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Rest for the Weary: Words from an Insomnia Expert

If you have suffered sleepless nights then you're familiar with a particular kind of torture. Minutes become hours, hours become eons, and problems you manage with ease during the day become nightmarish, circular conundrums when considered at 3 am. It's called insomnia, and not only does it cause frustration at night, it can also significantly impair you in the day. Consequences can include depression, extreme fatigue, poor concentration, lousy driving and even illness.

As many as 25% of Americans suffer from an occasional bad night of sleep, and approximately 10% have a chronic problem with insomnia. Each year 70 million Americans spend approximately $148 million on a variety of remedies to either put them to sleep at night or keep them awake in the day.

What is chronic insomnia?
Chronic insomnia goes on for several days, weeks or even months, and for most people this means a long-term problem. It does not necessarily mean that a person is suffering from nightly insomnia. Most people who suffer from insomnia for the long term experience it on several nights a month, but not every night. According to the National Sleep Foundation, people with chronic insomnia have, on average, 16 nights of insomnia out of every 30.

What are some non-drug therapies for insomnia?
Treatments include behavioral as well as pharmacologic treatments. The behavioral treatments for insomnia include things like sleep hygiene, stimulus control therapy, sleep restriction therapy, relaxation therapies and other therapy, such as light therapy, that might be helpful to sleepers.

What is sleep hygiene?
Sleep hygiene is really the development of good sleep habits. This refers to doing things like going to bed at the same time every night, getting up at the same time every morning, no matter what happened the night before. For most people, avoiding daytime naps, avoiding stimulants such as caffeine and nicotine, avoiding alcohol just prior to bedtime are all part of good sleep hygiene. Although alcohol is a sedative, it can really disrupt sleep. It's also important not to go to bed too hungry or too full, as both of those conditions can disturb sleep. And also making sure that one's environment is conducive to sleep-sleeping in a room that is dark, quiet, temperature controlled, humidity-controlled, and in a bed and surroundings that one finds comfortable.

And what is sleep restriction therapy?
In sleep restriction therapy, a sleep clinician determines how much time the sleeper is spending in bed and how much time the sleeper is actually spending asleep, and attempts to reduce the amount of time in bed to about the same amount of time that sleeper reports sleeping. So if someone is spending eight hours in bed but sleeping only six, the clinician will reduce the amount of time in bed to only six.

Once there are adjustments made over the course of several weeks, often the patient comes back into the office and says, "I'm now in bed for five hours, and I'm sleeping for most of those five hours." Once that point is achieved, the clinician and patient can work together to begin extending the sleep time, hoping that it remains consolidated. And it often does.

What is stimulus control therapy?
Stimulus control therapy was developed based on the idea that people with insomnia develop conditioned or learned reactions to their situation, and begin to associate the bed and the bedroom with wakefulness rather than sleep. So immediately upon getting into bed, instead of being prepared for wonderful, relaxing, delicious sleep, the person with insomnia becomes hyperaroused, agitated and experiences yet another night of insomnia, which of course reinforces the problem. So stimulus control tries to break those associations by making sure that the sleeper gets out of bed whenever he or she is awake. The primary recommendation for stimulus control therapy is to stay out of bed whenever you're awake.

How effective are these behavioral therapies?
People who use these therapies often report that they work very well. But one of the problems with behavioral therapies or for insomnia is they often take time to work, and patients don't want to wait. They're suffering. Their lives are impaired, and they want some immediate relief.

What are the various medical approaches to insomnia treatment?
There are a number of both over-the-counter and prescription medications used to treat insomnia. The over-the-counter medications often contain antihistamines, which are sedating medications. They can be used for a night or two to help relieve the problem of falling asleep or staying asleep. Some people respond reasonably well to them. Other people report that these medications don't work, or that they experience significant adverse effects when using them-things like dryness, morning grogginess, or fogginess. So the thing that the over-the-counter medication is supposed to help-waking up feeling rested and refreshed-is exactly what doesn't happen.

How do prescription medications work differently?
The older class of medications, known as the benzodiazepines, includes a number of drugs that have been developed specifically to help people fall asleep and stay asleep. These medications are effective, but there are problems with abuse or dependence with these drugs. In recent years, two new medications have come out-a class called nonbenzodiazepine sleep aids-and medications belonging to this new class of drugs include Ambien and Sonata. Both of these medications are believed to be as effective as the older class of drugs, but in many respects safer, and without the adverse effects of dependence.

Are there any side effects with this new class of drug?
If people do experience side effects, the most commonly reported are headache, nausea and dizziness. But for the most part the rate of side effects with these newer medications is pretty low.

What would be your advice to someone who is first experiencing insomnia?
If someone's experiencing sleep problems and they find these problems distressing, or if they're associated with any impairment in daytime functioning, that's the time to talk to a doctor. We know that insomnia is associated with a number of significant problems in daytime functioning, in health and so on, so there's no need really to go on with the problem unattended. Talk to a doctor whenever insomnia results in distress or impairment.

How do you determine which medication is best for a patient?
One of the keys in the clinical treatment of insomnia is assessing the problem and determining what type of prescription medication and/or behavioral treatments might be appropriate. And the medication choices can be customized. For instance, if someone is having difficulty falling asleep, they might receive a prescription for one medication versus a different medication if they are waking up in the middle of the night. Each patient's problem is addressed individually.