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Opinion: You Might Want To Rethink Taking Melatonin As A Sleep Aid

Editor's Note: Dr. Jennifer Martin is a licensed clinical psychologist, professor of medicine at the David Geffen School of Medicine at the University of California, Los Angeles and immediate past president of the American Academy of Sleep Medicine. The views expressed in this commentary are her own. View more opinion on CNN.

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You may know someone who has taken melatonin to help them sleep. Perhaps you've even taken it yourself. According to a study published in the medical journal JAMA, Americans took more than double the amount of melatonin in 2018 than they took in 2008.

This dramatic increase in use of melatonin reflects our inclination to try "shortcuts" to get a good night's sleep. Melatonin isn't the first one and it surely won't be the last.

As a clinical psychologist, I treat people with chronic insomnia disorder, which is defined as poor sleep at least three nights per week for at least three months. When I ask patients why they use melatonin, many tell me they want something that is "natural" and doesn't have side effects. Sometimes, they mention a friend who recommended a specific brand that's supposed to be "really strong." Then I ask them if taking melatonin has worked for them. Sometimes they say no – but sometimes they respond with an emphatic "Yes!"

I take those "yesses" with a grain of salt for a few reasons:

First, if melatonin supplements are working, a patient shouldn't need to see a psychologist like me for help with sleep.

Second, there is a strong placebo effect when it comes to insomnia treatment. Believing that melatonin will improve sleep can help people feel more relaxed when they get into bed and they stop trying so hard to fall asleep. This means the melatonin itself isn't helping them sleep and this initial benefit typically doesn't last over the long term.

Finally, people can become psychologically dependent on taking the supplement and become afraid of what will happen to their sleep if they stop taking melatonin. This can make it extremely hard to sleep because they feel anxious if they don't take the supplement.

After we discuss their specific sleep concerns, many of my patients start to realize they have been spending a lot of money on something that isn't solving their problem.

To understand how melatonin supplements work (and why they often don't), it's important to look at how the hormone naturally functions in the human body. Melatonin is linked to our 24-hour circadian rhythm. Natural melatonin production occurs in darkness and is suppressed by light. This makes melatonin pills useful for helping the body acclimate to a different time zone or for people who have circadian rhythms that don't line up with social norms, like extreme night owls who can't get up in time for work. However, it is not recommended as a sleep aid for insomnia.

In the US, melatonin, like all dietary supplements, is largely unregulated, and it can have side effects.

As CNN has reported, melatonin has been "linked to headaches, dizziness, nausea, stomach cramps, drowsiness, confusion or disorientation, irritability and mild anxiety, depression and tremors as well as abnormally low blood pressure." It can also have serious drug interactions that can lead to problems such as fever, muscle rigidity or seizures. This makes consulting a sleep specialist before taking melatonin all the more important.

What's more, a study published in April in JAMA found that some over-the-counter preparations contained higher levels of melatonin than the dose indicated on the label and many included cannabidiol (CBD). While this study focused on gummies, prior studies found similar problems with melatonin pills.

This is concerning because 1-2 mg of melatonin or less is all it takes to achieve normal levels of melatonin in the blood.

On a recent trip to my local drug store to pick up a prescription, I was shocked to see that 1mg is labeled as a "pediatric dose," while some "adult doses," were labeled 3-5mg and sometimes even higher. Because of similar irregularities, several countries—including the United Kingdom, Japan and Australia—and the European Union no longer allow melatonin to be sold as a dietary supplement and instead treat it as a prescription medication. This might be the right solution in the US as well, as it would force manufacturers to adhere to stringent rules about purity and dosing.

In addition to regulating melatonin supplements, we need to dispel the myth that melatonin is an effective sleep aid and instead spread awareness about a treatment that is proven to help with insomnia: cognitive behavioral therapy for insomnia (CBT-I). While few have probably heard of this specialized therapy, it can be a game-changer for people with insomnia disorder. CBT-I involves systematically targeting thoughts and behaviors that negatively impact sleep. It usually requires four to eight in-person or telemedicine sessions with a trained therapist, but online programs also exist. However, some insurance companies deny coverage for psychotherapy for insomnia even though they cover similar treatments for depression and anxiety. To prioritize health while providing relief from insomnia, insurance companies must recognize the need for this therapy and cover it.

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Finally, we need to be honest with ourselves about how we live. We don't prioritize sleep as an essential aspect of health. We prioritize work and recreation at the expense of basic healthy sleep habits like having a regular schedule, avoiding technology in the bedroom and limiting caffeine and alcohol, and we fail to reach out for help when sleep problems start to impact our daily lives. There is no dietary supplement that can fix chronic struggles with insomnia, but there are steps that can be taken to help you get a good night's sleep—and cognitive behavioral therapy for insomnia is a better option for most insomnia sufferers.

Correction: A previous version of this piece incorrectly listed Canada among some of the countries not allowing melatonin to be sold over-the-counter.

Scientists May Have Found The Missing Link Between Heart Disease And Sleep Problems

Woman in bed puts hands on face in frustration with alarm clock in foreground

People with heart disease often develop dreadful sleep problems, and now, scientists have identified a direct link between these conditions for the first time in a new study in mice and human tissues.

Published Thursday (July 20) in the journal Science, the research shows that heart disease may derail the production of the sleep hormone melatonin in the brain due to damage to a group of nerves that innervate, or plug into, both organs — the superior cervical ganglion (SCG).

Found in the neck, these nerves are part of the autonomic nervous system, which regulates involuntary processes in the body, such as breathing and heart rate. Because nerves originating from the SCG connect to both the heart and the pineal gland — the tiny brain structure responsible for melatonin production — issues with the heart could explain why the body's melatonin-maker falls off track.

"Imagine the ganglion as an electrical switchbox," senior author Stefan Engelhardt, a professor of pharmacology and toxicology at the Technical University of Munich, said in a statement. "In a patient suffering from sleep disturbances following a heart disease, you can think of a problem with one wire causing a fire to break out in the switchbox and then spreading to another wire."

Related: Irregular sleep may increase your risk of dying from cancer and heart disease

The research is "important and timely," Brooke Aggarwal, an assistant professor of medical sciences at Columbia University who was not involved in the study, told Live Science in an email, noting that it "suggests a novel mechanism that may help to explain why those with heart disease are more prone to sleep disturbances."

She went on to caution, though, that "future prospective studies need to be conducted, as well as clinical trials of any potential treatments stemming from this mechanism."

Struggling to sleep is a common side effect of heart disease — for example, up to 73% of people with heart failure experience symptoms of insomnia. Past studies have shown that melatonin levels are reduced in people with heart disease, but scientists didn't know why.

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In the new study, researchers analyzed human brain tissue samples from deceased heart disease patients and from people without heart disease. This postmortem analysis revealed a reduced number of nerve fiber, or axons in the SCG of people who had heart disease compared with the "heart-healthy" control group. The SCG of the individuals with heart disease were also markedly scarred and enlarged.

Illustration of brain with the location of the pineal gland highlighted

In supporting mouse experiments, the team found that immune cells called macrophages, which gobble up diseased and damaged cells, were present in the cervical ganglia of mice with heart disease, and the rodents' nerves showed signs of inflammation and scarring. The mice also had fewer axons in their pineal glands and less melatonin in their blood than healthy mice did. The rodents' circadian rhythms — the internal processes that regulate how the body responds to day and night — were also disrupted, as evidenced by changes in their metabolic rates and activity levels, for example.

Giving mice melatonin completely reversed this disruption, the team found. Additionally, when drugs were used to destroy the macrophages in the rodent's SCGs, their melatonin levels were restored.

Because these analyses were conducted in mice and only 16 humans, the findings "call for further studies" to reveal the mechanisms that drive immune cells to the SCG, the researchers noted in the paper. This may involve studying the nerve cells that link the heart and spinal cord, as well as messenger proteins called cytokines that summon macrophages.

Heart Disease Directly Impacts Sleep Hormone Production

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Researchers at the Technical University of Munich show – for the first time – that cardiac conditions directly impact the pineal gland's production of the sleep-related hormone melatonin. The study, published in Science, furthers our understanding as to why patients with heart disease experience sleep issues.

Heart disease and lack of sleep – what's the link?

An estimated 44% of heart disease patients experience sleep issues. Reduced melatonin levels have been detected in such patients, but the new study – led by Professor Stefan Engelhardt – is the first to demonstrate a direct causative link between cardiac conditions and sleep disturbances. The link is a ganglion found in the neck region.

What is a ganglion?

A ganglion is a collection of nerve cells found outside the central nervous system.

Melatonin, a hormone that regulates the body's sleep–wake timing and other physiological processes such as blood pressure, is produced by the pineal gland deep in the center of the brain. "In our work, we show that the problems with the heart muscle affect an organ that would seem at first glance to have no direct link to it," Engelhardt says.

The research team analyzed pineal glands from mice and humans with cardiac disease, where they found "substantial" denervation compared to control groups. Using a collection of sequencing tools, including single-cell, nuclear and bulk RNA sequencing, they discovered that denervation was occurring because of the cardiac disease, which caused macrophage accumulation in the superior cervical ganglion (SCG).

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Macrophages are a type of white blood cell that are important for the detection and phagocytosis of damaged or dead cells. Engelhardt and colleagues show that, in the SCG, the macrophages trigger inflammation, scarring and destruction of the nerve cells, the axons of which lead to the pineal gland in both mice and humans. In the study, the mouse models were found to have lower melatonin levels and their sleep–wake cycle was disrupted.

"To get a clear sense of our results, imagine the ganglion as an electrical switchbox. In a patient suffering from sleep disturbances following a heart disease, you can think of a problem with one wire causing a fire to break out in the switchbox and then spreading to another wire," says Stefan Engelhart.

Hope that drugs could prevent sleep disturbances

In models of early-stage cardiac disease, the research team could restore melatonin production by reducing the number of macrophages in the SCG via pharmacological means. "First, this demonstrates the role of the ganglion in this phenomenon. And second, it inspires hope that we can develop drugs to prevent irreparable sleep disturbances in heart disease," says Dr. Karin Ziegler, the study's first author.

For Engelhardt, the work provides new motivation to look closely at the ganglia when diagnosing health conditions: "New methods, such as spatial single cell sequencing, make it possible to investigate individual nerve cells much more closely. Our study could prompt researchers to start systematically searching for connections between other diseases in organs linked via ganglia acting as switchboxes and to look at ganglia as starting points in the search for new drugs," he concludes.

This article is a rework of a press release issued by the Technical University of Munich. Material has been edited for length and content.

Reference: Ziegler KA, Ahles A, Dueck A, et al. Immune-mediated denervation of the pineal gland underlies sleep disturbance in cardiac disease. Science. 2023;381(6655):285-290. Doi:10.1126/science.Abn6366

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