To sleep or not to sleep

Are we a nation of insomniacs?

by Janet Currie

Had trouble sleeping lately? You aren’t alone. In Canada and other comparable countries, insomnia is described as an epidemic and a serious public health problem. A recent study by the insurance company, Aviva, concluded Canada is the third most sleep-deprived country in the world, with nearly a third of Canadians saying they don’t sleep enough.

Media reports tell us a lack of sleep leads to an inability to exercise, overeating and obesity, affecting our work performance and our national economy. A study by the World Association of Sleep Medicine and Rand Europe claims lack of sleep costs the Canadian economy $21.4 billion a year due to lower work productivity.

Even kids aren’t immune to sleep problems. A recent Canadian ParticipAction report card reports a “sleepidemic” among children. The Canadian Sleep Society estimates about 30% of all children may have sleep problems. My quick scan of Amazon book titles found at least six popular books on methods parents can use to help their children sleep.

A study done in the US found the number of adults visiting their doctors for sleep problems doubled from 2.5 million in 1993 to 5.7 million in 2007. Insomnia diagnoses increased seven-fold and prescriptions for sleeping pills increased 30 times.

Although comparable Canadian research isn’t available, we do know that sleeping pills/benzodiazepines are among the most prescribed medicines in BC. The most common sleeping pill, Zopiclone, is the eighth most prescribed drug of any type in the province with 1,146,200 prescriptions in 2016. Other common sleeping pills such as lorazepam (Ativan) and clonazepam (Klonopin) are the 28th and 29th most prescribed drugs, both accounting for an additional 1,295,666 prescriptions. Other drugs, like atypical antipsychotics, which are usually approved only to treat psychoses, are often prescribed (inappropriately) as sleeping pills to older Canadians.

This high level of prescribing is despite the fact that sleeping pills and benzodiazepines are only intended for short-term use (for a few days only or for a few days intermittently). Common adverse reactions, which can occur at any level of use, include daytime sedation and confusion, leading to a higher risk of car accidents comparable to the effects of alcohol, memory problems, breathing difficulties and dizziness/loss of balance leading to falls and hip fractures.

Hip fractures can have serious consequences for older Canadians, sometimes leading to permanent disability or premature death. The annual cost of hip fractures to the Canadian health care economy is $650 million, estimated to rise to $2.4 billion by 2041.

One of the most serious outcomes of the longer term use of sleeping pills/benzodiazepines is drug-induced dependence: addiction. Simply put, addiction is a normal process that occurs when the brain becomes tolerant of some drugs, which leads to withdrawal symptoms if the dosage isn’t increased. Signs of addiction to sleeping pills include worsening insomnia, problems with anxiety, muscle pain and difficulties stopping the drug. If used longer term, sleeping pills/benzodiazepines should never be stopped abruptly, but tapered off slowly.

It may be surprising to learn that, despite their popularity, sleeping pills/benzodiazepines are not very effective for insomnia. Research has shown the brain quickly becomes tolerant of their effects so that, even after just a few weeks of use, they increase sleep time for an average of only 12 minutes a night. Considering all their risks, the benefits of sleeping pills are meagre. But the question remains: when sleep is a normal biological function why are so many of us suffering from insomnia to the point we are using dangerous medications to treat it? Are we really a nation of insomniacs?

It is completely normal for people to have insomnia from time to time and there may be more contributors to sleeplessness today than ever before. Irregular bedtime and wake-up times, shift work, stress, overuse of alcohol, the demands of multiple social roles, lack of regular exercise and increased use of technology can all contribute to problems with sleep.

Prescription drugs like Inderal (a beta-blocker), some thyroid medications (Synthroid), antibiotics (Floxin) and decongestants containing pseudoephedrine may also cause insomnia.

Some researchers have questioned whether we are actually experiencing a true “insomnia epidemic” or whether disease-mongering is really our public health problem. Disease-mongering occurs when the normal ailments of everyday life are classified as medical problems requiring treatment, usually with prescription drugs. Disease mongering is promoted by over-screening, over-diagnosis, over-treatment, economic waste and increased public anxiety and fear, often driven by “disease awareness campaigns.”

Disease awareness campaigns are often funded by pharmaceutical companies and other corporations with a vested interest in the sleep industry. They often partner with health providers, academics and pharma-funded patient groups and, explicitly or implicitly, promote the belief that conditions like insomnia are serious, widespread and require treatment.

For example, the multiple international partners involved in organizing World Sleep Day (March 16) aim to increase the worldwide awareness of sleep problems by encouraging countries all over the world to organize activities that promote the importance of sleep. Funders of World Sleep Day include insurance firms, several pharmaceutical companies, a company representing sleep health specialists and a mattress company.

The Canadian Sleep Society, which participates in World Sleep Day, is focused on increasing public awareness of sleep health in Canada. Current and past funding partners have included pharmaceutical companies such as Merck and Valeant, sleep clinics and a company selling sleep devices.

Sleep problems ARE big business. In Canada, millions of dollars are spent every year on direct medical costs related to insomnia such as prescription drugs, over-the-counter sleep aids, doctors’ and hospital visits and testing at sleep diagnostic labs, many of which are private and funded through workplace insurance plans. In 2013, there were at least 130 sleep testing labs in Canada.

In contrast to the hyper-awareness public education campaigns bring to sleep problems, there is a growing group of sleep experts who are telling us that a better approach to insomnia might be to become less concerned about sleep.

Sleep researcher Dr. Kenneth Lichstein believes the more that people worry about meeting certain strict guidelines for sleep (e.g. 7-8 hours of un-interrupted sleep a night) and catastrophize about the consequences of poor sleep, the more this contributes to insomnia.

He believes these anxieties can lead to the development of an “insomnia identity,” which includes a poor appraisal of sleep time and quality and fears about health risks even when there are none. Treating insomnia identity focuses not on a person’s sleep habits, but on changing the maladaptive thoughts typical to insomniacs – thoughts such as “I won’t sleep tonight.” “I won’t be able to function tomorrow.” “I am an insomniac.” – and adopting a more relaxed and accepting attitude towards sleep.

Lichstein found perceptions of poor sleep were more important than the amount of time someone actually slept. In other words, people who were technically “poor sleepers,” but did not consider themselves to have insomnia, did not experience distress, did not feel themselves to be impaired during the day and did not have anxiety about their sleep.

Sasha Stephens, a self-described 15-year insomniac and author of the The Effortless Sleep Method, also believes insomnia is driven by a fear of not sleeping. Although she recommends a few basic sleep hygiene methods – a quiet bedroom, a comfortable bed, regular exercise – her view is that external sleep crutches such as pills, herbal remedies or even elaborate sleep rituals all work to erode our trust in our own innate ability to fall asleep and are major contributors to insomnia.

We still may not know everything about how we sleep as we do. Historian Roger Ekirch, in his book At Day’s Close: Night in Times Past, used historical records to understand the sleep habits of our ancestors. These records indicate people slept in two distinct phases: an early first sleep that started a few hours after dusk, followed by a waking period of one to two hours and then a second sleep. People were often quite active during the waking period, chatting, visiting, eating, praying, having sex or meditating upon their dreams.

Segmented sleeps gradually disappeared in the 17th century, as street lighting in cities became more common, followed by electricity in the home. The industrial revolution, which demanded a more regulated labour force, ended the practice of the segregated sleep once and for all. An article in an 1829 medical journal urged parents to force their children out of the pattern of first and second sleeps.

Cognitive-behavioural sleep specialist Dr. Gregg Jacobs challenges the quality of some of the research on the dangers of insomnia, including the myth of the uninterrupted eight-hour sleep, and some of the research associating poor sleep with problems such as overeating and obesity. He and many other sleep specialists believe individual sleep needs are variable. Like Ekirch, Jacobs believes waking up at night may be part of normal human physiology.

It is unlikely we will ever return to the two-phase sleep pattern or even welcome a time in the middle of the night to meditate upon our dreams. However, an understanding, at least, of some of the reasons we may be wakeful when we don’t want to be may decrease our worries and ultimately be the key to sleeping better.

Resources

Video: an overview of non-drug approaches to sleep

Janet Currie is a writer, policy analyst and researcher. She works in the fields of justice and health and has a specific interest in medication (its use, safety and effectiveness). She is completing a PhD on off-label prescribing at UBC. While she cannot answer specific health concerns, if you have comments about the article, please contact her at note123@shaw.ca

photo © Valentin Armianu

1 thought on “To sleep or not to sleep

  1. Insomnia is to a large extent a luxury of the affluent, present in the life of those who live a sedentary life style. In countries where people work physically 12-14 a day, nobody reports insomnia. This implies that the body is built for physical activity most of the day, and in the absence of such activity, the body cannot fall asleep. So, for the most part, insomnia is the result of our life style.

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