Sleepless No More

Most insomniacs don’t seek professional help until they’ve endured months or years of chronic sleeplessness. By then, they’re reliant on over-the-counter medications or alcohol—or both—but nothing really does the trick anymore.

Only a minority of insomniacs ever mentions sleep loss to a doctor, though, and then it’s only in the context of other problems more likely to get addressed. Despite the ubiquity of sleep problems, physicians often haven’t been taught how to handle them.

University of Rochester sleep expert Michael Perlis cites a “pharmacologic renaissance” in the management of sleep problems. Newer drugs like Ambien (zolpiden) and Sonata (zaleplon), so-called nonbenzodiazepene hypnotics, improve the quality of sleep without destroying sleep architecture. People wake up feeling refreshed. “But most drugs are in fact underused,” he argues. Perlis blames what he calls “pharmacologic Calvinism”—fears that some pleasurable aspect of these drugs will lead to addiction.

Still, drugs are costly and work only for as long as they are taken. Equally effective in curbing sleep problems in the short haul (four weeks of therapy) is a version of cognitive behavioral therapy specific for insomnia (CBT-I). However insomnia starts, it is maintained by behaviors that began as attempts to compensate for sleep loss. CBT-I tackles the behavioral problems of insomnia head-on and holds the promise of working in the long haul.

But it’s not easy, and patients get worse before they get better. CBT-I takes people from mere fatigue (mental and physical weariness) to true sleepiness by restricting sleep. That, explains Arthur Spielman, “doesn’t feel good, but it jump-starts the sleep homeostat” and deepens sleep. He is among the growing ranks of clinicians who believe that CBT-I, which has been called “the jewel in the crown of psychology,” should always be considered for treating chronic insomnia.