Insomnia and the sleep racket

[Guest guest]

The sleepless epidemic

MARINA JIMENEZ From Saturday's Globe and Mail

November 15, 2008 at 1:09 AM EST

For years, Stacie Fox feared the night. From the moment she went to

bed, sleeplessness taunted her. Just as she began to drift off, it

would jerk her awake again. As a result, she waded through her days

with aching joints, swollen glands and a leaden heart. " I felt like I

was 80, " says the 32-year-old actor from Burlington, Ont. " I felt like

the whole world was going to end. My brain was in a fog. "

Using makeup and her acting skills to hide her exhaustion, she tried

everything she could think of escape her insomnia. A dairy-free diet.

Acupuncture. Massage therapy. Tai chi. Good sleep hygiene (no caffeine

or alcohol, no TV in the bedroom). She even went to the Matrix

Repatterning Centre in Aurora, Ont., where naturopathic doctors

claimed to help " correct the imbalance in soft tissue, organs and bones. "

Her family doctor tested her thyroid, liver and kidneys, her levels of

blood sugar and cortisol, the " stress hormone. " The results all came

back normal. Then her doctor prescribed sleeping pills.

Imovane, a tiny, bitter blue piece of magic, sent her into a sweet,

sustained slumber. Comfort, at last. She slept like a baby.

Actor and insomniac Stacie Fox of Burlington, Ont.

Many are loath to admit it, but more and more people both in Canada

and the United States are fed up with punching the pillow until dawn.

Consumption of sleeping pills has increased dramatically in the past

five years. Prescriptions for zopiclone, the generic name for Imovane,

rose 49 per cent from 2003 to last year, according to industry tracker

IMS Health Canada, while those for all sedatives went up 15 per cent.

Canada's pharmacists filled 5.6 million prescriptions for sleep

medication last year, representing $128-million in sales. IMS says 60

per cent of users are women, more than half of them between 40 and 60.

In the U.S., the phenomenon is even more remarkable: Sleeping-pill use

increased 60 per cent from 2000 to 2005, prompting Forbes magazine to

dub the business a $20-billion (U.S.) " sleep racket. "

" It's a virtual epidemic, " says Lipsitz, medical director of

the Sleep Disorders Centre of Metropolitan Toronto.

Sleep experts pin the increase on several factors: newer drugs

(Imovane here and Lunesta and Ambien in the U.S.), aggressive

advertising south of the border and a poor grasp of the mysteries of

sleep itself. About 10 per cent of the population suffers from

insomnia, but its causes are not well known. For some, such as Ms.

Fox, it is chronic. For others, it is situational, brought on by

divorce, or sudden stress, such as the recent global financial

meltdown. Even the hormonal changes women undergo in middle age can

make sleep more difficult.

Today's medications are much safer than those of the past – less

addictive and less likely to cause a hangover – but doctors still

prefer to prescribe them on a short-term basis only. Even so, many end

up taking them for months, even years, without knowing just how much

damage that may do to their health.

Most sleeping medication is tested, and approved, for up to four

months' use (the U.S. decision to allow Lunesta prescriptions to run

longer has sparked controversy). But even in the short term, the pills

can impair memory and co-ordination.

Stacie Fox never imagined that five years later, she would still be

taking Imovane. " Insomnia has defined my life, " she says. " It's

embarrassing. People are so quick to judge, and say, `This is your

problem,' implying it is all in my head.

" After my doctor put me on pills, there was no real follow-up. I had

to spend years searching for the causes of my own insomnia. " LIKE

SMOKING A JOINT

Taken properly, Dr. Lipsitz says, " sleeping pills don't cause

long-term medical problems, but neither do they solve insomnia. "

and , two old friends living in Toronto, know that, and

yet they still turn to Imovane when they crave a good night's rest.

Both are in their mid-40s and overwhelmed by the demands of juggling

children and their careers (afraid of repercussions, neither wants her

real name used). They look forward to the pills the way they enjoyed

smoking a joint in high school.

" On a recent girls' weekend, " says , a civil servant, " I brought

along magazines, jelly beans and a stash. I stopped drinking wine at a

certain time so I could take a sleeping pill. "

, who works in publishing, nods. " We called it our

`sleep-cation.' Some people feel it is a sign of weakness. But it's

something you know everyone is doing but no one ever talks about. "

adds: " No one ever says Imo-what? But at the same time it's a

personal issue, like discussing your salary or what deodorant you use. "

People have long relied on chemicals to wind down. Barbiturates such

as Seconal depress the nervous system, and were made famous in

n's 1966 novel Valley of the Dolls (the three main

characters all take " dolls " to get to sleep). By the 1970s, a new drug

family – the benzodiazepines, known as Valium and Halcion – came into

widespread use. Although still addictive, they were considered less

dangerous than Seconal.

Now, the zoplicones rule, and at least some of the current sales spike

can be attributed to aggressive promotion south of the border for

Lunesta. In 2005, the year it was introduced, its manufacturer spent

$270-million (U.S.) on advertising that featured a green moth that

lands on a teacher as she sleeps. In the morning, the moth flies out

the window, and the teacher has a fabulous day.

Canada prohibits the advertising of prescription drugs, and Lunesta

isn't available here, but viewers can see commercials for it and

Ambien, a similar product from Sanofi-Aventis, on American channels

and crave the relief they bring.

But the limitation of sleep aids is that they address the symptom,

insomnia, not what's causing the problem. Dr. Lipsitz believes the

inability to sleep is almost always a symptom of another problem –

ranging from stress, depression and anxiety to migraines and high

blood pressure.

But a minority of patients have insomnia as a primary diagnosis and

can't overcome it, no matter how much they meditate, or how many

massages they get. And nobody really knows why some people sleep so

soundly, while others wake up at the slightest sound.

Most sleep clinics concentrate on sleep apnea, a disorder that

obstructs the upper airway and is easier to diagnose. Insomnia affects

many more people but has no magic diagnostic test – and no cure.

Family doctors rarely have time to take a patient's " sleep history, "

or explore underlying psychological or physical issues, but some steer

insomniacs toward cognitive behavioural therapy (CBT) instead of the

drugstore.

Such therapy focuses on a patient's approach to sleep and, according

to psychologists, works well for about 80 per cent of people. It takes

much more time and effort than just popping a pill, but Jaan Reitav, a

Toronto clinical psychologist accredited by the American Academy in

Sleep Medicine, says a clinical trial conducted in Norway compared the

effect of CBT and Imovane on 46 adults and found the pills lost their

effectiveness after six months, while CBT did not.

Despite her early success with medication, Stacie Fox soon had to

increase her dosage, and then change to another product. At one point,

she went to a sleep lab, which said she was suffering from apnea and

fitted her with a special mask to keep her air passage open. However,

she couldn't get comfortable and would fling it off a night.

" It didn't solve my sleep problems, " she says, whereas the medication

gave her some rest, and let her carry on with her life and career. She

appeared in a recent TV commercial for WestJet and plays a naughty,

biscuit-snatcher in a Peek Freans ad.

A TYPE-A PERSONALITY

These days, she is trying a more holistic approach. She sees a

counsellor to address the root causes of the anxiety that she now

suspects is the real cause of her insomnia. As well, she attends a

workshop at Eli Bay's Relaxation Response Institute in Toronto that

she credits with teaching her to relax. " I am a type-A personality.

The on switch is always on and I don't know how to turn it off. "

There also may be a family connection. Her father suffered from

insomnia, as has her sister, Fair, for the past eight years.

Medication has provided relief to Ms. Fair, a 34-year-old hairstylist

with a six-year-old daughter. " There is a comfort certainly in finally

being able to take a pill, to have the luxury of falling asleep, " she

says. " People take it for granted, but when you cannot sleep, it is

very debilitating and really affects every facet of your life. "

Ms. Fair says there is a social stigma to resorting to medication, but

people are beginning to open up about their sleeping difficulties. " If

you're a diabetic, people don't slam you for taking insulin. "

But for some, such as Toronto civil servant Amana Karim, nothing seems

to work. The self-described " hard-core, lifelong insomniac " has tried

therapy, psychiatric sessions and sleep clinics, to no avail. Her

doctor has prescribed various sleeping aids, and they worked only for

a time.

" I would love to have my brain scanned to see what is going on there, "

says the 59-year-old native of Guyana. " Something is off. It's like a

computer chip that won't let me fall asleep. "

Her insomnia is so crippling, she says, it put strain on her

common-law marriage, which has since ended. She often turns down

invitations to the theatre or concerts because she is so exhausted she

has to turn in by 9 p.m.

Gayle Greene has heard hundreds of stories like Ms. Karim's since she

started her website, sleepstarved.org. " They are just desperate for

help. It is an amazingly awful thing, " says Ms. Greene, who teaches

English at Scripps College near Los Angeles.

She is also the author of Insomniac, a book published last spring and

recently praised by the New England Journal of Medicine for its

critique of specialists who have overlooked the role of neurobiology

and genetics in insomnia. She feels the problem is " so psychologized

and neuroticized " because doctors don't under-

stand the condition and are looking for " a way of passing the buck

back to the patient. "

Ms. Greene takes medication to sleep, and bemoans the lack of funding

for insomnia research. The National Institutes of Health spent just

$20-million in 2005 – a mere fraction of the $270-million spent to

advertise Lunesta that year.

Experts agree with her. Morin, director of the Sleep Research

Centre at Laval University in Quebec City, says more is known about

anxiety, depression and stress. " We don't know the biological

mechanisms behind the inability to sleep, " he says.

In fact, says Culebras, a neurologist at Upstate Medical

University in Syracuse, N.Y., " to try to understand insomnia through

psychological means is tantamount to investigating the structure of a

house by looking at the roof. We need to start researching the

foundations. "

For example, are women really worse sleepers than men, or are they

just more likely to seek help?

Some progress is being made. Recently, researchers studied images of

an insomniac's brain and discovered something Dr. Culebras calls

" hyper-arousal " – a persistent alertness despite the need for sleep.

In patients suffering from fatal familial insomnia, an incurable

condition that can kill within a year of its onset, there are

degenerative lesions in the thalamus, situated in the front of the brain.

" Sleep is a function of the brain, " he explains, " and sleeplessness is

the consequence of brain dysfunction. "

A SLEEPLESS GENERATION

and aren't hard-core insomniacs. But they believe that a

good night's rest is their due – and that it gives them a competitive

advantage over young up-and-comers in the workplace. And, in a life

where there is so much they cannot control, sleeping medication

guarantees when and how long they will sleep.

knows it is not natural to have to work as hard as she did in

her 30s, but there is often no choice. On nights when she lies awake

watching the clock, anxiety about missing sleep only fuels her

insomnia. She cannot chair a meeting, or present complex research

results on two hours' rest. " I think there is an entire generation of

people with sleep disorders, " she says.

, who has a one-year-old at home and works full-time, says she

feels she needs " seven hours of rest to enhance my performance. "

But is it possible that such expectations are too much – that there

never was such thing as a great night's sleep? In pre-industrial

Europe, for example, sleeping for eight consecutive hours wasn't

normal, American historian Ekirch says. While in Britain to

research his 2005 book, At Day's Close: Night in Times Past, he

discovered what he calls " segmented sleep. "

" The consolidated, seamless sleep we enjoy today was not the norm in

the 19th century, " he says on the phone from Virginia Tech, where he

teaches. " There is no idyllic past in terms of sleep. "

Instead, people slept for two to three hours, surrounded by braying

animals, people emitting terrible smells, and other environmental

disturbances. They awoke at midnight for one or two hours, and then

settled back down for a second " dawn " slumber.

In the interval, people stoked the fire, made love, prepared the next

day's meal, stole apples from the neighbours, prayed, meditated or

reflected upon their dreams. " Basically, they did anything and

everything imaginable, " Prof. Ekrich says with a chuckle.

His findings resonate with those of scientists at the National

Institute of Mental Health in Washington D.C., who have conducted

clinical research into segmented sleep and found that, without the

interference of artificial light, many people naturally slept in two

phases. " Insomniacs may simply be experiencing this pre-industrial,

once-dominant pattern of sleep, " Prof. Ekrich says. " Many insomniacs

find this a relief to know it's not a mental-health issue, and they

are not abnormal. "

But insomniacs who cannot spare a 10-hour block of time for

" segmented " sleep may still reach for the bitter blue pills to get

what they need.

" When you don't sleep, you look at the world through a dark storm

cloud and feel so hopeless, " Stacie Fox says.

" I feel ripped off of five years of my life. "

Marina Jimenez is a senior feature writer with The Globe and Mail.

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