Karl Doghramji, MD: Alternative Insomnia Care


From yoga to over-the-counter drugs, numerous options are available for the sleep condition.

Sleep condition patients, including insomniacs often come equipped with ideas to their own care at the doctor’s office. Some are effective, and some are clinically uncertain.

In an interview with MD Magazine®, Karl Doghramji, MD, a professor at Thomas Jefferson University, explained the known benefits of mind and body techniques including yoga and meditation for insomnia—and the uncertainty of over-the-counter drugs including melatonin.

MD Mag: How do mind and body practices benefit patients with insomnia?

Doghramji: So mindfulness techniques and mind-and-body relaxation techniques are useful to patients who a high degree of arousability. And arousability, or brain activation, is common in many insomniacs. So muting that or diminishing that activation may be very helpful.

So yoga, tai chi, biofeedback, meditation, these all may be helpful, and have shown to be helpful in a variety of conditions including anxiety disorders and so on and so forth. I do think they're useful, they're helpful. Again, the question is: are there enough trained therapists to do these, and the length of time that it takes to do these things? And to implement them may be a problem for some older individuals.

MD Mag: What over-the-counter therapies are available for insomnia?

Doghramji: There many substances that are available to insomniacs without a prescription, such as over-the-counter hypnotic medications. These typically are in the realm of diphenhydramine and doxylamine, the antihistamines. And there are many other compounds that are so-called natural compounds—nutri-ceuticals—which are available as well.

We find that many insomniacs have tried these compounds before they see a physician. The advantages of these agents of course, the perceived advantages are that they're cheap, they're available without a prescription, they're readily available to anyone who wants to use them, and they have the allure of having fewer side-effects or fewer burdens to the patient.

Unfortunately, most of these agents have not been well studied or well researched in clinical settings ,and many of them may have side effects which are not well known. The concern, of course, is that by combining many of these agents together, we may produce toxic metabolic effects, as well as CNS effects which people may not be necessarily aware of.

So we always recommend to older individuals that they use these agents judiciously, and report them to their physicians, so we at least have a knowledge of what they're on. One of the commonly used medications is melatonin. Melatonin is a newer hormone which is naturally secreted, and which is thought to regulate sleep and circadian rhythms, and in many formulations is available.

Meta-analytic data have shown that melatonin has very modest positive effects on sleep latency and sleep maintenance, so it may help people fall asleep more quickly behind the order of a few minutes, and maybe sleep a few minutes longer. So its effects don't seem to be all that striking, or all that impressive.

And the problem with melatonin also is that we just don't understand its side effects. There's some fairly well-done data suggesting that it increases glucose resistance and may also increase insulin production, with less insulin effects on target tissues. So I think the use of melatonin may be a good practice in some cases, but we don't understand its side effects well.

Finally, melatonin formulations vary quite a bit, and there's no regulation of its use by the Food and Drug Administration. So these natural products are available, widely utilized—we just don't quite understand if they have a positive effect, or what effects they do have, and more importantly, what their side effects are.

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