Time to wake up about sleep­ing pills

The Weekend Australian - Travel - - General Appointments - ROBERT KA­PLAN

IN­VES­TI­GA­TIONS into the death of the ac­tor Heath Ledger have drawn at­ten­tion to the role of the sleep­ing tablet Stil­nox (mar­keted as Am­bien in the US). There have been re­ports of users demon­strat­ing strange be­hav­iour such as eat­ing, sex, vi­o­lence or psy­chosis, in sleep.

To the pub­lic, this raises ques­tions about the safety of Stil­nox, but no one has con­sid­ered the un­der­ly­ing is­sue: should Stil­nox or, for that mat­ter, other tablets, be used at all for in­duc­ing sleep?

In­som­nia is among the five com­mon­est com­plaints that pa­tients present to their doc­tors. Ev­ery day GPs write hun­dreds upon hun­dreds of scripts for sleep­ing tablets. Yet, from the per­spec­tive of sleep medicine, it can be ques­tioned whether there is any ba­sis for such treat­ment.

There are two types of in­som­nia: pri­mary, due to a dis­or­der of sleep; and sec­ondary, where the dis­tur­bance arises from an­other phys­i­cal or psy­cho­log­i­cal con­di­tion. Most in­som­nia is due to a short-lived prob­lem that will settle and nor­mal sleep will re­turn. The com­mon­est sleep dif­fi­culty is known as psy­chophys­i­o­log­i­cal in­som­nia, a chronic prob­lem due to poor sleep hy­giene.

Sleep­ing tablets, re­gard­less of brand, do not pro­mote nor­mal sleep as much as they sup­press con­scious­ness. Their use is in­vari­ably fol­lowed by dis­tur­bance of what is known as the sleep ar­chi­tec­ture. In some cases, this can be so pro­longed that the use of sleep­ing tablets can be de­tected in sleep trac­ings six months later.

Psy­cho­log­i­cal disor­ders are in­vari­ably as­so­ci­ated with sleep dis­tur­bance, but there is no ev­i­dence that sleep­ing tablets pro­mote re­cov­ery and it is far bet­ter to treat the un­der­ly­ing con­di­tion with the right drugs. De­pres­sion, for ex­am­ple, has a char­ac­ter­is­tic sleep pat­tern (some even think de­pres­sion is a pri­mary sleep dis­or­der) and an­tide­pres­sants re­verse the sleep cy­cle back to nor­mal. Clin­i­cians can fol­low the re­cov­ery in mood by the changes in sleep.

Sleep medicine now has a range of ap­proaches to in­som­nia. Once the un­der­ly­ing dis­or­der is di­ag­nosed — for ex­am­ple, pe­ri­odic limb move­ment (twitch­ing and jerk­ing in sleep), brux­ism (tooth grind­ing and jaw clench­ing), obstructive sleep ap­noea (ob­structed breath­ing with heavy snor­ing) or sleep walk­ing — it is easy to in­sti­tute ef­fec­tive treat­ment.

With sec­ondary or chronic sleep prob­lems, psy­cho­log­i­cal meth­ods are used. Pa­tients keep a sleep diary for a week or two, are in­structed in sleep hy­giene (get rid of that doona so you don’t over­heat!) and to see a psy­chol­o­gist.

Of course there are sit­u­a­tions when the use of sleep­ing tablets is ap­pro­pri­ate, such as acute be­reave­ment or se­vere dis­tur­bance due to med­i­cal con­di­tions. How­ever, this is short­lived and should not lead to pro­longed use.

That any­one can ex­hibit strange be­hav­iour of which they have no aware­ness while sleep­ing is a source of some fas­ci­na­tion, but there is noth­ing new about this. Sources as far back as the Bi­ble and the Assyr­ian Codex show that sleep walk­ing, vi­o­lence and hal­lu­ci­na­tions are part of the hu­man con­di­tion.

In the deep­est stage of sleep,


is com­plete mus­cu­lar paral­y­sis while the me­mory banks are es­sen­tially vac­u­umed out to re­fresh short-term me­mory for the next day. The process lib­er­ates all sorts of thoughts, mem­o­ries or feel­ings which we ex­pe­ri­ence as dreams. If the process is in­ter­rupted or breaks down, we may re­spond to the im­pulses in an au­to­matic state. How­ever, if tested, the sub­ject would be re­vealed as still in a state of sleep and un­aware what is hap­pen­ing.

When dis­tur­bances are as­so­ci­ated with par­tial wake­ful­ness, the con­se­quences can be se­vere. The com­mon­est cause of death — to the pa­tient or peo­ple around them — dur­ing sleep is from sleep walk­ing. Other vi­o­lence, such as sex­ual as­sault, can oc­cur.

Noc­tur­nal gus­ta­tory syn­drome is where the sub­ject will go to the kitchen and eat in­dis­crim­i­nately, of­ten leav­ing food spilled or fridge doors open, but have no aware­ness the next day when be­rated by their part­ner.

Sleep paral­y­sis is as­so­ci­ated with ex­trareal­ity per­cep­tions such as space and time travel, as­sault by witches or ghosts, or alien ab­duc­tion. Yet it is a uni­ver­sal phe­nom­e­non, oc­cur­ring in 40 per cent of the pop­u­la­tion and the com­mon­est cause of vis­ual and au­di­tory hal­lu­ci­na­tions in nor­mal sub­jects.

There is a wide gap be­tween the world of pri­mary care, where GPs are un­der con­sid­er­able pres­sure to pre­scribe sleep­ing tablets, and spe­cial­ist sleep medicine. Ev­ery pa­tient with in­som­nia should have a sleep his­tory and al­ter­nate mea­sures con­sid­ered. It is easy to re­as­sure peo­ple about dis­turb­ing sleep be­hav­iour, pro­ceed­ing to sleep study and med­i­ca­tion if nec­es­sary.

The im­por­tant mes­sage for the pub­lic is that sleep­ing tablets are not the first or the last so­lu­tion for in­som­nia; they are no so­lu­tion at all. Robert M Ka­plan is a foren­sic psy­chi­a­trist at the Grad­u­ate School of Medicine, Wol­lon­gong. His book Med­i­calMur­der:The Dis­turbingPhenomenonofPhysi­cian­sWho Kill is to be pub­lished in Oc­to­ber.

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