WHO DOES INSOMNIA AFFECT?

According to Statistics Canada, one in seven Canadians over the age of 15 (or 3.5 million people) have difficulty falling asleep or staying asleep. Other data from the Canadian Community Health Survey, suggest 18% of these Canadians average less than five hours of sleep a night(5). These numbers are not comparable to the suggested hours of sleep the National Sleep Foundation recommends.Teens need an average of 8.5 to 9.5 hours of sleep, while adults should obtain between 7 and 9 hours(1). These numbers may not be exactly essential for all to receive, as many can get by with less without showing symptoms of insomnia throughout the day. However, regularly having problems getting enough sleep or feeling tired during the day may be a sign of insomnia(5).

HOW IS INSOMNIA DIAGNOSED?

The Diagnostic and Statistical Manual-IV-TR has four characteristics used to diagnose insomnia:

A. Patient has dificulty initiating or maintaining sleep, or non restorative sleep for at least 1 month.

B. The disturbance in sleep causes significant distress or impairment in social, occupational, or other important areas of functioning.

C. The disturbance is not co-occuring with another mental disorder.

D. The sleep disturbance is not due to direct physiological effects of a substance or a general medical condition.(6)

In many cases of insomnia, they are physician created. This is because sleeping pills are usually prescribed (most commonly benzodiazepines) when patients claim to have troubles receiving enough sleep. These hypnotic drugs are effective in increasing sleep, however a tolerance to these drugs easily develops and the dose must be continuously increased to produce its original effects.When patients on this type of medication try to discontinue its use, withdrawal symptoms can be experienced, including insomnia. The case study of Mr. B demonstrates this problematic circle:

Mr. B. the Case of Iatrogenic Insomnia

“Mr. B. was studying for a civil service exam, the outcome of which would affect his entire future. He was terribly worried about the test and found it difficult to get to sleep at night. Feeling that sleep loss was affecting his ability to study, he consulted a physician. His doctor prescribed a moderate dose of barbiturate at bedtime, and Mr. B. found that his medication was very effective…for the first several nights. After about a week, he began having trouble sleeping again and decided to take two sleeping pills each night. Twice more the cycle was repeated, until on the night before the exam he was taking four times as many pills as his doctor had prescribed.The next night with the pressure off, Mr. B. took no medication. He had tremendous difficulty falling asleep, and when he did, his sleep was terribly disrupted. Mr. B. now decided he had a serious case of insomnia, and returned to his sleeping pill habit. By the time he consulted our clinic several years later, he was taking approximately 1000 mg sodium amytal every night, and his sleep was more disturbed than ever. Patients may go on for years and years – from one sleeping pill to another – never realizing that their troubles are caused by sleeping pills.” (4)

Insomnia can also be caused by a number of other factors:

Stress
Nicotine
Anxiety or depression
Shift work
Poor sleep habits
Not enough exercise
Medications and medical conditions(7)

WHAT TREATMENTS ARE AVAILABLE FOR INSOMNIA?

Sedatives or hypnotics are the most common treatment for insomnia, however many problems can arise including drug tolerance, dependence, drug interactions, hangover effects, and severe withdrawl reactions. Alternative approaches have been proven effective in treating insomnia. These approaches include:

Education which provides information about normal age-reated changes in sleep and good sleep habits/hygiene
Cognitive therapy provided to help correct dysfunctional thoughts and attitudes about sleep
Stimulus control to strengthen the association between the bedroom and sleep by encouraging the patient to get out of bed when unable to sleep and only using the bedroom for sleep and sex
Sleep restiction therefore reducing the amount of time spent in bed to the actual amount of time the patient is sleeping
Relaxation techniques such as yoga or meditation(6)

It has been argued that pharmacological treatment should be used only as a last resort. Careful assessment to rule out the possibility of the insomnia being caused by another disorder or medication should be conducted even before behavioural or congnitive treatments are started(2).

WHAT ABOUT SLEEPING PILLS?

Sleeping pills are commonly prescribed for insomnia and may be helpful when taken for a brief period of time and when under the supervision of a doctor. It is important to remember however, that sleeping pills can't cure insomnia and are only a temporary fix. When used continually, they can actually make insomnia worse so it is best to limit the use of sleeping pills to situations where your health and safety may be threatened by lack of sleep. Longterm use can also cause dependence and/or tolerance so it is better to only use them for travel or medical recoveries.

Safety Guidelines

There are several things to keep in mind when using sleep aids:

1. They should only be taken when you have enough time to get 7-8 hours of sleep. If not, you may feel groggy or drowsy the following day.

2. Always read the package insert that comes with the prescription for a list of possible side effects, dosage instructions and a list of foods/substances to avoid while taking the medication.

3. Never mix alcohol and sleeping pills. Alcohol tends to disrupt sleep patterns and can also interact dangerously with sleep medications.

4. Do not drive or operate machinery after taking sleeping aids. You never know how these medications will affect you, especially when you first start taking them.(2)