Science says sleeping pills don’t work – so where does that leave insomniacs like me?
It was mid-September 2015 and I had not slept in six weeks, except for one night, which I still remember as the mysteriously offered slice of heavenly respite in an otherwise bewilderingly brutal period of insomnia. If not sleeping for six weeks sounds like drama and hyperbole, it isn’t. What you, if you are lucky, take for granted to be sleep – that thing that makes you feel you have fuel in the tank and that your systems have been restored – can actually evade people for days, weeks, even months.
Not for the first time, during that rash of sleeplessness in 2015, I grew desperate. I became obsessed with what was happening to me, and the sense that it would never end and I would never have my life back. And so eventually I went to the GP. I had held off doing so for ages because I had previous experience seeking medical help for my insomnia, which has dogged me since I was a child. In the past, I had been given standard sleeping pills – zopiclone and Ambien (zolpidem) – and while they had caused me to pass out, eventually, they made me feel poisoned the next day. I never wanted to take one again. But in September 2015, I’d have taken anything to break the cycle.
In normal times, I have many ways of dealing with my insomnia, and attitude has always been the most important. In that sense, a new study carried out by a team at Brigham and Women’s hospital in Boston is right: sleeping pills don’t work in the long term and, as the UK’s Sleep Charity added, what people with sleep problems need for permanent change is cognitive behavioural therapy, not drugs.
Saying sleeping pills don’t work in the long run, while therapy does, is pretty obvious. But life is more complicated. Therapy can take months to have an effect, and even then, it’s far from a dead cert. Nor, after weeks in which each day begins with gravelly-eyed misery and yet another sleep-deprived hangover, are people necessarily in a position to begin a course of therapy that will try to make them relax about the very thing ruining their lives.
Their patience – or mine, anyway – also grows thin at the wise words dispensed by so-called experts – for example, that we should avoid caffeine and alcohol, wind down at night, put screens away early, eat healthily and learn mindfulness. Yes, we know all that, and if those things made a difference, or were easily attainable (which for me, mindfulness certainly is not), then believe me, we’d be sleeping like babies by now.
Insomnia is not a one-size-fits-all problem and yet its treatment is depressingly crude. Yes, the researchers are right that people should practise ‘sleep hygiene’. They are right that since sleep is as much a psychological as a chemical activity, therapy is the correct arena for intervention.
But they miss the nub of the problem. Because there are so many different types of insomnia, you need someone who understands your type and your particular problem, and the desperate feelings – physical and mental – that accompany it.
Mine is that I can’t fall asleep, at all. And so if pills are off the table, then I need a therapist who gets this particular thorny problem – not a general issue with bad sleep. And anyone who doesn’t understand the sheer, reflexive horror at realising that your body can go on and on, seemingly forever, in the twilight state of long-term sleep deprivation won’t be able to help me either.
On that desperate 2015 trip to the GP, I lucked out. He was an insomniac himself, with a similar problem to me. He prescribed me a tiny nightly dose of an old, non-addictive anti-depressant called mirtazapine, which in small doses acts as a sedative. I still take it because I can’t sleep without it even though I often can’t sleep with it either. I’d rather be free of it, especially as it is far from reliable, but I haven’t been able to make the leap yet. As for the rest? I try to be resigned and to accept things as they are.
Long term insomnia is a mystery that has never been cracked. The worst thing insomniacs can do is obsess over and fight it. But that message only sinks in if it’s given by someone who really understands. And since acceptance can take a lifetime, sometimes you do need a quick fix to simply keep going.
If sleeping pills don’t work, what does?
By Luke Mintz
CBT-I
Cognitive Behavioural Therapy for Insomnia (CBT-I) remains the “gold standard” treatment, according to Professor Guy Leschziner, a neurologist at London Bridge Hospital. In six to eight sessions, a therapist will encourage a patient to examine and defuse damaging thoughts they have about sleep, such as “I need eight hours” (many people don’t need that much), or “If I can’t sleep tonight, I’ll mess up disastrously at work tomorrow” (usually, you don’t).
Dr Neil Stanley, former head of the Sleep Lab at the University of Surrey, says CBT-I is far more effective in the long term than medication. “When you stop taking a sleep tablet, it stops working, whereas CBT-I has been shown to be beneficial even after doing the treatment,” he says.
Sleep restriction therapy
An offshoot of CBT-I, sleep restriction therapy is designed to consolidate your sleep into one block by shortening the amount of time you spend in bed. In doing so, you “strengthen sleep desire”, says Stanley, and cut the amount of time you spend awake in bed, tossing and turning. Insomniacs are told to work out their average sleep in hours with a diary or sleep app, then add 30 minutes – and that’s the only time you’re allowed in bed each night. A patient who sleeps four hours each night should only spend four and a half hours in bed. Once sleep improves, you can gradually increase your time allowed in bed.
Sleep hygiene
Even if you can’t access therapy, small tweaks to your lifestyle might help. Stanley recommends making sure your bedroom is “dark, quiet, and cool”, and says you should avoid stimulating your brain in the few hours before bed (your smartphone is a particular enemy here). Smoking in the evening should also be avoided, as should drinking alcohol or caffeine. Some doctors also recommend cutting out caffeine in the daytime, but the evidence here is shakier.
Acceptance and commitment therapy (ACT)
In a cruel twist, anxiety about sleep actually makes our sleep worse. The longer we lie awake, fretting about how tired we might be in the morning, the more we come to associate our beds with stress. ACT is a fairly new approach, radically different to other forms of sleep therapy. Popularised by Dr Guy Meadows’ The Sleep Book, it teaches insomniacs simply to accept poor sleep as part of life. Stop fighting sleeplessness and come to peace with the fact you might sometimes be tired, patients are told. Over time, this approach makes you less anxious about bedtime – and so actually improves your sleep. But many doctors are yet to be convinced. “There’s very little evidence for ACT being beneficial – I think personally it’s a very strange idea,” says Stanley. Leschziner adds: “There’s less evidence to support the ACT approach, but… it does help some people, so it’s certainly worth trying.”
