March 26, 2012

Treating Insomnia
By Carolyn Gutierrez
For The Record
Vol. 24 No. 6 P. 24

Medications and cognitive behavioral therapy are strong options for those who can’t obtain sufficient shut-eye.

According to a data analysis from the Centers for Disease Control and Prevention (CDC), at least one-third of the US population suffers from sleep deprivation. The National Sleep Foundation recommends adults get between seven and nine hours of sleep per night, yet between 1985 and 2009, the percentage of people sleeping less than seven hours nightly increased from 23% to 35%. Those in a National Health and Nutrition Examination survey who reported a shorter duration of sleep experienced impaired concentration, memory difficulties, and trouble performing daily tasks.

Scientists have established that chronic insufficient sleep has far-reaching consequences on the body, including an increased risk of obesity, diabetes, and cardiovascular disease. Insomnia is one of many complex sleep disorders causing sleep loss. According to a 2011 study, about 22% of adults in the United States and France fit the clinical diagnostic criteria for insomnia.

To sleep specialists, it is important to distinguish insomnia from sleep deprivation caused by other disorders. According to Andrew Krystal, MD, a professor of psychiatry and behavioral sciences at Duke University’s psychiatry sleep clinic, “Insomnia is not just a problem of sleeping at night—it appears to be a 24-hour problem. And the 24-hour problem is associated with a hyper-alert, hyper-aroused state that seems to reflect activation of the fight-or-flight system. So this means that a person with insomnia is sort of on high alert all of the time.”

In its many permutations, insomnia can be a symptom or a side effect of another physical or psychological disorder. Acute insomnia is short term, lasting for days or weeks, typically brought on by stress or a traumatic event. Chronic insomnia can last from one to six months or longer. Much of the time, chronic insomnia is considered to be a secondary or comorbid disorder because it accompanies certain medical conditions and medications. It may also be paired with other sleep disorders such as sleep apnea or restless legs syndrome, or psychological conditions such as depression and anxiety.

An abnormal thyroid, acid reflux, pain disorders such as arthritis, and conditions resulting in difficult breathing, such as asthma and congestive heart failure, can provoke insomnia. Common substances such as caffeine, alcohol, decongestants, and certain steroids and beta blockers can also prevent sleep.

It can be difficult to diagnose insomnia as a stand-alone condition in a primary care setting because practitioners have no tools or blood tests to pinpoint it other than a patient’s account. Complaints of continuous nonrefreshing sleep and a lack of alertness during the day may warrant an overnight assessment in a sleep laboratory to rule out other sleep disorders.

Interestingly, even though people with insomnia sleep less at night than the general population, they are, on average, less able to fall asleep during daylight hours (if given the opportunity to sleep) than the general population.

“What makes insomnia insomnia is that given some loss of sleep, instead of compensating with the usual catch-up sleep, they can’t,” Krystal says. “These people continue to have a prolonged and sustained problem with shutting down and going to sleep 24 hours a day, especially in chronic insomnia.”

Medication Therapies
Currently, there are two main approaches to treating insomnia: nonmedication therapies, such as cognitive behavioral therapy (CBT), and medication therapies. “There is clear evidence that combining the two is quite possible and quite fruitful if you do it correctly,” notes Krystal.

After other underlying causes are ruled out or addressed, many insomnia patients suffering from significant impairment in their day-to-day function are given a hypnotic medication in the hope that it will help stabilize their sleep schedule and alleviate insomnia’s adverse effects.

 “The reason to treat is to address those adverse effects,” says Krystal, “and the reasons that medications can be advantageous is if their benefit, in terms of alleviating those symptoms, outweighs the risks of the drug. And I would argue that for many people, that trade-off is a positive one. For some people, it’s not. For some people, it’s hard to find a drug that works well enough to counter the side effects—and all drugs have side effects. I think one thing that’s emerged in recent years is that there are drugs that have excellent safety profiles and excellent risk/benefit ratios that didn’t exist 20 years ago. But somehow, the world, in my view, seems to continue to think about sleep drugs as somehow dangerous or scary in ways that are really unmerited by the data.”

The antidepressant doxepin, generally given in dosages of 75 to 150 mg for treating depression, was recently approved for treating insomnia. When used for insomnia, only 3 or 6 mg are needed. “At 75 to 150 mg, it’s got a pretty unfavorable side-effect profile,” notes Krystal, “but at 3 and 6 mg, it has a remarkably good side-effect profile. And this is a drug that doesn’t help people fall asleep, but it helps them stay asleep. And if you’re somebody who has trouble sleeping at the end of the night in particular, the risk/benefit ratio based on the control trials is actually quite good. So the risks are very small.”

The drug ramelteon, a melatonin receptor agonist, can be helpful for people who need help falling asleep. According to Krystal, recently approved medications such as zolpidem, eszopiclone, and zaleplon have good overall benefits compared with risks. Reformulations of these drugs, such as a sublingual form of zolpidem and a delayed-release form of zaleplon, are also being developed. There are new drugs under development as well, such as an orexin-antagonist, that may prove to be effective in treating insomnia.

“When used as directed, current hypnotic medications are effective and quite safe for most individuals,” says James K. Walsh, PhD, executive director and a senior scientist at St Luke’s Sleep Medicine and Research Center in Chesterfield, Missouri. “Hypnotics are particularly beneficial for those with situational insomnia, such as a few days or weeks of heightened stress, jet lag, etc. Hypnotics are also helpful for many individuals with more chronic insomnia, and there are many people who take a hypnotic every night for years without a problem or a need to increase the dose.”

Walsh notes that in rare cases of hypnotic medication use, unusual behavior may occur during sleep, such as sleepwalking, sleep eating, or sleep driving. In the majority of cases, he says these behaviors are due to misuse of the drug—for example, the dosage was too high or was combined with alcohol or another sedative.

As with many other medications, there is the concern of psychological dependence when hypnotics are used for insomnia. Older patients and patients with significant medical conditions require attentive monitoring when hypnotics are prescribed, particularly in the first few nights of treatment.

“The key here is that there are plenty of people who have sleep problems but don’t have significant impairment,” says Krystal. “For those people, there is no reason for them to take a drug. Because unless their sleep is really causing them difficulty and stress and is a great concern to them, generally it’s impairment in function or quality of life that drives the logic in using medications. Obviously, they’re not indicated for everybody.”

The body’s production of melatonin, a hormone secreted by the pineal gland, plays a vital role in the biological circadian rhythm that controls a person’s daily sleep/wake cycle. Because melatonin signals in the brain regulate a unique “sleep clock” within the body, supplements can be helpful for those with trouble sleeping. Although most melatonin supplement labels advise use two hours before bedtime, the drug should be taken before an individual’s melatonin levels peak naturally in his or her blood, which can vary from person to person. If taken too late in the sleep cycle, the melatonin will not be effective.

Because of the exquisitely complex and highly individualized circadian rhythm, it can be difficult to pinpoint the optimal time to take melatonin. Depending on the diagnosis, a sleep disorder patient may be advised to actually take the melatonin in the morning or at a different time in the evening.

Cognitive Behavioral Therapy
For the psychological treatment of insomnia, researchers agree that the gold standard is CBT. This type of therapy has been found to be 70% to 80% effective in patients with insomnia. Essentially, CBT involves working with patients to change maladaptive habits and beliefs that they’ve developed to cope with their lack of sleep. CBT sleep therapists also emphasize “sleep hygiene,” a series of recommendations to assist an insomnia patient in achieving a good night’s rest. It pays close attention to environmental factors in the bedroom, such as noise levels, temperature, and TV distractions, and examines and readjusts diet and exercise habits.

According to Andrea Harris, a researcher and graduate student at Ryerson University’s Sleep and Depression Lab in Toronto, Ontario, Canada, many sleep disorder therapists recommend having a standard bedtime and rise time and to adhere to that sleep schedule no matter what.

“We have people fill out a sleep log to record their sleep for a couple of weeks,” she says. “They bring that in and we’re able to see what time they’re going to bed and waking up—it involves a lot of calculations actually. We help them determine what their best bedtime and rise time is. We’re also looking to potentially restrict their time in bed. People with insomnia often are in bed for quite a bit longer than they are actually sleeping. For example, if they’re in bed for nine hours but are only sleeping for six hours, we might try to restrict that time in bed, so it more closely matches the time they’re actually sleeping—so there’s less time awake while they’re in bed. That helps alleviate the perception of how little sleep they’re getting.”

Another important aspect of CBT is to challenge a patient’s negative beliefs about sleep. Patients who have rigid misperceptions and anxiety over their own lack of sleep tend to exacerbate their insomnia. Sleep therapists work with patients to closely examine these beliefs and emphasize more realistic expectations. For example, some patients with insomnia may have a slightly different sleep/wake schedule than their peers. They may need more or less sleep than they perceive they are getting, and a therapist can help determine their optimal amount through sleep studies.

A therapist may suggest relaxation techniques and even subtle adjustments in a patient’s bedtime routine. Scientists have found that too much bright light in a bedroom suppresses melatonin production and impedes the brain’s preparation for sleep. Sleep disorder therapists can help insomnia patients adjust their sleep environment and routines to promote a more restful sleep time.

Safety Behaviors
At Ryerson University, Harris was part of a research team that studied the sleep habits of 397 undergraduates. The study, composed of a series of online surveys, revealed that 40% of the students were poor sleepers and engaged in “safety behaviors” that they believed help them to fall asleep yet were ultimately unhelpful.

“A safety behavior is anything that helps you cope with the problem in the short term, but in the long term, it actually perpetuates the problem,” Harris explains. “As an example, someone who drinks alcohol before going to bed. It does help them initially fall asleep—so it does, in the short term, help them fix the sleep problem. But we know from research that certainly alcohol can lead to a more disruptive sleep so they’re not really getting better-quality sleep. And, of course, the other thing is that getting hooked on having a drink every night before going to bed isn’t actually solving the root of the problem.”

Depending solely on medications to promote sleep was another safety behavior the researchers found to be helpful in the short term but damaging in the long run. “Sleep is supposed to be an effortless process,” says Harris. “By taking all of these measures to try to sleep and to convince yourself you need to sleep, that mindset can actually make it more difficult to sleep.”

Genetics’ Role
There are sleep disorders such as narcolepsy and restless legs syndrome that have been found to have a genetic component, and researchers suspect that some subtypes of insomnia may be genetically passed down as well.

“Certainly, the tendency to stay up late and sleep late or go to bed early and get up early is under strong genetic control,” notes Krystal. “It is behaviorally modifiable, but it is under strong genetic control. The basic mechanisms that control the biological rhythms in humans were discovered in the fruit fly. They were discovered by a brilliant set of experiments where it was found that you could breed a wide range of patterns of preferred sleep/wake timing into fruit flies.”

Scientists have established that people may have different vulnerabilities to sleep loss. Researchers are trying to understand possible genetic factors for the differential in people who experience sleep loss yet seem less impaired compared with those who have much more heightened suffering from insufficient sleep.

Health Repercussions
Alongside proper diet and exercise, sleep is paramount for optimal health and well-being. With few exceptions, all nucleated life forms on the planet follow a biological circadian clock. All life forms follow a pattern of activity and rest. If the rest cycle for any organism is taken away, its life span is shortened.

Based on our circadian clocks, scientists have determined that the ideal amount of sleep for the human body is seven to nine hours. Researchers have found that humans living out of sync with their biological rhythms experience a gradual but profound erosion of their health. Their immune system is gradually compromised, leaving them vulnerable to contracting illnesses or developing metabolic problems. When there is a lack of sleep, the neurological system can be affected, leading to a range of troubling effects on memory, concentration, and mood. Studies have shown that teenagers not getting adequate sleep were more likely than their peers to drink, smoke, and entertain suicidal thoughts.

Studies conducted by the CDC and the National Center on Sleep Disorders Research maintain that insufficient sleep is so pervasive that it has become a public health epidemic, with links to industrial disasters and motor vehicle accidents. Interestingly, the insufficient sleep epidemic seems to have coincided with the obesity epidemic. As the bombardment of new technologies created a 24-hour global society, research in the last 10 to 20 years has clearly shown that people are getting less sleep than ever before, and the consequences are daunting.

— Carolyn Gutierrez is a freelance writer based in New York City.