Anita Georges fondly recalls the days when she could sleep worry-free, sometimes for more than 10 hours at a time. "When I was a teenager, I could sleep until noon," Georges remembers. "Then I got married and had five kids. While my husband slept peacefully, I stood by the window, worrying and waiting for my kids to get home."
Georges is now 76 years old. She still frets over her kids, and she rarely gets a good night's rest. She has been diagnosed with sleep apnea a condition in which the airway constricts during slumber, causing snoring and interrupted sleep. She occasionally takes Ambien CR; she isn't the only one.
According to an Espicom Business Intelligence report, a firm that specializes in market reporting and analysis, Americans currently spend $2.4 billion on medications to treat insomnia. That number is expected to grow to $6 billion in less than five years. The United States accounts for 66 percent of the world market for insomnia products, and it is estimated that 37 million Americans have experienced some form of this condition. Local sleep experts contend that reaching for a pill isn't the cure. Understanding what lies behind or, in some cases, in front of sleeplessness is the better approach and one that can lead an insomniac back to the restful world of dozing and dreams. Cause or Effect? Dr. Katherine Smith, neurologist, psychiatrist and sleep specialist at Ochsner Clinic Foundation's sleep center, says that it's not always clear-cut whether someone's insomnia is a symptom of another disease or if it's the problem in and of itself. The latter situation is referred to as primary insomnia where there is no underlying disease state such as depression, substance abuse or a thyroid condition.
"That's the difficulty in treating it," Smith says. "It needs to be delineated."
Finding out what is causing insomnia will help determine whether the sleeplessness is the disease or a symptom of a disease. Smith says it requires a full assessment, which can include a psychiatric evaluation, medical evaluation and neurological evaluation of the patient. If Smith determines the patient has primary insomnia, she likely will use cognitive therapy, basically teaching the person new patterns of behavior when it comes to sleeping. Smith admits it is time-consuming, but it's very effective, especially compared to just medicating the patient.
"Out of the last 500 people I've seen, I can count on one hand how many times I've written a prescription just for insomnia," Smith says. "I just don't do it. I don't think it works."
Dr. Houman Dahi, a pulmonologist and director of the adult sleep research program at Tulane University's sleep center, says besides learning new behavior patterns, patients have to overcome those learned previously. As Dahi explains, there's a difference between wishing to sleep and trying to make yourself sleep.
"So if someone wants to sleep and tries to force themselves into sleep, they would have a hard time going to sleep because of all the stress and anxiety," he says.
For these people, the bedroom becomes a stressful place that worries them instead of being a calming setting for rest. Dahi approaches these cases by attempting to decrease the bedroom as a stimulus. He instructs his patients to use the bedroom only for sleep and intimacy no television, no naps and no eating. If they can't fall asleep quickly, they should leave the bedroom, he says.
This can be problematic in the post-Katrina world of temporary trailers, where there really is no separate bedroom. "It's a hard thing to address," Dahi says. "The first thing to do is to get them a better environment. They can try to limit noise and go to bed at the same time, but there's only so much that can be done in a FEMA trailer." Trailers don't help Dr. Smith also believes the trailers can be harmful and can make diagnosing a patient's insomnia difficult. Smith also believes these differences in environment have contributed to an increase in the number of people in the area experiencing insomnia.
"So many people are suffering, their living situations have changed and they're having more sleep difficulties and depression," she says. "That's a great example of where it's on an individual basis of which came first, the depression or the insomnia, or did they come together?"
Until recently, it generally was thought that insomnia was a result of depression. Now, according to Smith, physicians are beginning to realize that insomnia can lead to depression, and restoring a person's sleep can prevent depression. Conversely, mental illness particularly depression and anxiety disorders can produce insomnia. If, for instance, it's determined that insomnia is a symptom of the depression, Smith might refer the patient to a psychiatrist for therapy. In this case, when the depression is treated, the insomnia often will go away or can be addressed after the depression begins to subside. Smith cautions, however, that insomnia can worsen if the depression is only treated with medication.
To illustrate her point, she describes a situation involving someone living in a trailer who has become depressed. The person sees a doctor and gets a prescription for an antidepressant. After they take the medicine, they develop restless leg syndrome, a disorder characterized by uncomfortable sensations in the legs and an urge to move. The patient thinks the trailer is causing the syndrome when it actually is the antidepressant, and the restless leg syndrome then contributes to intense insomnia.
"The cure is sometimes the culprit," Smith explains. Know what you're taking It is critical for doctors and patients to be familiar with the medication prescribed and any potential side effects. Smith thinks this often is overlooked in regards to sleep medication. Harmful side effects can occur with long-term use, even with over-the-counter sleep aids.
Lunesta, AmbienCR and Sonata are three brand names for the latest class of sleeping pills, nonbenzodiazepine hypnotics. Prior to the nonbenzodiazepines, benzodiazepines were the most commonly prescribed sleeping pills sold as Halcion, Xanax and other names but they could be addictive and make users lethargic the next day. They are, however, still prescribed in cases in which a patient needs immediate rest. The nonbenzodiazepines, marketed as being nonaddictive, are quickly metabolized in the body, lessening after effects the next day.
These new sleep agents make it easy to "just throw a pill at them," Smith says, but cautions against this approach, adding that medications should be used in conjunction with therapy not as the permanent solution. Although these drugs are touted as being non-addictive, she says long-term users can become habituated. They need the drugs to go to sleep and, as time goes by, they require more of the drug for it to be effective.
"There's a downside to these, no matter what people think," Smith says. "I see patients all the time that say, 'Oh I was on Ambien and it made me crazy.' Like the old benzos, they can cause periods of amnesia, confusion and daytime hangovers, especially in the elderly."
Over-the-counter medications, which usually contain antihistamines like Benadryl (diphenhydramine), can also be dangerous for people over 65 years old. If they are only used periodically, they can be helpful, but continued use can cause memory loss and states of confusion.
Another problem with sleeping pills is that they can worsen sleep apnea, or cause it. When a person has sleep apnea, the breathing airway becomes so relaxed during sleep that it folds in on itself, obstructing breathing. This results in snoring and the person not getting enough oxygen. If someone doesn't breath in sufficient oxygen, the brain will arouse them so they take in a deep breath. Because of this brain stimulation, the person never falls into a deep sleep. Sleeping pills tend to relax the airway even further, so the brain constantly "wakes" up the person, although they are not conscious of it. "So now the patient is sleeping," Smith says, "but they feel worse. Sleep is even less restorative." Apnea is common Dahi reports that most of the people he sees at the sleep center have apnea. In many cases, the patients have lost their CPAP machines, which are mask devices that patients wear at night that use air pressure to keep the breathing passage open. For these patients, the answer to stopping their insomnia is as simple as putting the mask back on.
Unfortunately, Georges never got used to the mask. After trying for a couple of weeks, she gave the CPAP back to her doctor. If she feels she really needs help, she'll take an Ambien. Georges does try to create a peaceful atmosphere before bed by playing music and avoiding television, but she can't help set aside her concerns as a mother and a grandmother: "I worry about everything." She's become accustomed to waking up every couple of hours ("I always know what time it is," she says.) and every once in a while, she'll go back to a sleeping aid that's been around for years.
"I count sheep, and sometimes it actually works."