By Lauren Grawert, M.D.
I am an addiction psychiatrist, so it probably comes as no surprise that most of my patients come to see me for problems related to their addiction. They’re often at rock bottom, suffering from intense emotional and physical withdrawal symptoms stemming from substance abuse. I start by taking their history, including what brought them in, and hear a lot of similarities when it comes to symptoms. Insomnia is a common theme.
You may know insomnia as not being able to sleep, which can include lying awake all night, tossing and turning until morning. While this is true, there’s more to it. Some people have episodic sleep problems, which are sometimes related to a stressful life event and only last a short time, usually resolving on their own.
But others may struggle with longer-term, or chronic, insomnia, defined as sleep problems that occur at least three times a week for at least three consecutive months. Research shows that without enough sleep, you’re at increased risk for everything from depression, to car accidents, to relationship difficulties, to performance issues at work or school. Lack of sleep can also have a negative impact on your long-term health. So, it’s important for me to help patients find a solution.
I start by asking how often insomnia occurs and in what ways it impairs the patient’s life. To look for patterns, I ask patients to keep a sleep journal for several weeks. This includes details like sleep and wake times, how many times they wake up each night and what wakes them up (noise, light, etc.).
Using these details, I can get a better idea of the root cause(s) of their sleep troubles. More often than you’d think, it’s at least partially due to poor sleep hygiene. The stimulants in that late-afternoon cup of coffee or cigarette right before bed can make it harder to doze off, as can the use of electronic devices too close to bedtime. Stress, drugs and alcohol use (especially closer to bedtime), and nighttime or irregular work shifts can be culprits too. And sleep problems are a common symptom of depression, anxiety and post-traumatic stress disorder.
Age can be a factor as well. As we get older, our sleep patterns change, and eventually we see a marked drop in stage-four sleep, or deep sleep, which affects your energy level and immune function, among other things.
Can’t I Just Take a Pill to Fall Asleep?
Once my patients and I have a handle on what’s causing the insomnia, I’ll help them come up with a plan to alter their behaviors and thinking processes. But change can take time, and sometimes patients want some quick relief. Some ask if I’ll prescribe them a sleep aid to help in the short term. Because I’m particularly attuned to addiction, I’m hesitant to offer these medications as a first-line treatment for chronic insomnia. Many can be habit forming, especially those classified as benzodiazepines, which depress the central nervous system.
While prescription sleep medication can help you sleep in the short term, it can also result in many undesirable side effects, such as physical addiction, needing to take more to have the same effect (tolerance), falls, dizziness, headache, gastrointestinal problems, prolonged drowsiness, memory or functional problems during the day and increased risk of developing dementia. Some people even experience potentially dangerous sleep-related behaviors, including eating, walking or driving while not fully awake.
There are also certain people for whom these drugs are not recommended or safe, including pregnant or breastfeeding women, older adults or people already on existing sedative/hypnotic medications.
Treatment for Sleep Problems
Are you familiar with the saying, “Slow and steady wins the race?” That’s the best approach when it comes to treatment for chronic insomnia. Rather than jumping right to medication, I recommend what’s called cognitive behavioral therapy for insomnia (CBT-I). CBT-I is more effective than medication for treatment of chronic insomnia, since it addresses underlying causes instead of symptoms. Another bonus: It has none of the adverse effects of medication. CBT-I is especially great for the elderly, for whom medication often isn’t as effective and sometimes results in more severe side effects.
This approach teaches patients to identify and replace the actions and thoughts that negatively affect their sleep. Only a trained health care provider who has expertise in sleep disorders can provide CBT-I, but the idea is that patients will eventually be able to take what they learn in treatment and put it into practice on their own, which is helpful if/when insomnia pops up again later in life.
When it comes to sleep hygiene, I advise patients to get regular exercise—at least 10 minutes per day of anything active. I also recommend implementing a cutoff time for caffeine, nicotine and alcohol use based on their bedtimes, being mindful that caffeine and nicotine stay active for seven hours after last consumption. Additionally, it’s important to set a consistent bedtime and wake time and to stick to these times, even on weekends. Overall, it’s important to establish a relaxing bedtime routine that includes cutting screen time at least an hour before bed and doing something relaxing—like taking a warm bath or shower, reading a book or stretching—that lets your body know it’s time to wind down.
While CBT-I is even recommended by the American College of Physicians as a first-line treatment, there are times when it may not work for everyone and when medication may instead be a better option. A conversation with your health care provider is the best place to start.
Get Checked Out
While insomnia may just be insomnia for some people, it could be an indicator of a more serious underlying medical disorder, such as sleep apnea, where breathing temporarily starts and stops repeatedly throughout the night. Every insomnia evaluation should begin with a detailed medical history to rule out medical conditions that could be causing difficulty sleeping.
The bottom line: If you’re struggling to get enough sleep and don’t feel rested when you wake up, talk to your health care provider before reaching for a sleeping pill. He or she can offer the best tailored guidance to get you back to sleeping soundly.
For more information on insomnia and CBT-I, read a summary of clinical guidelines published in the Annals of Internal Medicine.
Lauren Grawert, M.D., is a board-certified psychiatrist with the Mid-Atlantic Permanente Medical Group. She sees patients at the Kaiser Permanente Falls Church Medical Center.
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