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Health Matters: Causes and treatment of insomnia

January 31, 2009
By Dr. Josh Schwartzberg

"The best cure for insomnia is to get a lot of sleep."

W. C. Fields (American Comic and Actor, 1880-1946)

Insomnia, either difficulty falling asleep or waking during the night, is one of the more frequent complaints I hear in my family practice office.

It is estimated that 30 million Americans struggle with chronic insomnia. A survey of primary care patients showed that 69 percent had some form of insomnia and at least 10 percent of all individuals will develop chronic insomnia, increasingly with age and affecting women more than men.

Insufficient quantity or quality of sleep impairs daytime activity, causing fatigue, poor concentration, impaired social or job function, mood issues and increased mistakes or accidents in the work place. Persistent worrying about adequate sleep can become a vicious cycle and perpetuate the problem.

Excessive daytime sleepiness affects about one third of normal adults and can be a cause of memory problems.

Poor sleep can be caused by conditions such as lung disease, Parkinson disease or Alzheimer's, prostate enlargement with frequent urination, arthritis or any other causes of pain.

Insomnia and depression frequently coexist and 45 percent of patients with chronic disturbed sleep may have clinical depression. On the other side of the coin, 80 percent of people with depression, anxiety, post traumatic stress disorder or restless leg syndrome have insomnia. Obstructive sleep apnea or menopause also can result in lack of a restful night's sleep. People with chronic insomnia have double the risk of automobile accidents.

Sleep duration requirement becomes less as we get older and some can function well on just a few hours. When a patient has insomnia, I look for other coexisting medical or psychological conditions rather than just prescribing a sleeping pill.

Hurried doctors often will treat the symptom rather than investigate the possible underlying cause. Many sleeping pills carry risk which includes not only side effects but also physical and psychological addiction with long-term use.

Generally sleeping pills are divided into two categories, including the benzodiazepines, which promote sleep and decrease anxiety and are in the family of the old-fashioned drug Valium. These medications can cause dependence as well as withdrawal symptoms including what is referred to as rebound insomnia. They are not recommended for long-term use.

The other category is the non-benzodiazepines, which generally don't have the same effects of withdrawal or dependency. The newer ones like Lunesta and Sonata have no restrictions on duration of use. The latest sleeping pill to win FDA approval, Rozerem, has less chance of being abused as it targets receptors in the brain for the sleep hormone melatonin.

The various sleeping pills differ primarily with regard to how quickly they take effect and how long the medication remains in your system.

For patients who have difficulty falling asleep a rapid onset is desirable whereas for sleep maintenance a longer duration of action would be more effective.

In addition, antidepressants with sedating quality are useful when insomnia and depression coexist. Studies have shown that the common over-the-counter antihistamine Benadryl is rarely of benefit, likewise the popular herb Valerian. Melatonin is effective only if levels are low to begin with.

In choosing which prescription sleeping pill to prescribe I consider whether there is sleep onset insomnia, which requires a short acting pill and has less residual drowsiness, or sleep maintenance insomnia which needs a longer acting drug to prevent waking during the night.

In other words, some sleep medicines are better at helping you fall asleep while others help you stay asleep through the night. Sleeping pill adverse side effects are a particular problem in the elderly. Rozerem has the least side effects, is not habit-forming and does not have prolonged sedation. Along with Sonata, this is a good choice for those who have difficulty falling asleep whereas for those complaining about waking in the middle of the night, a medicine such as Ambien or Lunesta might work better.

We need to remember that sleep medications treat only the symptoms and not the cause of insomnia.

Before starting medication it is best to treat chronic insomnia with behavioral therapy and making improvements in the sleep environment as well as keeping a regular bedtime schedule.

Dr. Josh Schwartzberg practices in Lake Placid, Willsboro and Burlington. He can be reached

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