Based on the medical condition, patients find themselves on one of two paths in medicine – fast or slow.  Fast medicine is a straightforward path with simple, restorative solutions.  For example, a sore throat: an exam and a swab reveal an infection with Group A Streptococcus bacteria, and a simple treatment plan gets you back to baseline –  fast medicine.  But slow medicine – for conditions like insomnia – is not so simple.  In a group of 464 “good sleepers” (defined by not having sleep complaints), 30.7% developed insomnia symptoms and 7.4% met criteria for an insomnia syndrome 12-months later.¹ Comparatively, in a cohort of 383 people with an insomnia diagnosis at baseline, 45.9% had persistent insomnia symptoms for 3-years.² In other words, even good sleepers are vulnerable to develop insomnia, and once present it tends to persist.  Insomnia can be a long, arduous journey on a winding path toward an uncertain destination.  As a Sleep Medicine Fellow, I frequently hear stories of people surviving off 3-5 hours of sleep.  They have tried multiple prescriptions, learned all about healthy sleep habits, and maybe even completed a therapy.  But a good night’s rest remains elusive.  Here is a difficult truth for those people – sleep doctors can’t fix your sleep.

But – before you stop reading – let’s recognize that some of it is out of your control.

You may be setup for failure

If you’ve lived with insomnia for years, then likely 2/3 of the problem is behind you – unless you have a time machine.  In the “3-P” Model, the development of insomnia is divided into Predisposing, Precipitating, and Perpetuating factors.  Many predisposing factors are intrinsic – such as female gender, old age, co-morbid anxiety or depression, or positive family history – and thereby unable to change.  Amongst these predisposing factors there are also societal and social pressures impacting your sleep – such as work schedules or social/cultural expectations for sleep norms.³  Precipitating factors include stressful life events (like a global pandemic⁴, death of loved one, or divorce), or other “psychological and health-related factors (e.g., pain, mental health problems).”² Since predisposing and precipitating factors are often beyond our control, evidenced-based practices focus on perpetuating factors.  These factors include, “maladaptive sleep habits (e.g., excessive amounts of time spent in bed, napping, chronic medication use) and dysfunctional cognitions about sleep loss and its impact on life (e.g., worry over sleep loss).”² By addressing these behaviors, sleep medicine providers equip you with helpful tools for your journey toward better sleep.

But maybe you’re wondering, “isn’t there something I can take?”

A pill is not going to fix your sleep

William Osler – the Chief of Medicine at Johns Hopkins from 1889-1904 – once said, “…the desire to take medicine is one feature which distinguishes man… It is really one of the most serious difficulties with which [doctors] have to contend.  Even in minor ailments, which would yield to dieting or to simple home remedies, the doctor’s visit is not thought to be complete without the prescription.” While trying to function on insufficient sleep is not a “minor ailment,” humanity’s desire for a ‘magic bullet’ to any malady rings true today.  Additionally, our current medical system does not incentivize good practice of slow medicine – a regrettable fact which compounds the problem.  Your primary care doctor typically has 15 minutes with you – maybe less – and all too often a prescribed sleep aid is the path of least resistance.

In many cases, treating insomnia with a prescription alone is short-sighted.  Long-term use increases the risk of rebound insomnia at discontinuation and is potentially dangerous for some populations (such as the elderly).^5,6 This is not to say prescribed medications do not have a place in insomnia treatment. Rather it should be a tool carefully considered within a broader management plan. A trial in 2009 found that patients who completed cognitive behavioral therapy for insomnia (CBT-i) – a 6-week program focusing on education, behavioral modification, and relaxation training followed by monthly maintenance visits – plus a prescribed sleep aid at bedtime had significantly better remission rates than patients treated with CBT-i alone.  Does that mean a green light for sleep pills if you do CBT-i?  No.  The patients with the best outcomes were those who stopped taking the prescribed sleep aid after the 6-week initial therapy program.⁷ Evidence clearly points toward psychological and behavioral interventions (i.e. stimulus control therapy, relaxation training, CBT-I, sleep restriction therapy, multicomponent therapy, or biofeedback) as effective first line treatment for insomnia.⁸

But what about the person who has tried it all?

Progress requires “a long obedience in the same direction”

There is no easy answer. I have given a brief explanation for why people experience insomnia and touched on research concerning treatment. But, this should not be conflated with your experience living with insomnia. A single mother working a swing shift experiencing anxiety and depression has a different set of barriers then a veteran with replicative traumatic nightmares.  Whatever your personal barriers may be, there is hope!  Progress is possible with consistent application.  Sleep specialists give you the tools to mitigate factors within your control, but we cannot do the work for you.  Progress only happens with a persistent commitment – on the scale of months to years – every night applying what you know.  There are no shortcuts – again unless you have a time machine (in which case call me).  But seeing as time machines are scarce, a provider who discusses a well-rounded management plan and celebrates every minute of gained sleep can keep you on the path of progress.  Like I said – sleep doctors alone can’t fix your sleep, but together you can move forward.

References:

• LeBlanc M, Mérette C, Savard J, Ivers H, Baillargeon L, Morin CM. Incidence and risk factors of insomnia in a population-based sample. Sleep. 2009;32(8):1027-1037. doi:10.1093/sleep/32.8.1027
• Morin CM, Bélanger L, LeBlanc M, et al. The Natural History of Insomnia: A Population-Based 3-Year Longitudinal Study. Arch Intern Med. 2009;169(5):447–453. doi:10.1001/archinternmed.2008.610
• Grandner MA. Sleep, Health, and Society. Sleep Med Clin. 2017;12(1):1-22. doi:10.1016/j.jsmc.2016.10.012
• Lin LY, Wang J, Ou-Yang XY, et al. The immediate impact of the 2019 novel coronavirus (COVID-19) outbreak on subjective sleep status [published online ahead of print, 2020 Jun 1]. Sleep Med. 2020;S1389-9457(20)30221-5. doi:10.1016/j.sleep.2020.05.018
• Jiang Y, Xia Q, Wang J, Zhou P, Jiang S, Diwan VK, Xu B. Insomnia, Benzodiazepine Use, and Falls among Residents in Long-term Care Facilities. Int J Environ Res Public Health. 2019 Nov 21;16(23):4623. doi: 10.3390/ijerph16234623. PMID: 31766368; PMCID: PMC6926709.
• Brewster GS, Riegel B, Gehrman PR. Insomnia in the Older Adult. Sleep Med Clin. 2018;13(1):13-19. doi:10.1016/j.jsmc.2017.09.002
• Morin CM, Vallières A, Guay B, et al. Cognitive Behavioral Therapy, Singly and Combined With Medication, for Persistent Insomnia: A Randomized Controlled Trial. JAMA. 2009;301(19):2005–2015. doi:10.1001/jama.2009.682
• Morgenthaler T, Kramer M, Alessi C, Friedman L, Boehlecke B, Brown T, Coleman J, Kapur V, Lee-Chiong T, Owens J, Pancer J, Swick T; American Academy of Sleep Medicine. Practice parameters for the psychological and behavioral treatment of insomnia: an update. An american academy of sleep medicine report. Sleep. 2006 Nov;29(11):1415-9. PMID: 17162987.