Sleep 101: The Sleep-Health Link, Sleep Stats, Problems with Sleep Meds & A Holistic Approach to Better Sleep (including Best Sleep Supplements)

November 7, 2019

WHY IS SLEEP SO CRUCIAL FOR HEALING AND OPTIMAL HEALTH?

Most of us know from experience how important sleep is as it relates to our health and general well-being.

 

We’ve all had short, restless nights here and there and can attest to the resulting grogginess, impaired cognitive abilities and slower reaction times. For those battling certain degenerative conditions, a poor night’s sleep can even exacerbate symptoms (ex. increased joint or muscle pain, increased trouble breathing, dysregulated blood sugar levels, etc.). When poor sleep becomes chronic things can really spiral downward and contribute to the development and progression of disorders like chronic fatigue syndrome and adrenal fatigue. Chronic sleep troubles can also impair wound healing and hormone balance, and lead to an increased dependency on caffeine and/or sugars (carbohydrates), which can further exacerbate issues like adrenal fatigue, blood sugar issues, pancreatic insufficiency and hormone imbalance.

 

SO HOW MUCH SLEEP IS IDEAL FOR HEALTH?

How many hours of high-quality sleep a night do we need in order to promote optimal health and function at our best? The answer varies slightly depending on the person, but most of the data (as well as the consensus opinion among sleep experts) points to somewhere between 7-9 hours of high-quality sleep a night for most adults…

 

 

HOW ARE AMERICAN ADULTS DOING WHEN IT COMES TO SLEEP?  

The general sleep situation in the U.S. seems to be trending right along with the rest of the general health situation in America (which is far from positive). Consider the following sleep stats...

 

* 80% (4 out of 5) American adult say they have sleep problems at least once a week.

 

* Nearly half of Americans (48%) say they generally don’t get enough sleep.

 

* On average, U.S. adults sleep over an hour less than they did 70 years ago. In 1942 the average U.S. adult slept 7.9 hours/night. In 2013 that number dropped to 6.8 hours/night.

 

* Data collected in 2017 from millions of nights of FitBit users paints an even more sleep-deprived picture, putting the average at 6.63 hours/night.

 

* In short, American adults are getting, on average, 60 to 80 fewer minutes of sleep each night than they did in the 1940s.

 

* The number of U.S. adults averaging less than 6 hours of sleep a night has MORE THAN TRIPLED in the last 70 years (ex. only 11% of adults averaged 6 hours or less in 1942; in 2013 some 40% of adults averaged 6 hours or less).

 

* An estimated 50-70 million U.S. adults (~25% of the adult population) have a sleep or wakefulness disorder.

 

* Certain sleep disorders increase the risk of cardiovascular disease, including heart attack and stroke. For example, people with untreated sleep disorders like sleep apnea have 2-4 times the risk of heart attack and stroke as those without apnea.

 

* Insufficient sleep and poor sleep quality have been shown to have a negative effect on mood, work quality and even relationships.

 

* Each year drowsy driving is responsible for over 5,000 deaths and 40,000-70,000 non-fatal injuries.

 

To sum up, American adults are getting 15-20% less sleep than they did 75-80 years ago, and the number of Americans averaging less than 6 hours of sleep a night has more than tripled over that same time span.

 

Approximately 25% of the adult population have some kind of sleep disorder, and certain sleep disorders increase the risk of developing other diseases, including heart disease (the #1 killer of American adults). Finally, drowsy driving is responsible for more than 5,000 deaths and around 50,000 injuries (many of which render a person permanently disabled). [1-8]

 

THE DRUG INDUSTRY’S ANSWER TO AMERICA’S SLEEPING PROBLEMS

In 2011 Americans filled some 60 million prescriptions for sleep medications, and in 2013 it was estimated that around 9 million American adults (1 in 20) are habitual users of sleep medications (important because sleep medications are generally only recommended for 7-30 days). Additionally, it’s estimated that approximate one- third of older adults regularly take sleeping pills.

 

Today, drugs that are used for sleep issues are generally going to come from 3 drug classes, including…

 

1.Benzodiazepines

Along with “z-drugs” (more info below), “benzos” are part of a group of drugs called sedative hypnotics (or minor tranquilizers). As the name suggests, these drugs work by inhibiting central nervous system (CNS) activity, more specifically, by having an agonistic effect on selective GABA receptors (GABA is one of the chief inhibitory neurotransmitters in the body and tends to have a strong sedating effect). Benzodiazepines have been marketed in the U.S. since the mid-1960s (starting with Valium), and in the late 1970s benzos were the most prescribed medication in the world. Common benzos include Xanax, Klonopin, Ativan, Valium and  Halcion.

 

2.Z Drugs

“Z drugs” include Ambien (zolpidem), Sonata (zaleplon) and Lunesta (eszopiclone), and are so-called because the letter Z is present in name of all 3 of the major drugs from this class. Like benzos, z drugs work as selective GABA receptor agonists, enhancing the sedating effect that GABA has on the nervous system and soft tissue. Z drugs are newer to the American pharmaceutical landscape than other classes of sleep

 

Unlike barbiturates (1903), antihistamines like diphenhydramine (1946) and benzodiazepines like Valium (1963), “z drugs” are relatively new to the American pharmaceutical landscape, beginning with King Pharmaceutical’s FDA approval of Sonata in 1999, which was followed by Ambien and Lunesta in 2005.

 

3.Antihistamines

Antihistamines hit the U.S. market in the mid-1940s and are also commonly used as pharmaceutical sleep aids. These drugs act in a couple ways, first by suppressing the activity of histamine (which tends to stimulate metabolic activity), and next by blocking the neurotransmitter acetylcholine, which can also have a sedating effect (it’s for this reason these drugs may also be classified as anticholinergics). The two main antihistamines

here are…

 

* diphenhydramine (found in Zzzquil [formerly Nyquil], Advil PM [along with ibuprofen], Tylenol PM [along with acetaminophen], Excedrin PM, Sominex and Benadryl) and

 

* doxylamine (found in Unisom)

 

Another class of drugs were regularly prescribed to treat insomnia and related sleep conditions. Barbiturates (aka downers) first hit the U.S. drug market way back in 1903 under the trade name Veronal. Over the next 3 decades the use of barbiturates exploded, to the point where a billion doses per year were being dispensed in the U.S. in the early 1930s. Barbiturate popularity continued through the 1970s, despite the increasingly widespread acknowledgement of their adverse side effects (which includes behavioral disturbances, high risk of physical dependency and suppression of REM sleep). Indeed, the deaths of actresses Judy Garland and Marylyn Monroe, as well as that of musician Jimi Hendrix were all due to barbiturate overdose. Today, the prescribing of barbiturates for sleep-related conditions is rare, in part due to well-established adverse effects, and in part due to the current popularity of benzos and z drugs.

 

In 2015 a new class of sleep medication did hit the U.S. market with the arrival of suvorexant (trade name Belsomra). An orexin receptor antagonist, suvorexant attempts to induce sleepiness by blocking the binding of the orexin neuropeptides, which are thought to signal wakefulness. A common complaint about the drug is that it doesn’t help users to sleep, and other adverse effects include nightmares, sleep terrors/paralysis, abnormal dreams and suicidal thoughts.

 

WITH SLEEP MEDS, DO THE BENEFITS OUTWEIGH THE SIDE EFFECTS?

So how effective are sleep meds at helping people fall asleep, stay asleep and sleep longer? It depends on which class of meds are examined. Surprisingly little research has been done on antihistamines and their effect on sleep, despite their relatively widespread use as a sleep aid. For benzos and z drugs, the existing data seems to suggest that users fall asleep 10-15 minutes faster and sleep for (drumroll)… 10-20 minutes longer. So that’s the PROS. The CONS? Other than what’s already been discussed above with barbiturates and orexin inhibitors, here are some of the side effects and adverse consequences related to sleep meds…

 

Next Day Grogginess, Impaired Memory, Increased Risk of Falls & Car Accidents…

* Common side effects for benzos, z drugs and antihistamines include next-day drowsiness, impaired cognitive ability, confusion, memory loss, dry mouth, constipation, trouble urinating, and liver and kidney dysfunction.

 

* In a Consumer Reports survey, of those taking an over the counter (OTC) or prescription sleep drug, 30-40% reported feeling foggy or drowsy the next morning.

 

* According to the American Geriatrics Society, there are safer and better ways to improve sleep than taking sleeping meds.

 

* Sleeping meds are known to cause memory loss and dementia in older adults.

 

* Regularly taking sleeping meds may double the risk of falls and hip fractures (likely due to next day grogginess). These are common causes of hospitalization and death in older people.

 

* A 2017 analysis that followed more than 4,000 adults over 65 years of age for two years found that those taking sleeping drugs recommended by their doctor were 34% more likely to fall than those not taking sleeping drugs.

 

* Those who take sleep meds have also been shown to have an increased risk of being involved in a car accident (again, likely due to next-day grogginess and/or impaired cognitive abilities).

 

* According to a 2015 study in the American Journal of Public Health that looked at the medical and driving records of more than 400,000 American adults, those who were prescribed sleeping pills were nearly twice as likely to be involved in a car crash as those not taking sleep meds (a risk similar to individuals with blood alcohol levels over the legal driving limit).

 

A Significant Increase in All-Cause Mortality and Cancer…

* A study published in the British Medical Journal in February of 2012 looked at more than 30,000 people and found that those taking sleep medications were nearly FIVE TIMES as likely to die as non-users over a 2.5- year period. The same study also found that heavy users were more likely to develop cancer.

 

Antihistamines and Weight Gain…

* While initially touted as safer than benzos, recent clinical reviews have found that Z drugs have few (if any) distinct advantages over their benzo predecessors and in many ways have similar adverse effects (especially zopiclone/Lunesta).

 

* Antihistamine use (especially long term) has been linked to weight gain (which I cover in another article).

 

Millions Misusing Sleep Meds + Tens of Thousands of ER Visits Each Year for Ambien Abuse…

* In 2010 and 2011 there were between 19,000 and 30,000 ER visits due to non-medical use of Ambien, an increase of more than 200% when compared to 2005.

 

* A 2018 study estimated that more than 30 million Americans use benzos- 25 million use them “as prescribed” whereas 5 million are misusing the medication. [9-21]

Image Source: www.darksideofsleepingpills.com/all.html

 

So are sleep meds the solution to America’s sleep problems? I’m going to say NO, for two reasons- first, the many (and sometimes serious) side effects listed above, and second, the existence of lifestyle interventions (including exercise, nutritional strategies and nutritional supplements) that are safer, more effective and that deal more directly with the root issue (or issues) causing the sleeping troubles in the first place!

 

A SMART, HOLISTIC, DRUG-FREE, EVIDENCE-BASED APPROACH TO IMPROVING SLEEP (7 STEPS)

What does an effective, drug-free, holistic approach look like? Well first it recognizes that there are several factors that influence sleep duration and sleep quality, such as…

 

1.Smart time management regarding sleep scheduling

This includes having a sleep plan with specific bed times and wake times that allow for enough sleep.

 

2.A proper exercise plan, regular exercise habit and proper amounts of physical activity during the day

The desired effect here is that your body is physically ready to fall asleep at your bedtime (and stay asleep after that). Personally I find that strength training earlier in the day is more conducive to quality sleep than cardio or mobility training.  For improving sleep quality I’d give preference to early morning exercise vs mid-day or evening exercise, especially if you can get outside in the morning and get some early morning sunshine. Which brings us to another important element of the holistic plan to optimize sleep…

 

3.Sunshine exposure, especially early morning sunshine

Sunshine exposure on the skin and to the eyes boosts the metabolism-boosting hormone cortisol and begins stimulating serotonin production, some of which will (later in the day when it begins getting dark) be converted to that sleep-inducing hormone melatonin so we can get some restful slumber! [22-23]

 

4.Healthy nutritional habits during the day

This includes staying hydrated (more water and less caffeine and sugars), no caffeine past 2pm or so, cutting out the hyper-allergenic and pro-inflammatory items (wheat/gluten, soy, most dairy, “bad” sugars, etc.), balancing macronutrients (plenty of low calorie veggies, moderate proteins and fats and keeping net carbs in the 50-150g/day range), not engaging in a regular habit of overeating and not eating notable amounts of food the 2-3 hours before bed. Remember, around 90% of serotonin (the relaxing neurotransmitter) is actually synthesized in the gut!

 

5.Having a mattress, pillows and sleep environment conducive to deep, relaxed, restful sleep

I’ve covered mattresses and pillows in some depth in other articles but in short this generally looks like a high quality foam or air mattress, high quality pillows (either low loft for back sleeping or higher loft for side sleeping), and an environment that’s dark, cool and quiet (white noise optional).

 

6. Limiting screen time at night and taking a bath or shower 90 minutes before your sleep time

A 2019 meta-analysis of more than 5,000 studies found that taking a warm bath or shower approximately 90 minutes before scheduled sleep times had a significantly positive effect on overall sleep quality. [24]

 

A quick word on obesity, Obstructive Sleep Apnea (OSA) and CPAP machines…

The average American adult is 30-40 pounds overweight, and the link between excess weight and the development and progression of obstructive sleep apnea (OSA) is well established. OSA is a condition in which the airway (involving the trachea, larynx, epiglottis and/or pharynx) becomes blocked during sleep, leading to interrupted breathing (which can occur dozens of times a night). Having sleep apnea not only impairs sleep quality but puts individuals at risk for several other conditions, including cardiovascular disease.

 

Conventional medicine’s first line treatment option for those with OSA is usually a CPAP machine (continuous positive airway pressure). I don’t have any qualms against people using a CPAP machine (as long as it doesn’t negatively affect their sleep quality and the machine is kept sanitized). Indeed, some recent research from early 2019 links the use of CPAP machines with greater weight loss in obese individuals with sleep apnea compared to obese individuals not using CPAP. While that’s great, an obese person losing even 10% of their body weight can often cure sleep apnea. [25-26]

 

 

So what’s the best way for people to lose weight, cure sleep apnea and stop using a CPAP machine (if they want to stop using it)? In my experience the safest and most effective weight loss approach centers around nutritional tools like clean eating (reducing pro-inflammatory items), portion control, carbohydrate restriction and time- restricted eating (i.e. intermittent fasting). This of course is optimized within a smart holistic approach that also emphasizes healthy exercise and physical activity levels, proper stress management and smart medical choices.

 

7.Utilizing high-quality sleep-supporting nutritional supplements at therapeutic doses

I am no chemist but I find it fascinating that so much pharmaceutical R & D is spent on figuring out patentable chemical compounds that help enhance the activity of inhibitory neurotransmitters like GABA when we already have nutritional supplements that do the same thing (and tend to do it with fewer adverse side effects!). There are several nutritional supplements that are regularly used in an attempt to enhance sleep. I’m going to place them into the following 7 categories…

 

  1. Soft tissue relaxing minerals         (ex. magnesium, potassium)

  2. Inhibitory neurotransmitters        (ex. glycine, taurine, 5-HTP, GABA)

  3. Neurotransmitter helpers             (ex. inositol, activated vitamin B6 [p5p])

  4. Botanicals                                        (ex. chamomile, lavender, valerian)

  5. Hormones                                        (ex. melatonin)

  6. Liver support                                   (ex. milk thistle extract/silymarin)

  7. Vitamins & others                           (ex. vitamin D3, theanine, Montmorency tart cherry)

 

My 4 Favorite Sleep Supplements…

So which of these sleep supplements are my favorites? With the caveat that every person is in a unique biological condition (and what’s best for one person may not be best for another), my 4 favorites are magnesium (either citrate or glycinate), vitamin D3, glycine and taurine (and usually in that order)…

 

Why magnesium? Roughly 60-70% of Americans are deficient in magnesium (an essential macro-mineral), and aside from improving sleep it has a whole host of additional benefits, including promoting healthy bones and teeth, muscle relaxation, nervous system support, cardiovascular health (especially helpful for arrythmias and preventing progression of atherosclerosis via calcium:magnesium balance), endocrine functioning and digestive system health (helps promote regular BMs). [27-28]

 

Why vitamin D3? At least 40% of the US population is deficient in vitamin D, and several studies have linked vitamin D deficiency to higher risks of various sleep disorders. Note that scientific evidence suggests that a 25(OH) vitamin D3 blood reading of 60-80ng/ml is needed for optimal sleep effects (which is notably higher than the 20-30ng/ml baseline threshold often used to diagnose vitamin D deficiency). This may indicate the need for higher dose vitamin D supplementation (equal to or even more than 10,000 IU/day). [29-34]

 

Why glycine? Glycine is a conditionally essential amino acid that also has inhibitory neurotransmitter effects (which produces a calming, sedating effect). A 2018 study made the case that the average 150lb adult has a 10g/day glycine deficiency which, among other things, may adversely affect sleep quality. Additionally, glycine also plays an important role in digestive health, and is regularly used to help heal and support the intestines. [35-36]

 

Why taurine? Technically an amino sulfonic acid, taurine is non protein-building but is nonetheless important in the body, where it has inhibitory neurotransmitter capabilities. A “Swiss Army Knife” amino acid, taurine is taken as a supplement for a variety of reasons, including cardiovascular health (arrhythmia, aFib, hypertension), ear issues (tinnitus), eyesight (taurine is abundant in the retina), liver support (helps thin bile) and exercise recovery.

 

As you might guess, all 4 of these supplements are also relatively popular for treating anxiety-related conditions. And regarding anxiety we need all the help we can get. Data from 2011 suggests that around 40 million Americans (roughly 1 in 5 adults) suffer from an anxiety disorder, according to the Anxiety and Depression Association of America. [37-38]

 

Other Sleep Supplements to Consider…

Inositol (aka vitamin B8): All major neurotransmitters — dopamine, norepinephrine, serotonin, acetylcholine, and GABA — rely on inositol to relay messages, and low levels of inositol can disrupt the function of dopamine and serotonin. Additionally, inositol provides some liver support as well.

 

Potassium citrate: Like magnesium, potassium is a major mineral that assists in soft tissue relaxation. And like magnesium, many Americans (>90%) are deficient in potassium. Potassium also helps support cardiovascular and renal functioning. Potassium would likely make it into my top 3-4 sleep supplements save for the fact that sometimes it can actually increase energy levels (it is an important electrolyte after all).

 

L-theanine: L-theanine is an amino acid analogue of L-glutamine (a conditionally-essential amino acid) and glutamic acid/L-glutamate (a non-essential amino acid) that’s naturally found in high amounts in green tea, especially Matcha (powdered green tea). When taken as a supplement, l-theanine tends to have an interesting calming/focusing/relaxing/energizing effect, which some call a “zen-like” effect. For this reason it is commonly taken as a subtle energizing supplement (powder often mixed in morning coffee) AND as a sleep aid. And it’s for this reason that it usually doesn’t make my top 3-4 sleep supplement list, although many people report great improvement in sleep quality when taking it before bed.

 

 

5-HTP: 5-Hydroxy Tryptophan, a form of tryptophan, which is one of the 9 protein building amino acids in humans. Tryptophan is a serotonin precursor and as a supplement is used to increase serotonin activity in the body and brain (which has a calming, sedating effect). 5-HTP supplements are somewhat notorious for causing nausea (especially at higher dosages), so for those considering 5-HTP I’d recommend starting at a lower dose (ex. 50mg) and looking for products that have an enteric coating.

 

GABA: GABA (or more formally, gamma aminobutyric acid) is an amino acid-like compound created from glutamic acid (a non-essential amino) and vitamin B6. There are four major neurotransmitters that regulate mood: serotonin, dopamine, norepinephrine and… GABA! And GABA is THE major inhibitory neurotransmitter of the brain, where it occurs in some 30-40% of all synapses there. Of all the neurotransmitters, GABA is second in prevalence only to glutamate, the brain’s major excitatory neurotransmitter.

 

Activated vitamin B6 (p5p): More formally pyridoxal 5 phosphate, p5p (or P-5-P) is an important neurotransmitter co-factor and helps with the conversion of amino acids into neurotransmitters (ex. aids in the conversion of tryptophan to serotonin). While sometimes taken as a sleep aid, P-5-P is also used to treat carpal tunnel and trigger finger, peripheral neuropathy, neuralgia (general nerve pain) and seizures.

 

Chamomile, lavender, valerian: Next to melatonin, these botanicals might be the most recognized natural sleep aids. Commonly taken in either tea or pill form, I think all 3 of these are fine sleep-assisting botanicals, but I do believe the other supplements mentioned above will be more effective for the majority of people. PS- watch out for valerian’s pungent odor!

 

Melatonin: Perhaps the first supplement most people associate with sleep, melatonin is an important hormone produced by the pineal gland that helps regulate sleep/wake cycles. As we discussed above, melatonin levels can be dysregulated due to a lack of sunlight exposure and/or excessive artificial light exposure, especially at night. I am not a huge fan of supplemental melatonin for a couple reasons. First, I think there are better, safer and more effective ways of boosting natural melatonin than taking the hormone itself. Second, I think that most melatonin dosages are way too high (5mg, 10mg… even as high as 20mg!). For those really wanting to take melatonin for sleep I’d suggest they start with a much smaller dose (300mcg an hour before bed) and then titrate up as needed/tolerated. PS- melatonin is a relatively potent antioxidant and free radical scavenger and some take melatonin to support immune health and/or to battle certain forms of cancer.

 

Milk thistle extract/silymarin: Many are likely familiar with milk thistle and its reputation as a liver supporting herb (which is backed up by a considerable amount of clinical research). While not normally taken as a sleep aid, because the liver is so active during sleep (and because so many Americans suffer from poor liver functioning and liver diseases like NAFLD), I do recommend people consider a liver supplement as part of their sleep supplement “stack.”

 

Montmorency tart cherry juice concentrate: A good natural source of melatonin, Montmorency cherry juice concentrate is used as a sleep aid and to help with gout and joint pain. While tasty, I don’t recommend it as often as some of the supplements above due to the notable amount of carbohydrates it provides.

 

 

SOURCES

1 http://bettersleep.org/better-sleep/the-science-of-sleep/sleep-statistics-research/better-sleep-survey

2 www.gallup.com/poll/166553/less-recommended-amount-sleep.aspx

3 https://blog.fitbit.com/sleep-study/

4 www.gallup.com/poll/181583/getting-sleep-linked-higher.aspx?g_source=sleep&g_medium=search&g_campaign=tiles

5 www.sleepfoundation.org/media-center/press-release/lack-sleep-affecting-americans-finds-the-national-sleep-foundation

6 www.cdc.gov/features/dssleep/

7 www.healthypeople.gov/2020/topics-objectives/topic/sleep-health

8 https://one.nhtsa.gov/people/injury/drowsy_driving1/Drowsy.html#NCSDR/NHTSA

9 http://sleepcenter.ucla.edu/sleep-medicine-growth-and-trends

10 www.tuck.com/barbituates/

11 www.aarp.org/health/drugs-supplements/info-2017/caution-these-10-drugs-can-cause-memory-loss.html

12 https://mentalhealthdaily.com/2015/02/20/dementia-linked-to-benzodiazepines-sleeping-pills-anticholinergics/

13 https://betterhealthwhileaging.net/medications-to-avoid-if-worried-about-memory/

14 https://bmjopen.bmj.com/content/2/1/e000850

15 www.addictioncenter.com/sleeping-pills/

16 https://well.blogs.nytimes.com/2012/03/12/new-worries-about-sleeping-pills/

17 www.choosingwisely.org/patient-resources/treating-insomnia-and-anxiety-in-older-people/

18 www.consumerreports.org/drugs/the-problem-with-sleeping-pills/

19 www.addictioncenter.com/sleeping-pills/ambien/

20 www.consumerreports.org/drugs/the-problem-with-sleeping-pills/

21 www.ncbi.nlm.nih.gov/pmc/articles/PMC3657020/

22 www.alexfergus.com/blog/how-to-improve-your-sleep-with-morning-sunlight

23 www.ncbi.nlm.nih.gov/pmc/articles/PMC5299389/

24 www.sciencedaily.com/releases/2019/07/190719173554.htm

25 www.mdedge.com/chestphysician/article/197827/sleep-medicine/cpap-use-associated-greater-weight-loss-obese-patients

26 www.health.harvard.edu/blog/weight-loss-breathing-devices-still-best-for-treating-obstructive-sleep-apnea-201310026713

27 www.ncbi.nlm.nih.gov/pmc/articles/PMC5637834/

28 www.ncbi.nlm.nih.gov/pmc/articles/PMC4586582/

29 www.ncbi.nlm.nih.gov/pmc/articles/PMC6213953/

30 www.ncbi.nlm.nih.gov/pubmed/28012936

31 www.ncbi.nlm.nih.gov/pubmed/22699141/ 

32 www.ncbi.nlm.nih.gov/pubmed/22583560 

33 www.ncbi.nlm.nih.gov/pubmed/21310306

34 www.vitamindcouncil.org/what-is-the-upper-limit-and-noael-and-are-they-justified/#.XQy-T-hKhPY 

35 www.ncbi.nlm.nih.gov/pmc/articles/PMC6153947/ 

36 www.ncbi.nlm.nih.gov/pmc/articles/PMC3328957/

37 http://time.com/5269371/americans-anxiety-poll/

38 www.washingtonpost.com/national/health-science/what-you-need-to-know-about-sleep-medications-their-side-effects-and- other- issues/2019/02/08/

 

 

 

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