Chains of thoughts storming your mind while you twist and turn, unable to sleep?
You jolt up with a nightmare and find it impossible to sleep again?
Burning the midnight oil on several nights, waiting for your eyes to tire out?
Sleeplessness, also known as insomnia, is a sleep disorder, in which people have trouble sleeping. They may have difficulty falling asleep or staying asleep for desired periods.
Insomnia is extremely common. Between 10 percent and 30 percent of adults have insomnia at any given point in time, and up to half of individuals worldwide have insomnia in a given year, making it the most common sleep disorder.
Older people and women are affected much more.
Around eight in every hundred individuals have insomnia lasting for over a month which heavily impacts their quality of life.
Insomnia is typically associated with,
Irritable (and at times depressed) mood
It affects learning, memory, attention and leads to high risk of road traffic accidents.
Post the COVID pandemic there has been a steep rise in insomnia cases, especially on the backdrop of lockdown, loss of routine, impaired work-personal life balance, work from home, limited social interaction, lack of mobility, increased digital exposure and rise in mental health conditions (such as depression and anxiety).
First-line healthcare workers and older people are among the worst affected by insomnia according to research.
Based on a study published in the Lancet in 2021 by Almoradi and colleagues, pooled data from 39 countries indicated that 31 percent of healthcare professionals, 18 percent of general population and 57 percent of COVID-19 patients suffer from insomnia.
For most of them, sleep problems were associated with anxiety disorders, depression and grief.
Long term sleeplessness may be caused by a slew of reasons, including,
Urinary tract infection
Certain medicines and addictive substances (such as caffeine, nicotine, and alcohol).
Ok, so insomnia is problematic. Now, what do you do to manage your sleeping woes? What can help you rest when your mind has wandered off in long search of sleep?
Sleeping Pills: Are These Sedatives The Answer?
Pop in one, and you pass out and rest – This is a common advice we all receive from our peers. “Just pop in a pill. Don’t stay awake!”.
Sedatives (commonly the medical group of drugs known as Benzodiazepines and Z-group drugs) are one of the commonest sold and prescribed medication in India.
Based on the official report submitted in 2019 by the National Drug Dependence Treatment Center (NDDTC), All India Institute of Medical Sciences (AIIMS) – about 1.08 percent of 10-75-year-old Indians (approximately 1.18 crore people) are users of sedatives (nonmedical, non-prescription use).
Sikkim, Nagaland, Manipur and Mizoram were the states with the highest level of sedative use. Prescription misuse is extremely common with sleeping pills, as the prescribed dose and duration are often exceeded.
Legislations have their own potholes through which individual 'equations' with pharmacists can easily facilitate access to sleeping pills in our country.
Why so much chatter? Are sleeping pills harmful?
If prescribed by a qualified medical practitioner – Of course, not!
But they have specified doses and duration, which need to be maintained.
However, they are NOT the primary solution for insomnia and considered as the second line of management.
What Are the Pitfalls?
Long term use of sleeping pills can lead to physical and psychological dependence (addiction)
Sudden stoppage can lead to rebound increase in sleep problems, anxiety, restlessness
Increased risk of falls, problems in memory and attention, risk of accidents, and daytime drowsiness
Over a period of time, many people need an increasing dose of sedatives as the original dose fails to work (a phenomenon known as tolerance)
A perceived ‘lack of sleep quality’ and ‘sleep satisfaction’ without the sedatives
Sleeping pills can change sleep architecture (electrical activity in the brain while one sleeps)
One of the most important functions of sleep is to consolidate our memory and processing of emotional content. Sedatives can interfere with that.
What Can Be Done Instead?
Sleep is a psychological process. You cannot induce it, and neither can you fight it.
A constant apprehension and worry about sleep will interfere in the sleeping process. Besides such thoughts, there are set assumptions and misconceptions about sleep that perpetuate sleeplessness.
Unrealistic sleep expectations
Myths about sleep quantity/quality and causes of insomnia
Performance anxiety (trying and trying to sleep)
Fear of the consequences of insomnia (hence catastrophizing the situation)
These factors can be modified through Cognitive Behaviour Therapy (CBT) which involves weekly sessions with a clinical psychologist. These sessions can also be delivered virtually.
CBT for insomnia (CBT-I) have specially designed modules. Some of these treatments include stimulus control therapy, sleep restriction, sleep hygiene, improved sleep environments, relaxation training, paradoxical intention and biofeedback.
The principles are simple and involve regulating the sleep-wake cycle and modifying the thought process (fear) maintaining the sleeplessness.
Lifestyle changes become extremely important. This forms the basis of treating insomnia, especially sleep hygiene.
Avoid daytime naps
Avoid frequent lying down during the day (Your body counts it as sleep and will cut down from the night’s quota)
Avoid large meals, carbonated beverages, alcohol and nicotine before bedtime
Maintain at least an hour gap between dinner and bedtime
Maintain a regular sleeping and waking up time
Soothing ways to relax before sleep (white noise)
Avoid phone gazing / net surfing when you cannot sleep
Keep the bedroom cozy as per your choice
Regular exercises / Yoga
Importantly, insomnia can be a harbinger of depression and also risk for suicide. Hence, promote and take professional help whenever necessary. Especially for older people, sleeplessness is a frequent marker of depression and anxiety disorders, which otherwise are easily missed.
It’s extremely easy to pop in a pill. It’s also easy to prescribe one. Both save time and encourage the reluctance for lifestyle changes. But they cannot be a permanent solution!
Yes, we do prescribe sedatives for a fixed duration when necessary, and they have their own role in management of insomnia. But please avoid self-prescribing or consumption based on your 'Google doctor'! They will only do more harm than good.
This World Sleep Day, the theme is 'Sleep is essential for health'.
Let’s incorporate a healthy lifestyle, and adequate sleep hygiene and promote mental wellbeing – for restful nights of healthy sleep.
(Dr. Debanjan Banerjee is a psychiatrist, Co-Chair, Advocacy and Awareness Committee, International Psychogeriatric Association (IPA), and Chair, IPA Old Age Awareness Week Task Force 2022.)