Season 6 | Episode 1
Insomnia Podcast
Joe McIntyre (Host): Welcome to another episode of the Merck Manuals Medical Myths Podcast. On this show, we set the record straight on today's most talked about medical topics and questions. Today, we're taking a closer look at sleeping disorders, specifically the common ones that most of us are familiar with but may be misinformed about: insomnia and sleep apnea. I'm your host Joe McIntyre, and I'm joined by Dr. Richard Schwab. Dr. Schwab is a professor at the University of Pennsylvania Perelman School of Medicine in Philadelphia, where he is the chief of the Division of Sleep Medicine. If that name sounds familiar, Dr. Schwab did a two-part series on sleep and dream myths last season. If you haven't listened to it, please be sure to check it out. Dr. Schwab, thanks for joining us on the podcast.
Dr. Richard J. Schwab: Thanks, Joe. Glad to be back.
Host: Oh, we're glad to have you. So let's start off with the topic of insomnia. Can you tell our listeners what exactly insomnia is and how it is different from occasional sleeplessness?
Dr. Richard J. Schwab: So insomnia is a perception of inadequate sleep. And all of us have insomnia some of the time, right? You don't sleep well one night and the next night, you sleep better, and you wake up fine. Typically, what happens in somebody who has chronic insomnia or prolonged insomnia, it's multiple nights where you have trouble sleeping,
Host: Does having insomnia mean not getting enough sleep? Or does it mean not getting any sleep? Is there a scale there? How does that work?
Dr. Richard J. Schwab: Yeah, it's hard because you're not measuring sleep in patients at home, at least we don't do that on a clinical basis. You could do it on a research basis. And again, it's this perception that you're not getting enough sleep, you may have actually had a lot of sleep, but you've perceived that you don't. And so we don't really know the answer that question. But you're getting some sleep. It's not as if you're getting no sleep, you get some sleep, but you just don't get enough sleep and you feel awake, you wake up and you just don't feel refreshed. You don't feel like you're yourself, you feel like you didn't get a good night's sleep. But it's more of this perception. So it's not so quantifiable.
Host: Does insomnia affect people in different ways? Meaning if someone gets, let's say, for example, five hours of sleep that may constitute insomnia versus if someone gets four hours of sleep, that may be okay, there may be enough sleep for them. How does that work?
Dr. Richard J. Schwab: Yeah, it really depends on how much sleep you need. And everybody's a little different. People need, in general, seven and a half to eight and a half hours of sleep. But it's really hard to figure that out. The only way you can sort of determine how much sleep you get is when you go on a vacation for two weeks and the first week and just kind of recover from all the sleep deprivation because we are all sleep deprived. That's why we all drink coffee. We're all sleep-deprived. But if you take a week off, and then you don't drink alcohol, and you don't exercise differently, you might be able to figure out what the normal amount of sleep you require. But most people don't know that most people get more sleep on the weekends because we're overworked during the week, but in general, seven and a half to eight and a half hours. But there are people on both ends of that. So there are people who need or can get by with five hours of sleep and other people who get by with 10 or 11 hours of sleep. But the insomnia piece of this is, well, if I normally get seven half hours of sleep and now, for whatever reason, I'm getting six hours asleep, or at least that's what I'm perceiving, then I'll feel like I have insomnia.
Host: Now let's dig into some of the myths surrounding insomnia. Is it true that a person can really live on no sleep at all?
Dr. Richard J. Schwab: No, everybody needs to sleep and pretty much every mammal that we know of needs to sleep. How much sleep... a little more debatable, but everyone needs to sleep.
Host: There's a common thought that some over-the-counter products, such as melatonin, are the be-all and end-all to any person troubled with this disorder. Is there any merit to that?
Dr. Richard J. Schwab: There is. First of all, we can get into this, alcohol is really bad. So, one of the things people will say is you know what, I have problems with insomnia. Let's try alcohol. Alcohol causes sleep fragmentation. It may get you to go to sleep but alcohol is a really bad choice. In terms of other over the counter products of the group, melatonin is the safest. One of the problems with melatonin though, is that we don't know what the right dosage is. It's not a medication, it's just a brand, and if you buy something that says one milligram of melatonin, you may not be getting one milligram, you may be getting less, you may be getting more. In general, you don't want to take any more than 10 milligrams, but it is a naturally occurring hormone. It's not generally dangerous, but if you take too much, it will be a problem. And there was a recent report about kids taking too much and opening up the bottle. So you really need to protect it from younger people. Most of the Benadryl-type agents are like Tylenol PM, anything with PM in it. There's really very little data to know if any of those products are any good. They have a long half-life. So, if you take Benadryl, you may sleep well into the next morning; they have anticholinergic effects, so they are not good for men who have large prostates. We don't really recommend the Benadryl agents very much. And I don't think anybody should really be taking advantage of like medication unless they have an allergy or skin rash or some other reason why they're taking Benadryl, but I'd be cautious of all the PMs and of the over-the-counter, melatonin is the best, but again, very little data to support its use.
Host: Good to know. Now let's get into some of the differences in age for a minute here. I've heard insomnia is just a normal part of aging. As you get older, you're probably going to experience insomnia. Is that true? Is that the reality?
Dr. Richard J. Schwab: No, I don't think that's true. I do think that menopause in women causes a lot of sleep fragmentation and hot flashes. It is not uncommon for women going through their menopause to have problems with insomnia. But I see plenty of patients who are 30 years old who have insomnia which is probably more genetic than anything else. As you get older, your sleep will be reduced; you often lose what we call delta sleep and you will get less sleep. But insomnia doesn't have to be a part of aging.
Host: I assume most people are aware that exercise is an important part of getting a healthy night's sleep. It's an important part of a healthy life. But how does diet affect our ability to sleep either positively or negatively?
Dr. Richard J. Schwab: Well, first, I want to say that exercise is really good for insomnia because, first of all, it relaxes you, calms down some of the anxiety, and makes you sleepier. So exercise is a great idea. In terms of diet, eating close to bedtime is a bad idea. Probably a lot of carbohydrates close to bedtime, a bad idea. And there are certain foods that make you sleepy, that's why Thanksgiving, the turkey or the tryptophan, maybe would help but there's again, no real good studies on these different dietary manipulations for insomnia.
Host: Now, many self-diagnosed insomniacs may say how their body has adjusted to the lack of sleep or poor quality of their sleep. Is the human body actually capable of adjusting itself to fewer hours of sleep over a long-term period?
Dr. Richard J. Schwab: Not really; I mean, if you start doing it, you're going to get sleep-deprived. I mean, there's plenty of studies out there that if you reduce your sleep to four hours a night, over time, you're going to be sleep deprived, and you're not going to function as well, from a mental standpoint, physical standpoint. So, I don't think your body can adjust. Now there's a sleep debt, and you can recover that sleep debt. That's sort of what we do on the weekends, right, we recover our sleep on the weekends. And that's common because again, as I described earlier, most of our entire society is sleep deprived The other thing that I would say is not so much that it's related to your body, but patients who have insomnia, people with insomnia typically focus on their insomnia. The more you focus on it, the worse it becomes. It's kind of like breathing; if you start focusing on your breathing, your breathing becomes really weird. It's like, I don't even know how to breathe anymore. So, the more you focus on insomnia, the worse it becomes, it's very hard not to do that. But I try to tell all my patients, listen, try not to focus on this; the more you focus on it, the worse it's going to become. Don't worry about your insomnia; it's going to get better.
Host: Now, I think we can probably guess that one of the effects of insomnia is you’re tired, but what are some of the other effects of insomnia on our health, either short or long-term?
Dr. Richard J. Schwab: So first of all, in terms of the tired piece, a lot of that's mental, and you think you're tired, but maybe you're not really so tired, you can probably do all the things you want to do. And in fact, it may take you a little longer because you're not quite as quick, mentally, but you can do all the things you're supposed to do as long as you don't let it affect you. That's one of the reasons why we actually think coffee is not a bad idea for someone who has insomnia. You don't want to have coffee close to bedtime because it will disturb your sleep, and obviously, you probably won't want to have any coffee after lunchtime, but in the morning, it's probably a good idea. But to answer your question, insomnia, at least associated with short sleepers has been associated with heart disease. So heart attacks, high blood pressure, heart failure. So, there is some cardiovascular risk. These are in epidemiologic studies. These aren't typically one person type, you're absolutely going to get that but if you look over big populations, short sleep with insomnia is a cardiovascular risk factor.
Host: Now, what are some best practices our listeners can implement to prevent insomnia? Let's say it's not totally a chronic problem. At this point. Maybe it's been a week or a few nights. What are some practices that they can do to prevent insomnia?
Dr. Richard J. Schwab: So, as I've kind of described, exercise is really good. And it's more cardiovascular exercise, not so much core training or weight training but cardiovascular exercise. Obviously, not drinking alcohol because alcohol causes sleep fragmentation and makes things worse, and then going to bed at the same time each night. So, one of the things that you don't want to do and it's very hard if you're a shift worker and you're in that becomes even more difficult, but if you're not a shift worker is to go to bed at the same time, get up at the same time. Maybe on the weekend, you sleep a little bit longer, maybe an hour, but you don't oversleep. So, the more your body absolutely gets used to going to bed at the same time, getting up at the same time.
Host: How much should we avoid our phones? Is there a time before bed we should avoid our phones? I think we've all heard about the importance of avoiding them as we get closer to bedtime.
Dr. Richard J. Schwab: Absolutely. The bed should be used for sleeping. It shouldn't be used for working, it shouldn't be used or looking at your phone, paying the bills, watching television, any of that. In terms of the phone, yes, especially blue light affects you and makes you less likely to be able to fall asleep. You do not want to use your phone within an hour or two before bedtime if possible, and absolutely not within the bed. And the bed needs to be used for sleeping, nothing else.
Host: Now, let's say we've had a bit of a chronic problem or an ongoing problem with sleeplessness. When should someone consult a doctor like yourself or someone else when they feel it's become a problem? Or how should they know that it is a problem?
Dr. Richard J. Schwab: That's a really good question. And there's probably not a great answer for that. But I think if you start having consistent problems, and especially if there are family members who have had the same problem because maybe genetic or something's changed. Typically, insomnia can happen after a terrible event, right? Somebody dies and then it gets better. But if it doesn't get better over three months, I would think about being evaluated in the sleep center. One of the things that sleep centers can provide independent of medications is something called cognitive behavioral therapy. And that's counseling. It does a lot of different things. It teaches you sleep hygiene techniques; it tells you what to do if you can't fall asleep in bed; it teaches you what to do and how to think about insomnia in terms of not overly manifesting in ways that you might think are terrible but really aren't. What they do more than anything else is make your sleep more efficient; they actually reduce your amount of sleep and then slowly increase it. So cognitive behavioral therapy is the best treatment for insomnia if you have chronic insomnia, much better than medications, or at least as good as medications and no downside, no side effects. And so if you really do have a persistent problem with insomnia, over again, about a three month period, I would see someone in the sleep center.
Host: Yeah. My next question was about, quote, unquote, sleeping pills. And whether they are a safe remedy or not, what is your perception there?
Dr. Richard J. Schwab: Yeah, the sleeping pills are interesting. They’ve all been designed for short-term use. So, six weeks, but my experience is once you get put on a sleeping pill, they are not stopped, you are on them for a long time. And they have real risks; they affect your memory, especially as you're getting older, and there are fall risks. So, you get up to go to the bathroom in the middle of the night, and you've got a sleeping pill on board, and you trip on the carpet, and you hit your head, and you break your hip. I mean, you can die from these things. So, we don't love to give out sleeping pills; sometimes, it's necessary. But they're not better than cognitive behavioral therapy. That's clear. There are real side effects. We don't really know what's the best medication; there are very few head-to-head trials, and there's some expense to this. In general, we like to do cognitive behavioral therapy. That being said, you can't get that for everybody. And again, a lot of people will try over-the-counter melatonin, which I think is fine. And you can try different sleeping pills. But that wouldn't be my first treatment.
Host: But there any other myths regarding insomnia that you want to clear up for our listeners or questions you’ve gotten from patients or even from students that you want to clarify here?
Dr. Richard J. Schwab: Sure. So again, just reiterate the fact that alcohol is a really bad choice. And then cannabis or cannabis-like products. It's not clear they help insomnia. They're very good for people with chronic pain. And they, I think, help people who have chronic pain sleep. But the one thing about cannabis in any of its forms, if you take it regularly, the one data point that I think is relevant is that when you stop it, you come off it, you are going to have very bad insomnia. So if you start a cannabis-like agent and you have insomnia, and you come off it, that's going to be a problem. Because that's the one feature of cannabis that's been shown over and over again, you stop it, you're going to have problems with insomnia. So, I'd be very cautious before I started anything like that. On the other hand, if you have chronic pain, I think kind of cannabis and the products are good for people with insomnia with chronic pain.
Host: Dr. Schwab, thank you so much for your time. For now, let's stop there, and on the next episode of the Merck Manuals Medical Myths Podcast, we can focus on the topic of sleep apnea; for our listeners looking for more information about insomnia, please head over to merckmanuals.com. Until next time, I'm Joe McIntyre, thanks for listening.
