Dr. Glazer: In order to function properly, we need to have enough sleep. Many patients do not get enough sleep. Whether that's due to psychiatric or medical reasons that is something we need to understand better.

William Dement, MD, PhD (Narrator): It's my pleasure to introduce an excellent program for you on how poor sleep affects the overall health of our patients. Almost every patient who is seen either in a family practice clinic or in specialty clinics does have something wrong with their sleep, and that if you address sleep problems, improvements can be made.

I've been surprised many times at the high prevalence and the good that can be done. So now it's very important that we're starting to translate all of the knowledge that has been accumulated into clinical practice.

Dr. Glazer: Dr. Becker, is there such a thing as normal sleep, and if there is, how would you define it?

Dr. Becker: There is normal sleep, although that simple question may have a complex answer. Let me keep it simple. Sleep is that time of rest that restores function. In a human, it means that the sleep is occurring at night, and it should be approximately 8 hours in an adult. But there are certainly differences with age and lifestyle.

In the sleep laboratory, we define sleep according to 5 stages. There's light "stage 1 sleep" through the deeper "stage 4 sleep." This is a transition, diagramed in this picture, through some steps that go down. Then there's the remarkable cycling of rapid eye movement sleep. These are occurring at approximately 90-minute intervals that will lengthen as the night goes on, although there are certain disorders and types of sleep that we are talking about in the program.

Dr. Glazer: What factors contribute to abnormal sleep?

Dr. Becker: We can all have a bad night of sleep, and there are lots of factors that can contribute. There are predisposing factors that may contribute to these difficulties. These are things such as underlying personalities (some people have always been poor sleepers, and will remain poor sleepers), the effects of circadian rhythms, and aging. We'll talk about some of the effects of aging.

Beyond this, there are precipitating factors. When we are under stress for any reason (situational, environmental, etc) it may be enough to push us over the edge and lead to these problems.

Probably the most important factors that we're concerned about are the perpetuating factors. We can't do a whole lot about the predisposing factors; we can deal with the precipitating factors when they arise. We would like to learn how to deal with perpetuating factors (poor sleep hygiene, conditioning factors that develop) and prevent an initial or short-term insomnia from becoming a chronic or persistent difficulty.

Dr. Glazer: And of sleep disorders, insomnia is by far the most common category?

Dr. Becker: Insomnia is the most common, absolutely.

Dr. Glazer: You defined normal sleep. What is the definition of insomnia?

Dr. Becker: Insomnia is a key factor, not only about sleep, but also about issues of next-day consequences. We can have difficulties falling asleep, difficulties staying asleep, or nonrestorative sleep, but these are the consequences on daytime function that determines whether this problem is insomnia.

Dr. Becker: The time focused assessment of insomnia is a key issue in terms of not only how the nighttime effects are felt during the day, but also how the daytime affects the nighttime. The operational discussions of insomnia include early morning awakening, onset insomnia, and maintenance insomnia. Each of these, in an investigation by Perlis, show that approximately 40% of individuals with chronic insomnia would have 1 of these 3 types, some having 2 or all 3 types.

Then there's the "wake zone," that time of day wherein we find ourselves unhappy, tired, slowed down, nervous, or anxious; where there is change in physical activity, headaches or pain, gastrointestinal (GI) malfunctions, fibromyalgia, and many other things that during the day show the consequences of the poor non-restorative sleep.

Dr. Glazer: I found this diagram very useful, and I learned that patients will fluctuate through different phases of sleep disorder. It's not always mid-morning awakening or difficulty falling asleep; it varies in the person from time to time.

Dr. Becker: Individual people will have individual presentations, which may change over time.

Dr. Glazer: Dr. Becker, what do we know about the prevalence of abnormal sleep?

Dr. Becker: The prevalence is approximately 10% across various industrialized nations. This chart shows different places and different studies across the world at time points over the last 10 years or so. The low prevalence is about 9% having chronic insomnia, defined in these studies as at least 2 weeks of poor sleep, up to as much as 18%, although generally we talk about 10% as the amount of expected chronic insomnia in the general adult population.

Dr. Erman: We have similar data from the United States as well, very good data that have been generated. These are data from work done by the National Sleep Foundation in its Sleep in America polls. These data show that about 9% have a chronic problem; about 27% have an occasional problem.

Dr. Erman: There are also survey data from primary care patients. About 50% of patients experience insomnia, for reasons we'll talk about, such as issues of pain, etc. This seems like a very high number to physicians, but it's interesting that only one third of patients ever mention this problem. Only 5% of patients seek treatment from their physicians for these conditions. These numbers may seem high to practicing physicians. But these are real conditions and patients suffer from them.

Dr. Glazer: That's a key point. A lot of people have sleep disorders, and they are not being treated and recognized.

William Dement, MD, PhD (Narrator): At Stanford University in our Sleep Disorder Center, we have been very interested in understanding primary care medical practice. It is very important -- the patients tend not to complain specifically about a sleep disorder. In other words, they don't make a clinical appointment with the problem of insomnia, and then doctors tend not to ask. The main reason for this, of course, is that a patient comes to a clinic for a specific reason, and if you go afield of that specific reason, you're going to take a lot of time and you're going to be off target.

I think physicians can actually encourage their patients to make an appointment to deal with a specific sleep problem, such as a very severe stress-related insomnia. As this cultural change occurs, it's going to make a huge difference in medical practice and in the diagnosis and treatment of sleep disorders.

Dr. Erman: Patients don't make an appointment for other reasons as well. They feel that the sleep problem is their fault. If they simply change their lifestyles (they exercised regularly, went to bed at the right hour, and drank less alcohol and caffeine) they would sleep better, which is true. There are lots of things we can do with sleep hygiene. But many of these patients would have problems no matter what, and it's unfortunate they avoid seeking care.

Dr. Becker: There are other issues too. Since it's so common, and patients know so many other affected people, a patient will look at himself and think, "I really don't seem to have something that the doctor's going to take interest in. Why should I even bring it up? Probably he'll just give me sleeping pills. I don't want sleeping pills. You get addicted to sleeping pills." Those are the issues we will address.

Dr. Glazer: Dr. Becker, what do we know about the impact of sleep disturbance on functioning? Do we have data?

Dr. Becker: There is certainly information, perhaps not as strong as we would like, but in some places we have good information.

This is a summary to try to address that. In the upper right, we see "reduced quality of life." That's certainly the area that patients are most concerned about. There is a higher absentee rate in individuals who have chronic insomnia. They also have increased risks of minor and occasionally major accidents. Of interest are the 40% higher healthcare costs that have been documented in a health maintenance organization (HMO) setting, wherein patients with insomnia of a chronic nature have a much higher rate of utilization of healthcare services.

The cognitive impairments are obviously there. All of us have experienced that, if we found ourselves sleep deprived. There is also the important interaction with psychiatric disorders. Psychiatric disorders result in problems of sleep, but there's also an impact on sleep that will have an impact on the presentation of the psychiatric disorder. Also there are interactions between sleep and medical illness.

Dr. Erman: I think the interactions with medical illnesses are very important. We have a great deal of data on the relationships. A number of disorders are associated with increased risk of insomnia, some of which are obvious in relation to the problems with various disorders of chronic pain, such as hip impairment and back problems. Others are where sleep is going to be disrupted: chronic obstructive lung disease and congestive heart failure.

What's interesting here as well (and we see across the board similar numbers for mild and severe insomnia associated with the most of these conditions) is the difference with depression; there are many more patients with severe insomnia associated with depression, about a 3-fold greater risk.

Dr. Erman: We also have a lot of data on the impact of poor sleep on daily functioning. What we see here is that across the board in terms of these various areas of functioning (coping, mood, personal relationships, etc) patients who have frequent sleep difficulties have the greatest risk of having impairment in functioning.

I think we can all extrapolate from our own experiences with a poor night of sleep, and consequently our next day is not as good as it would be. If we imagine this going on day after day and expect that it will persist day after day, I think we can appreciate why the patients with frequent or chronic difficulties are so likely to have these impairments.

Dr. Glazer: What's the impact of sleep disturbance on psychiatric disorders?

Dr. Becker: I'd like to cite the study of Ford and Kamerow. This was of 8000 Americans in 5 locations; 4 of them were urban, 1 was rural. They all received comprehensive psychiatric evaluation, and in that psychiatric evaluation, there were 2 questions having to do with sleep. One dealt with sleepiness, but the other, which is important to our talk, dealt with the issue of insomnia: 2 weeks or more during the last 6 months, have you had difficulty sleeping?

If the answer was "Yes, for 2 weeks or more I have had difficulty sleeping," we found that approximately 10.2% ended up having problems of insomnia. In terms of the issue of insomnia and the relationships to other types of disorders, in the case of drug abuse and alcohol abuse, 4.2% to 7%, respectively, have a problem.

When we start talking about the more significant issues that impact sleep in the psychiatric category such as dysthymia or major depressive disorder, and if you combine them, since dysthymia and depressive disorder present together, around 23% of patients have insomnia. Anxiety disorders as well are up there at 24%. These major issues result in the fact that 40% of all respondents with insomnia had 1 or more psychiatric disorders, while 16% of the respondents with psychiatric disorders had no sleep complaints.

Dr. Glazer: But this study is associational; we don't know cause and effect from this, which would be more correlational. Dr. Erman, do we know that sleep disturbance causes psychiatric disorder? Any support for that?

Dr. Erman: There are very good data from a number of studies, showing that there are causal relationships, that the presence and persistence of insomnia over time is associated with increased risks of depression. The same Ford and Kamerow data looked at this from a perspective of what happens when insomnia is present on a more persistent basis.

The data show that those who had insomnia at baseline and still had insomnia a year later had about a 40-fold increased risk of developing depression compared with individuals who had no insomnia at baseline; very dramatic data. In addition, there are increased odd ratios for anxiety disorders and other conditions, but I think these are very strong data supporting the notion that the presence and persistence of insomnia is associated with increased risks of depression.

Dr. Becker: Another study that I think is of interest to physicians was a study done at Johns Hopkins University School of Medicine in Baltimore, Maryland. Between the late 1940s and into the early 1960s, a medical questionnaire was completed by all members of the medical school student body.

In a study by Chang, individuals were asked about their sleep, and then followed up for a median of 34 years. Approximately 10% of this group developed problems of depression. When they looked at who had a higher risk, there was a 2-fold increased risk that the people who had insomnia in medical school will develop depression about 30 years later.

If we take just students who, under stress, had trouble sleeping, there was 1.8-fold increased risk in developing depression.

Dr. Glazer: People said, "I normally sleep okay, but when I'm on call overnight, the stress of what's going on really affects me. I can't sleep."

Dr. Becker: That could certainly be one area, but this was during simple times of milder stress, and that was a predictor of the later problems of depression.

Dr. Erman: I think we can extrapolate that if the simple stresses are enough; these people are likely to have a greater impact.

Dr. Erman: We have data from a number of other sources too; about 6 different studies show and reinforce the relationship between insomnia and increased risk of depression. There is some work done by Breslau and colleagues. They looked at an HMO population that they assessed, looking at what happened to patients who had either insomnia complaints or no insomnia complaints. They followed them out for a period of about 3.5 years -- a shorter follow-up than the one in Johns Hopkins School of Medicine data, but with similar results.

We see significantly a greater risk for the development of depression in those patients who had insomnia and had no psychiatric problems at the time of assessment.

There were similar results for anxiety, alcohol abuse, and drug abuse. This is something we see in a number of other studies as well; the presence of insomnia seems to be a risk factor that may increase the tendency to rely on alcohol and drugs as a way of promoting sleep, which may later lead to the development of a clinical drug or alcohol abuse disorder.

Dr. Glazer: Dr. Becker, how do you distinguish between primary sleep disorders and sleep disorders that are associated with psychiatric illnesses? Can you do that easily?

Dr. Becker: I've tried to do that here. Down the left column are the typical symptoms of major depression. It's important to recognize that depressive illness is a syndromal disorder characteristic of certain features. Out of the 9 possible features in clinical depression, 6 used in Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) can be influenced significantly by sleep.

We have symptoms like sadness, insomnia, sleepy, tiredness/fatigue, poor concentration, and guilt/suicide. Clearly, all of these are going to be far more likely to occur with major depression. The one that is, perhaps, a little less dependent on the individuals and their age is the type of depressive illness that they have, whether they're sleepy, but all the others are conceived by the nature of symptoms occurred.

Dr. Becker: Now we will move into the primary medical disorders of sleep: sleep apnea, restless leg syndrome, and periodic limb movements of sleep. These disorders may certainly be an impact of the problem, but when we talk about the specific disorders, these are very important. These can result in presentations that will mimic problems of depression.

From the standpoint of sleep apnea, it's not only the snoring; the key issue is the pause, the break in breathing. We had a patient who did that for 2.5 minutes; that was the longest. We allowed him to go that long, figuring that person must do that every night. The problem of airway collapse and consequently the falls in oxygen saturation has an impact on the central nervous system. One of the areas will be to worsen clinical depression. Treat the apnea and, in some cases, the depression will be significantly better.

Restless leg syndrome is the uncomfortable sensations deep in the muscles of the legs as the person is trying to rest and relax in the evening. When they move, there is relief. This problem is one of the most severe causes of insomnia, and is effectively treated with the use of dopaminergic therapies. The most common things that are used, although at much lower dosages for the problem of restless legs, are the same treatments that we use for Parkinson's disease.

There are also periodic limb movements of sleep. Most commonly this is a sleep disrupter during the night, a sleep maintenance problem. Although, there often have to be other factors. To figure out that underlying sleep disorder with the insomnia, one of the best ways is to determine if the person is sleepy during the daytime. Most patients with insomnia are not sleepy; in fact, they're hyperaroused during the day. But the person who has a primary medical disorder of sleep is more likely to have problems of being sleepy.

Dr. Glazer: Dr. Becker, what's associated with poor sleep, from a historical perspective, function-wise?

Dr. Becker: I had mentioned earlier about impact and issues of absenteeism, and we have a study by Zammit and colleagues that looked at the issues of work and insomnia's impact. They found that individuals with chronic insomnia had as much as 16 days of lost work time, compared with those without any problems of insomnia, for whom it was only 1.6 days.

Dr. Erman: What causes these people in the morning not to be able to go to work? Poor sleep or it may be the issues such as use of over-the-counter agents that may lead to residual sleepiness.

Dr. Becker: There are also issues of accidents. These are both minor accidents and major accidents, but again, we're talking about a much higher rate of problem in this uncontrolled study by Balter and Uhlenhuth, looking at this issue of an impact of sleep problems with insomnia.

Dr. Glazer: Dr. Erman, Dr. Becker was just talking about people who are in the workplace. You also mentioned the elderly earlier.

Dr. Erman: There are many changes associated with the aging process that affect sleep. And there are some misconceptions; for example, there is a widely held belief that we need less sleep as we age. That's not really the case. We don't sleep as well as we age, for various reasons.

One of the reasons is that we have a lot of medical conditions that may impact on our functioning. When we have medical conditions, and particularly those that are associated with pain, we're going to have difficulties. We have some data, showing that older adults who are experiencing bodily pain have a problem of poor sleep.

These are some data from, again, the National Sleep Foundation's Sleep in America poll survey that was done in 2003, showing that those patients who had bodily pain at least a few days per week were worse in terms of their sleep than those who rarely or never experienced pain.

Dr. Erman: They were almost twice as likely to experience some problems with insomnia, and more than twice as likely to wake during the night feeling unrefreshed in the morning, and to have significant problems with daytime sleepiness.

Dr. Glazer: Dr. Becker, what can patients do on their own to improve the quality and quantity of sleep that they're obtaining?

Dr. Becker: There are the issues of sleep hygiene, sleep practices that, from a physician's standpoint, involve simple instructions -- perhaps a bit more challenging for people to do in the middle of the night.

The night for insomniacs is a time of loneliness. They often get caught up in their own thought patterns during that time. Sometimes they're trying too hard to fall asleep; you have to give them methods to interrupt that.

One of the better ways is stimulus control, the instruction that you should only go to bed when you are sleepy. If you are not able to fall asleep within 10 or 15 minutes of estimated time, then the individual should get out of bed, go into another room, do something that will help him to recognize that he is getting sleepy again, and then return to bed, repeating this in-and-out pattern. It is difficult to do over the first few days. But as they begin to consolidate their sleep, begin to de-associate the activation with their own bedroom, they are going to begin to sleep much more effectively.

There is the classic idea of relaxation. The problem is that people with insomnia try too hard. We want to have them over-learn the method of relaxation during the daytime. Probably for up to 2 weeks, they should practice before they bring it into the bedroom to apply that relaxation, so they have it so much in their head they don't even have to think about having to relax.

Dr. Glazer: Dr. Erman, what can specialists and therapists use, short of pharmacology?

Dr. Erman: I think there are some techniques that specialists use that generalize very well to those who are not specialists in sleep. This is the area of sleep hygiene. There are a number of elements that we can incorporate and tell people to do in their lives.

These are sort of the "apple pie and American flag" of sleep: things such as regular sleep schedules, trying to get a regular time of awakening, reducing naps, avoiding caffeine and alcohol use, and working very hard to make the bedroom a quiet, dark, comfortable, and safe environment where they can sleep without excessive anxiety or stimulation.

Dr. Glazer: Should you go to bed at the same time every night?

Dr. Erman: Not necessarily. I think regular schedules are helpful. We don't want people varying tremendously, going to bed at 10:00 PM one night and 2:00 AM the next night, and then saying, "I had such a lousy night. I'm going to bed tonight at 7:00 PM," because they will then try too hard, and in fact, it's that time in their circadian cycle where they're not really ready to sleep.

So I think you should really be working to promote a state of relaxation, using the bed, for example, for sleeping, reading, or sex. Reading is one of those areas that you'll often see in lists as "Don't do." What I like to do with patients is to say, "What effect does reading have on you, and what do you like to read?" Don't read something that's going to be too alerting or arousing, but reading things that relax you can be very helpful.

Dr. Erman: A light snack before bed for some patients may be helpful if they're hungry. Exercising, I think, is helpful in general, and also a part of a good stable healthy routine, but not in the hours before bedtime. Try to promote relaxing activities before bed, using techniques such as relaxation techniques, reading, listening to music, and trying to limit activities that otherwise are going to cause people to be more alert or aroused.

I guess patients who don't want to be working on their taxes until 2:00 AM, suddenly realize it's time for bed, and try going to bed with all those schedules and lists of expenses in their head. That's not a way to promote entry into sleep.

Dr. Becker: I would point out that these are all important for the poor sleepers. All of these good habits that we encourage, those who are basically good sleepers can do many of these things negatively and still find themselves to be able to sleep.

Dr. Erman: But even for those who are better sleepers, I think what they find is that when they have a spate of insomnia, they can be very helpful.

Dr. Becker: I'm talking about those who are blessed and can do almost anything and still sleep well.

Dr. Becker: Certainly these simple methods of relaxation would be of benefit. Specialists also can utilize other forms of therapy. There are specialized cognitive behavioral approaches that can be very helpful for insomnia, and much is being published now about these approaches. In the past, there has been biofeedback, paradoxical intention, and a technique of sleep restriction that can be very helpful. For persons who say that they're in bed for 8 hours but sleep for only 6, the instruction is to only be in bed for 6 hours.

Dr. Glazer: Let's turn our attention to pharmacologic strategies for sleep disorders. What types of agents are being used in the treatment of insomnia?

Dr. Becker: The most common things are what the patient has readily available. There's alcohol, but also over-the-counter agents, diphenhydramine primarily. There are very limited studies available for diphenhydramine and its impact on sleep. In the few studies there's a suggestion that they did not last sufficiently long enough.

This study, done for allergy patients, was a comparison of a nonsedating vs a sedating agent. Diphenhydramine was given as 50 mg 3 times a day and when compared with placebo, diphenhydramine was sedating and had more of a daytime negative effect rather than positive.

Dr. Glazer: A lot of psychiatric medications are used to treat insomnia, correct?

Dr. Erman: Correct. And I think there are appropriate uses for these agents. I guess a great example would be the patient who has depression and sleep problems; antidepressants, sedating agents may be used. For the patient who may have residual complaints despite the use of an antidepressant, we could consider adding a sleep-promoting agent.

A lot of these medications are being used off label as well, and there are examples of antipsychotics, antidepressants, and anticonvulsants. I think there is a misperception that these agents are inherently safer than the sleep medications. They're also not scheduled so that they're more readily available. It drives their use, but I think there are safety issues related to the usage of these drugs. We need to be very concerned about them.

Dr. Glazer: Let's talk about the medications that are US Food and Drug Administration (FDA) approved for sleep disorders.

Dr. Erman: We have a broad range of medications that have been approved. There are benzodiazepine agents. These agents were first approved as the safer and newer agents that are available. These agents range from a very short half-life to the very long half-life of Dalmane (flurazepam).

For treatment of poor sleep, we would much rather have an agent with a rapid onset of action and a short half-life. And triazolam (Halcion) certainly got a large share of that market.

Dr. Erman: Now we have a newer class of agents, and these are nonbenzodiazepine agents by their pharmacology, by their structure. Two of these are available in the United States. These are zolpidem (Ambien) and zaleplon (Sonata). Both have rapid onset. Zolpidem is short in terms of its duration of action, which is ultra-short for zaleplon.

Dr. Glazer: Say more, Dr. Becker, about the difference between zolpidem and zaleplon.

Dr. Becker: For those who have just occasional problems of insomnia and do not take medications, they can take sometimes only 5 mg of either agent. Ten mg is the more standard adult dosage for both of these agents, and in the elderly, the lower dosage is the most appropriate therapy.

Zaleplon is labeled for use up to 20 mg. But they're comparable in their onsets of action. They both have rapid onsets of action with a longer overall half-life that is short in the case of zolpidem and ultra-short for zaleplon.

Sleep onset is reduced by both agents, while nocturnal awakenings are reduced more by zolpidem. Total sleep time is somewhat longer. They are schedule IV agents; therefore, there are, at times, concerns about using them. But, in fact, their abuse potential is surprisingly low, unless you have someone who is at risk for abuse.

Dr. Glazer: Dr. Becker, you brought a case to tell us about.

Dr. Becker: It's a woman who was 54 years old when she came to see me, a mother of 2, divorced, and she was sent to me rather than a psychiatrist because she had such a prominent sleep complaint.

This person had early morning awakening, she was up often before 4:00 AM. She had major problems of sleep onset, with reported sleep onset of 60 minutes; she just can't seem to turn off her mind. Also she said she would, at times, bounce in and out of sleep. Sometimes different points of the insomnia were worse than others.

Dr. Glazer: How would you develop a treatment plan for this patient?

Dr. Becker: These are all the available treatments that might be apparent. Some of the things we've covered; some we have not. But the issues of a patient such as this would benefit from appropriate antidepressive or hypnotic therapy to affect the different presentations of the insomnia.

She was having insomnia across the phases, so the selection was for a sedating form of antidepressant. In this case it was mirtazapine (Remeron). I should mention she lost 15 pounds with this particular problem, so I thought mirtazapine to be a very good choice. But it was not enough. In this case, zolpidem was also added to provide for sleep onset and for some sleep maintenance benefits.

Research studies have shown that the use of sedative hypnotic agents causes a more rapid reduction of the Hamilton Depression Rating Scale (HAM-D), although the final benefit is the same after 8 weeks of therapy with an antidepressant. Combination therapy can be helpful, and that was also the case for this woman; she began to sleep better and feel somewhat better, until she was able to get the better benefit of the antidepressant agent.

Dr. Glazer: More specifically, what about medication strategies? Can you line up medications that you would choose for patients, based on what part of the day their problem occurs?

Dr. Becker: We want to give more activating agents, such as the selective serotonin reuptake inhibitors (SSRIs), in the morning, and then begin to move into the more sedating agents in the afternoon. There are some specific areas where you can utilize sedative antidepressants to the benefit of sleep, but you also have to commonly add sedative hypnotic agents to help with anxiety or other aspects of the sleep problem.

Dr. Glazer: Dr. Erman we've talked a bit about chronic use of these medications. What are the issues that are associated with chronic use?

Dr. Erman: I think there are a number of issues. There are concerns, partly because of the scheduling issues. These are scheduled agents, class IV. There are also issues that develop as a consequence of the labeling for about these medications: use for a couple of weeks, reassess, don't use more than 28 days, etc.

But I think we need to remember that insomnia can be, and often is, a chronic disorder, and we should really approach it from that perspective. If we think of it as a chronic disorder that may be like a condition such as diabetes or hypertension, we need to try to not only alleviate the symptoms, but also to reduce the impact that may be present on health consequences.

As we've seen, the persistence of insomnia over a period of time is associated with increased risk of depression. We don't know specifically that treating in the interim is going to reduce that risk, but it makes sense. We want to do everything behaviorally to help with the treatment of insomnia.

We want to consider various agents, use the lowest effective dose of agents that are available, try when possible to use intermittently (and certainly intermittent use is an option for many patients), and monitor the potential negative consequences that may ensue from the longer-term use of these agents.

But I think it is an option that needs to be considered, particularly when we look at the issue of what is safe. We consider the use of agents such as antipsychotics that may have risks, for example, of tardive dyskinesia, and an increased risk of diabetes from their use. It's not necessarily more rational to use a low dose of an antipsychotic than one of these agents that is specifically designed for use in treating these conditions.

Dr. Glazer: From the data you've been showing, the long-term use of theses agents is a big issue with this patient population.

Dr. Erman: I think we have a number of circumstances. Certainly there are some patients who may do poorly at home or in many other circumstances. They come to the sleep laboratory, and it's a somewhat neutral environment. There, people are caring for them, and they may have an atypically good night. Typically the night is not perfect, but the patients say, "This is a much better night than I have at home."

There are other patients who may tell us, "I didn't sleep at all; this was a typical poor night." We look at their sleep record, and their numbers don't look terribly abnormal. That's a condition called sleep state misperception.

That's one of the issues of cognitive behavior therapy. These are patients for whom we now have some data to work with. We can say, "Your perception of sleep is that it's bad, and yes, it's not perfect, but the good news is, it may be better than you think it is. Here's what we can do to help you to increase your depth of sleep, help you to relax about the impact your sleep is having, and hopefully reduce the longer-term problems."

Dr. Becker: It is true that patients with chronic insomnia become very poor in their ability to recognize when they're awake or asleep. But it's also important for the physician to realize that it is very difficult to perceive that.

Dr. Glazer: So they probably are sleeping better at home and don't know that. That's one of the explanations. There also could be environmental precipitants and other factors.

Dr. Becker: There's the psychological issue of finally having someone taking their problem seriously, so they sleep better.

Dr. Erman: First, we should recognize that although the sleep apnea patient is thought of as being a hypersomnia patient, they may present with an insomnia complaint, with a complaint of fatigue and disrupted sleep. "I wake during the night and I'm not restored in the daytime." I think we want to do what we would ordinarily do with these patients: determine if they have significant apnea, and treat them.

We did a study some years ago, looking at the impact of zolpidem on sleep apnea. It had a very minimal effect in reducing the absolute lowest oxygen (O₂) saturation. This was an untreated population, but otherwise consolidated sleep. My point is not to say, treat your snores with a sleep medication.

We have very little concern about using a sleep-promoting medication if needed, which may be very helpful for these patients in promoting deeper sleep. We do need to help them adjust to the use of the continuous positive airway pressure (CPAP) equipment. So I think we want to take that condition seriously. The good news is that if they are appropriately treated with CPAP, we don't have any concerns about the impact of a sedating medication on exacerbating their sleep apnea.

Dr. Becker: And the patient who's a bit more anxious could probably benefit greatly from the initiation of a hypnotic at the same time that they're receiving CPAP, because that individual will be able to enter sleep, be more comfortable with this inconvenient therapy, and get through the adjustment period more effectively.

To answer the question a different way, there was a study from the early 1980s of different sleep centers and different reasons for insomnia, and of those who came to the sleep centers with the problem of insomnia, only 6% were found to have sleep apnea. But now with the recognition of the more subtle breathing problem of upper airway resistance, there probably are higher instances where upper airway resistance is causing problems of disturbed sleep, making it difficult for someone to fall asleep or stay asleep.

For that reason they are calling themselves insomniacs when they come to the sleep laboratory, although only about 1 in 5 chronic insomnia sufferers end up in the sleep laboratory; 80% are treated just by history and examination alone.

Dr. Becker: That could also be a difficult patient. It requires a comprehensive evaluation to assure that you're not dealing with generalized anxiety disorder. But it is also important to make sure you're not dealing with sleep state misperception; you're pouring medications into them, they are sleeping, but they're not able to perceive when they are sleeping.

When you know that is not the case, then I am more comfortable utilizing a combination therapy. What I commonly use for my most difficult patients in that group are the new novel neuroleptic agents.

There is certainly going to be a subset of people who will not benefit from the therapies available. But that's really going to be the minority of potential patients.

Dr. Erman: This is a complex issue. One of the elements that contributes to the difficulty is that there are regulatory issues in long-term care facilities about what medications can be used. In terms of sleep hygiene issues, we would like to incorporate as many of those elements as possible, which would include those who are trying to have much activity in the daytime, have light exposure into the evening hours, and strengthen the circadian drive for sleep.

Although I think it's very rational to use sleep-promoting agents in these patients, again, there are regulatory issues that supervene. We may consider sedating antidepressants; I would probably use the older tricyclic agents. But there are risks of cardiac effects, risks of orthostasis, and increased risk of falls. We may consider some of the anticonvulsant agents that have some sedative properties, and we also may consider some of the newer neuroleptic agents that have sedating properties.

But, with all of these, we have some increased risk of side effects and other medical consequences. I think we often end up with some polypharmacy we would like to avoid, but until we have agents that are allowed for use under regulatory guidelines and have demonstrated safety and efficacy, we have this difficult problem.

Dr. Becker: I think there's a lot of inappropriate concerns at times. Nonbenzodiazepines are remarkably safe medications. The irony is that for patients with other chronic conditions, no one has a problem with a cyclooxygenase-2 (COX-2) inhibitor, or a nonsteroidal anti-inflammatory drug (NSAID) for chronic arthritis, where there are real risks of GI bleed and other medical consequences. So I think there's a misperception, perhaps based on scheduling issues, and also based on long-term outdated perceptions about safety issues with hypnotics that cause people to be concerned. I think these are very safe medications, and their use, even in long-term circumstances, can be very appropriate.

Dr. Becker: Data are emerging. There was a recent study published looking at another agent at a 6-month period of exposure. And there also is very good evidence of some change within the FDA about their attitudes that may open the door to longer-term use over the near future.