Insomnia - the dos and don'ts of a modern epidemic

  • 14/03/2012

By Dan Satherley

As you settle in for a good night's sleep tonight, spare a thought for those who'll wake up tomorrow morning feeling worse than they did the night before – if they manage to get any sleep at all.

This Friday is World Sleep Day, an annual celebration of sleep held to raise awareness of sleep-related issues.

Treatable conditions like sleep apnoea and insomnia cost the country tens of millions of dollars in lost productivity every year. They can lead to other illnesses like diabetes, cardiovascular disease and respiratory failure - not to mention the emotional toll that comes from being in a permanent state of mental and phycisal fatigue.

I've suffered from chronic insomnia for the past year or so, and was intrigued by the annual event.  

Having read what must have been hundreds of articles, theories and old wives' tales on sleep, and battled with sleeping pills – as well as the odd doctor – the chance to speak with one of the country's foremost experts was too good to pass up.

Dr Alex Bartle, founder of Sleep Well Clinic, says lack of sleep is a problem that's only getting worse – and GPs don't have the tools to fix it.

He was a GP himself for 30 years, before going to Sydney to study sleep and how it affects people's health because it wasn't being taught here in New Zealand.

"There is almost no sleep medicine taught in medical school," says Dr Bartle. "It should be GPs who deal with this, and they don't know anything about sleep, basically."

Last week 3 News revealed a 42 percent jump in the number of New Zealanders using sleeping pills in the last five years, and last month a US study linked sleeping pills to up to half a million deaths a year in that country.  

"The problem is that pills are often very effective to start with, and people like that because it gets them to sleep, but in the medium to long term, they're bad news," says Dr Bartle.

For several months I was on and off sleeping pills – usually, but not limited to, the hypnotic zopiclone – and found it remarkably easy to get a prescription for whichever pill I wanted to try that week.

It's been two months since I last took a sleeping pill of any sort, but have no doubts I could walk into my GP's office tomorrow and get some without much difficulty.

I asked Dr Bartle what he thought of GPs' readiness to prescribe the highly-addictive pills instead of offering other options, like cognitive behavioural therapy (CBT).

"Most GPs are a little bit concerned about that themselves, but they don't have any other options – they don't know anything else," he says.

"CBT takes time, and there aren't many people who know about CBT… I've been trying to get psychologists, trying to get GPs to understand a little bit about what behavioural techniques you can use to help people get to sleep, rather than just dishing out a pill."

Dr Bartle says there is "no question" that CBT is the most effective therapy for people having trouble sleeping.

But not once, in six or seven months since my problems with sleep began, did any of the doctors I saw even mention CBT. I discovered it in that most modern of ways – Wikipedia, via Google – and on mentioning it to my GP, found out that not only did the practice have a psychologist trained in CBT methods on staff, the treatment was funded by the Government.

I told Dr Bartle I found this lack of communication frankly, quite incredible.

"It's not incredible at all to me," says Dr Bartle. "It's very sad, to be honest, and it's exactly what I'm really getting frustrated about.

"That's why I went off and did some specialist study in it, because there's no way as a GP I would ever have learnt that. I had to go to Sydney and do all my education on sleep medicine through Sydney University… but it's not being taught in med schools [in New Zealand]."

Dr Bartle says in six years of medical training, there's only one lecture given on the treatment of sleep disorders, a situation he calls "pathetic".

"I actually get 100 GPs at my talks, and get them to answer fairly simple questions on sleep, and the average is about 50 percent correct," says Dr Bartle.

There are several different types of sleep disorders, but the most common are sleep-onset insomnia and sleep apnoea.

The former, when a person just can't get to sleep when they should, is "largely the result of increased stress" according to Dr Bartle.

"The stress of today's living, of altering the light/dark cycle or the day/night cycle by having lots of things going on in the evening – there's a lot of electronic media particularly creating problems in the evening, so that's a huge issue.

"The level of anxiety, financial, family stress, relationships, all those sorts of things are much higher than 30 years ago."

The rise in sleep apnoea on the other hand, is closely associated with the obesity epidemic. People suffering from sleep apnoea might not have much trouble getting to sleep, but wake up several times a night due interrupted breathing patterns, often caused by blockages of the airway.

Dr Bartle says around 80 percent of people suffering sleep apnoea are overweight, and the problem is only getting worse.

But there's a simple, though not foolproof, way to tell if your night-time awakenings are the result of sleep apnoea: "Ninety-five percent of people with sleep apnoea are actually snorers," says Dr Bartle, "so most of the time you need to have a report of someone that you're snoring pretty regularly and loudly, and then you're likely to have some sleep apnoea."

So what can people suffering from insomnia or sleep apnoea do?

The first thing is realising that waking up during the night is not abnormal. Dr Bartle says everyone wakes up at night, they just don't realise it.

"Most people who think they sleep through the night actually wake up, but they go straight back to sleep within two or three minutes, which is a period of amnesia just before you go to sleep, and therefore they don't have any recall that they've woken.

"And that's why if you disrupt that time, if you become aware that you're awake, it becomes quite disturbing and distracting."

If you wake up and can't get straight back to sleep, get up. It sounds counter-intuitive, but in the long run, research suggests it works.

"Start to associate bed with sleep, rather than with anxiety," says Dr Bartle.

"During the night if you wake, then you need to get out of bed. If you can't settle back to sleep immediately… you should get out of bed."

But don't stay up for longer than 15 minutes.

"Don't wait until you feel sleepy again, because it may be two or three hours, but go back after about 15 minutes. If you don't manage it you get out of bed again."

Another key move is to rid your bedroom of any clocks, particularly those with bright digital displays. 

"Looking at the clock immediately makes us very alert and upset that we've seen the time," says Dr Bartle.

"You may need an alarm in your room, but not one that actually keeps looking at you and you can keep on seeing."

A third (and also somewhat counter-intuitive) thing you should try is, at least to start with, restrict the amount of time you spend in bed.

Dr Bartle says he tells patients to spend a couple of weeks keeping a sleep journal, keeping a track of how much time they actually sleep, then restrict the amount of time they spend in bed to that number of hours (a minimum of five).

"So if you come and say, 'I'm only sleeping four or five hours a night," then I'd say you're not allowed to go to bed until 1am, and you have to get up at six o'clock in the morning," he says.

"Then when we start getting a sleep efficiency – that means most time in bed, you're asleep – then you go to bed a little bit earlier, or get up a little bit later."

I told Dr Bartle I'd read about that technique, but not tried it as the author of the article considered it "controversial".

"Not in the sleep world, it's not," says Dr Bartle. "In the sleep world, that's the most useful technique. Most insomnia clinics around the world would use sleep restriction therapy."

And it's not as if we need as much sleep as we think we do. It's the quality of sleep that matters, says Dr Bartle.

"A lot of people with sleep apnoea get eight or nine hours sleep, but they wake up feeling terrible because the quality is so poor."

Still, Dr Bartle says the minimum amount of sleep anyone can effectively live on is six hours a night. ACT MP and former Auckland mayor John Banks famously claims to only sleep four hours a night.

"They say they do, but they don't," says Dr Bartle. "They're not functioning properly. To start with, to lay down memory, to consolidate memory, you need at least six hours of sleep – that's fairly well-established now.

"You'll get by, but you won't actually function properly."

That's something anyone who's ever experienced chronic insomnia knows all too well. Between the mental fog and the physical aches, more sleep can often seem like better sleep, no matter how it's achieved.

But anything that chemically induces sleep – whether it’s a sleeping pill or a bottle (or two) of wine – doesn't get you the sleep you need.

Many sleeping pills suppress REM sleep, which as Dr Bartle says, assists with the consolidation of memories. Alcohol does the same, as well as increasing the need to urinate during the night – which it's always good to wake up for, no matter how tired you are.

"Most of your deep, physically-restorative sleep is going to be in the first two or three hours of the night," says Dr Bartle. "So if you get solid sleep in the first three-to-four hours of the night, then you're going to get most of your deep, non-REM sleep.

"Towards the end of the night you get most of your REM, or your light sleep, and you might wake more frequently at that time – that's not so much to do with physical restoration. You get the growth hormone and all the physical aspects of restorative sleep in that first three hours."

Since undergoing CBT earlier this year, my sleep – though not quite back to normal – is enough to get by. Barely. Sure, I still have the odd what I call 'disaster night', and I'm genuinely shocked if I make it through a whole night without getting the chance to listen to some Pink Floyd at 2am, but it's on the improve.

The therapist I saw earlier this year helped me turn the corner with a simple, two-word phrase lifted straight from the cover of Douglas Adams' Hitchhiker's Guide to the Galaxy: Don't panic.

Dr Bartle uses the same two words to finish up our interview.

"Don't panic about waking – remember that's actually normal, it's just being able to turn over and go back to sleep [that's difficult]."

For more information, visit http://www.worldsleepday.org.

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