Doctors and the Sleeping Pill Question

The use of sleeping pills is on the rise, with 8 percent of Americans now using them at least a few nights a week. By some folks’ lights this is not a good thing. Doctors are too quick on the draw with the prescription pad, is a complaint I often hear.

But I’ve had more experience with doctors of the opposite persuasion, who declare they don’t do sleeping pills at all.

Some doctors are comfortable prescribing sleeping pills and others aren'tThe use of sleeping pills is on the rise, with 8 percent of Americans now using them at least a few nights a week. By some folks’ lights this is not a good thing. Doctors are too quick on the draw with the prescription pad, is a complaint I often hear.

But I’ve had more experience with doctors of the opposite persuasion, who declare they don’t do sleeping pills at all. I’ve moved quite a few times over the years and had to change health plans and doctors, and I’ve come across several of these pharmacological Puritans. The minute I mention even occasional use of sleeping pills for insomnia and ask for a prescription, I morph into Hester Prynne with a scarlet letter on my chest: “A” for Ambien.

I know these drugs have their downsides, and there are certainly reasons to avoid them. Arguably there are better ways to deal with insomnia over the long term. But if a prescription is simply not on the table for discussion, I have to wonder what century these doctors think they’re living in.

One Woman’s Experience

I met May as I was conducting interviews for my book. A soft-spoken retired mathematics professor, May had reported sleep problems to her doctors for years. One advised going to a mental health clinic, but aside from poor sleep she wasn’t having any problems so she didn’t pursue it. Another suggested taking Benadryl, but May had read that antihistamines had negative side effects so she decided not to do it. A third doctor simply checked a box for sleep problems on his patient history form and moved on.

One year May took matters into her own hands. “I took my cat’s Valium,” she said. “My cat was prescribed Valium and since he slept all the time, I tried taking them. Not every night, though — I’ve read too much about getting addicted. I took them just about five times a month. They were 2 mg tablets and I would break them in half.” One milligram of Valium – hardly enough to make a wombat blink – taken every five or six days was all it took to give May the best year’s sleep of her life.

Where, oh where, is the harm in that? I know some people are prone to abusing sleeping pills, and physicians are rightfully leery of prescribing them to patients they suspect might take that path. But May would be the last person to use pills unwisely, and after years of treating her as a patient, her doctors should have known that.

A Different Approach

Humor, I sometimes think, might be a way to avoid the awkwardness of raising the issue of sleeping pills with new GPs. The minute the doctor walks into the consulting room, I announce my credentials as a pharmacological conservative. “The truth is,” I tell the doctor, “I don’t like drugs. My mother was a Christian Scientist so I grew up thinking they were evil. I’ll never ask for an antibiotic. When I get a cold, not even Tylenol crosses my lips. But when it comes to getting to sleep, pure thoughts don’t always suffice …”

I’m sleeping a lot better these days, so I don’t feel the need for as many sleeping pills as before. But I don’t have much patience for pharmacological Puritans. If a doctor responds to my request for a prescription with a lecture, our relationship is history. I’m out the door.

 

Short Sleep Affects Personality

Short sleep—sometimes defined as sleeping less than 6 hours a night, and other times defined as sleeping less than 5—is associated with a higher risk of hypertension, obesity, and type 2 diabetes, investigators at Penn State Hershey have said. Some research has even shown there’s a link between short sleep and increased mortality.

Now a new study finds that short sleep also has effects on personality.

short-sleepShort sleepers get short-changed in more ways than one. Short sleep—sometimes defined as sleeping less than 6 hours a night, and other times defined as sleeping less than 5—is also associated with a higher risk of hypertension, obesity and type 2 diabetes, investigators at Penn State Hershey have said. Some research has even shown there’s a link between short sleep and increased mortality.

A new study published in the International Journal of Behavioral Medicine finds that short sleep also has effects on personality. European investigators Sakari Lemola and colleagues, after evaluating medical data on about 1,800 Americans aged 30 to 84, concluded that people who sleep less than 6 hours a night are less optimistic than people who sleep 7 to 8 hours a night, and that short sleepers have lower self-esteem.

Pessimism and low self-esteem are also characteristic of depression. But even when the researchers controlled for symptoms of depression, the relationship between short sleep and decreased optimism and self-esteem held up.

The Upshot

This study supports a growing awareness that the amount of sleep people get can affect their sense of well-being. And it adds to the body of research suggesting that short sleep is linked to poorer health. “Longitudinal studies indicate that optimism and self-esteem are predictors of better health rather than just consequences,” the authors write.

One limitation of the current study is that, unlike the protocol followed at Penn State Hershey, short sleep was assessed subjectively rather than being objectively validated in a sleep lab. And a major caveat in all the short-sleep studies is that none of them allow for assumptions about causality. Whether short sleep actually leads to lower optimism, lower self-esteem and poorer health or vice versa is not known.

Still, it gets harder and harder for anyone to say that people who consistently experience short nights should just buck up and bear them. If there’s any silver lining to the cloud, this is it.

Awake in the Middle of the Night

The bed—so sleep experts maintain—should only be used for sleep and sex. People who can’t sleep should get up and do something: iron shirts, look at picture books, plan a backyard stupa. Anything, for God’s sake, but toss and turn among the sheets.

I know I should follow this advice. But every fiber of my body cries out for staying flat on my back.

The bed—so sleep experts maintain—should only be used for sleep and sex. People who can’t sleep should get up and do something: iron shirts, look at picture books, plan a backyard stupa. Anything, for God’s sake, but toss and turn among the sheets.

This bit of advice has always put me off. Especially when I wake up in the middle of the night and can’t fall back to sleep, I’m bone-tired and brain-dead. I can barely face getting out from under the warmth of the covers to go to the bathroom, let alone contemplate walking downstairs, turning on a light and settling down with a book. Every fiber of my body cries out for staying flat on my back.

Making Hay While the Darkness Reigns

But I’ve met insomnia sufferers of the middle-of-the-night-awakening type who decided at some point that they were not going to take their wakefulness lying down.

My former colleague Claudia is a journalist with a greeting card business on the side. She used to lie awake fretting when she couldn’t fall back to sleep. Now when she wakes up at 1 a.m., she goes upstairs to make birthday cards.

“It’s like playing around,” she says. “It takes my mind off everything, and sometimes I think it helps me mellow out a little, too.” After working a couple of hours on her cards – an activity she says is fun but not cerebral – she crawls back into bed again and can usually get a few more hours of shut-eye. She’d rather deal with insomnia this way than take sleeping pills.

Marty is another example. Self-employed, he goes to bed around 9 p.m. and uses the time he’s awake in the middle of the night to work on an online newsletter. “I do my best writing between 2 and 5 in the morning, “ Marty says. Then he goes back to sleep for another hour and a half. He’d like to sleep more, and to get all his sleep at one go, but his body seems to have different needs.

Bimodal Sleep in Nights Past

Historian A. Roger Ekirch claims this pattern of broken sleep was actually common before 1800, when people lived without artificial lighting in their homes. Ekirch has found several references to nights in which people took their “first” sleep from about 9 or 10 p.m. to somewhere past midnight. Then they got up to brew a tub of ale or chat with neighbors, or they stayed in bed to pray, make love or meditate on dreams. At last they fell into a “second” or “morning” sleep that lasted until dawn.

Experiments conducted by sleep researcher Thomas Wehr in the 1990s suggest this bimodal pattern of sleep is the pattern humans might well fall into today in the absence of artificial lighting. Our modern lights-out period lasts for seven or eight hours a day year-round. But in temperate climates in the pre-industrial era, during the winter months when darkness lasted 14 hours, people spent a lot more time in rest and relaxation.

When Wehr re-created these conditions by giving his experimental subjects a 14-hour sleep window, they settled into a routine in which their sleep fell into two distinct periods. One came at the beginning of the “biological” night and one at the end, with a period or periods of quiet wakefulness in between. Wehr concluded that bimodal sleep may actually be more “natural” than the consolidated sleep period that is the norm today.

The notion may not be reassuring to insomniacs unable to turn middle-of-the-night awakenings to their advantage, or whose work or families demand that they be up at the crack of dawn. Nor does it jibe with the thinking of most sleep experts, who suggest that a consolidated period of sleep is for the insomniac the Holy Grail. But if segmented sleep really does come more naturally to some poor sleepers, then the Claudias and Martys may be better off going with the flow.