Sleeping Pills: More Sleep or Better Sleep?

I roll my eyes when I see articles about how we humans are prone to miscalculating sleep time—in particular, people with insomnia. We tend to underestimate how long we sleep, and the conclusion is often that if we knew how long we were really sleeping, we wouldn’t complain so much.

That’s not the message of the latest of these articles, written by Derek Thompson in The Atlantic. Thompson looks at how the quest to prolong sleep ties in with the use of sleeping pills—but I think his analysis falls short.

count-sheepI roll my eyes when I see articles about how we humans are prone to miscalculating sleep time—in particular, people with insomnia. We tend to underestimate how long we sleep, and the conclusion is often that if we knew how long we were really sleeping, we wouldn’t complain so much.

That’s not the message of the latest of these articles, written by Derek Thompson in The Atlantic. Thompson looks at how the quest to prolong sleep ties in with the use of sleeping pills—but I think his analysis falls short.

Yes, We Are Unreliable

To show how unreliable we are at estimating sleep, Thompson presents data from two surveys. In one, Americans report averaging 6 hours and 45 minutes of shut-eye a night. In the other, Americans report an average of 8 hours and 42 minutes’ sleep—a whopping two-hour difference. He goes on to cite a sleep study in which New Yorker writer Elizabeth Kolbert thought she lay awake for 3 hours before finally drifting off. In reality, according to the study, she fell asleep within 10 minutes of getting in bed.

Not only are we in the dark about how much time we’re sleeping, Thompson says. The number of insomnia diagnoses and sleeping pill prescriptions has more than quintupled since 1990, yet Americans not sleeping any longer today than they were then. He concludes by suggesting that we need more accurate data about how long we’re sleeping and better drugs.

My Take

I’m all in favor of calling for better sleeping pills. The ones we’ve got now—like Ambien and Lunesta—have side effects and alter the nature of the sleep we get. But I’d like to steer the conversation away from the unreliability of our sleep estimates and the idea that prolonging sleep should be the main gauge of a drug’s effectiveness.

There are explanations for why humans—especially people with insomnia—tend to miscalculate how long we sleep. It’s easy to perceive Stage 1 sleep, the earliest and lightest stage, as wakefulness. In a retrospective study published in October 2013, Belgian investigators found that as we fall asleep, people with insomnia tend to have more high-frequency activity occurring in our brains than do normal sleepers. This suggests a higher degree of information processing, which may feel like wakefulness rather than sleep. In another recent study, German researchers found more high-frequency activity occurring in the brains of insomniacs during Stage 2 sleep.

No wonder we’re unreliable at estimating sleep time. Some of the sleep we get feels like wakefulness. So the real culprit for some of us may not be sleep length at all. It may be our poor sleep quality—an inability to shut the brain down completely and keep it offline for a sustained period of time.

In Search of Sleep Quality

There’s no definitive way to measure sleep quality today; it can’t be assessed in a sleep lab. But a recent meta-analysis of sleep studies concludes that people with insomnia get less deep sleep—associated with feelings of restoration—and less REM sleep—associated with dreams and emotional processing—than good sleepers. Maybe these are not exactly measures of sleep quality. But I’ve got a hunch they’ve got something to do with it.

What insomniacs need is not just information about how long we’re sleeping, and it may not even be that we need drugs that greatly prolong our sleep. The real problem for many of us is poor sleep quality.

Hey, Big Pharma, give us drugs to improve that.

What are your main sleep complaints? If you’ve tried sleeping pills, have they helped?

Animal Sleep: A Few Fun Facts

Envy is what I feel about the sleep of cats. They’re unconscious the second they close their eyes!

The sleep habits of some wild animals are even stranger.

cat-on-guitarEnvy is what I feel about the sleep of cats.

They’re unconscious the second they close their eyes!

Location doesn’t seem to matter, or comfort, or security.

 

 

Could a champion sleeper like my husband sleep with his chin wedged between boards or draped around the wheel of a truck? I don’t think so!

cat-on-wheel2Unlike us, cats sleep like predators. They blithely snooze away for up to 13 hours every day.

Sleep needs and sleep characteristics differ quite a bit from one species to the next:

  1. Giraffes sleep very little– less than two hours a night–and can go for weeks without any sleep at all. Large grazing mammals with relatively slow metabolisms seem to need the least amount of sleep. Other short sleepers are horses, donkeys, and elephants.
  2. Small meat-eating mammals with high metabolisms need lots of sleep. At the long end of the continuum is the brown bat, that sleeps nearly 20 hours every day. Bats’ wings aren’t strong enough to propel them into flight from a standing position. So they sleep upside down, which enables them to fall into flight when they sense danger.
  3. Like humans, all mammals experience rapid eye movement (REM) sleep, when dreams occur. During REM sleep dogs bark and make running movements with their legs. Platypuses make movements similar to those they make when stalking and killing crustacean prey.
  4. Dolphins’ sleep is “unihemispheral.” While one hemisphere of the brain is asleep, the other is awake, enabling these marine mammals to swim to the surface and breathe even as they’re sleeping.
  5. Ducks that sleep at the end of a row, where they’re more exposed to danger, often sleep with one eye open—the eye facing outward–to better watch out for predators. Birds sleeping at the edge of a flock do the same.
  6. Some birds sleep on the wing. The bar-tailed godwit flies 7,200 miles from Alaska to New Zealand in eight days without touching down for refueling or sleep. The most likely explanation is that they’re able to fly with parts of their brain asleep while at the same time keeping other parts awake.

If you’ve noticed anything funny or unusual about the sleep of animals close to you, please take a minute to share it!

Quick Quiz on Sleep

How much do you know about sleep? See if you can answer these eight questions correctly. Check your answers at the bottom of the page.

computer-quizHow much do you know about sleep? See if you can answer these eight questions correctly. Check your answers below.

1. Most dreams occur

a)      At the beginning of the night

b)      In the middle of the night

c)       At the end of the night

2. We sleep most deeply

a)      At the beginning of the night

b)      In the middle of the night

c)       At the end of the night

3. In a sleep cycle, we move from light sleep to deep sleep and back to light sleep, and then into REM sleep. How many sleep cycles do we typically go through each night?

a)      2-3

b)      4-5

c)       6-7

4. Rapid eye movement (REM) sleep is when most dreams occur. During quiet (non-REM) sleep, the brain is mostly inactive. The 3 stages of non-REM sleep are stage 1 (very light), stage 2, and stage 3 (deep sleep). Healthy adults spend the greatest percentage of the night in

a)      Stage 2 sleep

b)      Deep sleep

c)       REM sleep

5. During deep sleep, there’s a spike in

a)      testosterone

b)      Melatonin

c)       Growth hormone

6. The pineal gland starts secreting melatonin

a)      About 2 hours before bedtime

b)      When it gets dark outside

c)       Just before we enter deep sleep

7. Which of the following is untrue? As we age,

a)      We get slightly more REM sleep

b)      We get less deep sleep

c)       Men experience more dramatic sleep stage changes than women.

8. Which is the most common sleep problem?

a)      Restless legs syndrome

b)      Insomnia

c)       Sleep apnea

 

ANSWERS

  1. C. About 80 percent of our dreams occur in the last half of the night.
  2. A. Deep sleep is discharged in the first half of the night.
  3. B. 4-5 cycles/night
  4. A. About 50 percent of the night is spent in stage 2 sleep.
  5. C. The production of growth hormone spikes during deep sleep.
  6. A. Melatonin secretion begins about 2 hours before bedtime.
  7. A. REM sleep slightly decreases as we age.
  8. B. Insomnia is the most common sleep problem.

How did you fare? Let me know if any of these answers need explaining.

Is Quality Sleep for Sale?

When it comes to sleep, I’m convinced that quality is more important than quantity. Hands down, I’ll take 5 ½ hours of sound slumber over restless dozing that stretches out for 7 hours.

So I have mixed feelings about sleeping pills. Many meds invented to give us more sleep degrade the Zzzz’s we get and can actually worsen insomnia.

pharmacyWhen it comes to sleep, I’m convinced that quality is more important than quantity. Hands down, I’ll take 5 ½ hours of sound slumber over restless dozing that stretches out for 7 hours. So I have mixed feelings about sleeping pills. Many meds invented to give us more sleep degrade the Zzzz’s we get and can actually worsen insomnia.

The case of Michael Jackson is relevant here. Propofol, the hypnotic Jackson was given by Dr. Conrad Murray for sleep, knocked Jackson out but robbed him of precious REM sleep. Sixty days of propofol injections amounted to the equivalent of Jackson being sleepless for 60 straight days, Harvard sleep specialist Charles Czeisler testified during Jackson’s wrongful death trial, according to Time Magazine online. The accumulated effects of propofol may have led to Jackson’s untimely death.

Of course, propofol is an anesthetic, not a sleeping pill. It has never been approved for the treatment of insomnia, likely because it so radically alters the nature of the sleep it provides. But sleeping pills also affect sleep quality, and it’s important to understand how.

What Does Quality Sleep Look Like?

There is no objective measure of sleep quality. But normal sleep consists of both REM sleep (when we’re dreaming) and non-REM, or quiet, sleep. Deep sleep is a key component of the non-REM sleep. Apparently we need a certain amount of both REM and non-REM sleep (particularly deep sleep) to survive.

REM Sleep Deprivation

Subjects deprived of REM sleep are moody and emotional and have memory problems. Barbiturates—sleeping pills widely prescribed through the 1970s—put people to sleep but, like propofol, deprived them of REM sleep. Nightly users who tried to stop taking drugs like Nembutal and Seconal experienced “REM rebound”—nights fraught with terrifying dreams.

REM rebound was so awful that it led people to resume taking the drug, and eventually to drug dependency and ever-increasing doses, sometimes resulting in overdose and death. This is why barbiturates are rarely prescribed for insomnia anymore.

Deprivation of Deep Sleep

Subjects deprived of deep sleep have memory and learning problems, experience compromise of various bodily systems, and typically wake up feeling unrested. Benzodiazepine drugs such as Restoril, Halcion, and Ativan—which are prescribed for insomnia today—reduce the amount of deep sleep users get. They may keep you sleeping longer, but, if you take them for prolonged periods, you wake up feeling unrefreshed.

What about the popular “Z-drugs,” zolpidem (Ambien) and eszopiclone (Lunesta)? Taken nightly, they too may result in small reductions in deep sleep, although not to extent that benzodiazepines do. And zolpidem was recently discovered to increase the occurrence of “sleep spindles”–events during non-REM sleep that, in excess, heighten users’ memory for negative events.

I’ll be the first to argue that sleeping pills have a place in the treatment of insomnia. I don’t have patience for pharmacological Puritans who insist they be avoided at all costs. Yet to use them—especially for long periods—is a little like robbing Peter to pay Paul. Keep this in mind as you’re deciding if and when to pop an Ambien.

If you’ve used sleeping pills for extended periods, what effect did they have on your sleep?

A New Look at Trazodone for Sleep

Trazodone has never been approved for the treatment of insomnia. Yet it rose to the top of the bestseller charts as a medication for sleeplessness in the 1990s and enjoys great popularity still. Here’s one explanation for its appeal.

It’s been a stretch for me to accept that trazodone, a sedating antidepressant, is such a popular treatment for insomnia. Clinical trials have never shown it helps put people to sleep or keeps them sleeping longer. And even at low doses (50 mg.), the drug is known to produce cognitive and motor impairments the following day.* Trazodone has never been approved for the treatment of insomnia, yet it rose to the top of the bestseller charts as a medication for sleeplessness in the 1990s and enjoys great popularity still.

Trazodone

Confession: this is the sort of knotty paradox that keeps me awake at night.

Now, I have insomniac friends who swear by trazodone, and I know they’re not delusional. They use low-dose trazodone because it works for them, and they don’t need to understand why.

But I’m a stickler for evidence, and this gap between subjective experience and objective proof is a real sore point. So imagine my thrill at finding a paper that explains why it might be that trazodone works.

Trazodone and REM Sleep

The traditional view of insomnia holds that it’s basically a problem of non-REM (or quiet) sleep. Insomniacs may not be getting the same percent of deep sleep as good sleepers, or the problem may be in how deep sleep is discharged. Deep sleep is the restorative stuff, the kind that “knits up the raveled sleeve of care.” Alternatively, the quality of non-REM sleep may be compromised by lots of high-frequency brain activity that enables you to sense things even while you’re asleep.

But for insomniacs who struggle with frequent awakenings in the middle of the night, the problem may in fact be occurring during REM (or active) sleep, when you’re dreaming. A new analysis shows that percent-wise, people with sleep maintenance insomnia get less REM sleep and awaken more often during REM sleep than good sleepers. The hypothesis is that these insomniacs may be suffering from “REM sleep instability.”**

Despite its otherwise underwhelming characteristics as a sleep medication, trazodone does cut down on nighttime awakenings and make sleep feel easier. Unlike most other antidepressants, the drug does not suppress REM sleep. So as a sleeping pill, trazodone may have a claim to legitimacy after all.

Perhaps you’re one who knew it all along, but I was a skeptic, and this bit of news has done wonders for my sleep!

Effects of Trazodone

** REM Sleep Instability

Tired of Waking Up to a Bad Mood? Try Dreaming

Waking up on the wrong side of the bed often has to do with being short on sleep, and in recent years scientists have begun offering theories about why this is so.

Rosalind Cartwright’s research suggests that one function of sleep is the down-regulation of negative emotion so we can wake up in a happier frame of mind.

P1000151It’s one of those days: you’re depressed and defeated the moment you open your eyes. The weight of things you should have done and all the things you need to do makes it a struggle to crawl out of bed. Or it’s the kind of day when you wake up feeling sullen and out of sorts. Anyone who crosses your path—partner, child, colleague, friend—gets the crabby treatment.

Waking up on the wrong side of the bed often has to do with being short on sleep, and in recent years scientists have begun offering theories about why this is so.

Sleep scientist Rosalind Cartwright discusses her theory in her latest book, The Twenty-Four Hour Mind: The Role of Sleep and Dreaming in Our Emotional Lives. Cartwright’s research suggests that one function of sleep is the down-regulation of negative emotion. This leveling out of emotion does not occur during quiet sleep, which takes place mostly in sleep cycles in the first half of the night. Rather, it occurs toward the end of the night during episodes of REM sleep, when you’re having dreams.

REM Sleep Deprivation

The evidence that REM sleep regulates mood comes mainly from studies where subjects have been deprived of REM sleep. Invariably, they awaken in a bad mood. Overall they’re more fearful, more easily thrown off kilter by problems that arise during the day, and less able to enjoy events that would normally bring pleasure.

So how could REM sleep deprivation lead to waking up in a bad mood? Cartwright notes that the majority of dreams with emotional content are disturbing rather than pleasurable. The function of these disturbing dreams, she claims, is to enable you to process the negative experiences you have during the daytime.

How Dreaming Works

Your waking experiences get reactivated during sleep, carried forward into REM sleep, and matched to memories of earlier experiences of a similar emotional tone. Dreaming does not lead to the forgetting of recent disturbing events but rather helps to defuse their emotional charge. You then awaken in a more positive frame of mind.

So getting a full night’s sleep helps you smooth out negative emotions and stock up on emotional reserves. If you can’t sleep your fill, whether you’ve gotten to sleep too late or awakened too early, it’s REM sleep and dreaming that often get shortchanged. And “loss of REM,” Cartwright says, “may equal direct expression of negative mood.”