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Are Doctors Sleepwalking Through Treating Your Insomnia?

Desperate to get a good night’s rest, insomniacs may be forgiven for counting sheep, popping an allergy pill or drinking a glass of wine. While all of these have only the slightest connection to promoting a deep, restful sleep, doctors may not be able to do much better.

Despite a growing list of sleeping pills that have gained the government’s stamp of approval, doctors seem to be treating insomnia with just about everything else. The number one prescribed drug for restless sleepers is Desyrel, an anti-depressant that has never been approved for insomnia. Close on its heels are similar treatments for depression, along with sedative drugs that are meant to treat conditions ranging from bipolar disorder to allergies.

Vaughn McCall, MD, chair of the department of psychiatry and behavioral medicine at Wake Forest University, said that these drugs can make people drowsy enough to fall asleep. Even so, he cautioned, "there’s very little evidence that they work for insomnia."

Indeed, a great deal of confusion surrounds the question of what is the best approach to treat the millions of Americans who have chronic sleep problems. At a special insomnia meeting organized by the National Institutes of Health (NIH), the best that a panel of experts could come up with was a call for further research.

"There are many gaps in the scientific literature that need to be filled." said Alan Leshner, MD, who headed the NIH panel.

The Difference with Insomnia
Just about everyone will have a bad night’s sleep at some point, but insomnia can keep people tossing and turning for months on end. Drugs called benzodiazepines are specifically designed to treat chronic insomnia. The Food and Drug Administration (FDA) has also approved a group of newer sleeping pills, including Ambien, Sonata and Lunesta.

But there has been a puzzling shift in the management of sleep disorders, said McCall, which dates back to the 1980s. Between 1987 and 1996, the number of prescriptions for FDA-approved insomnia medications dropped by 54 percent, while the use of Desyrel and other sedating anti-depressants increased 146 percent.

McCall, who presented these findings to the NIH panel, said that this change is probably related to the fact that antidepressants are far easier to prescribe. The FDA requires strict safeguards on sleeping pills because they carry the risk for addiction and abuse. As a result, McCall said, "doctors are more vulnerable to prosecution when they give these drugs for a prolonged time."

Yet, unapproved treatments for insomnia are not without their own risks, he pointed out. Desyrel, for example, is associated with low blood pressure. This can be especially troublesome for older people, where a rapid drop in blood pressure can lead to dizziness and falls. Various sedatives can make people feel groggy the next morning, and in the case of using the anti-anxiety drug Ativin, this sluggishness can last one or two days.

"My personal concern is that many patients are being treated with unproven medications." said Leshner.

How to Really Treat Insomnia
Leshner and other NIH-panel members said that the one of the best ways to treat insomnia does not rely on drugs at all. Cognitive behavior therapy, which combines two forms of psychological methods, has proven highly effective at combating insomnia. The cognitive part trains people to understand how their thinking can cause sleep problems, while the behavioral component helps them overcome sleepless situations. The only trouble is finding a practitioner who is skilled enough to teach these methods. Insomnia patients can turn to psychiatrists and sleep specialists as a resource, panel members said.

Although many restless sleepers turn to over-the-counter remedies, such as anti-histamines or herbal remedies, like melatonin and valerian, the panel said there is little evidence that these work for insomnia. McCall agreed that cognitive behavior therapy should be the first choice, but it takes weeks to learn, and when faced with needing a good night of sleep immediately, many will want to take the easy route.

Changing behavior is a lot harder than taking a pill." he said.

One sleep drug, Lunesta, can be safely used for at least six months, according to the FDA. Charles Zorumski, PhD, a psychiatrist at the Washington University School of Medicine who was on the NIH panel, said that Lunesta and other new sleeping pills appear to have less potential for abuse than the older drugs. Still, he cautioned, "they are a controlled substance."

"Absolutely." said Leshner, who used to head the National Institute on Drug Abuse.

Given the concerns about growing dependent on sleeping pills, McCall recommends using the lowest dose over the shortest amount of time. He has even prescribed anti-depressants to some sleep deprived patients.

"It’s like Cinderella finding that perfect fit." he said.