- The Reflective Doc
Seeking Restful Sleep?
My father, a family medicine physician, practiced in a small town in rural North Dakota. In the absence of specialized emergency room physicians, during call nights he saw anyone who came through the hospital door. Our phone was often ringing in the early morning hours, waking him from sleep and forcing him out of bed. I remember hearing him tell my mother how difficult it was for him to return to sleep during those on-call nights. My siblings and I were encouraged to modify our noise level for him the next day, though we rarely succeeded unless we were bundled up and propelled outdoors. Not surprisingly, he would eventually have difficulty sleeping even on nights when a colleague was covering the hospital.
In my work as a psychiatrist, my toolbox for treatment of depression, anxiety, bipolar disorder and schizophrenia, though not perfect, is broad and well-researched. What leaves me discouraged, however, is the recurrent statement I hear when they return for follow up, “I definitely feel better, but my sleep is still terrible.”
Looking back at my notes from medical school and residency didactics, I was struck by the absence of training in sleep disorders. One would think that poor quality sleep was a rarity, or at least a minor problem compared to diabetes, heart disease, or cancer, for example. However, when I started to investigate and teach about sleep disorders, I grew increasingly concerned about the massive public health risk of sleep deprivation. Though insomnia more often reflects anxiety about sleep quality than true sleep loss, it can be dangerous in patients at risk for mental health issues.
Insomnia rates continue to rise in the setting of the pandemic, contributing to increasing rates of depression and anxiety, as well as worsening symptoms of other severe mental illnesses. My patients, for example, will call after several nights of poor sleep, dismayed by the return of previously well-controlled panic attacks or intrusive anxious thoughts. This then becomes a vicious cycle of dread as the night approaches, with an increase in worried thoughts as well as alcohol use and over-the-counter sleep aides, often just various formulations of diphenhydramine.
The incidence of psychiatric illness in patients with insomnia is estimated near 50%, with the highest rates noted in depression, bipolar disorder, and anxiety disorders. One key factor I always discuss with patients managing bipolar disorder is the importance of a consistent sleep schedule. A flight to Japan requires more than just a passport and an eye mask. We need to discuss their strategies to achieve adequate sleep, and identify a support network, should sleep deprivation lead to a dangerous manic episode. I have heard frightening stories of individuals, unaware of the danger of sleep loss, who have found themselves ill and wandering the streets of a foreign city, recklessly seeking out connection without the self-awareness to protect themselves from danger.
Many people just like my father struggle with insomnia, and may be prescribed medications that are inadequate at best, and carry significant morbidity risks at worst. These sedative-hypnotics are designed for short-term use, but are frequently continued beyond the recommended time frame. Again and again, patients describe a short-term prescription of sleeping pills leading to several years, even decades, convinced they cannot sleep without their clonazepam, Ambien, even Benadryl. A gentle exploration often reveals fear that I will “take away” what has worked for them. However, when we dig deeper, we usually come to the mutual conclusion that the sleeping pills have not provided the quality sleep they believed they would.
The lasting benefits of cognitive behavioral therapy for insomnia (CBT-I) have been demonstrated repeatedly and it is recommended as the first line treatment for insomnia by the Clinical Guidelines of the American Academy of Sleep Medicine, Center for Disease Control, and National Institute of Health. However, a shortage of providers trained in CBT-I significantly limits the availability of this effective treatment option, particularly in rural areas like my hometown.
Typically a 6-week therapy, CBT-I has also been modified for brevity in primary care offices. In addition to the sleep hygiene recommendations such as keeping technology out of the bedroom, and avoiding large meals and exercise directly before bed, patients learn techniques to improve their sleep efficiency (i.e. number of hours asleep divided by number of hours spent in bed). As a pragmatic physician, I love seeing the rapid results during a course of CBT-I. Often it takes only 1-2 sessions to notice a striking change in their sleep patterns and self-confidence. More than one patient has said “I can’t believe I’m already sleeping so well. Where was this therapy 20 years ago?”
As my parents age, their challenges with sleep have intensified. My father, a classic “morning lark,” would be in bed by 8pm if social activities, or my mother’s gentle teasing, didn’t preclude such behavior. My mother, on the other hand, watches her BBC dramas late into the evening, reporting “I can’t sleep, just like my mother.” Any physician who has tried to treat a family member recognizes the challenge I face in guiding them to better sleep. I try to sneak in some recommendations between anecdotes about their grandchildren, but I imagine they would prefer to take medical device from someone they hadn’t previously seen talking to her stuffed animals in her princess pajamas. I don’t blame them.
The growing number of individual suffering from chronic insomnia, with our without other mental health issues, suggest we simply need more providers working in this area, along with novel delivery methods for care. Individuals like my parents, as well as patients I treat in my practice, all deserve the numerous health benefits of restful, high-quality sleep.
Interested in Dr. Reid's online course in CBT for Insomnia? Download your free guide to better sleep habits here, and sign up to learn more about the course.
Sites to search for CBT-I Providers:
Society of Behavioral Sleep Medicine
American Board of sleep Medicine