Dopamine Agonists in Psychiatry

The dopamine agonists pramipexole and ropinirole are drugs used in the treatment of Parkinson Disease.

These drugs are now well-established in treating restless legs syndrome (RLS) and periodic limb movement disorder of sleep (PLMS), which are frequent problems afflicting about 10% of the population, and which can negatively impact quality of life & mood symptoms.

There is a small body of evidence showing possible benefits of dopamine agonists in the treatment of depression.

Unfortunately, dopamine agonists can exacerbate addictive/compulsive behaviour: http://www.ncbi.nlm.nih.gov/pubmed/20484726 

Here are some references about the role of dopamine agonists in RLS and PLMS:

http://www.ncbi.nlm.nih.gov/pubmed/20120624

Here's a good review article on the use of ropinirole to treat these conditions: http://www.ncbi.nlm.nih.gov/pubmed/20421915
Here's a recent review of dopamine agonists in general to treat RLS: http://www.ncbi.nlm.nih.gov/pubmed/20206780
Here's a 2008 meta-analysis comparing ropinirole with pramipexole for treating RLS.  Pramipexole is shown to be slightly superior:
http://www.ncbi.nlm.nih.gov/pubmed/18226947

In this 2010 study, gabapentin was compared to ropinirole for treating RLS.  While ropinirole was superior in reducing objective measures of periodic limb movements, subjects taking gabapentin had a higher subjective benefit:
http://www.ncbi.nlm.nih.gov/pubmed/20049491


Here's a case study showing remission of depressive symptoms with ropinirole used as an augmenting agent:
http://www.ncbi.nlm.nih.gov/pubmed/20188777 

Here's a 2005 study looking at ropinirole augmentation in treating depression:
http://www.ncbi.nlm.nih.gov/pubmed/15999953
This 2010 review in Lancet showed a direct antidepressant effect of pramipexole in Parkinson Disease patients:  http://www.ncbi.nlm.nih.gov/pubmed/20452823
Here's a rather weak but positive 2010 paper describing a group of patients with bipolar depression who appeared to benefit from longer-term pramipexole treatment; doses averaged about 1 mg/d:  http://www.ncbi.nlm.nih.gov/pubmed/20425143


The side effects from these drugs include frequent nausea and dizziness, possibly some daytime sleepiness.  Psychiatric adverse effects can include hallucinations, and increased compulsive or impulse-control problems.

In summary, I think dopamine agonists have a role in selected psychiatric conditions, particularly if there are restless-legs symptoms contributing to insomnia or nocturnal discomfort.  They may help treat refractory depression, but there is a risk of causing impulse control problems or hallucinations in predisposed individuals. 

Sleep, Hormones, and Obesity

Here are some excellent references about the interaction between sleep, hormones, and obesity. They were contributed by a reader (thank you very much!):


http://www.ncbi.nlm.nih.gov/pubmed/16459757

http://www.ncbi.nlm.nih.gov/pubmed/18591489

http://www.ncbi.nlm.nih.gov/pubmed/19056602

http://www.ncbi.nlm.nih.gov/pubmed/15531540

http://www.ncbi.nlm.nih.gov/pubmed/18564298

Lastly a good review paper and shows the basics (along with some fun diagrams)
http://www.jpp.krakow.pl/journal/archive/1205_s6/articles/01_article.html


Comments:

These references make it very clear that inadequate sleep increases the likelihood of obesity.

The last article was interesting, but oddly lacked any discussion of culture or psychology with respect to eating behaviours or obesity.

In terms of advising a fixed, early wake time, I believe this is entirely consistent with a plan to get adequate, optimal sleep. In fact, I believe that when individuals who are struggling with insomnia have a habit of sleeping in, the overall sleep quality diminishes, the insomnia pattern is exacerbated and perpetuated, and the health problems associated with inadequate sleep are likely to worsen.

Therefore, I believe that sleep quality and the restorative health benefits of sleep are most optimal if wake times are consistent and early. Possible exceptions to this could occur in adolescents, who probably need more sleep (but even then, it would be better for them to get that additional sleep by sleeping longer hours but getting up at the same time every day, rather than by sleeping in on weekends). Another exception could be in the setting of a physical illness, in which case one might need to stay in bed longer to recover.

Physical Warmth promotes Interpersonal Warmth

In an amusing study by LE Williams and JA Bargh, published in Science in 2008, subjects exposed to warm objects behaved in a manner which was more interpersonally warm. Here is the reference:
http://www.ncbi.nlm.nih.gov/pubmed/18948544

In the first experiment described by the authors, subjects in the elevator on the way to the study lab were asked to hold an experimenter's drink cup for a moment, while the experimenter wrote some identifying information down on a clipboard. The experimenter in the elevator did not have knowledge of the study's hypotheses. In the study lab afterward, the subjects were given a brief written description of a person (the same description given to all subjects), and were asked to rate that person in terms of a variety of personality dimensions. The subjects who briefly had held a cup of hot coffee gave personality ratings that were significantly "warmer," compared to the subjects who had held a cup of iced coffee. The ratings for warmth were 4.71 out of 7 for the "hot coffee" group, compared to 4.25 out of 7 for the "iced coffee" group; these differed with a p value of 0.05. "Warmth" in this sense refers to traits such as friendliness, helpfulness, and trustworthiness.

The second experiment was more blinded, in that the experimenters did not know whether the subjects were handling a warm or cold object. This time, subjects were offered a choice of two types of gifts after the experiment: the first type would be for personal use, the second would be a gift for a friend. Those who had handled a warm object were substantially more likely to choose a gift for a friend, rather than for themselves.
Those who had handled a cold object chose a "selfish" gift 75% of the time.
Those who had handled a warm object chose the "selfish" gift 46% of the time.

The authors discuss attachment theory, and suggest that one explanation for these findings, on a neurobiological level, is that the insular cortex in the brain is responsible for processing information about both physical and psychological warmth, therefore the two types of warmth perception may influence each other.

I find this type of cross-sectional social-psychological research fun and a bit lighthearted, but often containing kernels of wisdom.

It would be interesting to do similar studies of this sort, but with different groups of subjects who are stratified according to interpersonal style, depressive symptoms, etc. Perhaps there are subjects who are most sensitive to these environmental effects.

I'm amused and delighted, in any case, that figurative or "metaphorical" warmth seems to match up with literal or physical warmth. A nice meeting of the metaphorical with the literal. Perhaps this is typical of what the brain does.

In any case, this little piece of evidence further supports the recommendation to do sensually pleasing, "warmth-oriented" activities, as part of a regimen for maintaining psychosocial health. There may be something in particular about heat which could be therapeutic. Hot baths are anecdotally helpful for relaxation, pain relief, and to promote deeper sleep. I've encountered a few examples in which people found saunas quite helpful for seasonal depressive symptoms. Maybe a very warm, cozy sweater can be helpful for your mental health, and even have positive effects on others!

Here are references to a few studies showing improvement in insomnia following hot baths:
http://www.ncbi.nlm.nih.gov/pubmed/10566907 {a 1999 study from the journal Sleep, showing improvements in sleep continuity and more slow-wave sleep earlier in the night, in older females with insomnia who had 40-40.5 °C baths 1.5-2 hours before bedtime}
http://www.ncbi.nlm.nih.gov/pubmed/15879585 {a 2005 study in the American Journal of Geriatric Psychiatry showing improved sleep in elderly people with vascular dementia, following 30 minute baths in 40°C water, 2 hours before bedtime}

A precipitant of some seasonal depression, at least in Canada, may be not only the darkness but the cold. The cold may lead not only to a disinclination to go outside, but also to a less generous or a "colder" interpersonal stance, which would further perpetuate a depressive cycle. This is another reason to heed that advice mothers often give young children, to dress warmly in the winter.

Here is a link to the abstract of a study from Japan, published in Psychosomatic Medicine in 2005: http://www.ncbi.nlm.nih.gov/pubmed/16046381

In this study, mildly depressed subjects were randomized to receive one of two treatments, 5 days per week, for 4 weeks, in addition to daily physical and occupational therapy:
1) "thermal therapy" in a 60 °C sauna for 15 minutes, followed by 30 minutes wrapped in a blanket, in a 28 °C room.
2) "non-thermal therapy" of 45 minutes in a 24°C room

The thermal therapy group had a 33% reduction in psychological symptoms, compared to a 14% reduction in the non-thermal therapy group.
The thermal group had a 42% reduction in somatic complaints, compared to an 8% reduction in the non-thermal group.

The research literature on this subject is quite limited, but there is some evidence that warmth--physical and psychological--is therapeutic!

Prazosin and other treatments for PTSD-related nightmares

Nightmares are a common symptom of post-traumatic stress disorder (PTSD).

Various psychotherapeutic approaches can help people to deal with nightmares, both to be more psychologically prepared for them, and to be able to let them pass with a smaller amount of distress. Techniques include simply keeping a written record of the nightmares, with or without doing some cognitive therapy exercises based on this record; practicing relaxation techniques; exposure therapy during the daytime (by evoking the imagery of the nightmares, possibly "rescripting" the sequence of events); or by planning for a "rescripting" of the nightmare during the nightmare itself. Here is a reference to a review article about psychotherapy for nightmares: http://www.ncbi.nlm.nih.gov/pubmed/18853707

Sedative drugs can change dreaming activity, but often times these medications are problematic: tolerance or oversedation may develop, or sometimes the nightmares continue despite other types of sleep improvement.

Prazosin is a cardiovascular drug which blocks alpha-receptors, and is commonly used to treat high blood pressure. Alpha receptors are stimulated by adrenaline, which causes constriction of blood vessels, therefore increased blood pressure. In the brain, increased stimulation of alpha-receptors may be one of the mechanisms driving PTSD-related sleep disturbances such as nightmares. Prazosin has been shown to help reduce PTSD-related nightmares. Here are a few references:

http://www.ncbi.nlm.nih.gov/pubmed/18447662 {a good review article}

http://www.ncbi.nlm.nih.gov/pubmed/17069768 {a 2007 randomized, controlled, crossover study published in Biological Psychiatry, showing pronounced reduction in PTSD-related nightmares with 10-15 mg bedtime doses of prazosin}

http://www.ncbi.nlm.nih.gov/pubmed/12562588 {a 2003 randomized study published in The American Journal of Psychiatry showing substantial benefit in PTSD-related sleep symptoms with prazosin at an average of 10 mg/d}

There is the suggestion in these studies that prazosin, if dosed in the daytime as well, could help treat other PTSD symptoms.

Prazosin has been used for over 35 years in the treatment of hypertension. Interestingly, it is also one of the treatments of choice in the medical management of severe scorpion stings. It may also be a promising option in the treatment of alcoholism (reference: http://www.ncbi.nlm.nih.gov/pubmed/18945226).

Prazosin is well-tolerated by the majority of people taking it. It appears to have minimal psychiatric side-effects. Sedation does not seem to be common. If the dose is too high, too soon, it can cause excessive postural blood pressure drops, with dizziness and a risk of fainting (syncope). It may cause nasal congestion or headache. Priapism (a medically dangerous sexual side-effect) is possible but very rare.

Melatonin: benefits and risks

Melatonin is a hormone synthesized in the pineal gland, and is thought to be important in the regulation of circadian (day-night) rhythms.

It has been used to treat insomnia and sleep-phase abnormalities.

The most interesting study I found regarding long-term use of melatonin was published in JAMA in 2008: http://www.ncbi.nlm.nih.gov/pubmed/18544724
In this prospective, blinded study, elderly patients with dementia were given 2.5 mg melatonin near bedtime, over an average of 15 months of follow-up. Patients in another group were exposed to bright light during the day (approximately 1000 Lux indoors, from 10:00 AM to 6:00 PM). A third group received both melatonin at night and bright light in the day. Placebo groups received no melatonin, or were exposed to typical indoor office lighting, of about 300 Lux.* Interestingly, caregivers were not able to tell whether their site had the ordinary lighting or the bright light (the increased light intensity was measurable with a meter, but was not noticeable subjectively).

The results showed that melatonin consistently improved sleep, particularly helping reduce the time required to fall asleep, and increasing total sleep time.

However, the group receiving melatonin alone showed worsening mood (less positive affect & more negative affect).

The group exposed to bright light in the day, plus melatonin at night, did not show worsened mood.

The authors conclude that bright light in the day helps with mood, cognition, and function in elderly dementia patients. Melatonin alone helps with sleep but has a negative impact on mood. Bright light plus melatonin had a positive impact on all the symptoms studied.

Based on this study, I would encourage anyone using melatonin at night to ensure that they get plenty of bright light during the daytime. It also suggests that any study looking at melatonin treatments should also consider daytime bright light exposure as an important variable which could affect response to melatonin.


Here's a reference to a study showing that 2 mg of sustained-release melatonin improves sleep:
http://www.ncbi.nlm.nih.gov/pubmed/18036082

In this study, children with intellectual disabilities experienced relief of their insomnia (including reduced time to fall asleep, reduced time awake, and increased total sleep time) with 5 mg melatonin supplementation over a 4-week period:
http://www.ncbi.nlm.nih.gov/pubmed/18261024

Here's a study showing improved sleep, with no adverse effects, due to melatonin administration to autistic children:
http://www.ncbi.nlm.nih.gov/pubmed/18182647

Here's a study showing improved sleep in children with epilepsy who were treated with adjunctive melatonin (6-9 mg). There were no significant side-effects:
http://www.ncbi.nlm.nih.gov/pubmed/15794175

High-dose melatonin (1 mg/kg body weight) has been used experimentally to treat intractable epilepsy, but more research is needed to evaluate effectiveness & safety. Here is one reference:

http://www.neurology-asia.org/articles/20043_114.pdf

This study showed improved sleep in adolescents with ADHD, when they were given 5 mg melatonin over a 30-day trial. However there was no improvement in ADHD symptoms:
http://www.ncbi.nlm.nih.gov/pubmed/16670647

Melatonin has been associated with autoimmune conditions. Here is a case report associating melatonin use with autoimmune liver disease:
http://www.ncbi.nlm.nih.gov/pubmed/9412927

Here is an article about melatonin possibly exacerbating rheumatoid arthritis (various reports show increased melatonin levels in rheumatoid arthritis patients):
http://www.ncbi.nlm.nih.gov/pubmed/19069959

Yet, in various other reports, melatonin has been shown in animals to protect the liver from various forms of artificially-induced toxicity. (e.g. http://www.ncbi.nlm.nih.gov/pubmed/15386534)


In conclusion, melatonin appears to be have a reasonable safety profile, and is a potentially effective treatment for insomnia, particularly "initial insomnia" in which there is difficulty falling asleep at the beginning of the night. Typical doses of melatonin range from about 2 mg - 6 mg.

The one main concern about adverse effects concerns possible exacerbation of autoimmune diseases such as rheumatoid arthritis, although the evidence is not clear on this point. Other types of toxicity, while possible, appear to be rare. Melatonin may even protect cells from a variety of different types of harm. But it is important to recognize the possibility that there could be other unknown adverse effects over long periods of time.

As with any treatment, we have to balance risks against benefits: insomnia itself clearly has a variety of negative long-term health effects (ranging from increased risk of physical and psychiatric illness, to increased risk of accidents). Other treatments for insomnia have their own risk/benefit profiles.

Cognitive-behavioural therapies for insomnia are clearly the safest and most beneficial, and should be optimized before any other medical therapy. But it appears to me that melatonin ought to have a place in the medical treatment of insomnia, alongside other established therapies.

*here are some measures of light intensity in different settings, to help give you some reference points to compare:

50 Lux -- family living room

100 Lux -- very dark overcast day

300-500 Lux -- recommended office lighting

400 Lux -- sunrise or sunset on a clear day

1000 Lux -- overcast day

10 000 Lux -- clear day (not direct sun)

100 000 Lux -- direct sun

Kava

Kava is a perennial shrub native to islands of the South Pacific. It has been ingested there as part of local culture. It has a relaxing effect.

Kava has been associated with liver toxicity: there have been cases of liver failure necessitating liver transplant, and there have been fatalities. As a result, the sale of kava is restricted in Canada.

Here is a reference about the liver toxicity issue:

http://www.ncbi.nlm.nih.gov/pubmed/15068826

In this 2008 article from a liver disease journal, cases of kava toxicity are reviewed. It is concluded that liver damage is a rare side effect of kava. It also found that many of those experiencing liver toxicity had used higher doses of kava, for longer periods of time, than recommended.

http://www.ncbi.nlm.nih.gov/pubmed/18989142

Effectiveness:

Here is a 2009 prospective, randomized, controlled study from Australia, in which 3 weeks of kava treatment (250 mg kava lactones per day) had minimal side-effects and led to substantial, clinically significant improvements compared to placebo in generalized anxiety symptoms and depressive symptoms:

http://www.ncbi.nlm.nih.gov/pubmed/19430766
As a critical commentary here, I think that 3 weeks is a VERY short study period, and therefore has limited clinical relevance. A great many approaches can relieve anxiety over a brief period of time (e.g. benzodiazepines); it's of much greater interest to see what happens after 3 months, or after 3 years!

Here is a 2003 Cochrane review, showing significant benefits in anxiety symptoms from kava treatment:

http://www.ncbi.nlm.nih.gov/pubmed/12535473

Here is a negative study from 2005, which showed that neither valerian nor kava differed from placebo in relieving anxiety or insomnia. The study participants were recruited on the internet, and were sent the blinded medication or placebo through the mail (another example of an interesting new study design):

http://www.ncbi.nlm.nih.gov/pubmed/16010204

In conclusion, kava seems promising as a treatment for anxiety. But there appears to be a small risk of very dangerous liver toxicity. It will require ongoing study to clarify risks vs. benefits, or to discover ways to minimize the risk of liver damage.

Valerian

Valerian is a perennial flowering plant native to Europe. Its sweetly-smelling flowers have been used to make perfume. Extracts from valerian root have been used as natural remedies in the treatment of insomnia and anxiety since ancient times.

Here is a review of the evidence:


This is a reasonably-done randomized 2009 study showing no effect of valerian vs. placebo in arthritis patients with insomnia:
http://www.ncbi.nlm.nih.gov/pubmed/19114414

This interesting 2007 study--in which subjects were recruited via a TV health program, randomly mailed placebo or valerian, with results collected on-line--showed a very slight improvement in symptoms with valerian, with no differences in side effects, compared to placebo. Subjects in the valerian group took 3600 mg of Valeriana officinalis one hour before bedtime, for 14 days. Perhaps the most significant bottom-line result from the study to report here is that 9.1% of the valerian subjects reported feeling "better or much better", compared to 3.7% of the placebo subjects, after the end of the study period.
http://www.ncbi.nlm.nih.gov/pubmed/17940604


Here is a 2007 review from a sleep medicine journal, concluding that valerian is safe but not effective in the treatment of insomnia:
http://www.ncbi.nlm.nih.gov/pubmed/17517355


Here's a 2006 Cochrane review, showing no evidence of valerian helping with anxiety disorders (mind you, the amount of data is very small):
http://www.ncbi.nlm.nih.gov/pubmed/17054208

Here's one positive 2005 study from Sleep, showing a modest benefit in sleep parameters and quality of life, from 28 days of a valerian-hops combination, compared to placebo, in the treatment of mild insomnia:
http://www.ncbi.nlm.nih.gov/pubmed/17054208

Here's an interesting reference suggesting that valerian could have been the first treatment for epilepsy: but its potential benefit would have been extremely inconsistent, and at this point it is certainly not a practical treatment for epilepsy.
http://www.ncbi.nlm.nih.gov/pubmed/15509234

There are some other articles of dubious quality, which I found in some of the herbal medicine journals.

There could be dangerous interactions between valerian and other medications:
This is a case report of side effects with valerian + lorazepam:
http://www.ncbi.nlm.nih.gov/pubmed/19441067


In conclusion, I am not impressed with the evidence about valerian. It does appear to be quite safe. Mind you, there does not appear to be a good evidence base about possible dangerous interactions with other compounds. I recommend avoiding it, or using it with extreme caution, if you are taking other psychotropic medications. It may have modest benefits for some people, but for the vast majority the evidence suggests that it does not differ from placebo.

Valerian-based perfumes or scented oils might be pleasant and safe to use as aromatherapy for insomnia or anxiety, in conjunction with other relaxing activities.

Insomnia

Sleep problems can be frustrating and exhausting. Sometimes a person can have trouble sleeping for no apparent reason, and with no other associated symptoms.

More commonly insomnia is a symptom associated with another medical or psychiatric problem. Here are some of the causes of insomnia:

A) Physical Medical Problems
Here's a partial list:

• any painful condition

• infectious diseases (anything from a common cold to any more severe disease)

• endocrine disorders (e.g. hyperthyroidism)

• respiratory diseases

• bladder or kidney problems (e.g. causing a need to use the bathroom in the night)

• heart disease (e.g. in heart failure it may be very uncomfortable to lie flat)

B) Psychiatric Problems

• depression

• anxiety

• psychotic disorders

• mania

• situational stress

• substance use disorders

• specific sleep-related disorders such as sleep apnea or narcolepsy

• post-traumatic stress disorder (e.g. in which the past trauma occurred at night)

C) Environmental Problems

• uncomfortable bed, bedding, or pillow

• noisy bedroom at night

• too much light in the bedroom (e.g. street lights shining through a window)

• too hot, too cold, poor air quality, etc.

• sleeping next to someone who snores loudly or moves around a lot during sleep

In the management of insomnia, it is important to consider all of the above categories. A medical check-up to rule out or start treatment for physical diseases will be important. All possible improvements to the bedroom environment should be made. Evaluation and treatment of other psychiatric symptoms or conditions is important. If there is any question of breathing problems during sleep, or of a specific sleep disorder such as narcolepsy, then other tests may need to be done, such as an overnight sleep study.

For some people with allergies, I have found at times that a simple measure--such as starting a nasal spray at night which allows for easier breathing, or starting an antihistamine--can be a remarkably effective relief for insomnia and resulting mood/energy problems.

Beyond this, there are specific ways to manage sleep problems:

1) Careful documentation of exactly what is happening with sleep:
A sleep log can be very useful. In the sleep log, you can keep the following records for each day:
a) what time you went to bed
b) what times you were actually asleep
c) what time you got out of bed
d) what times you spent in bed or asleep during the daytime
e) your assessment of how good the quality of your sleep was
You can keep your log in the form of a chart, with sleep times indicated by a solid bar going across the chart, and times spent awake represented by interruptions in that solid bar. Here are some examples of a sleep log:
https://www.healthatoz.com/ppdocs/us/cns/content/atoz/tl/misc/sleeplog.pdf
http://www.snoozeorlose.com/index.php?id=40

2) Behavioural treatments:

• maintaining a constant wake time: it may be impossible to control when you fall asleep, but it is possible (even if difficult) to control when you wake up and get out of bed. If you are out of bed at the same time every morning, you will be more sleep-deprived after a night of insomnia, and will therefore have an easier time sleeping the next night. If you allow yourself to sleep in after a night of insomnia, you will not be as sleepy, and will have a harder time sleeping the next night.
  
• If you have a hard time waking and getting out of bed at the same time every morning, external stimuli can help, such as a timer circuit which turns on a bright light next to your bed in the morning, or even an automated coffee machine which starts at the same early time.
  
• leaving the bedroom if you are having a hard time sleeping. Otherwise there is a conditioning effect in which your brain associates your bed with being awake. Go back to your bed when you feel more sleepy.
  
• avoiding wakeful activities in the bed, such as watching TV or reading. Do these things in another place.
  
• avoid or minimize napping. If you must nap, keep it earlier in the afternoon if possible, and as brief as possible.
• sleep restriction: for example, if you are in bed for 9 hours per night, but are only asleep for 5 of those 9 hours, then you can try going to bed exactly 5 hours before your planned wake time. This strategy is intended to cause you to become more sleepy before you go to bed, to have deeper sleep while you are in bed, and to spend less time lying awake in bed. If this strategy works, a next step can be to gradually start going to bed earlier in order to extend the total number of sleep hours. It is harder to adjust to an earlier bedtime, so this process has to be very slow, perhaps trying a bedtime 15 minutes earlier than your previous bedtime, then sticking with it for a week or so, before adjusting again.
  
• morning exercise -- here's a link to a study showing this: (http://www.ncbi.nlm.nih.gov/pubmed/14655916)
  

3) Cognitive Treatments

• There are many thoughts which occur in the midst of insomnia; some of these thoughts can perpetuate the insomnia, or be part of a vicious cycle. For example, as you lie awake you might think:
• - "oh, no, not again! I'm still awake! I'll never be able to function tomorrow!"
• -"It's 3:21. I've been awake for 57 minutes. I have only 3 hours and 39 minutes before I have to get up."
• -"I can't slow down my thoughts! I'll never fall asleep!"
• -"No matter what I do, I still can't sleep."
• In working on insomnia cognitively, it is important to "talk back" to all of these thoughts in a way which is brief, without becoming an inner intellectual debate (this would be another example of a cognitive process which would keep you awake). Much of the "talking back" might involve reassuring yourself, accepting the thoughts and then letting them go, letting go of the need to control your thoughts, and accepting that sleep will happen on its own without your intellectual input, or regardless of whether your thoughts are active or not.
  

There is some solid evidence that cognitive-behavioural techniques are effective in treating insomnia. Here are some references:
http://jama.ama-assn.org/cgi/reprint/295/24/2851
http://jama.ama-assn.org/cgi/reprint/285/14/1856
http://archinte.ama-assn.org/cgi/reprint/164/17/1888

4) Other physical treatments

• Light therapy: use of a 10 000 lux light box for 45 minutes in the morning can help with night-time insomnia. Here's a reference:http://www.ncbi.nlm.nih.gov/pubmed/15172210
• There is some evidence that using a light box in the EVENING can help "early morning awakening insomnia". In depressed states, waking too early in the morning is a frequent sleep disturbance. It could be an interesting and low-risk therapy for this to use evening bright light. Here's a reference: http://www.ncbi.nlm.nih.gov/pubmed/16171276
  
• There is a lot of evidence that sedative medications are effective short-term treatments for insomnia. Mind you, some of the evidence is not as robust as one might think it should be. Unfortunately, most of these sedatives tend to be habit-forming or addictive. And tolerance tends to develop to the sleep-promoting effects.
  
• Sedating antidepressants (e.g. trazodone, amitriptyline, doxepin, mirtazapine) could be useful in selected cases. Sedating antipsychotic medications in low dosages can also help sometimes (e.g. quetiapine). There is some current interest in very low-dose doxepin for treating insomnia, because it appears to have a very selective antihistamine effect at these doses; here's a link to an abstract about this-http://www.ingentaconnect.com/content/apl/eid/2007/00000016/00000008/art00014
  
• Melatonin: There is some modest evidence that melatonin can help with insomnia, with few side-effect problems. Here's a link to a study, in which they were looking at the effectiveness of 2 mg of prolonged-release melatonin: http://www.ncbi.nlm.nih.gov/pubmed/18036082