Nearly all suffer the consequences: feeling sleepy and tired during the day and any other time they’re not trying to sleep. With impaired concentration, attention and memory, persons with insomnia are less productive at work and more vulnerable to mistakes. Studies show that inadequate sleep is associated with slower reaction times and more automobile and other accidents.
Insomnia is not a disease, although it may be a symptom of an underlying medical condition. Left untreated, it can cause headache, upset stomach, irritable mood and problems with interpersonal relationships. Over the long term, recent research suggests it’s a major risk factor for high blood pressure, type 2 diabetes, depression and weight gain. According to one study, lack of sleep is a greater risk for early death than smoking, hypertension or heart disease. If insomnia is bothering you, don’t wait until it becomes ingrained as a habit. Your doctor can look for medical conditions that may be contributing to your sleep problems and help you find a way to get to sleep.
Acute Problems, Don’t Panic
Acute or short-term insomnia–defined as lasting less than four weeks–usually has an overt cause–a problem at work, worry about finances or intrusions on the sleeping environment such as a neighbor’s loud, late-night parties. For insomnia lasting five days or less, the best approach is usually to do nothing. With time, sleepiness will descend upon you and you’ll make the adjustments necessary. Sleeping in, taking naps, going to bed earlier or lying for hours wide awake can throw your sleep rhythms into even greater disarray.
Chronic insomnia is defined as sleep problems occurring three or more nights a week for at least four weeks. But insomnia lasting even a week should be addressed promptly before negative patterns are established. Sometimes lifestyle changes are enough–getting regular exercise, avoiding daytime naps, going to bed and waking up at the same time every day and cutting back on caffeine and alcohol in the evening.
If problems persist, the causes may be complex and require the help of a doctor and sometimes a sleep laboratory to sort out and resolve. The first step is usually to look for medications or medical conditions that may be contributing to the problem. Medical conditions than can cause sleeplessness include restless leg syndrome, breathing disorders, snoring, arthritis pain, headaches, panic attacks, heartburn or depression. Hot flashes are a common source of insomnia for menopausal women. For a male, an enlarged prostate can cause urinary problems and frequent night-time trips to the bathroom that interfere with sleep.
Commonly used drugs or substances that can contribute to insomnia include amphetamines, quinolone antibiotics, anti-migraine drugs, beta blockers, thyroid preparations, bronchodilators, oral contraceptives, corticosteroids, levodopa, decongestants, caffeine and nicotine. In many cases, treatment of the underlying medical condition or a change of medication may be enough to resolve the insomnia. If an emotional issue is keeping you awake, you may need counseling or some kind of resolution of the problem that’s causing you stress.
When insomnia has become serious enough to require treatment, the easiest–although not always the best–course involves medication. Over-the-counter sleeping pills are rarely the answer and should not be used for more than a few days in a row to avoid a habituating or rebound effect. If depression is part of the problem, antidepressant medication and therapy may have a positive effect on the insomnia. A doctor may also prescribe one of several sleep-promoting medications recently approved by the FDA.
Ambien, Lunesta, Sonata and Ambien CR all have a sedating effect, and they differ mainly in how long they last. Another drug, Rozerem, works in an entirely different way, affecting melatonin receptors that regulate the sleep/wake cycle. Although these medications are less likely than older sleeping pills or over-the-counter remedies to cause habituation, tolerance or side effects, the safest course is still non-drug treatment. Several short-term behavioral techniques, requiring two to five sessions with a trained therapist, have been found effective. These may be combined with relaxation therapy, such as progressive muscle relaxation.
Stimulus control therapy focuses on promoting the bedroom as a place to sleep and have sex, and nothing else. TV, books and other distractions should be removed. The patient may also be advised to get out of the bedroom when attempts to fall asleep are proving futile, thereby re-establishing positive associations between the bed and sleep.
Cognitive therapy focuses on correcting distorted attitudes about sleep and relieving the anxiety that eventually tends to consume the person with insomnia. A National Institutes of Health expert panel has endorsed the behavioral/cognitive approach. While conceding that newer sleep medications show promise and have few severe side effects, they pointed out that the long-term safety of these substances has yet to be established. In addition to being safer, cognitive/behavioral approaches have been found more effective, at least for certain individuals and certain situations.
Michelle Herbert Thomas, PharmD, CDE
Clinical Director, Richmond Apothecaries Inc.
