Expert Lawrence Epstein's Advice on Treating Insomnia and Staying Asleep
"If you have to wake up at 5 a.m., go to sleep at 9:30—don't wait up for the Tonight Show monologue."(LAWRENCE EPSTEIN)
Lawrence Epstein, MD, is the regional medical director for the Harvard-affiliated Sleep HealthCenters, an instructor at Harvard Medical School, and past president of the American Academy of Sleep Medicine. He is coauthor of The Harvard Medical School Guide to a Good Night's Sleep.
Q: When I have trouble sleeping, I depend on coffee to get through my morning. Will that make it harder to fall asleep the next night, too?
A: Coffee can make insomnia worse. You've got to remember that the effect of caffeine can be long-lasting. The half-life of caffeine is four to seven hours, so it will be in your system for longer than you think, affecting your behavior, your alertness, and your ability to fall asleep. Some people drink caffeine in the afternoon when they feel tired, but it becomes hard to fall asleep at night, which perpetuates the problem. I recommend avoiding all caffeine after noon.
Q: Some nights it takes me an hour or two of tossing and turning to fall asleep. When—and how—should I seek medical help?
A: Almost everyone will have an occasional problem sleeping, but you can usually directly relate that to a cause, like a fight with your significant other, work trouble, jet lag from multiple-time-zone travel, etc. These problems can often resolve themselves in a few days.
But if you have trouble sleeping for more than a month even after those issues have been resolved, you may want to see a doctor. Additionally, if you're having symptoms suggestive of a sleep disorder—such as gasping or snoring, frequent kicking or movement at night, disruptive sensations in the legs or arms, or difficulty getting to sleep when you used to be a good sleeper—make an appointment with a physician. Your primary care doctor may refer you to a specialist trained in sleep medicine.
Q: Recently, I've been waking every night to use the bathroom between 2 a.m. and 4 a.m. Why could this be?
A: First, you should try to figure out if you're waking up because you have to go to the bathroom, or if you're waking up for another reason and then deciding to go while you're up. If you're waking up with the urge to urinate, look at your fluid intake and cut down on the amount you drink in the evening. If that doesn't help, see a doctor to rule out a bladder or prostate problem; it may not even be a sleep problem.
If you aren't being awakened by the urge, aging could be the culprit. Your sleep need doesn't change over the course of your lifetime, but your sleep habits do. You wake more as you get older, and your sleep becomes less continuous, so you may need more time in bed to get the same amount of sleep. Most people start to notice a change in their 40s and 50s or during menopause. Waking once or twice at night as you get older is very common and doesn't indicate a problem.
[ pagebreak ] Q: I've been diagnosed with insomnia, but I don't want to get addicted to medication. Are there effective, nonaddictive options?
A: Sleeping medications can be very effective when used in the appropriate setting, but not everyone needs to use medication. Getting an evaluation from a sleep specialist can help. Over-the-counter drugs may be effective for a night or two, but they're not for long-term use, since they haven't been studied for long-term safety or efficacy.
If you use sleeping medications, try to use them for as short a time as possible and hope that it resolves the underlying problem. They can be helpful by breaking bad patterns or associations and getting people back into better sleep habits. Addiction to sleep medication isn't likely, but for long-term use, you may experience withdrawal symptoms. (Newer medications are less likely to cause this.)
If you prefer, you can try to solve your sleep problem without medication by adjusting your environment (light, noise, and temperature), and by practicing behavioral techniques and good sleep habits.
Q: I've been taking sleeping pills for several weeks and they stopped working. Now what?
A: It's not unusual for medications to be less effective after using them consistently for an extended period of time. You should slowly bring yourself off the medication and reassess your sleep problem with a non-pharmaceutical solution.
There are a variety of approaches that can address insomnia, including cognitive-behavioral therapy and meditation. These techniques can teach you to relax in bed without the aid of medication, if you have trouble doing so on your own.
Q: I'm a smoker who has a drink or two most evenings, and I have trouble sleeping. Could my cigarettes and alcohol be affecting my sleep quality?
A: One of the main ingredients in cigarettes is nicotine, which is a stimulant. It can disrupt sleep. Chronic smokers can adapt, but for good sleep and overall good health, anyone who smokes should be encouraged to give up cigarettes. Some people use alcohol to fall asleep, but it's not a very good method. It does make you sleepier, but as the alcohol level in your system drops, it wakes you. Drinking alcohol leads to poorer sleep quality.
Q: I've been diagnosed with depression, and I also have trouble falling asleep most nights. Could the depression be causing my insomnia?
A: Untreated depression can cause problems with sleep—so if you haven't already, see a mental health professional to get proper treatment. If you've had depression for a while, you may have developed bad sleep habits or bad associations with your sleep environment. Medication can often help resolve both the depression and the insomnia. If your depression has been treated but your sleep problems remain, your insomnia should be addressed primarily as a sleep problem.
[ pagebreak ] Q: When I travel for work, I can never fall asleep in unfamiliar hotel rooms. I'm always a wreck for presentations and conferences. What can I do?
A: Insomnia can be acute, meaning very short-term, or chronic, meaning long-term. Short-term insomnia related to travel or something dramatic happening in your life is definitely a possibility. If you have trouble sleeping in unfamiliar surroundings, try to follow your regular bedtime routine as much as possible in your new setting. Bring things with you—a pillow, a picture frame—so it's more like your home environment. Also, keep track of what you're drinking while traveling—many of us drink more caffeine and alcohol than usual, which can affect sleep quality. If nothing else works, sleep medications can help some people get the rest they need, so discuss your situation with your doctor.
Q: I recently started taking prescription sleeping pills, and a few times, I've woken up in strange places, with no memory of getting there. What's happening?
A: There have been a number of reports that sleeping pills can trigger parasomnias—sleep disorders including sleepwalking and even sleep eating or driving. It's quite rare, but this is a known side effect of the hypnotic class of prescription medications. It can be disturbing, especially if you wind up in an unsafe setting—like behind the wheel.
If this happens to you, talk to your doctor and don't use the drug anymore. Mixing these medications with alcohol seems to trigger sleepwalking in some people, so be aware of what you're drinking before bed. People who experience sleepwalking once may be prone to it, so it may happen again with a different medication.
Q: I fall asleep fine at night, but I tend to wake up a few hours early. Can I take a sleeping pill that close to my wake-up time?
A: You can take medication for this problem, but first, you should try to figure out what's going on. If you're getting older, sleep naturally becomes less continuous, so you may have more repetitive awakenings and arousals—including the early morning. Depression can cause early morning awakenings; so can a condition called advanced sleep phase: You go to bed earlier and wake for the day earlier than is typical.
Once you determine the cause, you can look for an appropriate solution. You can try cognitive-behavioral therapy to change your habits without the help of medication, but medication may be appropriate in some situations. In these cases, a longer-acting sleeping pill can help. But you don't take the medicine at four in the morning when you wake up; you take it at night as a preventive. Talk to your doctor to find out what's right for you.
Q: All night I'm wide-eyed and can't rest—and I'm sleepy all day long. I've heard that napping can make insomnia worse, but how else can I cope?
A: Napping can be good or bad, depending on the situation. If someone is sleep-deprived, a nap can help him feel more awake and alert, which can prevent problems such as drowsy driving. But someone who has insomnia should avoid naps. You want to use that sleepy feeling to fall asleep at bedtime. If you nap, it will decrease your sleep drive, which can perpetuate the problem.
[ pagebreak ] Q: I wake up at 5 a.m. for work, so I relish my weekend mornings—when I can sleep until 8 a.m. Is this making my insomnia worse?
A: The body performs best with regularity. Some people can shift their wake-up time on the weekend without a problem, but if you have problems sleeping, you have to stick to a regular sleep schedule. This is a lifestyle change, not a medical problem. These are the toughest things to treat in medicine, because people don't want to change their lifestyles.
The reason why you don't want to wake up on the weekend is likely because you're sleep-deprived from your workweek. So if you have to wake up at 5 a.m., go to sleep at 9:30—don't wait up for the Tonight Show monologue. There's no exact rule, but most people need an average of seven to eight hours of sleep every night. If you don't give yourself enough, it can lead to sleep deprivation.
Q: If I'm still awake a whole hour after I get into bed, I get up and watch TV for a while. Is this a good idea, or is it making my insomnia worse?
A: If you have this problem, wait until you're sleepy before getting into bed. If you're already in bed and feeling frustrated, don't wait a whole hour; get out of bed and do something else. Staying in bed can create associations in your mind that you can't sleep, which can make the problem worse. It's better to be be frustrated and annoyed in the living room rather than the bedroom.
While you're up, do something that you find relaxing. If watching TV is relaxing, fine. But if it's stimulating, that's no good. Reading and listening to music are good options; doing your taxes or playing war games on the computer are not. Do this relaxing activity until you feel sleepy, and then go back to bed and try to fall asleep.
Q: I think I would really benefit from a visit with a sleep expert. How do I find one?
A: It's a good idea to see a doctor about insomnia and other sleep disorders, because they can lead to health problems if they're not addressed. You can start by seeing your primary care physician. He or she may refer you to a colleague who can help.
You can also look for a certified sleep specialist or an accredited sleep center. The accreditation means that they have met quality standards and have been verified by the American Academy of Sleep Medicine. You can look for sleep centers in your area on the academy's patient website, SleepEducation.com.