It is stressed that getting an appropriate amount of sleep each night is critical for our physical and mental health — essential, in fact, to give our body the time it needs to recover and prepare for the next day. For those who have trouble falling asleep or staying asleep, the notion of getting sufficient rest can cause anxiety, and many turn to what they think is a quick fix for falling asleep — melatonin supplements.
Melatonin is a hormone made in the brain that helps play a role in a person’s daily sleep-wake cycle. Melatonin levels rise in the evening once the sun has set, as its production is influenced by the amount of light available and why people sleep when it is naturally or artificially dark. Levels then drop once light, such as sunlight, reappears and causes you to wake up naturally.
While it is thought that taking a melatonin supplement can aid sleep when one is experiencing insomnia or jetlag, or to even help one fall asleep more regularly, little is known about what role the over-the-counter aid really plays.
S. Justin Thomas, Ph.D., assistant professor in the University of Alabama at Birmingham’s Department of Psychiatry and sleep disorder clinician and researcher, breaks down myths and facts associated with melatonin supplement usage and how clinical intervention can ultimately help those in need seek the sleep resources that best fit their lifestyle.
Q: Do melatonin supplements actually help people sleep?
A: Melatonin does work to help with sleep. The best evidence for the use of melatonin is in determining the timing of sleep (e.g., whether you begin to feel sleepy at 10 p.m. or 2 a.m.). Specifically, in small doses, it is useful in shifting an individual’s circadian rhythm; but there is less evidence to support its use in helping people to fall asleep. However, in larger doses (closer to the 5mg you find in stores), it does have a sedating effect for some people.
I have many patients who start taking melatonin before they see me in my Behavioral Sleep Medicine Clinic at UAB, as melatonin supplements are often perceived as a quick fix. I think it is becoming increasingly used because melatonin can be easily purchased over the counter, and it is generally considered benign. However, since there are few guidelines on its use, I typically see it being used inappropriately.
Q: What do patients seem most concerned with regarding sleep?
A: Honestly, any sleep disruption is concerning to patients. There is some sense that waking up in the middle of the night tends to be most distressing because you are awake while everyone else is asleep. Also, many patients tend to attribute daytime fatigue, sleepiness and perceived cognitive impairment to poor sleep when, in reality, many factors outside of sleep can contribute to these daytime concerns.
However, the anxiety around sleep and daytime functioning only serves to worsen sleep. I tend to find that younger adults experience more difficulties falling asleep, sometimes due to delayed circadian rhythms. As people age, many experience more difficulty staying asleep.
Q: What should consumers know about melatonin supplements?
A: It’s important for people to realize that melatonin is typically purchased as a supplement, and as such is not subject to regulation by the Food and Drug Administration. Therefore, the dose of melatonin on the package may not actually be what is in the pill. For example, a recent study published in the Journal of Clinical Sleep Medicine found that, of 31 over-the-counter melatonin supplements tested, the melatonin content ranged from less than 83 percent to more than 478 percent of the labeled content, with 25 percent of supplements tested having some levels of serotonin detected.
Consumers should also know that the timing and dosing of melatonin depends on the type of sleep disorder one has, for instance if they have a delayed sleep wake disorder versus insomnia. Therefore, working with a trained clinician in order to properly dose and time melatonin use is key. It is important to understand how melatonin could be integrated as a sleep aid, or how it may actually be a detriment on one’s sleep-wake cycle.
Q: What are some tips for improving sleep quality and duration that people may try first before scheduling an appointment at the UAB Behavioral Sleep Medicine Clinic?
A: There are a few things that fall under “sleep hygiene” that can help before having to make an appointment.
Caffeine
The half-life of caffeine is three to seven hours, depending upon the individual. Therefore, the common rule is to limit caffeine after noon if you have trouble sleeping. Caffeine is found in many different things, so it is not just coffee or soda to steer clear of but also other items like tea and chocolate that may be triggers.
Physical activity
Exercise or physical activity can help improve sleep quality, particularly for people who are sedentary, although you should avoid vigorous physical activity an hour or two before bedtime.
Light exposure
Limiting light exposure in the evening and night definitely helps, as light is the primary deterrent of melatonin release. Therefore, it is counter-productive to be exposed to light at night, which suppresses melatonin, and then have to take medication for sleep. This includes natural and artificial light, as well as the light from electronics.
Continuity
Keeping a consistent wake time is helpful for many people, with a routine lending itself to promoting regularity. We do see a lot of patients who experience orthosomnia, a new term used to describe patients who put too much emphasis on the sleep data reported by wearable watch-type devices. In general, caution should be exercised before placing too much faith in the data they report, as most are not very accurate and anxiety produced by their data can actually worsen sleep.
Self-care
Stress management not only is important for overall mental health, but also is critical for sleep. Individuals who are under significant stress tend not to sleep well. Therefore, in addition to sleep hygiene, it is key that people exercise generous self-care by making sure they are not overextended and are tending to personal stress appropriately as needed.
Q: What is your advice to people who are looking for help sleeping? What would you recommend?
A: The American College of Physicians recently published a position paper indicating that cognitive behavioral therapy for insomnia (CBT-I), not hypnotic medication, should be the first line of treatment for insomnia. Importantly, assessment of insomnia symptoms is critical because other sleep disorders may be present, and treatment of these co-occurring disorders could result in improvements in insomnia symptoms. For example, obstructive sleep apnea (OSA) often presents as difficulty maintaining sleep and frequently co-occurs with insomnia. Furthermore, insomnia also co-occurs with mental health disorders. Therefore, I always recommend formal assessment of insomnia symptoms prior to initiating treatment.
Other sleep disorders may also contribute to difficulties sleeping, and a sleep disorders center like ours at UAB is extremely helpful in making the correct diagnosis and offering a variety of treatment options.
The Society of Behavioral Sleep Medicine meeting is actually going to be here in Birmingham in September, and we will be doing a roundtable discussion on appropriate use of melatonin and light therapy, which will be a great opportunity to explore this topic further.