Insomnia is a common complaint, and most of us have transient insomnia from time to time. As a sleep physician for over 30 years, it has been obvious to me that chronic insomnia and milder sleep apnea are frequently related . But until just the last few years, I did not realize how frequent that association was. I have come to believe that mild sleep apnea is the real cause of chronic insomnia in most patients. Many of my patients who complain of insomnia actually have a milder version of sleep apnea, called “Upper Airway Resistance Syndrome,” described almost 25 years ago by Dr. Christian Guilleminault.
Many times, though, these patients think their minds “just won’t shut off.” Or they awaken in the first Rapid Eye Movement period of sleep, about 90-120 minutes after they finally fall asleep, and cannot get back to sleep. They have a small amount of sleep under their belt, and the neurotransmitter responsible for sleep initiation, adenosine, has decreased in the part of the brain that initiates sleep. So they have chronic sleep maintenance insomnia, are tired the next day, and not as attentive as they should be to optimize the quality of their lives.
Patients with insomnia lasting for more than three months are often treated with sleep medications because they’re told by their family doctor that they must be a little depressed. But in many cases these medications do not provide good sleep, and do not prevent insomnia. And all these medications have side effects, some of them serious.
The irony of it all is, it’s hard to know which comes first, the chicken or the egg, sleep apnea or mild depression, in patients with mild depression, because patients with sleep problems frequently have anxiety or depression. Or what we call dysphoria. The world is gray. They’re unhappy. Life doesn’t sparkle any more for them.
Here’s the good news. Many times sleep problems do not require long-term psychiatric drug use or psychological evaluation.
Several years ago, when screening patients for a clinical trial on a new medication for insomnia where a sleep study was required to rule out other sleep disorders, my sleep specialists at the RNI could not find patients to enroll in the study because all the patients screened had another sleep disorder (sleep apnea or Restless Legs Syndrome, or RLS).
This fact was also confirmed in a recent article in Mayo Clinic Proceedings presented in this video entitled Pharmacotherapy Failure in Chronic Insomnia Patients. The conclusion that most patients complaining of chronic insomnia refractory to medications really have Sleep Apnea, that sleep apnea is the real cause of chronic insomnia,
In fact, 91% of 1,200 patients observed had Obstructive Sleep Apnea. Many of the patients had been on sleep aids literally for years.
People with chronic insomnia frequently have symptoms caused by sleep apnea, including frequent urination during the night (nocturia), dry mouth, morning headaches, daytime sleepiness, and snoring. The video linked to above explains how sleep apnea causes these symptoms. Unfortunately, both patients and primary care physicians are not aware of the connection of insomnia with sleep related breathing problems and often do not ask about these symptoms.
These studies show that both patients and primary care physicians need to be aware that patients with chronic symptoms of insomnia need evaluation in a certified sleep center. The causes for chronic insomnia we now know are not predominantly psychological, but are related to a physical condition involving obstruction of the upper airway during the relaxation that normally occurs during sleep initiation and maintenance.
So see a sleep specialist if problems going to sleep or staying asleep last for more than three months. And always see a sleep specialist for snoring or leg movements associated with problems sleeping. Drug therapy may not be right for you if these problems are present. Don’t let your doctor just reach for the script pad when problems initiating sleep or staying asleep linger on and on and become chronic.
And remember: Whatever you do, don’t drive drowsy!