two columns on insomnia. - New York Times
Americans' use of sleeping pills is skyrocketing, up nearly 60 percent since 2000, with about 42 million prescriptions filled last year. Experts surmise that "modern lifestyles" and the accompanying stress of too much to do in too little time are largely responsible for the growing need for the drugs.
That may be true. But I see an altogether different explanation for the flagrant use of sleeping pills. In the last decade, there has been a sea change in the kinds of drugs available to induce sleep, and these drugs have been widely promoted in print and on television. You could hardly have missed that pale green luna moth (sans antennas) drifting over peaceful sleepers in ads for Lunesta, which has joined Ambien, Sonata and others in a new class of sleep aid.
A Tempting Offer
How tempting it is when people hear that, say, five milligrams of Ambien can temporarily sweep their worries under the mattress, allow them to fall asleep within 15 minutes and awaken the next morning refreshed and raring to go. I took it myself for several months last winter when the painful aftermath of knee replacements rendered a restful night's sleep impossible.
Unfortunately, with the ease of writing and filling a prescription and the mostly good press these new drugs have gotten to date, millions of people are now taking them without first exploring the reasons for their sleep problems and possible nondrug routes to cure them.
Insomnia can have serious underlying causes. Failure to diagnose and treat these causes merely perpetuates the need for sleep medications, allows a health problem to worsen and in some cases can prove life-threatening.
No one questions the value of a good night's sleep. Whether you are biologically programmed to sleep 4 hours, 10 hours, or, like most people, 7 or 8 hours a night, failure to get the amount of sleep you need can impair learning and memory, problem-solving ability, safety, emotional stability, immune defenses, cardiovascular health and even body weight.
Sleep-deprived people tend to be irritable, impatient, moody, unable to cope well with stress and too tired to do the things they enjoy. Their appetite-controlling hormones are disrupted and may lead to overeating and weight gain. Resulting daytime sleepiness can impair work performance and result in accidents.
Insomnia describes various forms of sleep disturbances that result in unrefreshing sleep or too few hours of sleep: difficulty falling asleep, frequent awakenings, waking up too early and being unable to fall back to sleep. Insomnia is classified medically according to its cause and duration.
It can be a primary disorder caused by a biochemical or neurological disruption of a person's ability to sleep. Among these are restless leg syndrome, characterized by maddening sensations that compel sleepers to kick their legs when they lie down; obstructive sleep apnea, in which breathing periodically stops and sometimes awakens the sleeper; and circadian rhythm disorders, in which a person's sleep-wake cycle is out of whack. Treatments are available for all primary sleep disorders, but sleeping pills are not among them.
With regard to duration, transient insomnia, which usually lasts no more than a week, is typically associated with a short-lived situation or stress: jet lag, a new job, a temporary illness or pain, a deadline or exam, overexcitement, a change in sleep schedule or sleeping in a strange place.
Short-term insomnia usually lasts several weeks but can run to six months. It commonly results from a more persistent stress: loss of a loved one, divorce, a new job, financial difficulties, a serious illness or environmental disturbances like noise.
Chronic insomnia, which afflicts 10 to 15 percent of the population, can stem from serious physical or emotional problems that persist for many months or years. Medications taken for other health problems can also result in chronic insomnia.
Coping with the sleep problem requires identifying the underlying health factor causing it and treating that condition appropriately. Simply taking a sleep aid is not the solution, though that or other drugs may be part of the treatment. For example, anxiety disorders and persistent depression are common psychiatric causes of chronic insomnia, as are bipolar disorder, panic disorder and post-traumatic stress disorder.
Some depressed people sleep too much; others can't sleep enough, typically awakening early in the morning and being unable to go back to sleep. The treatment for the resulting insomnia is to acknowledge and treat the underlying emotional disorder — with psychotherapy, cognitive behavioral therapy and often psychotherapeutic medication.
Physical causes of chronic insomnia include heart disease, diabetes, obstructive pulmonary disease, chronic reflux, restless leg syndrome, incontinence, hyperthyroidism, chronic headaches, painful arthritis, fibromyalgia and other chronic pain syndromes, epilepsy, Parkinson's disease, advanced cancer, dementia and sleep apnea.
Women are more likely than men to suffer from chronic insomnia. In pregnant women insomnia may last several months. During and after menopause, many women are plagued with frequent hot flashes that can disrupt sleep for months or years.
Creating a Cycle
Older people are also more prone to insomnia, in part because they have more health problems and pain syndromes than the young. Compounding the problem is the opportunity to nap by day to make up for poor sleep at night, resulting in a vicious cycle of daytime naps and short nights.
The list of medications that can interfere with sleep is long indeed. They include corticosteroids, decongestants, diuretics, anticonvulsants, antihypertensives, bronchodilators, MAO inhibitors, thyroid hormone, theophylline, beta blockers and stimulants for the central nervous system.
Recreational drugs can also be a problem. Among those that interfere with sleep are stimulants, caffeine, nicotine and alcohol. The infamous nightcap may help you fall asleep initially, but later in the night alcohol disrupts sound sleep.
Rather than simply write a prescription for a sleeping pill, a physician should try to find the cause by taking a thorough history. Depending on the findings, the history may be followed by a physical exam, especially important if the patient has any of the physical causes of insomnia, or if sleep apnea or restless leg syndrome is suspected.
Sometimes spending a night or two in a sleep laboratory is needed to find a cause for insomnia. Many people with sleep apnea are unaware of the dozens of "microawakenings" that cause excessive daytime sleepiness and increase their risk of dying early from heart disease.
Faith Sullivan of Minneapolis was having a really hard time getting a good night's sleep. For years, she had slept about seven hours a night. Then, in her late 50's, something changed. After going to bed at 10 or 11 p.m., she would wake up around 3 a.m., unable to fall back to sleep.
No, neither depression nor hot flashes were disrupting her night's rest. It was caffeine. She never drank caffeinated coffee in the evening, but she often had it as a midafternoon pick-me-up. Though she found it hard to believe that coffee at 4 p.m. could disturb her sleep at 3 a.m., at the suggestion of a friend she tried cutting it out. The result was striking. Within a day, she was back to sleeping seven hours a night.
While not every insomniac's problem is so easily solved, many if not most of the millions of Americans who now rely on sleeping pills could cure their insomnia simply by changing their living and sleeping habits.
Food, Drink and Drugs
Caffeine is not just in coffee. It's in tea, colas and other soft drinks, some herbal teas, chocolate and some medications (Anacin and Excedrin, for example). There's even a little caffeine in decaffeinated coffee and tea. For people highly sensitive to caffeine, its stimulant effects can last as long as 20 hours. Even decaffeinated coffee in the evening can keep me awake.
Alcohol is a sedative. It's O.K. with dinner but ill-advised as a nightcap. When broken down by the body, alcohol lightens sleep and can cause early awakening.
Likewise, a large meal before bed makes many people sleepy initially, but can result in disrupted sleep. This is not to suggest you should go to bed hungry. Rather, stick to a light snack, preferably one high in carbohydrates or the amino acid tryptophan, the precursor of serotonin, which reduces anxiety and relaxes the brain.
Good choices include warm milk, turkey, chicken, whole-grain bread or crackers, cereal with milk and banana, and low-calorie popcorn. But at bedtime avoid spicy and fatty foods, which can cause indigestion.
Of course, there are many excellent health reasons for quitting smoking. But for the insomniac, the stimulant effects of nicotine may prove most persuasive. Nicotine raises blood pressure and heart rate and stimulates the brain, countering the slowdown you need to get a good night's sleep.
If you are on medication (prescribed or over-the-counter) and having trouble sleeping, check with your doctor to see if a drug could be the cause. Often, another medication that does not disrupt sleep can be substituted.
Several over-the-counter pain remedies, like Excedrin and Tylenol, come in a "PM" version free of caffeine but with an antihistamine that makes people sleepy.
Sometimes sleep environment is the problem: noise from the street or a neighbor, or a snoring bed mate. Try using earplugs, a white noise machine or a fan that hums to block out the disruptive sounds. If you can get a snorer to sleep on a side instead of the back, it may get rid of the raucous noise.
Is your bed comfortable? Remember the three bears? Although firm mattresses are often recommended for back support, some people sleep better on a mattress that conforms more to their bodies. Also choose a pillow that supports your head in a position that does not strain your neck.
Good sleepers can do anything they want in bed. But those with insomnia are advised to use their beds only for sleeping and sex. No watching television, reading, knitting or what-have-you. The bed should be associated with sleep.
Select a comfortable blanket with the appropriate warmth and weight. I find it almost impossible to sleep well under a heavy cover, a blanket that is too hot, or any blanket or sheet that is tucked in at the foot or side. Consider the sheets as well. Is the fabric irritating?
Keep the room cool. A sleeping temperature of 60 to 65 degrees is best for most people, even in the dead of winter. In hot weather, use a floor or ceiling fan to create a breeze, or an air-conditioner set at about 70 degrees.
Light can be more disruptive than many people realize. Even the dial of a luminous clock can disturb some people's sleep. Cover or move the clock, use blinds or dark shades or drapes on bedroom windows if they are exposed to street lights or passing headlights, or wear an eye mask.
However, if you are likely to get up during the night to use the bathroom, use a flashlight or night light to reduce the risk of falling.
If you know you have to get up at a special time, perhaps earlier than usual, set an alarm clock or timer lest your anxiety awaken you several times during the night to see what time it is.
Sleep Schedule
People who have trouble sleeping do best if they maintain a consistent sleep schedule, going to bed and getting up at about the same time every day, including weekends and holidays. This keeps your body programmed with a predictable sleep-wake cycle. But if you stay up until 2 a.m. and sleep until noon on Sunday, you may have a hard time falling asleep at 11 Sunday night and getting up at 6 or 7 Monday morning.
Despite the known rejuvenating value of a "power nap" for ordinary people, those with insomnia are advised not to nap during the day lest they disrupt a hard-won sleep-wake cycle. A nap is no substitute for a full night of restful sleep.
Go to bed only when you feel sleepy and allow yourself 15 or 20 minutes to fall asleep. If sleep won't come, get up and do something relaxing: — take a warm bath, read a dull book, have a glass of warm milk. Go back to bed when you feel sleepy again.
The worst thing to do when you can't sleep is to worry about the fact that you're not sleeping. Instead, try to envision a relaxing scene or activity, like basking in the sun or watching waves, or count sheep sleeping in a meadow.
Exercise regularly, but not within three hours of bedtime.
Nondrug Treatments
If the above remedies are insufficient, there are a few medically directed treatments that steer clear of drugs. Perhaps the most popular is progressive relaxation therapy, which teaches the patient first to recognize tense muscles and then learn how to relax them one by one, starting at the toes and working up to the head.
Another approach is guided imagery and meditation. With it, patients learn to focus on pleasant, nonstimulating images. Or biofeedback may be used to achieve muscle relaxation.
A third technique may seem counterintuitive to someone who is already not getting enough sleep. It's called sleep restriction therapy, and its goal is to exhaust patients until sleep is inevitable. Patients are allowed to sleep for only a few hours at first, with the time gradually increased as insomnia wanes.
If all this fails to cure your insomnia, the final option is to consult a sleep specialist. The National Sleep Foundation — at 1522 K Street NW, Suite 500, Washington, 20005, at (202) 347-3471, or on its Web site, sleepfoundation.org, can help you find a nearby sleep center.
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posted by LC at 1:27 PM
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