What to Do When You Can't Sleep

Here's a wake-up call for the 30 million people in the United States for whom bed has become the enemy, a place where night after night they hope to burrow into restful and refreshing slumber but wind up battling with the pillows and blankets as they watch the hours flash along on the digital clock and know that morning will only bring exhaustion and frustration.

Sleep, it turns out, is a lot like weight loss and heart health. There are pills that can help, but like diet and exercise, learning to get a better night's sleep requires lifestyle changes, hard work and practice.

"In many instances, sleep habits are learned over time," says Susan Rubman, a psychologist at the sleep disorders center at New Britain General Hospital in Connecticut. When sleep becomes a problem, it is often because people unwittingly have fallen into destructive patterns, akin to the overweight person who stops for a doughnut every day on the way to work.

Insomnia is defined as the inability to fall asleep or stay asleep. It is different from physiological problems such as sleep apnea and restless-leg syndrome, which also interfere with sleep but can be best treated medically. Of an estimated 70 million people in the United States who have sleep problems, about 30 million struggle with insomnia.

Most of the time insomnia is caused by anxiety or other mood disorders. Sometimes it is just the routine stresses of the day that keep people up at night - the sales meeting in the morning, the checkbook badly out of balance, the kids' demands for help with homework, the vacation that must be planned and paid for. Sometimes, a couple of sleepless nights can snowball into a nightmare of its own, so that the very sight of the bed sets off a lather of anxiety.

Companies that make sleep medications such as Ambien and Lunesta would like you to believe that a little pill magically summons the sandman. Apparently 8.6 million people believe it, too. That's how many people took prescription drugs to help them sleep in 2004, according to an analysis of insurance claims by Medco Health Solutions, a company that administers prescription-drug plans.

But sleep specialists say that pills are no more than a Band-Aid. They might work for a night or two, but after several weeks, patients report taking more and more pills and never sleeping better.

"You should not be locked into a situation where you're taking these pills seven days a week," says Dr. Keith Dixon, a sleep specialist at Gaylord Hospital in Wallingford, Conn.

Rubman says more than half the people who seek sleep counseling at the New Britain center are taking prescription, over-the-counter or herbal sleep remedies - none of which is working.

While the newer prescription sleeping pills can help with short-term sleep problems, such as jet lag, the National Institutes of Health in June recommended that talk therapy - including relaxation training and counseling targeted at anxiety and erroneous beliefs about sleep and sleep loss - should be the first line of treatment for insomnia.

The first step for many insomniacs is to forget the notion that everybody needs eight hours of sleep, experts say. Some people function well with seven hours of sleep, others need 10. But one of the worst ways to ensure enough shut-eye is to get into bed before you are drowsy, even though the alarm is set to ring eight hours later.

"Going to bed early doesn't mean you're going to get more sleep," Rubman says.

If you've been in bed for 20 minutes and are still awake, get up, Rubman and Dixon both advise. Tossing and turning only reinforces the idea that bed is a hateful place where you try and try but are unable to rest. Leave the room, find a comfortable spot with low light and perform some kind of restful activity, perhaps knitting or light reading, experts suggest. Do not return to bed until you are sleepy, but do not allow yourself to fall asleep anywhere but in bed.

Ensure that the activity you choose is not so stimulating and enjoyable that you are rewarding yourself for waking up during the night. Dr. Daniel McNally, director of the sleep disorders center at the University of Connecticut Health Center in Farmington, recalls one of his patients who got up, had a bowl of ice cream and watched "Law and Order" re-runs when she couldn't sleep.

"Sure," says McNally, "I'd get up too to have ice cream and watch 'Law and Order."'

For patients whose looping anxieties keep their heads spinning on the pillow, Dixon at Gaylord suggests an exercise: Take a pile of index cards and label one with the name of every problem that keeps you awake at night. One card could perhaps be labeled "Finances"; another, "I hate my job"; another, "What am I going to cook for dinner tomorrow?"

On each card write out a plan for how you plan to approach the problem today, tomorrow and next week. Keep the index cards next to the bed. When one of the worries disrupts your sleep, check the card, assure yourself that you have a plan, then put it in the drawer and go to sleep.

Patients who seek help for insomnia at a sleep session can expect to participate in weekly counseling sessions, either individually or in groups, for about five or six weeks. Insurance usually pays for sleep therapy, but not always. Patients learn relaxation techniques and other strategies for getting a better night's sleep. But as with diet and exercise, there is no such thing as an overnight miracle. It takes work and practice for people to change their sleep habits.