Health & Medicine
Losing Sleep
You stare at the ceiling. You try to ignore the clock. You consider your son's lousy report card. You avert your eyes from the clock. Your mind latches onto the next day's PowerPoint presentation. Too many bullets? Too few? Oops--you look at the clock. Aargh . . . even if you fall asleep right now, you're only going to get five hours of sleep. You'll be exhausted tomorrow, you'll lose your job, you won't be able to pay the mortgage, your kids will land on the street, and omigod, now it's only 4 1/2 hours.
Insomnia is nothing new. Cave men probably agonized about being too tired in the morning to catch a really good mammoth. But many sleep specialists suspect--no one can say for sure--that a world that offers TV, 24/7 interconnectivity, and boundless workdays is swelling the insomniac population. Insomnia increasingly is being viewed as a medical problem, drawing a new generation of pills and talk therapy. Sleep drugs claimed to be free of the grogginess and addiction risk of older potions are flooding the market, with more to come. And cognitive-behavioral therapy, widely used in other disorders, is being wielded against insomnia.
Insomnia isn't just an inability to fall asleep; it's more like an inability to sleep well. The classic insomniac lies in bed, wide-eyed, before managing to drift off. Another awakens during the night and can't go back to sleep, while still another snoozes straight through but wakes up unrefreshed. Insomnia may be linked to bigger health problems. Insomniacs are more likely to suffer from intractable, worsening pain, more likely to have accidents, and more likely to be diagnosed at some point with depression. And insomnia can indicate other health problems, such as sleep apnea.
Pill popping. Sleep drugs have joined Viagra, Botox, and other "lifestyle drugs" that target well-being rather than disease. In the first seven months of 2005, nearly 25 million prescriptions for sleep medications were filled, according to IMS Health, which tracks such statistics. And the number of adults ages 20 to 44 who took prescription sleep medications doubled between 2000 and 2004, according to a survey released this week by Medco Health Solutions, a manager of drug benefit programs. The market for the drugs should become even livelier as geared-up ad campaigns urge bleary-eyed consumers to bug their doctors.
Current sleep medications aren't as miraculous as their marketing suggests, but they're far superior to barbiturates--deadly when mixed with alcohol and with a low threshold for overdosing--and most sleep experts consider them improved over sleep inducers such as Halcion and Restoril that were introduced in the 1970s and 1980s. Those drugs boost the activity of a receptor molecule on the surface of brain cells, setting off a chain reaction that damps down brain activity and brings on sleep. They can make patients feel woozy and lose coordination, and are classified as controlled substances because of their potential to be habit-forming.
The newest drugs on the market--Ambien CR, Sonata, and Lunesta--affect brain chemistry the same way but are choosier about the receptors they target. Their side effects are generally milder than those of older drugs, and the risk of psychological dependence seems lower, but they are still classified as controlled substances. More such drugs are coming--Indiplon, for example, could be approved by the Food and Drug Administration and available by next summer.
Different drugs work better on different kinds of insomnia. Sonata, for instance, spikes quickly and then falls off steeply, so it may be best suited to insomniacs who need help falling asleep but don't wake up after that. This month, Sanofi-Aventis launched a slower-acting, longer-lasting version of Ambien, the top-selling prescription sleep medication. Ambien CR (for controlled release) is aimed at those who toss and turn all night or who wake up and can't go back to sleep. A slow-release version of Indiplon will be marketed for the same purpose.
Zero abuse. Rozerem, which became available late last month, is the first prescription sleep drug that has no potential for abuse and thus isn't listed as a controlled substance. It binds to receptors on cells in the brain's master clock, called the suprachiasmatic nucleus, triggering the cells to stop sending out the signal that keeps the brain awake. The drug is probably more useful for falling asleep than staying asleep, says psychiatrist Daniel Buysse, who studies sleep at the University of Pittsburgh Medical Center, but it will take a while to see how well it works compared with other drugs.
Many physicians resist prescribing sleep drugs because how patients will react over the long haul is unknown--the clinical trials that lead to a medication's approval last only a few months, while people may take the drug for years. "There's just kind of a disconnect," says Buysse.
The medication most commonly prescribed for insomnia is not a sleep drug at all but low-dose trazodone, an antidepressant. It's a legal but "off label" use, since the drug was approved for depression, not insomnia, and, again, its long-term effects on insomnia patients are an open question. "We just don't know anything," says Thomas Roth, a sleep researcher at Henry Ford Hospital in Detroit. He notes that because of side effects at high doses, the drug is rarely prescribed now for depression.
Dosing insomnia with over-the-counter products like Benadryl and Tylenol PM often produces next-day grogginess (the active ingredient is usually the same antihistamine that the manufacturer uses in its cold products), not to mention occasional constipation and, in some elderly people, delirium. And taking such medications for a long time has unknown effects.
A synthetic version of melatonin, a hormone that is part of the body's sleep mechanism, is a popular alternative therapy for insomnia. But a recent research review found that it doesn't seem to work for insomnia. Valerian root, an herbal supplement, supposedly has sleep-inducing qualities, but the evidence is shaky. (A current trial may give answers next year.)
Booze for a snooze? The good ol' nightcap has a long tradition of fighting insomnia--or trying to. Alcohol, a depressant, might induce sleepiness initially, but it will most likely wake you up later. "As it clears your system, you rebound," Roth says, and your sleep gets worse. "If I put an IV line and put alcohol in your system all night long, you'd do fine." (Your doctor may not agree.)
But drugs aren't the only way to attack a problem whose source is the brain. As sleep centers multiply, evolving from their academic roots to include freestanding centers and units at private hospitals, many have started offering cognitive-behavioral therapy. In widespread use for treating problems such as obsessive-compulsive disorder, depression, and addiction, this therapy helps a patient recognize fears that are out of proportion and develop tools to gradually erode them, says Edward Stepanski, a clinical psychologist and director of the Sleep Disorders Service and Research Center at Rush University Medical Center in Chicago.
Among those concerns, says Stepanski, is the fear of terrible health and personal consequences if someone doesn't fall asleep right away--a notion reinforced by widely reported studies on the importance of a full night's sleep. The anxiety only reinforces the insomnia. "Lying in bed thinking, 'I'm going to get fired if I don't get to sleep in the next half-hour,' is counterproductive," says Stepanski.
Therapy can also help patients understand that the tactics they may be using with increasing desperation to manage their sleep probably just make matters worse, says Jack Edinger, a clinical psychologist at the Veterans Affairs and Duke University medical centers in Durham, N.C. Naps, for instance, only scramble the body's internal clock, as does trying to catch up on sleep by going to bed earlier or getting up later.
Take an individual who thinks she needs eight hours of sleep every night. In fact, she may need only seven hours, but if she believes otherwise, the quality of her sleep may be disrupted to the point that she's getting just five or six good hours. Edinger would help someone like her work out a schedule that retrains her by establishing the correct amount of sleep she needs and by limiting the time she spends in bed. "We don't give them a lot of extra time to spin their wheels," he says. "It's not rocket science."
Drugs or therapy--which is better? "The question always makes me crazy," Roth says. "If somebody has elevated cholesterol, do you put them on statins or do you change their diet? You put them on a statin, and you say, 'Stop eating pork rinds.' Both things make you better." A study published last year in the Archives of Internal Medicine found that cognitive-behavioral therapy worked better than Ambien and helped patients more in the long term. But therapy isn't right for everyone. It's expensive, and drugs are usually the better choice for short-term problems like jet lag or stress from a death in the family, says Edinger. But drugs have side effects, so if your insomnia has a long history, many specialists suggest trying therapy first.
Whatever causes your insomnia, it can be treated, says Edinger: "Although insomnia can be a chronic disorder, that doesn't mean that the person has to have it forever. It's just that they haven't yet found a way to get over it."
This story appears in the October 24, 2005 print edition of U.S. News & World Report.