Sleeping pills have been in the news again this year, this time after a study in BMJ Open, which found an association between sleeping pills and early death. Well, pick your poison: too many sleeping pills and there’s an increased risk of lung, colon and prostate cancer; not enough sleep and you run an increased risk of getting diabetes, cardiovascular disease and depression.
The paper’s authors acknowledge that an association between sleeping pills and early mortality doesn’t mean the sleeping tablets are to blame. And as University of Auckland insomnia specialist Dr Tony Fernando points out, people who use sleeping pills are also likely to suffer from depression, anxiety, chronic pain or other health problems, and be in a nursing or rest home. “By the very nature of their condition, they are at a higher risk of earlier mortality.”
The study focused mainly on prescription sleeping pills known as hypnotic drugs, such as benzodiazepines (or benzos), which switch on the neurotransmitters that act on the brain as a natural “nervecalming” agent. (Which is distinct from the sedative effect of over-the-counter antihistamines.)
Chances are your GP will already be loath to prescribe them, except as a short-term solution to insomnia or for long-haul flights. Benzos are effective, but can also be addictive; people can become tolerant to the drugs, requiring a higher dose, or dependent, unable to sleep without them.
However, the chance of that isn’t as high as we are often led to believe, according to Fernando. “I see a lot of people who suffer so much and who have given everything a try. They’ve seen psychologists, tried Eastern practices, natural therapies, homeopathies…some of them have spent thousands of dollars because their GP told them they’d get addicted on sleeping tablets. I say show me the paper. There is a risk of dependence, but our estimate is that the risk is lower than 20%. But a lot of GPs seem to think the risk is 100%.”
Fernando says sleeping pills could be seen as the pharmacological equivalent of alcohol (the drugs work on the same neurotransmitters); not everyone who drinks becomes an alcoholic and not every one who occasionally uses sleeping pills will get hooked on them. “There are a few who just become dependent quickly. The problem is we don’t know who they are… these [drugs] have advantages and risks, and patients and doctors should make an informed consent, not one based on hearsay.”
On the other hand, in the first instance he would take a psychological and behavioural approach when treating people with primary insomnia – that is, people with insomnia who don’t have depression, anxiety, mental health or other medical conditions. Although 60-70% of such people might benefit from this approach, few have access to the requisite six to eight sessions with a sleep specialist. So Fernando set out to identify the most useful component of the average psychological/behavioural programme for insomniacs and concluded that “bed time restriction” is the most effective strategy.
As the name implies, it’s about getting people to spend less time in bed. “A lot of people with insomnia actually don’t need eight hours, but they stay in bed for eight or nine hours and sometimes 10, because they hope to catch more sleep. Which doesn’t happen.“The more you stay in bed, the more fragmented your sleep is. So you do the reverse: make the brain a little thirsty for sleep.”
The approach involves less psychology (the aim of which is to change a person’s perspective on sleep) and more behavioural therapy, aimed at actually getting people to sleep. One thing often leads to another. “My thinking is that if you’re getting good sleep from the behavioural approach, the psychology will follow.”
Fernando says a couple of 15-minute sessions with a GP is all the instruction a patient needs to follow the programme. He has led a small study that suggests it works, and one of his university colleagues is replicating the research with a larger group.
The issue then will be to find a way to spread the message. “We’re thinking of developing an interactive application, like a smartphone app.
“But there needs be a buy-in from the GP, and GPs and practice nurses need to be coached properly in how to sell it. The main difficulty is stickability … the fi rst two weeks will be difficult, like being jetlagged for two weeks. But for many people, the response is miraculous.”
GOODNIGHT AND GOOD LUCK
“Bed time restriction” is a simple behavioural intervention, best for those with primary insomnia who spend a lot of time in bed but not much of it sleeping. For instance, if you typically spend nine hours in bed, but only sleep for six, you might try getting up at the usual time but going to bed later – at midnight, perhaps, rather than 10pm.
This should be done for two weeks, after which people generally report deeper and more consolidated sleep. They can then start making any adjustments, such as giving themselves another half hour. This is more likely to work if you also practise what doctors call “sleep hygiene”: avoiding drugs such as coffee, booze and cigarettes in the evening; no napping during the day; not doing any vigorous exercise late in the evening (except sex); and not going to bed before you’re tired.
Surfing the web just before bedtime is also out; light from the computer screen is thought to reduce the production of melatonin, a hormone secreted by the pineal gland to promote sleep. If you can’t get to sleep after about 20 minutes of going to bed, get up and go back to bed when you’re feeling sleepy – the theory is that you don’t want to start associating the bed with insomnia.
If you’re wakeful later in the night, avoid looking at the clock; it’s likely to make you panic, which is the worst thing you can do.