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Sleep is like food and water—sufficient amounts are necessary for physical and mental well-being and deprivation can lead to death of the organism. More often, insufficient sleep can cause a range of biological, psychological and social problems in humans. This is true whether that insufficient sleep comes from sleep deprivation or from insomnia, which are separate problems. The health and performance consequences of sleep deprivation—i.e., not putting aside enough time for sleep—and of insomnia—i.e., having difficulties initiating and maintaining sleep—need to be taken very seriously. Recognizing the dangers, the U.S. Center for Disease Control and Prevention recently called insufficient sleep a public health epidemic.
In a rapidly evolving American society, people are sleeping less and less. Yet, due in part to the economic strength of the pharmaceutical industry, they are often not receiving proper treatment. And the larger cultural forces at work, crucial for understanding 21st century sleep, are rarely considered to be a causal factor.
Sleep is a highly complex phenomena. In fact, science does not even understand why our bodies really need sleep. Yet we do know that there are many different individual and social factors that are related to the amount people sleep, including age, circadian and homeostatic traits, anxiety and depression, medical conditions, alcohol and drugs, work, family, social obligations, and bedroom conditions.
While sleep deprivation and insomnia are both related to insufficient sleep, they are actually two quite different phenomena.
Increased sleep deprivation, or sleep deficit, has sometimes been described as a symptom of the recent decrease in leisure time in American society (see, for example, Juliet Schor's bestseller The Overworked American). Working hours increased during the second-half of the 20th century, along with sharp growth in American productivity and prosperity. A doubling of productivity could have translated into both higher incomes and decreased working hours, yet today employees rarely have a choice between getting paid in time or money. Instead, Americans, relative to the past, work more, earn more, and spend more. This focus on work and consumption over leisure time has brought about an increased “time squeeze." While this is especially true for the average American woman, the time squeeze cuts across gender, social class, and marital status.
Moreover, the recent growth of digital media and smartphones has dramatically raised productivity expectations and blurred the line between work and personal life. This decrease in free time and increased pace of life and stress has brought with it reduced sleep, with real consequences for physical and mental health, performance at work, and quality of life. For example, in the 1960s, the average amount of time Americans spent sleeping was between 7 and 8.5 hours a night, while today 50% of the population averages under 7 hours, and, according to a 2008 survey, 1 out of 3 Americans say they get a good night’s sleep only a few nights a month or less.
Research shows that negative consequences of sleep deprivation include increased risk of physical problems such as diabetes, infection, and cardiovascular disease; excessive daytime sleepiness; micro-sleep episodes (often outside of awareness) during waking hours; lapses in concentration, attention, memory, and judgment; reduced creativity and mental flexibility; increased irritability; and decreased motivation, interest, and initiative.
Additionally, automobile driving skills suffer and several major accidents (e.g., Exxon Valdez, Chernobyl) have been linked to sleep deprivation, underlining the seriousness of the issue as a public safety hazard.
Insomnia, as opposed to sleep deprivation, is defined by the World Health Organization as a problem in initiating and/or maintaining sleep, or the complaint of nonrestorative sleep, that occurs on at least three nights a week and is associated with daytime distress or impairment. Severity is usually determined by the amount of time it takes to fall asleep and the duration of awakenings, as well as frequency and duration of sleep difficulties. Most people, at some point or another, experience acute insomnia in life; this is normal and must be distinguished from persistent insomnia that lasts more than a month. Hyperarousal and hypervigilance around sleep are important factors in persistent insomnia.
Several psychological and quality of life symptoms appear to be caused by insomnia. These include daytime fatigue (as opposed to daytime sleepiness, which is associated with reduced arousal) and emotional disturbances such as irritability, anxiety, depressed mood, and helplessness. Longitudinal studies suggest that persistent insomnia may be a risk factor for developing clinical depression (and having depression is also a risk factor for insomnia). Somatic complaints such as gastrointestinal and respiratory problems, headaches, and non-specific aches and pains are also linked with insomnia. Interestingly, cognitive impairments resulting from insomnia, such as those in attention, concentration, and memory, appear to be more limited than those resulting from sleep deprivation.
Expensive marketing campaigns waged by pharmaceutical companies have been misinforming the American public about sleep. Ad spending has skyrocketed since the mid-1990s. Despite dangers reported by non-pharma researchers, such as evidence linking the use of sleeping pills to cancer and premature death, the international sleep medication market is today estimated at well over $5 billion, with the United States far in the lead.
Unlike in the U.S., direct-to-consumer pharmaceutical advertising is tightly regulated in Europe, as are medication prices under national health systems there, making sleeping pills a less profitable product. Nevertheless, there is evidence of a similar rise in insufficient sleep in Western Europe as well, and this region constitutes an important market, as does Japan.
The elderly, for whom insomnia is a big issue, are seen by some industry analysts as an important new target demographic; this group was recently described as having "highly untapped" revenue potential across industrialized countries. In America, this means older folks might expect a sleep drug ad blitz in coming years.
Despite the media and PR onslaught aimed at consumers and doctors, the most effective proven long-term treatment for insomnia is short-term cognitive-behavioral therapy. Top sleep professionals who are not working for the pharmaceutical industry report that cognitive-behavioral therapy works just as well as sleep medication in the short-term and is actually more effective than sleeping pills in the long-term. Even so, the use of sleep medication in America has increased in recent decades (news flash: advertising works even when it makes irrational claims).
Cognitive-behavioral treatments for insomnia are usually time-limited and can focus on several different components. These components can include stimulus control therapy (limiting the amount of time spent in the bed/bedroom while awake, and restricting the kinds of behaviors one engages in in the bed/bedroom), sleep restriction therapy/sleep scheduling (requiring patients to limit the amount of time they spend in bed, whether asleep or not, in order to increase sleep efficiency), cognitive restructuring (changing false beliefs that restrict ability to sleep), relaxation training, phototherapy, sleep compression, and neurofeedback.
Many people with difficulty sleeping have what sleep professionals call poor “sleep hygiene.” There are several simple ways experts recommend that you can improve your sleep hygiene and increase the likelihood of a good night’s rest.
Here are some general tips for overcoming insomnia:
1. Restrict time spent in bed in order to consolidate and deepen sleep. Use bed only for sleeping (and sex). Reading, using a computer or smartphone, or doing other things in bed only conditions your body and mind that bed is a place to remain alert. Similarly, if you can’t get to sleep after 20-30 minutes, get out of bed and do something else. Only return when you feel relaxed and ready for sleep to engulf you. Also, do not try to fall asleep, this only makes the problem worse. Avoid daytime napping.
2. Get out of bed at the same time each day, even on weekends. This helps set your biological clock.
3. Avoid alcohol, tobacco, and caffeine in the 4 hours before bedtime. This is an easy mistake to make, especially for alcohol. Alcohol has an initial depressant effect but later in the night becomes a obstacle to restful sleep.
4. In general, lowered body temperature and sleep go together; increased body temperature can be a detriment to sleep. Avoid hot baths right before bed, and think about letting in some fresh air at night.
5. Extreme environmental temperatures deter sleep. Avoid making your bedroom too hot or too cold.
6. Make sure the bedroom environment is free from light and noise.
7. Do not go to bed hungry. However, avoid heavy meals just before bed.
8. Regular exercise helps initiate and deepen sleep. However, avoid vigorous exercise in the 3 hours before bedtime—such an increase in arousal before bed can have the opposite effect.
9. Put the clock under the bed or turn it so that you can’t see it—clock watching can provoke anxiety or anger which interfere with sleep.
Two further points: “Sleep debt” is cumulative over the long-term, which means that if you don’t ever make up lost sleep you increase your risk of developing future health problems. Also, people have individual differences in sleep needs, but most adults need between 7 and 8.5 hours to feel rested and alert throughout the day.
If you find yourself chronically sleep-deprived, your social and cultural environment is likely to blame for putting you at risk for future health problems. Think seriously about making minor or major lifestyle changes in order to improve your overall health and work performance. And if you’re one of the estimated 10-14% of people experiencing persistent insomnia, look for a therapist who specializes in cognitive-behavioral sleep therapy. Sleep medication, whether alone or in conjunction with therapy, is recommended and effective only for acute problems sleeping. A large body of empirical evidence shows that cognitive-behavioral therapy is more efffective for persistent insomnia.
So it's pretty clear that the most effective ways to cope with chronic sleep problems don't involve popping a pill. But shouldn't we also think about how to prevent those problems from occuring in the first place? Societal, cultural, and economic factors need to be considered if the alarming trend towards less and less sleep in America, along with the associated suffering, is ever going to be reversed.
Resources:
Find a sleep professional near you (U.S. only):
http://www.sleepfoundation.org/find-sleep-professional
Further reading on insomnia treatment:
http://www.mayoclinic.com/health/insomnia-treatment/SL00013
http://www.apa.org/monitor/mar02/studyfinds.aspx
http://www.apa.org/topics/sleep/why.aspx?item=12
Further reading on social-economic changes in the US related to sleep deprivation: https://www.nytimes.com/books/business/9806schor-overworked.html
References:
Perlin, M. L., Jungquist, C., Smith, M.T., & Posner D. (2005) Cognitive Behavioral Treatment of Insomnia: A Session-by-Session Guide. New York: Springer.
Morin, C.M. and Espie, C.A. (2004) Insomnia: A Clinical Guide to Assessment and Treatment. New York: Springer.
Schor, Juliet B. (1992) The Overworked American. New York: Basic.
© Yosef Brody PhD, 2013.
