Why Can’t I Sleep And What Can I Do About It?

As a part of National Sleep Week the National Sleep Foundation just released the results of a new survey. They found that 75% of American adults have at least one symptom of a sleep problem and 25% have symptoms at least several times per week that cause problems with daytime functioning. Insomnia is defined as problems with either falling asleep, staying asleep, or early morning awakening that causes next day consequences like excessive fatigue, daytime sleepiness, poor concentration and/or irritability.

Why are so many people having problems? A physician friend of mine told me recently that he’s reluctant to treat insomnia since it’s just a symptom of depression. But is this true? It is according to the old paradigm, but now we know it’s usually the opposite. The new paradigm is that untreated insomnia causes depression. Of course depression worsens insomnia and then they both snowball. It’s the chicken and the egg.

One study found that only 16% of patients with insomnia were depressed. Another 24% had an anxiety disorder. But 60% had other causes of their sleep difficulties. Many things can cause problems with sleep on a frequent or nightly basis. The most obvious is high stress.

Many medical problems especially chronic pain, gastro esophageal reflux, heart disease, respiratory illness – in fact just about any chronic illness has a negative effect on sleep. Many substances including alcohol, tobacco, and caffeine can cause problems as a direct effect +/- as a rebound effect. Changing schedules, shift work, and jet lag disrupt normal sleep patterns. Specific sleep disorders like restless legs or myoclonus (muscle jerks during sleep) – usually noticed more by the bed partner are common.

Sleep problems tend to increase with age. 50% of the elderly experience significant sleep problems. Women have more sleep problems than men, especially premenstrually, during pregnancy, post partum, perimenopause, and menopause. As if all that is not enough many of the medications that we take worsen sleep, including antidepressants, stimulants, cardiovascular, respiration medications, and others. Medications may interfere with sleep directly and/or cause rebound symptoms as they are wearing off.

Fortunately we have excellent medications for treating insomnia. I believe everyone needs to have available a safe/effective sleep medicine to take at least on an as needed basis. Just this week, we now have a new sleep medication, Lunesta. This new medication might be good for those that don’t have success with Ambien or Sonata. Some people wake up in 3-4 hours when taking Sonata, or wake up in 5 hours when they take Ambien. Lunesta lasts significantly longer and is more likely to provide 7-8 hours of sleep. Lunesta was also well tolerated in research studies. I will still need to see how it works in the real world before we can whole heartedly endorse it. Also, this summer a controlled release Ambien is coming out. This will presumably increase duration of action.

Unfortunately only 7% of people with sleep problems go to their doctor to get sleep medication. Of people with sleep problems who are seeing a doctor for another reason only 1 out of every 3 will bring it up. How amazing is that? 2 out of 3 people with insomnia don’t discuss it with their doctor or ask for a sleep medication.

Insomnia hurts mental and physical health. It interferes with work, study, relationships and hobbies. It reduces quality of life. Insomnia is usually easily treated. The sleep medications Lunesta, Ambien, and Sonata not only are safe and effective but provide normal sleep – both deep sleep and dream sleep. Benzodiazepines like Xanax decrease deep sleep. Antidepressants decrease dream sleep. OTC’s (antihistamines) don’t provide normal sleep and are more likely to have next day side effects. Of course, not every sleep problem requires a sleeping pill. Sometimes cognitive behavioral changes are adequate. See the Sleep Do’s and Don’ts Handout

Why are so many people hesitant to ask for or use medication for sleep? It may be that the importance of insomnia is trivialized or that people are afraid of becoming hooked on “sleeping pills” or still have the old stigma of addiction (associated in the past with barbituates and benzodiazepines).

Current sleep medications, Ambien, Sonata, and Lunesta have a very low abuse potential. Addiction means compulsive use despite negative consequences. This is almost non-existent with the new sleep medications. Physical dependence means physiologic adaptation resulting in serious withdrawal symptoms if a medication is abruptly stopped. This is also extremely rare with the new sleep medications.

As always we want to compare possible risks with probable benefits. This one is a no brainer. Do whatever it takes to ensure quality sleep every night. Your health and longevity depend on it!

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