Time to wake up about sleeping pills
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.