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The New York Times - March 24, 2012

The Case for Sleep Medicine


ACCORDING to a new study in the journal BMJ that has received wide media coverage, people who regularly took sleeping pills were nearly five times more likely to die over a two and a half year period than those who didn’t take them.

Oh no, I groaned, reading the headlines, not another scare story about sleeping pills. As a lifelong insomniac who has extensively researched the topic, I find such stories alarming — but not because of the information they present. Rather, I’m afraid that they will cause doctors to stop prescribing these medications to people who need them.

The risks of sleeping pills are real, as I well know, having taken them for three decades. But so are the risks of chronic sleep loss. As the pioneering sleep scientist William Dement has argued, sleep is “the most important predictor of how long you will live — perhaps more important than smoking, exercise or high blood pressure.”

Sleep deprivation ratchets up the stress system, leaving you more susceptible to even relatively mild sources of strain. When University of Chicago researchers led by Eve Van Cauter deprived young, healthy people of a few hours of sleep for six nights, they produced in them the hormonal profiles of much older people: higher levels of stress hormones and lower levels of growth hormone (essential to cell repair). The study’s participants developed hormonal imbalances conducive to weight gain and levels of insulin resistance like those of people with diabetes.

Loss of sleep also compromises immune resistance and leaves you more vulnerable to everything from the common cold to cancer. In a University of Chicago study led by Karine Spiegel, participants whose sleep was restricted to four hours a night for six nights had, when vaccinated for influenza, less than half the immune response of those who had slept well. Michael Irwin and colleagues at the University of California, Los Angeles found that even modest sleep loss — only one night, between 3 and 6 a.m. — significantly reduced white blood cell activity, a crucial line of defense against infection and cancer.

Then there are the ravages of sleep deprivation on the mind and mood. After a night with four hours sleep or less, I can’t think, can’t work, can barely string words together to make a sentence. Sleep deprivation undermines focus, creativity, motivation and judgment, and leads to a wide range of emotional disturbances including volatility, impulsivity and depression. Studies show that insomniacs have a hard time getting jobs, performing at jobs and holding on to jobs, let alone building careers. No wonder so many people make the trade-off that I’ve made: medication for functionality.

The recent study in BMJ about the dangers of sleep medications had methodological shortcomings: It compared a large group of people who had been prescribed sleep medication with a large group that had not, matching them in terms of age, sex, ethnicity, body mass index, smoking and drinking — but not in terms of how well they slept. Given that those taking the medications had more hypertension, heart failure, obesity, asthma and other health problems associated with poor sleep to begin with, it’s not surprising they had higher mortality rates.

Which is not to say that the drawbacks to sleep medication aren’t real; they are. These medications alter sleep cycles, so that the sleep they provide may not have the deep restorative benefits of natural sleep. They adversely affect memory and coordination, which can be bad news for the elderly, the group that takes them most. And you can develop a tolerance to them, causing you to take larger and larger doses to get the same effect. But the sleep they provide may make the difference between having a life or not.

The study in BMJ alludes to “the meager benefits” of sleep medications and the greater success of behavioral methods of dealing with insomnia, which include things like going to bed and getting up at set times and using the bed only for sleep. But such strategies are not as effective as is sometimes claimed: studies that demonstrate their efficacy tend to look at small numbers of carefully screened, self-selected and highly motivated subjects. Face it, if behavioral modification were that simple, there wouldn’t be so many of us taking medications.

It’s not fun to rely on medications that carry risks. Nor is it fun to rely on doctors who are often not very sympathetic or knowledgeable about sleep, whose medical training is a hazing in sleep deprivation, and who often pride themselves on how little sleep they need. Insomniacs need doctors who will work with us to troubleshoot our condition; we do not need doctors who have been scared into a one-size-fits-all solution, when one size so obviously does not fit all.

We need to be allowed to work out our own terms with sleep and balance one set of risks against the other, so we can get on with our lives.

Gayle Greene, a professor of English at Scripps College, is the author of “Insomniac.”


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