In search of a good night's sleep

Who among us hasn't spent a night-or maybe more-tossing and turning, longing for sleep, and looking for the dawn? According to the American Insomnia Association, more than a third of American adults experience occasional insomnia, nearly half have brief periods of difficulty sleeping, and 1 in 10 is plagued by chronic insomnia (lasting two weeks or longer). In our highly stressed society, where people work too hard, stay up too late, and worry too much, sleep deprivation is a common problem that can lead to more serious illnesses, accidents, or low productivity.

No wonder so many medical researchers are looking for the key to a good night's sleep. At Brigham and Women's Hospital (BWH), for example, investigators are conducting studies that examine the effects of sleep deprivation on nurses, medical residents, and healthy volunteers.

Other scientists at the hospital are working with NASA to find ways for astronauts to adapt to the length of day on the international space station or on other planets. "We're looking at the best sleep cycle, the best pattern, and medications that can help advance or delay people's internal body clock," says Dr. Sanjay Patel, an instructor of medicine at BWH's Sleep Medicine Division and Harvard Medical School.

A few blocks away, at Beth Israel Deaconess Medical Center (BIDMC), investigators are studying the brains of people with narcolepsy, a chronic neurological disorder that causes them to fall asleep at inappropriate times.

Sleeping too much
By some estimates, 1 in 2,000 people in the U.S. suffer from the disorder. But there may be far more than that, says Dr. Tom Scammell, associate professor in neurology at BIDMC and Harvard Medical School. About half of all Americans with narcolepsy don't know they have it.

Scammell explains that recently researchers have discovered the cause of narcolepsy to be a deficiency in a brain chemical called hypocretin. His team is investigating whether people with narcolepsy fail to produce the chemical or whether the neurons that make the chemical have been injured, and if so, what causes the injury. They are also starting a clinical trial that examines the link between narcolepsy and a slower-than-normal metabolism.

"This is a frustrating problem for people with narcolepsy," says Scammel. "They often gain weight despite eating a normal amount of food."

Pills vs. therapy
By far the most common sleep problem among Americans is insomnia, the inability to fall asleep even when they're tired. Gone are the days when people simply treat the problem with a warm glass of milk. The majority of patients who seek treatment for insomnia today are prescribed sleeping pills. With sleeplessness being such a widespread problem, drug companies are working overtime to develop pills that safely send the nation into dreamland. That's good news for some people, says Dr. Gregg Jacobs, author of the book Say Goodnight to Insomnia (Henry Holt, 1999).

"There are definitely new and better sleeping pills coming out now and in the future." But, he adds, they aren't appropriate for everyone. The most commonly prescribed sleeping pills are Sanofi- Synthelabo's Ambien and King Pharmaceuticals' Sonata, along with benzodiazepines and antidepressants. New drugs in development include Sepracor's Estorra, Neurocrine Biosciences' Indiplon, Takeda's melatonin agonist, and a sustained-release Ambien.

But while these new drugs may have fewer side effects than existing remedies, Jacobs cautions, they do not cure insomnia. Sleeping pills are good for shortterm problems, such as jet lag, or a major stressful event that causes sleeplessness, such as the death of a loved one, says Jacobs, who is also a professor of psychiatry at Harvard University and a sleep psychologist at the Sleep Disorders Center at BIDMC. But "they are not appropriate for chronic insomnia." Why not? Pills don't work that well, and they don't work for everyone, says Jacobs. That means some people can "take multiple pills and still be up all night." In addition, many people who take sleeping pills over the long term develop "psychological dependence." That is, they fear not being able to get to sleep if they don't take a sleeping pill, which becomes a problem of its own. Last, even if the pills do work, they only work while a person is taking them. "Every study shows that once you stop taking the pills your insomnia comes right back," says Jacobs. "At some point, you might as well deal with the source of the problem, which the pills don't do."

A treatment plan
The best way to treat chronic insomnia's underlying causes, says Jacobs, is through a kind of therapy known as cognitivebehavioral therapy, or CBT. CBT is based on the idea that chronic insomnia is learned and can be unlearned. People who undergo CBT learn to modify stressful, inaccurate thoughts about sleep, modify maladaptive sleep behaviors, improve relaxation skills, and improve lifestyle practices that affect sleep. The Sleep Disorders Clinic at BIDMC is one of the few in the country that specializes in CBT for insomnia, says Jacobs. But he adds that patients don't have to visit a clinic. Studies show that CBT is also effective when administered through books or online.

For 80 percent of patients, CBT produces clinical improvement, says Jacobs. For the remaining 20 percent, medication is an appropriate treatment. By far the most common sleep problem among Americans is insomnia, the inability to fall asleep even when they're tired.