To sleep…perchance to dream
Insomnia, dissatisfaction with sleep quality or duration, is a common problem. Some 10% of Americans have chronic insomnia and another 15-20% have occasional insomnia.
While scientists do not fully understand why we (and virtually all living animals) need to sleep, lack of sleep contributes to many problems, including interpersonal, school and work functioning, depression and hypertension.
There are specific medical problems that may underlie insomnia. Restless legs and obstructive sleep apnea lead this list and will respond to specific therapies. Your bed partner is more likely to pick up on these than are you, and a session in the sleep lab will usually confirm the diagnosis.
Shift workers are particularly at risk for insomnia and the problem may not go away until you get a regular work schedule.
Most have insomnia as its own problem. Insomnia may have started at the time of a life stress or due to jet lag and then persists.
What can you do? There are many ‘common sense’ hints that may be all you need. Try to go to bed and get up at the same time every day, including weekends. Be sure your bedroom is dark and cool. Exercise early in the day, not in the evening. Do not work right up until bedtime; allow yourself time to decompress by relaxing reading or music. Do not eat within 2 hours of bedtime.
If these do not work, what next?
Sleeping pills, whether over-the-counter or prescription, are fine for short-term use but are not that effective when used chronically, and the more effective prescription drugs can have side effects.
Older individuals are at particular risk of falls, morning confusion and even dementia with chronic use of benzodiazepines (Valium, Ativan etc.). The so-called “Z drugs,” (Zolpidem, zaleplon and eszopiclone) have black-box warnings because of sleepwalking and other potentially risky sleep behaviors.
Sedating antihistamines like Benadryl have limited efficacy and cause dry mouth and daytime sedation. They are also potentially causes of dementia if used chronically.
Most experts strongly recommend cognitive behavioral therapy (CBTI) before medication. The success rate is high and there are no side effects. The problem is the lack of trained therapists and the cost.
An alternative is a web-based or phone app. These have been found to be almost as effective as in-person coaching. Two web-based programs that have good studies behind them are no longer available. I was able to download Shuteye, which promises a full year of coaching for $30 which appears good, but I have not fully tested it. Similar, and free, is Insomnia Coach, developed by the VA.
Also recommended, for technophobes, is the book Quiet Your Mind and Get to Sleep.
Should CBTI not work, young adults whose problem is falling asleep can try melatonin or a short-acting benzo. If sleep maintenance is the problem, low-dose doxepin or similar drugs are useful. Also approved for this use are three orexin receptor antagonists (ask your doctor!), which have fewer side-effects than benzos but are quite expensive. If you are going to use medication, be sure to also practice good “sleep hygiene” as noted above.
Sweet dreams.
Edward Hoffer MD is Associate Professor of Medicine, part-time, at Harvard.
What Does The Doctor Say?
By Dr. Edward Hoffer