Insomnia: Are Primary Care Doctors Still Getting It Wrong?

It’s not always easy to find help for insomnia. Several people I interviewed for “The Savvy Insomniac” reported that their primary care doctors didn’t seem to take the complaint seriously or prescribed treatments that didn’t work.

I thought the situation must have changed since persistent insomnia is now known to be associated with health problems down the line. But a recent report on the Veterans Affairs (VA) health system shows that insomnia is still overlooked and undertreated by many primary care providers.

Here’s what you may find—and what you deserve—when you talk to your doctor about sleep.

Insomnia is not always treatable by primary care providersIt’s not always easy to find help for insomnia. Several people I interviewed for “The Savvy Insomniac” reported that their primary care doctors didn’t seem to take the complaint seriously or prescribed treatments that didn’t work.

I thought the situation must have changed since persistent insomnia is now known to be associated with health problems down the line. But a recent report on the Veterans Affairs (VA) health system shows that insomnia is still overlooked and undertreated by many primary care providers.

Here’s what you may find—and what you deserve—when you talk to your doctor about sleep.

Insomnia Addressed in Primary Care

Investigators surveyed 51 primary care providers (PCPs) in the VA system as to their perceptions and treatment of insomnia. About 80% of the respondents said they felt insomnia was as important as other health problems. Yet they tended to underestimate its prevalence and often failed to document its presence.

Other research has shown that the prevalence of poor sleep quality among veterans is extremely high: over 70% in veterans without mental illness and even higher in veterans with a mental health diagnosis. Yet most PCPs surveyed estimated that only 20% to 39% of their patients experienced insomnia symptoms. When insomnia emerged as a problem, only 53% said they regularly entered it into their patients’ medical records.

Insomnia Conceived Of as Secondary Problem

Scientists now have plenty of evidence that insomnia is a disorder in its own right—regardless of whether it occurs alone or together with another disorder. Yet many PCPs seemed to view it as merely a symptom or a condition secondary to another disorder.

All of the PCPs endorsed the belief that when insomnia occurs together with a health problem such as depression and PTSD, successful treatment of the depression or PTSD will eradicate the trouble sleeping. Current scientific evidence does not support this belief.

Insomnia Treated With Sleep Hygiene

The first-line insomnia treatment recommended by the American Academy of Sleep Medicine and other professional organizations is cognitive behavioral therapy for insomnia (CBT-I). CBT-I is available at VA facilities.

Even so, the insomnia treatment PCPs most often recommended to their patients was counseling on good sleep hygiene. But sleep hygiene doesn’t work as a stand-alone treatment for insomnia. What’s more, it may make the prospect of CBT-I less palatable, given that some CBT guidelines call for behavioral changes that resemble the rules of good sleep hygiene.

Still Getting It Wrong

It seems like primary care doctors are just as outdated in their conception and treatment of insomnia as they were 10 and 20 years ago. I’m not alone in voicing this concern. Here’s how Michael Grandner and Subhajit Chakravorty titled their commentary on the survey results: “Insomnia in Primary Care: Misreported, Mishandled, and Just Plain Missed.”

There’s no ambiguity here.

Help You Deserve From Your Doctor

Your PCP may be responsive to your complaint of insomnia and current in his or her knowledge of how to diagnose and treat the condition. If so, well and good.

But your doctor may not be quite so on the ball when it comes to dealing with trouble sleeping. Don’t let that deter you from seeking help for insomnia elsewhere. A good doctor will:

  1. Respond to concerns about insomnia as attentively as he or she would to concerns about double vision or shortness of breath. Insomnia can be debilitating, and chronic insomnia can result in changes that compromise health and quality of life. A doctor who dismisses it as trivial or hands you the rules for good sleep hygiene before waving you out the door is not the right doctor.
  2. Ask questions about the duration, frequency, and severity of your problem, and possible underlying conditions. This type of inquiry is crucial to arriving at an accurate diagnosis and appropriate treatment. Doctors who don’t have the time or knowledge to ask these questions should refer you to someone who does.
  3. Discuss treatment options that are research based and individualized. CBT-I may require referral to a specialist, yet there may be no specialist certified in behavioral sleep medicine practicing in the area. Likewise, a prescription for sleeping pills is useless to a patient who has no intention of filling it. Treatment discussions should be dialogs, and doctors should encourage patient participation.

This is the kind of response we deserve when we bring up the topic of insomnia with PCPs.

But it may not be the kind of response we get. How has your doctor reacted when you’ve mentioned trouble sleeping? (If you found this post helpful, please like and share on social media. Thanks!)

Sleep Hygiene May Keep You From Backsliding

Observing the rules of good sleep hygiene may not work as a standalone treatment for insomnia. But now that I’ve learned to manage my insomnia, I follow most of the rules because they help me maintain sounder, more regular sleep.

Some are especially helpful in preventing backsliding. They may help you, too.

Observing sleep hygiene can hold insomnia at bayObserving the rules of good sleep hygiene may not work as a standalone treatment for insomnia. But now that I’ve learned to manage my insomnia, I follow most of the rules because they help me maintain sounder, more regular sleep.

Some are especially helpful in preventing backsliding. They may help you, too.

Maintain a regular sleep routine.*

After sleeping when I could and all I could for decades, I finally faced the music: consistent bed and rise times were actually helpful to my sleep. Of the two, I think a consistent rise time is the more important. Getting up at the same time every day helps keep circadian rhythms synchronized and allows time enough for sleep pressure to build until it puts you to sleep and keeps you asleep at night.

But life isn’t as regular as clockwork. By the end of the week you may be feeling sleep deprived. To catch up on lost sleep, sleeping half an hour or even an hour later than usual on weekends may not throw your sleep off track.

But when I’m short on sleep, getting extra sleep at the beginning of the night (i.e., going to bed earlier than normal) works better than allowing myself to sleep late. That way, I catch up on lost sleep but avoid setting myself up for Sunday night insomnia.

Don’t watch TV or read in bed.*

If watching TV in the bedroom or reading in bed reliably puts you to sleep, you may want to ignore this rule. In an earlier blog post, I mentioned one sleep expert who finds that reading in bed is exactly the kind of soporific he needs to fall asleep.

For other insomniacs (I was one) engaging in wakeful activities in the bedroom does not reliably put us to sleep. On the contrary, activities such as reading or studying in bed lead to more wakefulness at night. Then anxiety about sleep starts creeping in.

“It’s midnight and I’m still not sleeping,” you may find yourself thinking. “It’s 1 a.m. . . . it’s 2.” If night after night things continue in this vein, simply being in bed starts to cause anxiety about sleep. But anxiety is not compatible with sleep. Insomnia, which may have begun as an occasional thing, becomes a permanent state of affairs.

It’s hard to unlearn this association between the bed and wakefulness and reprogram your brain to expect sleep. At a very minimum, it involves moving every activity except sleep (and sex)—reading, TV watching, grading papers—outside the bedroom, and leaving the bedroom if you find you can’t sleep.

Kicking and screaming, I finally managed to do it: learn to go to bed expecting to sleep rather than lying anxiously awake. And now that I’ve done it, I’m loath to go back. I follow this rule in both letter and spirit, using my bed only for sleep and sex. Period.

Exercise to promote good quality sleep.**

I was never quite a couch potato. I knew a sedentary lifestyle wasn’t healthy, so I jogged, hiked, or rode my bicycle the recommended 3 times a week.

It was when I started to keep a sleep diary that I noticed a correspondence between aerobic exercise and my sleep. After days when I exercised, I fell asleep more quickly and had good quality sleep.

Thirty minutes of vigorous exercise every afternoon hasn’t exactly turned me into a jock. But now I find a daily dose of exercise is something I crave. And when I can’t have it, I get fidgety and sometimes a little bit cross. I don’t fall asleep as easily or sleep as soundly that night.

So I build swimming or working out on the elliptical trainer into my days as regularly as I do my meals. It’s a small price to pay for holding insomnia at bay.

Establish a regular relaxing bedtime routine.**

You may feel exhausted, but going straight to bed after a long, hard day can be a setup for insomnia. It was and is for me. So no matter how late I’m out or how absorbing my daytime activities are, I always make time for a wind-down ritual at the end of the day. Beyond incorporating the necessities (bathing, brushing teeth), a bedtime routine should be calming (no surfing the internet) and enjoyable (no washing the dishes).

Reading a novel works for me. Not only does it divert my attention away from the events of the day. Now that it’s habitual it also cues sleep. Suddenly I’m yawning and nodding over my book. After a few failed attempts to return to reading, it’s time to head to bed. I’m out in a flash.

If you’re a clock watcher at night, hide the clock.*

Viewing clocks at night makes me anxious. It’s another learned association, one I’ve never managed to break. So ever since going through sleep restriction (where I had to watch the clock, which drove my sleep anxiety sky high) at night I simply turn my clocks to the wall.

Observing these rules of sleep hygiene may not cure your insomnia. But once you’ve found a way to manage your sleep, it may keep your sleep more regular.

What change of habit has helped your sleep the most?

*American Sleep Association

**National Sleep Foundation

Saintly Thoughts on Sleep Hygiene

We often hear that Americans are not getting enough sleep. Electric lights (and now screens) are usually cited as the culprits, and Thomas Edison gets blamed for saying we should all sleep less. But the Catholic saints had the same opinion. The shorter their nights were, the more time they could devote to prayer and charitable work.

I just finished reading Father Aloysius Roche’s Bedside Book of Saints, and it’s clear to me that the saints would take issue with several ideas promoted by sleep experts today, including advice for insomnia sufferers looking for a better night’s sleep.

Good sleep hygiene, while useful for insomniacs today, would not appeal to the Catholic saints

We often hear that Americans are not getting enough sleep. Electric lights (and now devices with screens) are usually cited as the culprits, and Thomas Edison gets blamed for saying we should all sleep less. But the Catholic saints had the same opinion. The shorter their nights were, the more time they could devote to prayer and charitable work.

I just finished reading Father Aloysius Roche’s Bedside Book of Saints, and it’s clear to me that the saints would take issue with several ideas promoted by sleep experts today, including advice for insomnia sufferers looking for a better night’s sleep.

 

Most Adults Need 7 to 8 Hours of Sleep a Night

I doubt the saints would agree. The story is that Saint Macarius went without sleep for 20 days at a time but lived to the ripe old age of 90. Such a steady diet of sleep deprivation would surely be the ruin of modern Americans. We hear about the nasty consequences of sleep deprivation all the time: Insulin resistance will develop and later, diabetes. Stress hormones will flood our bodies and put us at risk for heart disease. Plaques will form in our brains. Dementia will set in.

Likewise, Saint Elphide, Saint Colette, and Saint Catherine de Ricci purportedly went for long periods without sleep.

Did they suffer as a result? No, says Father Roche. Going without sleep was “a miraculous privilege akin to that of those who lived without any other nourishment than the Holy Eucharist.”

Go to Bed and Get Up at the Same Time Every Day

Saints in the contemplative orders might agree with this advice, bound as they were to rigid schedules 24/7. But not Saint Catherine of Siena. She embraced insomnia, sleeping briefly every two nights. This she called “paying the debt of sleep to the body.” As if to say, “Sleep is a bother, but at least I can dispense with it every other night.”

Make the Last Hour before Bed a “Wind-Down” Time

The need for a “wind-down” period before bed would probably have puzzled the saints. Sure, life was full of mortification and risk-taking for the boldest among them, yet they had one big advantage over most of us today, says Father Roche: their minds and hearts were in a habitual state of tranquility.

“The Saints were free from the guilty worries and anxieties which undermine the repose of the worldly,” he writes. “They had that most restful of all pillows—a good conscience.”

So there would be no need to wind down at the approach of bedtime. On the contrary, the saints often did their best to stay awake. Saint Dorotheus kept himself up making mats. Saint Jerome tried to stay awake and when he found himself nodding off, he “dashed himself upon the ground.” (Readers undergoing sleep restriction, take note!)

Make Sure Your Bed Is Comfortable

The saints would have dismissed the notion of a comfortable bed as self-indulgent. Why sleep in comfort when there were other, more righteous ways to sleep: on the ground (Saint Martin of Tours), on the straps at the bottom of a chair (Saint Dominic), or sitting upon a stone (Saint Pachomius).

Saint Charles Borromeo normally slept in a chair. He was eventually persuaded to sleep on a mattress, but it had to be made of straw. His advice for people complaining about a cold bed was rather chilly, notes Father Roche:

“The best way not to find the bed too cold is to go to bed colder than the bed is,” the saint said.

Do Not Read in Bed

The saints would definitely have disagreed with this rule of good sleep hygiene. Pious reading was exactly what one was supposed to do in bed (when not praying).

And maybe Saint Jerome’s advice will be useful for at least some insomnia sufferers looking for a better night’s sleep: “Let holy reading be always at hand,” he said. “Sleep may fall upon thee as thou lookest thereon, and the sacred page meet the drooping face.”

Insomnia and Napping: No One-Size-Fits-All Prescription

If you have insomnia, you’ve probably heard it’s best to avoid naps. Maybe you heard it from your doctor in a conversation about the rules of “good sleep hygiene,” or maybe you read it in a magazine. Is the advice to refrain from napping really sound advice and, if so, do you have to swear off napping completely to get a better night’s rest?

There are no one-size-fits-all answers to these questions, say researchers who recently reviewed the evidence behind the recommendation to avoid napping and other sleep-related do’s and don’ts. It depends on your age and situation.

Chronic insomniacs should avoid naps, but people whose sleep problems are less severe need not abstainIf you have insomnia, you’ve probably heard it’s best to avoid naps. Maybe you heard it from your doctor in a conversation about the rules of “good sleep hygiene,” or maybe you read it in a magazine. Is the advice to refrain from napping really sound advice and, if so, do you have to swear off napping completely to get a better night’s rest?

There are no one-size-fits-all answers to these questions, say researchers who recently reviewed the evidence behind the recommendation to avoid napping and other sleep-related do’s and don’ts. It depends on your age and situation.

Chronic Insomnia

If you’ve got chronic insomnia (trouble sleeping at least 3 times a week for at least 3 months accompanied by daytime impairments), then forgoing naps may improve your sleep. Research has shown that the pressure to sleep builds higher and higher during the daytime and is released at night during deep sleep. Napping during the daytime may result in the early discharge of some of the sleep pressure. This can make it harder for people with persistent insomnia to fall asleep and stay asleep at night.

Accordingly, if you go through cognitive-behavioral therapy (CBT) for insomnia, you’ll be asked to refrain from napping during treatment. The fact that CBT works as well as it does supports the idea that cutting out naps is a useful strategy for insomniacs who want to improve their sleep at night.

What should you do if you can’t survive without a nap? Sleep therapists may recommend the following:

  1. Keep the nap short—30 minutes or less—to avoid descending into deep sleep
  2. Refrain from naps in the evening, when the pressure to sleep is high.

Mild or Occasional Sleep Problems

If you’re basically healthy and your sleep problems are occasional or less severe, then it’s not so clear that cutting out naps will help. Nor is it evident, in insomnia associated with aging, that the benefits of napping don’t compare favorably next to the difficulties created when the nap is cut out.

Napping occurs more frequently as people age, so the subjects in most studies of napping in naturalistic settings have been older adults. The results have not been consistent from one study to the next. However, the majority have not identified a significant association between daytime napping and nighttime sleep in older adults. Nor did researchers who conducted a study involving healthy young and middle-aged nappers find such an association.

Adding a Nap

Researchers have also looked at how adding a nap into people’s daily schedules affects their sleep at night—mostly in middle-aged and older adults. Here, too, the results are mixed. In some studies, naps resulted in shorter, less efficient sleep at night; in other studies, the naps had absolutely no effect on nocturnal sleep.

Of note is the fact that no researchers have ever conducted a study to determine whether depriving habitual nappers of their naps actually improves their sleep at night.

So the recommendation not to nap that appears on the list of habits consistent with good sleep hygiene? Unless you have chronic insomnia, for now, take this recommendation with a grain of salt. There may be other more effective paths to reliably sounder sleep.

If you take naps, what effect do they have on your sleep at night?

Sleep Hygiene: Revisiting the Rules

A few weeks ago I blogged about managing insomnia by doing whatever works. It turns out that sleep experts (some of whom also struggle with insomnia) flaunt a few rules of good sleep hygiene themselves—regardless of recommendations they make to us.

exercise-nightA few weeks ago I blogged about managing insomnia by doing whatever works. It turns out that sleep experts (some of whom also struggle with insomnia) flaunt a few rules of good sleep hygiene themselves—regardless of recommendations they make to us.

You’ve heard that insomniacs are not supposed to read, eat, or watch TV in bed? Sleep expert David N. Neubauer has a qualified view on this.

“I think the ‘no reading in bed’ rule makes sense for chronic insomniacs,” Neubauer, associate professor at Johns Hopkins University School of Medicine, is quoted as saying in an article in Huffington Post, “but I find reading relaxing. I feel like I can put the book down when I get tired.”

Dr. W. Christopher Winter, medical director of the Martha Jefferson Hospital Sleep Medicine Center in Charlottesville, Virginia counsels his patients to work out early in the day. Yet he himself gets more of a benefit from exercising at 10 or 11 p.m. He also takes daytime naps—another thing insomniacs are routinely advised to avoid.

How Much Stock Should You Put in the Rules of Sleep Hygiene?

The suggestions you see in magazines and on the web exist for good reasons. Either they’re validated by scientific studies—such as the rule about going to bed and getting up at the same time every day—or based on observations made by clinicians, such as the advice to get up and do something when you can’t sleep rather lying in bed awake.

But each and every rule may not have value for all insomniacs. How could it be otherwise, when the sleepless are such a motley crew? Some of us have trouble getting to sleep; others, trouble staying asleep. Bad nights leave some insomniacs with short tempers; they leave others of us with brains that rattle along in second gear and never reach cruising speed.

Such a diverse array of symptoms implies to me that the causal mechanisms of our insomnias are probably different. So how could remedies proffered to the masses be uniformly beneficial to all?

Overall, I think we’re wise to pay attention to the rules of good sleep hygiene. But we’re also wise to experiment and find what works best for us.

Which rules of sleep hygiene are helpful to you, and which are not?

Insomnia? The Doctor Is Out to Lunch

I’ve had some excellent medical care over the years, but when it comes providing help for insomnia, many doctors are out to lunch. They grab hold of a single idea about insomnia—it’s due to poor sleep hygiene, it’s due to stress, or it’s due to psychic damage that needs to be sorted out—and treat insomniacs as if we’re all alike.

Insomnia and DoctorsI’ve had some excellent medical care over the years, but when it comes providing help for insomnia, many doctors are out to lunch. They grab hold of a single idea about insomnia—it’s due to poor sleep hygiene, it’s due to stress, or it’s due to psychic damage that needs to be sorted out—and treat insomniacs as if we’re all alike.

I’ve spoken with several other insomniacs who feel the same way. Especially irritating are the doctors convinced that every person with insomnia has a mood disorder.

Jennifer’s Story

Jennifer, whom I interviewed a few years ago for my book, had tried several drugs to combat the sleeplessness she’d been plagued nearly all her life, and her doctor finally referred her to a psychiatrist. But the psychiatrist’s attempts to peg her as a depressive contradicted her belief that, apart from her sleep problem, she was basically a happy person.

“He was like, ‘Oh you look depressed today, I think you’re depressed.’ He kept trying to convince me I was depressed.”

“I’m like, ‘I’m not depressed.’ It was really annoying.”

“If I moved my fingers around at all, he was like, ‘Oh, you’re fidgety, you’re fidgety.’”

“I’m like, ‘OK.’ So I learned to keep my fingers still when I was around him.”

“And he’d say, ‘Oh, you’re calm today.’ He was just so eager to think he was doing something right. I stopped seeing him because it got to the point where he was trying to convince me that I was depressed when I was not.”

“I’m not depressed,” Jennifer continued. “Most people think I’m the cheerful one, open, outgoing. I don’t sit at home and cry. I’m not sad about things. I don’t have one single symptom except that I can’t sleep.”

Bill’s Story

Bill had a similarly negative experience with doctors who he believed had misdiagnosed his sleep complaint as depression:

“The doctors want to suggest that I’m depressed, and I deny it. I say I’m exhausted,” he said when I spoke with him on the phone. “The only time I really admit to something approaching depression is when you guys [the doctors] start trying to pin a DSM cultural label [a mental disorder] on me.”

Not All Insomniacs Are Alike

It’s true that many people with insomnia are also afflicted with mood disorders, but not all of us. The causes of insomnia are many and varied, and while sleep experts now acknowledge this, many other doctors are still in the dark.

Peter Hauri, a pioneer in sleep research who died two months ago, said in an interview in 2010 that one of the most important things he learned from his research was that every sleep problem was unique. “There is no one set of rules that can be mimeographed and given to every patient who comes into the office,” Hauri said.

Amen, I say. But how long will it be before medical schools start turning out doctors who are similarly savvy about insomnia and sleep?

What experiences have you had talking about insomnia with doctors? Have they explored the problem to your satisfaction, or not?

 

Coffee and Sleep: Are They Compatible?

I came of age when drinking caffeinated beverages was frowned on for people like me. Sleep experts exhorted people with insomnia to “stay away” from caffeine; a story in Working Woman stated that “the stimulant effect of coffee may last as long as 20 hours.”

Warnings like these made me feel guilty about indulging my java jones. Were my two cups of coffee, one at wake-up time and the other later in the morning, keeping me awake at night?

There’s nothing I love more in the morning than coffee. From the acrid smell of the grounds and the steam wafting upward with the first sip to the slightly bitter taste and the thrill of my world coming into sharper focus, no drink comes close to satisfying me like a piping hot café au lait.

But I came of age when drinking caffeinated beverages was frowned on for people like me. Sleep experts exhorted people with insomnia to “stay away” from caffeine; a story in Working Woman stated that “the stimulant effect of coffee may last as long as 20 hours.” Warnings like these made me feel guilty about indulging my java jones. Were my two cups of coffee, one at wake-up time and the other later in the morning, keeping me awake at night?

Unlikely, is the message I came away with from a sleep seminar I attended a year ago. “They’ve gone overboard on this one,” said behavioral sleep medicine specialist Michael Perlis, referring to the recommendation to steer clear of caffeine as part of good sleep hygiene. Studies where subjects have taken caffeine right before bedtime show that the drug interferes with the timing and quality of sleep. But used judiciously in the morning or even mid-afternoon, Perlis says, caffeine can reduce the daytime impairments associated with insomnia without harming sleep at night.

Moderate Use of Caffeine in the Morning

A recent study from the University of Pittsburgh School of Medicine bears this out. Researchers reviewed data collected from 65 insomniacs and 29 good sleepers with three questions in mind:

1)   how did the use of caffeine – and the plasma concentrations of its main metabolite, paraxanthine — compare between the two groups,

2)   was use of caffeine related to increased caffeine and paraxanthine plasma concentrations in the insomniacs compared to the good sleepers, and

3)   did caffeine consumption affect subjects’ sleep, and did the effect differ in insomniacs and good sleepers?

Researchers found no differences between the two groups in the amount of caffeine they consumed (no one drank more than 4 cups of coffee a day) or plasma concentrations of caffeine and paraxanthine. Nor did subjects differ in when they used caffeine, with most reporting use early in the day. And – here is the key finding – the caffeine had little if any impact on any of the subjects’ sleep, assessed both subjectively and objectively in a sleep lab.

“This study demonstrates that low to moderate caffeine use” (mainly in the morning) “did not have a powerful effect upon sleep in either good sleepers or primary insomniacs,” the authors conclude.

People differ in their sensitivity to caffeine and the speed at which their bodies metabolize it, so decisions about when and how much to use are individual matters. Me, I turn a deaf ear to caffeine purists these days. No way am I going to break off my steamy morning affair with Java Joe.