In the nights after Brady died I lay awake for hours, listening intently for sounds of someone in distress. At any noise I jolted alert, my heart pounding while terrifying images filled my mind and I struggled to master an urge to leap from bed and rush outside.
Many grieving people report similar insomnia symptoms where they are unable to go to sleep or stay asleep for long. In a moment I’ll report on some brand-new evidence for a coping strategy that seems effective at helping grieving people get some sleep. First, my experience.
Pills for Insomnia
The day after Brady died I saw a physician at the health maintenance organization that my insurance company contracted with. As soon as I told him what had happened, he began rapidly writing out prescriptions.
I got one for clonazepam or Klonopin, an anti-anxiety medication similar to Valium and Xanax. Another was for propranolol or Inderal, a beta-blocker normally used to treat high blood pressure. I specifically requested this one on the advice of a mental health professional who said it could help with PTSD symptoms if taken soon after a traumatizing event. A third was for trazodone, an anti-depressant often used for insomnia. A fourth was for citalopram, another antidepressant often used for grief-related depression.
At first I took the pills, except for the citalopram, as instructed and was able to get some sleep. However, I didn’t want to keep taking them for long
At first I took the pills, except for the citalopram, as instructed and was able to get some sleep. However, I didn’t want to keep taking them for long. Klonopin like other benzodiazepines is highly addictive and shouldn’t be taken regularly for more than a few weeks. The support for Inderal as a PTSD treatment is weak, I found.
Trazodone, like many antidepressants, can be difficult to wean yourself off of without experiencing unpleasant symptoms including yet more insomnia. Same for citalopram. I had a lot of trouble getting off an antidepressant years ago and didn’t want to go through that again.
After about a month and a half, I wasn’t taking pills for anything including sleep. Instead I was using non-medicinal approaches.
I quit the Inderal after a few days and began cutting back on Klonopin soon after. I never started the citalopram, so that wasn’t an issue. I took trazodone for insomnia as ordered for a few weeks to help with my continued difficulties sleeping and then weaned myself off of it, reducing the dosage over a few more weeks until I was off of it completely.
After about a month and a half, I wasn’t taking prescription pills for anything including insomnia. Instead I was using non-medicinal and over-the-counter approaches to tackle sleep issues.
Soon after Brady died I began seeing a therapist who had considerable experience with PTSD, of which insomnia is a common symptom. After a few sessions he began teaching me to use cognitive behavioral techniques to deal with the thoughts and feelings that were keeping me awake.
When the idea that someone might be in serious danger and needed my help crossed my mind in the night, I was taught to pause and remind myself that the night Brady died was in the past. In the present, in reality there was almost no chance that anyone was in danger in the backyard and needed help.
I was taught to pause and remind myself that the night Brady died was in the past.
As I lay in bed quivering with hypervigilance, I would repeat to myself, “That was then. This is now. No one is dying in the backyard. No one needs my help.” I could feel the tension leak out of me when I did this. I still couldn’t easily fall asleep, however, so I kept taking the trazodone until I could taper off the dosage over several weeks and finally quit it altogether.
After that I tried taking non-prescription melatonin tablets, which are said to promote sleep. But the first time I did this I had extremely terrifying nightmares and so did not repeat the experiment. (I recall at the time how strange it was to wake from a mind-melting nightmare only to find that reality was even worse.)
My next move was to take non-prescription Benadryl, or actually the generic version sold as diphenhydramine. I tried a single 25 mg pill 15 minutes before lights-out, then went up to two pills. I did this nightly for several months and it seemed to help. Some recent research suggests that medications such as diphenhydramine may cause early dementia, so I wanted off that ASAP as well. I started tapering down and am currently taking half a 25 mg pill when I do take it. Many nights I’m not taking anything.
Over the next month or so as I got off the trazodone and kept using the cognitive behavioral techniques, I also began looking into other drug-free insomnia treatments and ran across the concept of sleep hygiene. This is a set of practices and environmental elements that are said to promote sleep. They include:
- Going to bed and getting up at about the same time every day
- Not taking daytime naps
- Avoiding caffeine, alcohol and nicotine late in the day
- Keeping the bedroom dark
- Avoiding screens including TV, laptop, tablet and phone for a couple of hours before bed
- Getting regular exercise, preferably in the morning
- Not letting the bedroom get too warm or cold
- Using the bed only to sleep or have sex.
- Avoiding reading and watching TV in bed.
- Getting up after 15 minutes or so if sleep won’t come.
- Thinking about positive or relaxing things at bedtime instead of focusing on problems.
- Practicing relaxation techniques such as yoga breathing
I started doing and still do almost all of these pretty regularly, as well as when necessary the CBT technique I learned from my therapist. I read before sleep on a tablet sometimes but when I do I try to remember to use a pair of special glasses that are supposed to block the blue light from the display that interferes with sleep.
I don’t drink alcohol or smoke so those aren’t issues. But I avoid eating or drinking anything at all for an hour or two before bed. I have the frequent urination issues many men in their 60s experience as a result of prostate enlargement. I don’t want to wake up to use the bathroom more than necessary, so I try not to drink anything late in the evening and also visit the commode just before lights out.
Yoga breathing refers to patterns of breathing that are supposed to help you relax. The pattern I use is to breathe in for four seconds, hold the breath for seven seconds and then breathe out slowly for eight seconds. I repeat this 4-7-8 breathing exercise twice when I’m trying to go to sleep and if I wake in the night. It helps me to go to sleep usually within a few minutes.
One thing I haven’t seen in any sleep hygiene prescriptions is the use of white noise. I run a free iPhone app called “White Noise” all night when I’m home and it seems to help. I do without it when I’m not in my own bed. The white noise as well as the 12.5-mg diphenhydramine dose may mostly provide only psychological benefit. But I’m not turning down anything liable to help.
The white noise as well as the 12.5-mg diphenhydramine dose may mostly provide only psychological benefit. But I’m not turning down anything liable to help.
I’ve also recently started wearing a sleep mask on the advice of a friend who said after he started using one regularly he began remembering dreams for the first time in a long while. I would like to have and remember more dreams with Brady in them, so that was one reason I started using the mask. Also, I have trouble keeping my room really dark because of a nearby street light. So far, it seems to be helping somewhat. I did recently have one dream with Brady in it, although to be honest I would just as soon not have remembered that one.
None of this works faultlessly and unfailingly. But today I generally sleep pretty well. I go to bed about 10 o’clock and normally sleep until 4:30 or so when I get up to use the bathroom. Then I can usually go back to sleep until 6:30 or so. This seems like a sustainable sleep schedule and amount.
New Evidence on Grief-Related Insomnia Treatment
There has been lots of research into insomnia treatments but my attention was caught today by a new study that specifically compared strategies for coping with insomnia after bereavement. “The Effect of Treatment Type on Improvement of Subjective Sleep Quality in Complicated Grief” was described in an issue of Biological Psychiatry dated May 2018.
This looks like a well-done study. The researchers are all from prominent US medical schools including Harvard, Columbia and New York University. Biological Psychiatry is a well-regarded and widely cited peer-reviewed journal.
For this study researchers looked at 395 patients diagnosed with something called complicated grief. In this condition a survivor’s grief symptoms are more intense and longer-lasting than with a typical bereavement. The study also included a randomized control group, which is usually a sign of a well-done study.
More than 90 percent of these patients diagnosed with complicated grief had scores indicating significant trouble with insomnia.
To start, patients were assessed using a couple of standard assessments, including the four sleep-related items on the Quick Inventory of Depressive Symptoms and a version of the Pittsburgh Sleep Quality Index tailored for grief. More than 90 percent of these patients diagnosed with complicated grief had scores indicating significant trouble with insomnia.
The patients then were randomly split into four groups. Over 20 weeks, each group received one of four treatments: 1) Complicated Grief Therapy (CGT) with citalopram, 2) CGT with placebo, 3) citalopram alone and 4) placebo alone.
CGT has been found to be an effective treatment for complicated grief in some large studies. It involves repeated exposure to the traumatic details by, for instance, retelling the story of the death. (I did this in my therapy and found it grueling but highly effective.) In addition to re-experiencing past trauma, patients are guided to focus attention forward on personal goals and relationships.
Citalopram is a serotonin reuptake inhibitor similar to Prozac. It’s been investigated as a treatment for complicated grief symptoms, not just insomnia, in a few studies like this one from 2016. The evidence for citalopram effectiveness seems weak to me. But, for some reason it was looked at for this new study.
The bottom line of this study is that if you are having trouble with insomnia after bereavement, especially if you have been diagnosed with complicated grief, you might do well to consider CGT while skipping the pills.
The results were encouraging. Most patients had significantly improved sleep disorder scores with the CGT, while neither the citalopram nor — not surprisingly — the placebo helped much. The bottom line of this study is that if you are having trouble with insomnia after bereavement, especially if you have been diagnosed with complicated grief, you might do well to consider CGT while skipping the pills.
The Usual Caveat
One problem with essentially all medical research is that it deals in probabilities and likelihoods. For instance, not every person who smokes will get a smoking-related illness. Similarly, not every bereaved insomniac who tries CGT is likely to experience the same or even any improvement in sleep. But evidence from this study suggests that odds are CGT will work better than the pills.
For me, a combination of all these things — with only brief exposure to the medications — did the trick reasonably well. That was my experience and mine alone. Your mileage may vary.
I hope you’ve gotten some ideas for coping with grief-related insomnia. If not, my apologies. I am sorry for the losses that brought all of us here and hope we each can get some peace today and some sleep tonight.