital programme that has been evaluated in more than two dozen clinical trials and has showed efficacy as high as 76%. It also includes helping people to fall asleep faster, sleep better, and feel better the next day. Big Health’s programme received clearance from the FDA in August of 2024. A 2024 meta-analysis of 15 studies that compare in-person and electronically delivered CBT-I concluded that the two approaches were equally effective12.
I was cautiously excited to learn about the dual-recombinant (DORA) drugs that were included in the story on sleep medication for the Nature Outlook. These work by blocking a molecule that promotes wakefulness, and they have fewer side effects and a lower risk of dependence compared with other sleep aids. My PA was familiar with one of them, Belsomra, and said I could try it.
McGregor is investigating cannabinol (CBN), a molecule that develops in cannabis as the psychoactive component tetrahydrocannabinol (THC) oxidizes. His group reported that CBN increased sleep in rats to a similar degree as zolpidem, but without the drug’s known negative side effect of suppressing rapid-eye-movement sleep9. Unpublished data of a single-night trial with 20 people with insomnia disorder show that people fell asleep 7 minutes faster after taking 300 milligrams of CBN compared with those taking a placebo; participants also reported subjective improvements in sleep and mood. Although 7 minutes “doesn’t sound like a lot”, it is on a par with what benzodiazepines and Z-drugs typically accomplish, says Camilla Hoyos, a sleep researcher at the Woolcock Institute of Medical Research in Sydney, who led the work. McGregor, Hoyos and their colleagues are aiming to follow up the work with a large, community-based trial in which people with insomnia take either CBN or a placebo for six weeks at home.
Compared with benzodiazepines and Z-drugs, which inhibit activity all over the brain, DORA drugs affect only the neurons activated by orexins (see ‘Blocking wakefulness’). “The beauty of it is it does nothing but block the stimulation of wakefulness,” says neurologist Joe Herring, who heads neuroscience clinical research at Merck in Rahway, New Jersey. “It’s a physiologically better way to promote sleep.”
The main drawback to DORA drugs, Buysse says, is not medical but financial: their high cost keeps them out of reach of many people who could benefit from them. “There are many patients I would like to prescribe these drugs for, but I know in order for them to get one of these medications we’ll have to go through trials of several other drugs before the request will be considered,” Buysse says. DORA drugs are also available only in a few countries, so far.
Miranda has experience with many of these products. When she first developed chronic insomnia as a child, her paediatrician recommended melatonin, which is available without a prescription in the United States. It helped her fall asleep, but it did not keep her asleep. She was prescribed trazodone and mirtazapine by different doctors during her teenage years. But they came with what she calls “torturous” side effects: she felt constantly anxious and exhausted during the day, and her memory became “incredibly foggy”.
It is not for everyone and it does not work for everyone. Miranda has tried it and has received conventional talking therapy for over a decade, with limited success. She says that it only helps so much.
The Infuriating, Costly Road to a Good Night’s Sleep: Why Do Many Americans Live in an Insomniac State?
In the United States, about 12% of adults have been diagnosed with chronic insomnia — when a person struggles to sleep for more than three nights each week for at least three months, and experiences daytime distress as a result. The worldwide figure is thought to be 10–30%. It also often co-occurs with and creates a vicious cycle with other conditions, including chronic pain, depression and anxiety.
As I write this, I’ve been taking Belsomra on and off for a month. When it works well, I fall asleep quickly and soundly, and wake up feeling clear-headed and rested. I have trouble sleeping about 25% of the time due to my anxiety cutting through the medication. My PA said that I can try doubling my dose to the maximum 20 milligrams, by taking two tablets each night. But I haven’t tried this yet, because I’m aware that each pill I pop before bed is about the same price as ordering a fancy cocktail.
It shouldn’t be this way. Medical professionals should be the ones calling the shots on what care their patients need — not insurance companies that are focused on ringing out as much profit as possible from clients who are already paying exorbitant premiums. The system isn’t going to change soon, and as a result, millions of people are going to resort to medication that may have harmful long-term effects, even though the most advanced therapies remain out of reach.
Source: The infuriating, expensive road to a good night’s sleep
Sleep during the 2024 US Presidential Election: An Empirical Physician’s Assistant Advices Against the Prescribing of DORA
Last year, my struggle to sleep markedly worsened. Stress appeared to be in plentiful supply. It is becoming harder and harder for me to make ends meet, because my job as a science journalist is not enough to make up for the collapse of the media industry. At night, my chest would tighten as I tried to imagine a viable future in my chosen career. Layered on top of that were the stressors of the 2024 US presidential election and interpersonal drama with my increasingly conservative father.
I found a sympathetic primary-care provider in the form of a physician’s assistant (PA) — a licensed medical professional who, in some states, can prescribe medications but isn’t actually a physician. She asked me questions about my life. At the end of my appointment she agreed that I should try bupropion. After the election I had trouble sleeping, and I got more anxious at night. “Sadly, we are getting a lot of these messages,” my PA said when I told her about this. Buspirone has been added to my daily regimen. I immediately started sleeping better. The buspirone made me feel deflated, numb, and uninspired during the day. My PA suggested that, as long as I didn’t develop serious depressive thoughts, I should stick it out for a month to give my body time to adjust.
It took almost three weeks for me to receive the prescription, and my insurance would not cover it. There are no generic DORA drugs that are similar to DORA drugs. A pack of 30 tablets of Belsomra was going to cost me more than US$500. But, I was desperate to get some sleep and my pharmacist was able to find a coupon that knocked $150 off the bill. I paid after I sucked it up.
