Insomnia is a common problem in America, and no matter the reason, letting the problem fester can make getting a good night's sleep even tougher, says Emerson M. Wickwire, assistant professor of psychiatry and medicine at the University of Maryland School of Medicine and the director of the insomnia program at Maryland's Midtown Medical Center.
He explains new medical guidelines that call for cognitive-behavioral treatment as the first line of treatment.
When is sleep trouble considered a disorder, as opposed to the occasional problems most people experience?
According to the National Sleep Foundation, on any given night, 30 percent to 40 percent of adults in the U.S. are having a poor night's sleep. That's a lot of trouble sleeping. The good news is that most of the time, these restless nights go away on their own and healthy sleep returns. Unfortunately, for nearly one in five adults, short-term sleep problems develop into a chronic sleep disorder. Once that happens, sleep troubles are unlikely to go away and require targeted treatment. Most diagnostic guidelines suggest that to be considered chronic, certain kinds of sleep troubles must take place three nights per week or more, for one to three months or more. Common symptoms include daytime tiredness, fatigue, irritability, depressed mood, poor brain function (e.g., memory problems or difficulty staying on task), pain, or just feeling run-down. A good rule of thumb is that if you are reading an article like this one or wondering about your sleep problems, it's time to ask an expert.
What typically are the causes of insomnia?
Insomnia simply means trouble falling asleep, trouble staying asleep, or both. We tend to think of 30 minutes as a threshold for insomnia. In other words, if it takes you 30 minutes or more to fall asleep or if you are awake for 30 or more minutes during the night, and if these problems are frequent and ongoing, you might have insomnia. And you are not alone. Insomnia is the most common sleep disorder among adults, impacting 10 percent to 15 percent of the U.S. populace. Insomnia increases with age and tends to be more common among women than among men. Sometimes insomnia is caused by an external stressor — for example, a medical illness, job transition, loss of a loved one or dissolution of a romantic relationship. What I tell patients, though, is that regardless of what originally caused the insomnia, your sleeping troubles have now taken on a life of their own. You've had a lot of practice at being a lousy sleeper, and you've become quite good at it. So the solution is we need to retrain your body to sleep.
Is insomnia normally treated with drugs or behavioral therapy, or both?
The most common treatments for insomnia are sleep medications called sedative hypnotics. Most of these drugs work by stimulating the brain's sleep system. The Food and Drug Administration has approved a number of medications for insomnia, and many medications are also often prescribed off-label for sleep. There are a few problems, however. First, all medications carry risk of side effects, and many patients prefer nondrug approaches when available. Second, no pill can teach your body how to sleep. Third, a very specific nondrug sleep training approach called cognitive-behavioral treatment for insomnia (CBTI) has been shown to be equally effective to sleep medications in the short-term, with gains significantly better maintained over time. And because CBTI is designed to leverage the body's natural sleep system to improve sleep, there is minimal risk of side effects, withdrawal symptoms, or rebound insomnia.
Will treatment change because of new guidelines from the American College of Physicians, which call for all insomnia patients to get cognitive behavioral therapy?
The American College of Physicians (ACP) is the largest professional organization representing internal medicine physicians in the United States. So it is an important statement that they recommend CBTI as first-line treatment for chronic insomnia. In doing so, the ACP joins leading scientific organizations including the National Institutes of Health, the British Association for Psychopharmacology and the American Academy of Sleep Medicine in recommending CBTI as the first-line treatment option. In my opinion, there are three important factors for the public to consider about the ACP guidelines. First, sleep is a vital component for overall health and well-being. If you are not getting enough sleep or not getting enough quality sleep, it really matters. Second, regardless what originally caused your sleep problems, your body can be retrained to sleep. CBTI brings relief to the majority of patients who undergo treatment and is considered safe and effective. Sleep experts and the general medical community agree that CBTI should be included as a central component of insomnia treatment plans. Third, I think it's important to point out that sleep medications are not inherently bad, doctors who prescribe them are not necessarily wrong, and people who take medications should not feel weak or ashamed. Indeed, medications can have an important role, especially newer medications with more favorable risk-benefit profiles. For example, at the University of Maryland Sleep Disorders Center, we frequently prescribe sleep medications in combination with CBTI. But a thoughtful approach is required, and we work closely with our patients. It's not enough for a doctor just to write a prescription and send patients on their way. Sleep disorders require careful assessment, diagnosis, and ongoing expert management, especially when medications are involved. In terms of the future, my hope is that the ACP guidelines will help increase awareness regarding sleep disorders and the need for personalized care. There is such a lack of public awareness about best practices in sleep medicine. Improving long-term outcomes will require active collaboration between academia, industry, and government, and of course health providers and their patients.
What else do the guidelines call for?
In addition to recommending CBTI as first-line treatment, the guidelines recommend a thorough discussion of the pros, cons, and risks of sleep treatment options. This is just good common sense. At the University of Maryland Medical Center, we view sleep treatment as a partnership between patient and provider. We have these discussions with every one of our patients, every day.
What can patients expect from treatment?
My patients range in age from 18 years to over 90. Some are students, some are parents, some are grandparents, and others live alone. Some have trouble falling asleep, others have trouble staying asleep, and others want more sleep. Virtually all would like to sleep better through the night and to feel more refreshed during the day. After all, who doesn't want to be more productive or to increase engagement in recreational activities? In terms of patient experience, at the University of Maryland Sleep Disorders Center, we employ an integrated approach and often combine medication and behavioral treatments. All patients undergo a comprehensive evaluation that might include in-lab or at-home sleep testing to rule out other sleep disorders like obstructive sleep apnea. Personalized treatment plans vary from patient to patient, but CBTI typically ranges from 4-8 encounters depending on medical history, current medication use, and so forth. I'm a psychologist and sleep disorders specialist by training, but I don't provide primary mental health care. To a casual observer, CBTI would appear a mix of medicine and executive coaching. And I learn from my patients every day. One reason why working in sleep medicine is so exciting and so much fun is that our treatments work. We help patients get the rest they need and sleep they deserve. My goal as a health care provider is for every one of my patients to awaken refreshed, revitalized, and centered, ready for the adventure of a new day.