What's Holding Up the Sandman?
By Jane E. Brody, New York Times, April 11, 2006
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.
This is the first of two columns on insomnia. Next: treating insomnia without drugs.