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Medical Intervention for Sleep Problems

Program: Sleep Disorders: Obstructive Sleep Apnea and Snoring
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Andrew Schorr:

Dr. Chang, so we talked about kind of the simple things; have your bedroom be a good sleep environment, don't drink coffee too late, don't drink some of these caffeinated drinks at the wrong time, you know, maybe have a good mattress, good sense, but now lets talk about where people need some intervention.

So I'll start with insomnia because that affects a lot of people. People see a lot of TV ads about it. There are prescriptions medicines. I think of Ambien and Lunesta. I know there are others now. There's one that start with an "R" I can't think of it right now. The drug company person is yelling it…

Dr. Chang:

Yes, Rozerem I think is what you're talking about.

Andrew Schorr:

Yes, they're probably yelling it at us right now, but okay. I know there are some. When are these medicines used, and can they be used forever or just for the short term? When are they appropriate, and how do you evaluate that?

Dr. Chang:

So insomnia usually is the result of some other cause, and we kind of talked about that earlier in the program where someone may have a shoulder pain or a medical reason for developing insomnia or life stresses such as financial or emotional stress and more importantly depression, and depression and insomnia are highly linked together, and a lot of patients who I see for insomnia may have an underlying depression that was not diagnosed, so those with insomnia need to focus on the root cause, what's causing them to have the insomnia to begin with.

Having said that, for those with insomnia, there are multiple treatment options now on the market, and as you mentioned the TV ads makes you almost wonder that everyone should be on a sleep aid just because they're so prevalent on TV ads.

I personally thing that sleep aids, such as the ones that you see on TV, Lunesta and Ambien, the two more popular ones, should be taken under the discretion of your physician. Having said that, the Lunesta and the Ambien CR actually can be taken for a longer period of time than the Ambien, which is a shorter acting medication. My personal practice is that these sleep aids should be taken, again, short term, and more importantly behavioral therapy for insomnia.

So as a firm believer in insomnia and where does it come from, treatment with cognitive-behavioral therapy in my personal opinion is the most definitive treatment for insomnia. What that entails is actually meeting with a sleep specialist for six to ten weeks, and what I say it's like going to a sleep coach, and the coach will keep you on task to relearn better behaviors to sleep better, and it is highly effective. In one research study they showed that 70% of patients who undergo cognitive-behavioral therapy actually sleep better one year out after undergoing this therapy, and all you're doing is really just changing and modifying the behaviors that may be preventing you from falling asleep such as mind racing or perseverating over things that happened during the day or will be happening tomorrow, and those are common things that I hear about with those with insomnia. Including medication works, but by the time people come to me, Andrew, they have been on all the sleep aids on the market, and so they're more willing and more open to another treatment option for their insomnia.

Andrew Schorr:

Dr. Chang, while we've been talking we got a question in from a listener, Brian in Boulder, Colorado, about all this. He's worried about his wife, and I just want to share a little bit of this because I think we've answered most of it, but I just want to check. She's been having sleep problems for most of her life, and she's now become anxious about the whole process, and sleeping pills, and you mentioned them, Ambien, Ambien CR, Lunesta, they don't seem to solve the problem, and so the question was, can she get along with four, five, or six hours of sleep a night? If she isn't getting enough sleep, could she die basically of not getting enough sleep, and I think I guess what we'd worry about is could somebody fall asleep at the wheel or have some sort of accident and make some kind of mistake. Obviously if you're in the construction industry, you could have a serious industrial error or things like that, so I know it comes into play. He wonders, can you forget how to sleep, and if she stops taking the pills, let's say stops taking the pills, will there be problems as she withdraws from the pills?

You mentioned, he asked about depression, I have a lot rolled in here, we spoke about that. So lets talk about can insomnia kill you and what about when you stop taking the pills can you sleep normally again after that?

Dr. Chang:

So, regarding insomnia and overall health, there's no known research data linking insomnia and an increased risk for mortality. Okay, so just to allay that fear, there's no known linkage, but having said that, we know that sleep is very important. We spend a third of our lives sleeping, all of us do, and so clearly there's a function for restorative of the body function, mentally, physically, would be the two things that sleep is used for.

Regarding this particular question, insomnia with medication works but unfortunately for a lot of patients they have to either increase the dosage over time, or they need to switch to different medications, and when you do come off the medications, for some individuals their sleep does get worse before it goes back to whatever it was before they went on the medication.

I think from what I can gather from this history clearly seeing a sleep specialist would be of benefit for his wife because I think the sleep specialist can interject the cognitive-behavioral therapy component that I mentioned earlier because it think in this situation, again speaking to a sleep specialist would be of most benefit, but generally speaking I see plenty of patients like this where they've been on multiple sleep aids and are still concerned with the sleep, and cognitive-behavioral therapy I think is the best course given the information that you presented to me.

Andrew Schorr:

Okay, and the evaluation for anxiety and depression as well as you were mentioning, the underlying cause.

Dr. Chang:

Yes.

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