A conversation about sleeping pills with Dr. Wallace B. Mendelson (#20)

Transcript

Martin Reed:
Welcome to the Insomnia Coach Podcast. My name is Martin Reed. I believe that nobody needs to live with chronic insomnia and that evidence-based cognitive and behavioral techniques can help you enjoy better sleep for the rest of your life.

Martin Reed:
The content of this podcast is provided for informational and educational purposes only. It is not medical advice and is not intended to diagnose, treat, cure, or prevent any disease, disorder, or medical condition. It should never replace any advice given to you by your physician or any other licensed healthcare provider. Insomnia Coach LLC offers coaching services only and does not provide therapy, counseling, medical advice, or medical treatment. The statements and opinions expressed by guests are their own and are not necessarily endorsed by Insomnia Coach LLC. All content is provided “as is” and without warranties, either express or implied.

Martin Reed:
Okay, Dr. Mendelson, thank you so much for taking the time to come on to the podcast today.

Dr. Mendelson:
Well, thank you, Martin. I’m delighted to have a chance to chat with you.

Martin Reed:
I’m really excited to cover this whole topic of sleeping pills, but before we move on to that, specifically, can you tell us a little bit more about your own background and how you got interested in the field of sleep?

Dr. Mendelson:
Well, sure. I guess the best way to describe, it is that I was a student in the 1960s. And it was a remarkably exciting time. In the field of psychiatry, the 1950s and early 60s, saw a revolutionary kind of evolution, prior to that time, the dominant process in American Psychiatry had to do with psychoanalytic treatment and Freudian notions which involve things like understanding the unconscious and the very powerful influence of early childhood on adult life. Although this was a very interesting thing and still I believe a very important thing. It didn’t fully address the range of psychiatric patients in my opinion. And then suddenly in the 50s, a whole new era opened up, and it began with a discovery of Thorazine which revolutionized the way hospitalized patients were taken care of, the two major kinds of antidepressants, anti-inhibitors and tricyclic antidepressants came along.

Dr. Mendelson:
Probably a little more relevant to our today’s talk, and 1961 the first benzodiazepine, Chlordiazepoxide, became available in the US and was seen as a very remarkable improvement for anxiety compared to the barbiturates, and I’ll talk about that later. It was a very exciting era, and that in combination with a chance occurrence, which had to do with military service obligations during the Vietnam era, put me in contact with Richard Wyatt, who is a very well known psychiatrist. Who was very involved among, other areas, sleep. He and his colleague, Chris Gillan, were very important influences on me and led to my interest in sleep.

Martin Reed:
That’s great. So for those who don’t know, how I found out about you is through two books that you’ve authored, Understanding Sleeping Pills is one of them, and the other one is The Science of Sleep. And in those books, you outlined the development of sleeping pills. And what was interesting to me was, you mentioned how each generation of sleeping pills seemed to kind of bring improvements on the previous generation. But after that initial enthusiasm, of this newest generation died down, we’d usually recognize limitations and then move on to a new generation. So can you talk us through this a little, like the evolution of sleeping pills?

Dr. Mendelson:
Well, sure. Yes, indeed, medicines for sleep have gone through many generations. Just to talk about relatively recent history. Certainly the barbiturates were the dominant sleeping pills starting at the beginning of the 20th century. And as years went on, and experiences gained with them, their many limitations became very, very obvious, and we’re very clear by mid- century. Among these were… They were very lethal in overdose. They were dependence producing, they could suppress respiration in people who already had some kind of underlying pulmonary disease, including, of course, sleep apnea. And their use was, very, very widespread. A very good description of it were in… Non-medical terms was the Jacqueline Susann’s book The Valley of the Dolls, which described lifestyles and abusing barbiturates, very clearly. From a scientific point of view, there was REM sleep had been relatively recently discovered in the 1950s.

Dr. Mendelson:
And it was found that barbiturates were powerful suppressors of REM sleep, although nobody was quite sure what the significance of that was. Now, in any event, starting in 1961, with the first benzodiazepines and then 1971, when flurazepam or Dalmane — the first benzodiazepine that was specifically recommended for sleep came along on. People recognized a number of benefits of benzodiazepines compared to the older barbiturates, among others that they didn’t suppress REM sleep. They were relatively safer in overdose. And I say relatively because this is true, relatively true in people who are medically healthy and who have not taken a second drug. But the vast majority of overdoses are in combinations of drugs and usually with alcohol. And in that case, benzodiazepines can become very toxic and indeed lethal. So this is a relative improvement compared to barbiturates.

Dr. Mendelson:
Unlike barbiturates, they didn’t stimulate the liver enzymes to break down other drugs more quickly. Originally, it was thought that they had little effect on respiration, but in later work that I and others did, we showed that again, compared to barbiturates is much less but it’s still nonetheless, was present. So these were seen as improvements over earlier agents as the decades went on, of course, and number of things that come to light. One was that, they too could be drugs of abuse. Another one is that, the respiratory suppression which I mentioned. One, which I thought was very interesting was that although there was this initial enthusiasm that they didn’t suppress REM sleep, it turned out that they’re very, very powerful suppressors of slow wave sleep or deep sleep. And I guess, now we’re learning more and more about the function of sleep stages. But at the time, it wasn’t clear whether suppressing one stage was more or less advantageous than suppressing another.

Dr. Mendelson:
But the point was, they did not mimic normal sleep neither drug did. And other thing, were issues of tolerance and dependence as I mentioned. Other people have felt that their lives were altered by taking long-term benzodiazepines in terms of cognition, anxiety and other things. And that’s something we can talk about later. So benzodiazepines too, have although initially greeted, rightfully with enthusiasm compared to barbiturates also, were seen to have limits. In the 80s, we began to see the advent of the newer drugs, usually referred to as the Z drugs, zolpidem, zaleplon, and zopiclone or in the US eszopiclone. They were perceived to have advantages too, one of them was that they had relatively little effect on total amounts of REM sleep or slow wave sleep. Although they do have some, they had less respiratory suppression in susceptible patients. Although again, they did have some.

Dr. Mendelson:
And the shorter acting ones seem to have relatively little effect on daytime performance, although the longer ones clearly did. So once again, as time has gone on, we’ve gained decades of experience and seen that they do have limitations. They can be drugs of abuse and are, like the previous two classes we’ve mentioned, are so called scheduled drugs by the DEA. There’s been concern raised about sleepwalking related behaviors. Most of this is focused on zolpidem, but I think really can happen with any sleeping pill. But then certainly in the public, lower in the press, a lot of concern about complex behaviors during sleep. So each generation then seems to be greeted with enthusiasm. And then over times, we’ve learned that they probably do have some improvements over earlier ones but still have their own kinds of limitations.

Martin Reed:
So when I was reading your book, it was really interesting how you… Just as you’ve done now talked about each generation and how each generation was slightly different, initially seen as an improvement, recognize some limitations, and the next generation comes out. So we had this path of starting with the barbiturates, and the benzodiazepines, nonbenzodiazepines, and we’re still moving forward on that path and we were seeing these other drugs now that work even in different ways, like these drugs like Ramelton, Suvorexant. What’s the difference between… What we see as like this newest generation of sleeping pills compared to the benzodiazepines and the Z drugs?

Dr. Mendelson:
Well, the 2000s have seen the introduction of the three drugs you mentioned and they’re each quite different. Certainly Ramelton is one and it’s a melatonin receptor agonist. It had the advantage of not significantly being a drug of dependence and being not scheduled by the DEA, had relatively benign in terms of effects of next day alertness and so on. The limitation is that it’s effect is primarily for difficulty going to sleep without much effect on awakenings during the night or total sleep. And very often people have combinations of those problems, not just simply isolated, trouble going to sleep which can be a limitation. Another one of the newer drugs is really a new cast on an old drug and that is low dose doxepin. Doxepin is a tricyclic antidepressant that’s been available for several decades. The new twist on it is giving it on extremely low doses, much lower doses and those that are used typically to treat depression.

Dr. Mendelson:
Again, it’s not a DEA scheduled drug. And although there is some misuse of tricyclics, it’s much less and disadvantages are in an antidepressant kind of doses, tricyclics are very lethal in overdose. And in fact, at one time, they were the second most common reason for admissions to medical ICUs, after aspirin, but again, that’s usually related to higher doses. They have the advantage of not being clear respiratory suppressants unlike most of the previous drugs we’ve mentioned and it comes with one limitation and that limitation is it is primarily effective for awakenings during the night, which is of course a very important thing. But as I mentioned before, many if not most people with sleep difficulty have combinations of sleep symptoms, that is difficulty going to sleep, awakenings during the night or too short sleep or unrefreshing sleep. So that can be a limitation on its use.

Dr. Mendelson:
Suvorexant was an exciting new development, because it worked by a very different mechanism than previous sleeping pills in that it was orexin antagonist, it blocked the effect of a natural arousing substance, orexin. It too had its limitations besides issues of daytime sleepiness and things of this nature. It tends to have higher amounts in the body, in the obese and in females, and so it was learned that it’s often wise to be more cautious with dosage in those groups. And it also introduced a new side effect pretty much not seen with other sleeping pills and having to relate to its action as an orexin antagonist, and that is that some people could have symptoms of sleep paralysis or hypnagogic hallucinations and although that’s rare it does happen. Again, we have a new generation with three different kinds of very different drugs and each has certain benefits and each has certain limitations.

Martin Reed:
Yeah. Something interesting that came to my mind, as you described how all these different medications work is, that they aren’t targeting what we would say are dysfunctional areas of the brain or fixing any kind of chemical imbalance, so to speak. I think that’s an important point, because many people with chronic insomnia might think that they’re beyond help, or they can’t do anything to improve their sleep, because their insomnia is caused by some kind of chemical imbalance. So, not only is there no evidence to support the idea that insomnia is caused by a chemical imbalance, it sounds as though sleeping pills aren’t targeting a chemical imbalance either.

Dr. Mendelson:
We’re learning more and more about how these agents work. And for instance, in the benzodiazepines and the Z drugs, we have a pretty clear idea that they tend to block the… Sorry. They tend to augment the activity of GABA — gamma hydroxybutyrate type A receptors — and GABA is the most important inhibitory neurotransmitter in the brain and enhancing its activity particularly in the hypothalamus, at the base of the brain, seems to result in more tranquility and sleep and so on. So we’re beginning to understand the function for those other individual sleeping pills as we just gave the other example of Suvorexant and the orexin system. I don’t know whether you call those issues chemical imbalance, but I’d rather put it in a positive way and say that we’re getting to understand how these drugs act physiologically.

Martin Reed:
Just to summarize without getting too technical and correct me if I’m wrong in anything I’m going to say here, but it sounds as though we have drugs that increase levels or activity of an amino acid such as GABA that helps slow brain activity. We got the benzodiazepines, such as triazolam, temazepam, and even the non benzos, like zolpidem (Ambien), the latter being thought to be better since… From what I understand from your book, they bind to a more limited number of receptors so the effects tend to be more specific to sleep. And then we have these drugs that weaken the wake-promoting areas of the brain in different ways, like Ramelteon, Suvorexant, and doxepin. With this in mind, is it fair to say the sleeping pills are generating sleep or are they instead just weakening wakefulness and generating sedation?

Dr. Mendelson:
Well, I think there’s more than one road to the same place. And wakefulness and sleep result from a balance of forces, that tend to push in the direction of wakefulness and other physiologic processes attempt to push in the direction of sleep. And of course, sleep is also highly influenced by the circadian body clock which can also be influenced by some of these drugs. In addition, sleep is influenced by the homeostatic system which tends to try to make up for decreased sleep, if there’s been prior sleep deprivation. So there’s a multitude of forces impinging on whether we’re awake or asleep and drugs that promote sleep and can work by promoting or decreasing any of these forces.

Martin Reed:
The reason I asked that question is because a lot of times when I’m working with people with insomnia, they feel that a medication, regardless of what it might be, is somehow generating sleep. And I do like to try and shift the mindset to one of… Well, any sleep we get is being generated by our own bodies, so no pill in itself can generate sleep. But what a pill can do is promote relaxation, maybe help lower that initial barrier or obstacle to sleep, which might be, worry about sleep, anxiety, higher levels of arousal. But once that barrier is lowered, and the sleep occurs, it’s the body that’s generating the sleep because no pill can actually generate sleep itself. Would you say that’s something reasonable to say?

Dr. Mendelson:
I’m not sure how we can be held to define the concept of generating sleep, I prefer to think of it the way that we mentioned it before, that sleep and wakefulness result from a balance of forces and what sleeping pills tend to do is to alter that balance. I think the situation that you described, it might be more applicable to a tranquilizer, for instance. So for instance, if somebody was being kept awake by anxiety, and medicine decreased anxiety, it might allow the normal processes of sleep to be more likely to occur, but in terms of medicines that promote sleep, I guess I better take a pass on that one.

Martin Reed:
Something that can be quite misleading when it comes to the effectiveness of sleeping pills might be how we measure clinical effectiveness. Because I think some people can be surprised that for a sleeping pill to be considered clinically effective, it might only need to improve sleep onset by around say 10 minutes compared to a placebo, sleep duration by around 20 minutes compared to a placebo. What are your thoughts on this? Do you think that sleeping pills truly are as effective as we might think they are?

Dr. Mendelson:
Well, yeah. I do actually. Let me just go back to your question of how do we measure whether something’s effective. The numbers you mentioned are true but not the whole picture. They’re numbers that have to do with polygraphically measured sleep. And there’s a number of ways to getting an effectiveness, one of them is the use of the polygraph signature. Another equally important is how people experience sleep after medicine, so what they report about their sleep and in many ways can even be more important. After all, a patient doesn’t go to a doctor or therapist to say, “hey, my polygraphic sleep is 10 minutes too long or too short.” They say, “hey, I’m feeling like my sleep isn’t deep and it’s not restful. I don’t feel good in the morning.” All right? So both methods are important. The patient reports are very valuable because they actually get it that they complain. The reason a person wants a treatment. Their weaknesses is that they’re not as quantifiable as a physiologic measure like the polysomnogram or PSG for short.

Dr. Mendelson:
On the other hand, the polysomnogram with its advantage of being quantitative has disadvantages, and one of those is it’s very hard to relate the number of minutes of shortening polygraphically defined sleep, to the clinical experience of a good night’s sleep, or to the good experience of feeling in the morning, that sleep is restful. I guess another advantage of the polygraphically measured sleep, besides being quantifiable is that it helps us make sure that a person doesn’t like a medicine for the wrong reason. Some medicines might be euphoriants for instance, and somebody says I like that because they felt a sense of euphoria. A polygraphic sleep helps remove some of those extraneous reasons for liking or disliking the drug. So I think it’s true but incomplete to say that clinical effectiveness of any treatment is only 10 minutes shorter falling asleep or 20 minutes longer sleep. That’s part of a one measure and not the whole picture.

Martin Reed:
I think you raised a really important point with this subjective versus objective measure of sleep, because especially in insomnia, we see that… For example, the amount of sleep someone with chronic insomnia reports, is typically less than what we would see if they took an overnight sleep study. So there is this mismatch, but ultimately, all that really does matter is what you perceive to be good sleep or poor sleep because sleep is so subjective. So if you feel that you’re getting a good night’s sleep, you feel like you’ve got enough energy to get through the day. Really, that’s all that matters. It doesn’t really matter so much how many hours a machine is saying you’re getting of sleep. If it feels like you’re getting good restorative sleep and you’re getting through the day, the chances are your sleep’s pretty good.

Dr. Mendelson:
Well, again, I think as you pointed out, and as I say, the reason, of course I go to the doctor, generally is because the sensation and experience of not sleeping well. So in many ways, the very important test for the treatment is how they feel about their sleep.

Martin Reed:
Absolutely. I was going to ask you more about the potential side effects of sleeping pills. But I think you’ve covered quite a lot of this already, when you were talking us through the different types of sleeping pills. But one thing that I did want to ask you about, and you mentioned this, in your book, Understanding Sleeping Pills was to do with the potential for some daytime impairment, whether that’s sedation or memory issues, things like that. You mentioned that very often, someone might be impaired, but not even be aware of it. So they might say that, “no, I don’t feel any of these daytime effects.” But objective testing tells us otherwise. Can you tell us a little bit more about this and why this is perhaps an important point?

Dr. Mendelson:
Well, sure. You raise an important issue… Again, different sleeping pills may have different or little or no effect on wakefulness and performance the next morning, giving an example Ramelton has very little if any effect on next day when taken in the recommended dose in the evening, while other medicines may… Benzodiazepines buried in that result depending on the duration of action of the drug so a very short acting drugs, like zaleplon had relatively little effect next day, whereas longer acting drugs like a eszopiclone could indeed reduce wakefulness and performance the next morning. One result of that in the case of eszopiclone was that in 2017 if I recall, correctly, the recommended starting dose was lowered by the FDA in order to reduce the possibility of daytime sleepiness, so different drugs have different results in regard to that.

Dr. Mendelson:
The other point which I hadn’t mentioned you brought up, it’s a really important one. And that is that for many drugs, especially benzodiazepine, a person is not always aware that they’re impaired. If you were aware of it, and you just sort of felt bad, a reasonable person would take precautions not to expose themselves. Anyway, they could be accidentally harmed by being too sleepy and so on. But one characteristic of benzodiazepines, is that very often a person is not aware of it. So using the example of flurazepam or Dalmane, they were very nice studies that show decreased performance on different kinds of psychomotor tests. But a person’s subjective report was that they did not feel impaired.

Martin Reed:
I think another important point on the issue of daytime sedation, fatigue, morning grogginess, memory impairment and things like that is we can easily attribute symptoms like that to a poor night of sleep or insufficient sleep duration or insufficient sleep quality, when it could actually be a side effect of whatever medication we’re taking. Would you say that’s a possibility or that’s fair to say?

Dr. Mendelson:
Well, I think it works in both directions. Now, the issue of benzodiazepines and cognition is one that’s received a lot of attention. I know there was one analysis a few years ago of 13 studies that found that people taking benzos, which is short for benzodiazepine for over a year, found deficits in a number of areas like verbal learning and speed of processing and things like this. Now, things to remember is that it wasn’t clear how clinically significant these measures were. It’s just like the same issue of how clinically significant is 10 minutes less sleep latency. And another issue is whether these were actually direct effects of benzos on cognition or whether they were secondary to sedation. The good news is that generally these clear up when a drug is stopped.

Dr. Mendelson:
But the thing to remember is the other side of the coin which is that anxiety and insomnia can both influence cognitive studies themselves. So it’s very hard to separate whether cognitive impairment is secondary to anxiety or insomnia or whether it’s due to the medication.

Martin Reed:
We’ve been talking quite a lot about side effects. I think it’s important for us to distinguish or just to talk about whether these risks are different short-term versus longer-term. What do we see in terms of effectiveness and potential side effects with sleeping pills over the long-term? Are they effective over the long-term? And is there any risk associated with taking sleeping pills over the long-term versus just short-term use?

Dr. Mendelson:
Well, we’ve just talked about a study which analyzed all the available literature that met a certain quality for people taking benzos for over one year, and I think we’ve addressed that pretty clearly. Now another concern about long-term use, it’s been raised and appropriately set off alarms in the last few years has been some studies that seem to suggest that long-term use of benzos might be associated with a greater likelihood of developing dementia. Some of these studies were a better quality than others. We really haven’t been certain about this, although it’s been a suspicion. Happily a study came out this year. That was a huge study, it had about over 200,000 patients in it. And it happened to be depressed patients.

Dr. Mendelson:
So they looked at people with extensive use of either benzodiazepines or the newer Z drugs, and they found no increase in the rate of dementia. I think it was 6.1 year follow-up. So what I can say is that suspicion has been raised, but happily, at least in the case of patients with depression who are taking benzos or Z drugs. This is very, very large study, did not see any evidence of a higher rate of dementia. I guess another issue that you hear about a lot is whether sleeping pills are associated with higher mortality. A lot of this came up in the 1970s, partly as a result of re-analyzing data from the American Cancer Society national study. It’s the same study that first raised alarms about smoking and cancer, but as it happened, they had a lot of other kinds of questions in there about health and so on. And it was thought that there was some association.

Dr. Mendelson:
Again, that was an alarming kind of thing but there’s a number of things to bear in mind. One is that further analysis of these types of data began to show that any association wasn’t really with prescription sleeping pills, it was with over-the-counter sleeping pills and with other kinds of medicines that were used off label to promote sleep. In other words, the questions were asked was did a drug that you used for sleep associated with these things? It turned out prescription sleeping pills weren’t so clearly associated, it was more of these other things. Now another issue is that the studies showing a higher mortality with sleeping pills usually did not take account of the presence of either psychiatric illness or sleep disorders. One study which went back and reviewed that found that when they did take into account the presence of psychiatric illness or sleep disorders there was no longer an association with mortality.

Martin Reed:
Something you just touched upon, which I thought was really interesting and leads me into my next question is one way we might be tempted to improve our sleep, but maybe expose ourselves to fewer potential side effects is with the use of non-prescription over-the-counter medications, supplements or herbal preparations. Things like antihistamines, melatonin, valerian, they’re all quite popular as sleep aids. So are these effective treatments for chronic insomnia? And, although you’ve kind of touched upon this already, since they’re available over-the-counter, does this mean that they’re safe and don’t carry any risk of side effects?

Dr. Mendelson:
Well, you brought up a very important issue because a lot of people follow a reasoning which says, “Well, if it’s not prescription, maybe it won’t help but it can’t hurt.” And actually that’s simply not true. Different kinds of nonprescription agents can have a number of health consequences. Before I go into them, I just want to remind us all that everything that I’m saying today should in no way be construed as advice for an individual for their healthcare for their insomnia, other than… Is not what I’m talking about is general principles.

Dr. Mendelson:
And again, any person who has trouble sleeping or has any of the other illnesses we may have mentioned, should go to their doctor and talk about it and be evaluated by their doctor. So we’re not providing health advice today.

Dr. Mendelson:
And we’re talking about some general principles about these medicines. Okay, having said that, let’s look at some of the ones in turn. Antihistamines have had a long history of being used for sleep. It actually turns out that, of course, at least the first generation of them certainly does make you feel sleepy in the daytime. The question is whether they experience you feeling sleepy when you take them in the daytime translates into improving sleep when you take them at nighttime. And it actually turns out it doesn’t translate very well. The studies are complicated but overall, it’s not so easy to show a whole lot of benefit in formal studies of taking sleeping — of taking antihistamines — as sleeping pills. There was even one study done in Europe which would seem to show that diphenhydramine can disturb sleep.

Dr. Mendelson:
That’s also they of course have their own set of side effects, which needs to be taken into account. Now another, I think what you’ve mentioned is valerian, which has the appeal of being a natural herb. The thing to know about it is that again, the studies are not absolutely consistent as to how much benefit it might or might not have, and it’s certainly not free of side effects it can cause headaches, stomach problems, dizziness, and some in people it would actually disturb sleep. And it can interact with other agents. One in particular is St. John’s wort. And when valerian and St. John’s wort are taken together, they serve an increase of their qualities and among other things that can result in impairment in thinking, judgment, coordination. Melatonin is yet another one again, it has a certain appeal of being a natural body hormone. But there’s many things to remember.

Dr. Mendelson:
One is, although there was initially enthusiasm about it as a sleeping pill, as more and more data accumulated, my studies are among these, there really is not very good evidence that improves sleep in folks with regular non circadian insomnias and that conclusion has been reached by the professional organizations related to sleep and some of their recommendations. It can be a useful treatment in situations like jet lag, in which sleep disturbances are related to very clear changes in the body clock. But that’s a sort of a different situation. Again, it can have side effects including headache, nausea, sedation the next morning, and there’s actually a pretty long list of drugs that can interact with… Melatonin can interact with anticoagulants, anticonvulsants, contraceptive drugs, some diabetes medicines, and some medicines for suppressing the immune system.

Dr. Mendelson:
So it’s not an entirely benign substance, just because it’s not a prescription. The other thing to know about it, of course is that the doses of melatonin that mimic what the body produces physiologically are very low. Whereas the doses that are available, over the counter can be much, much higher than that. So if you’re taking one of these higher doses, you’re not necessarily mimicking normal physiology. The other point about any of these agents that we’ve just mentioned, is that over-the-counter products are not given the same scrutiny as to purity and quantity that prescriptions are. I know, there was one famous study of melatonin products, bought off the shelf. The show they varied very, very widely in their content compared to what the label said. So that’s always an issue with any over-the-counter drug.

Martin Reed:
We’ve covered a lot of ground on sleeping pills for insomnia, how they evolved, how they can carry a risk of some side effects. And that ultimately… We still don’t know for sure how they might affect our health, especially over the long-term. In your book, Understanding Sleeping Pills, you wrote that if someone’s sleep isn’t getting better on sleeping pills, instead of searching for more and more medicines, it might be worth considering whether an alternative approach might be appropriate. And one of these alternative approaches is Cognitive Behavioral Therapy for Insomnia (CBT-I). A number of organizations, such as the American College of Physicians, and the American Academy of Sleep Medicine, now recommend that individuals with chronic insomnia receive CBT-I as the initial treatment intervention.

Martin Reed:
Since improvements typically continue after completion of treatment, and typically comes with fewer side effects, and as you pointed out in your book, the benefits of CBT-I can be slower to appear compared to taking a pill but they do tend to last longer. So I wanted to ask you what your thoughts are on CBT-I as a first-line treatment for chronic insomnia. Do you think it should be available as a first-line treatment?

Dr. Mendelson:
Well, sure, there’s a lot of roads to the same result. We’ve talked today about pharmacologic treatments, which happens to be what I study, but it’s very important to know that there’s there are many important nonpharmacologic therapies for sleep of which the best documented is CBT-I. My own feeling is that the first step for anybody with sleep disorders or sleep complaints is neither CBT-I or sleeping pills. The first step is to go to a doctor to determine whether there is some other process that may be disturbing sleep. Sleep can be disturbed by any number of illnesses, it can be disturbed by psychiatric disorders such as depression, which is often not recognized by the patient himself or herself. And it can be disturbed by other medicines that a person may be taking for some entirely other reason.

Dr. Mendelson:
So to me, the very first step when a person is troubled by insomnia or excessive sleepiness is to get a thorough medical evaluation for any of those possible things. Now, if those are not found then I think every person should make their own choice as to the appropriate treatment, some fit one person better some fit the needs of another person better. I tend in a situation where a person has already been medically and psychiatrically evaluated and nothing has been found. I think it’s very appropriate to begin with CBT-I for the reasons that you have mentioned.

Dr. Mendelson:
Also, I think it’s important to note that a good doctor for insomnia, maybe giving medicines but actually does many of the things that are incorporated into CBT-I as part of helping the patient. A good doctor is not a dispensing machine where you put in a quarter and get a pill he is a human being interacting with another human being, with concern and with discussion of sleep habits. And many of the other things that actually happen in CBT-I.

Martin Reed:
One thing I think you touched on a great point there of seeing doctors as pill dispensing machines. I think it’s important to recognize that a lot of people who may be taking sleeping pills now might never have even been offered an alternative to sleeping pills when they sought help for their insomnia. I know just from when I talk to people with insomnia, that even today, a lot of people who go to their doctor they’re offered sleeping pills or information on sleep hygiene, and for those of us in the sleep field, we know that sleep hygiene isn’t helpful for chronic insomnia. Other people might be told about CBT-I techniques, but there’s really that lack of access to professionals who can actually help them implement the techniques. So this is a real challenge. And in my opinion, it’s where the healthcare sector is letting people with insomnia down somewhat.

Martin Reed:
And going back to what you said about avoiding this ongoing search for the next medicine the next pill, I find it quite ironic that this is kind of the opposite of what we see the pharmaceutical industry doing in a way. As you described, at the start of our conversation, each generation of pills aims to address a limitation of the previous generation. So while we see that moving from pill to pill probably isn’t the best long-term solution at the same time, we see the industry coming out and doing just that. Coming out with the next pill, the next generation and the next generation. And that in a way can keep us hooked on that journey of moving from pill to pill to pill.

Dr. Mendelson:
I agree with you that it’s very important that all healthcare providers explain the range of treatments that are available for insomnia and a very important part of that range is CBT-I and related treatments and I certainly do agree with you about that.

Martin Reed:
So in your experience, what’s the best solution for getting off sleeping pills for those people that want to do so, is there a trusted reference a trusted resource or a best practice for this?

Dr. Mendelson:
Well, again, let me emphasize that my answer does not constitute medical advice, but just some comments on some general principles, but if a person is on a sleeping pill long-term and wishes to stop the first step is to do this in conjunction with a doctor and not on your own and to do it under the doctor’s supervision. What is generally done is to taper the medicine that is to gradually lower the dose. And this is very important to avoid any kind of discontinuation side effects. Speaking as a clinician, not really as a scientist, as a clinician, what I often do is try to have a person feel that they’re not giving something up but rather that they’re trading one approach for another by having them enter CBT-I or other kinds of talking therapies for insomnia before tapering and stopping sleeping pills, and in my own experience in the clinic is that’s very often a useful approach.

Martin Reed:
I think that makes a lot of sense because once someone does tend to come off the sleeping pills, because the sleeping pills aren’t addressing these behaviors that typically perpetuate insomnia and sleep disruption, we do often see that rebound insomnia, so by, at the same time having one strategy of tapering off the sleeping pills, but also addressing these thoughts and behaviors by implementing something such as CBT-I, you’re really giving yourself the best chance of success and minimizing the potential for that rebound insomnia.

Dr. Mendelson:
Well, again, just speaking from my own experience, I think it can often be useful to do that while tapering medicine under the supervision of a doctor.

Martin Reed:
Yeah, absolutely. So I really appreciate the time that you’ve taken out of your day to come on today, Dr. Mendelson. I think people are going to find our conversation really interesting. You’ve shed a lot of great information about sleeping pills and potential alternatives. I do have one last quick question for you. It’s one that I try and ask everyone that comes on. If someone with chronic insomnia is listening, and feels as though they’ve tried everything, that they’re beyond help and that they can’t do anything to improve their sleep, what would you tell them?

Dr. Mendelson:
I think if a person is so concerned about their sleep and doesn’t know what to do, certainly the first step is seeing your physician to look at other kinds of causes such as medical illnesses, or medicines, that may be disturbing sleep. A second, and very important step is finding a reputable and licensed healthcare provider whose specialty is sleep.

Martin Reed:
That’s great. Thank you so much again for your time. Dr. Mendelson.

Dr. Mendelson:
Okay, thank you. I have enjoyed speaking with you.

Martin Reed:
Thanks for listening to The Insomnia Coach Podcast. If you’re ready to implement evidence-based cognitive and behavioral techniques to improve your sleep but think you might need some additional support and guidance, I would love to help. There are two ways we can work together. First, you can get my online coaching course. This is the most popular option. My course combines sleep education with individualized coaching and is guaranteed to improve your sleep. You will learn new ways of thinking about sleep and implement better sleep habits over a period of eight weeks. This gives you time to build sleep confidence and notice results without feeling overwhelmed. You can get the course and start right now at insomniacoach.com/online.

Martin Reed:
I also offer a phone coaching package where we start with a one hour call. This can be voice only or video, your choice, and we come up with an initial two-week plan that will have you implementing cognitive and behavioral techniques that will lead to long term improvements in your sleep. You get unlimited email-based support and guidance for two weeks after the call along with a half-hour follow-up call at the end of the two weeks. You can book the phone coaching package at insomniacoach.com/phone.

Martin Reed:
I hope you enjoyed this episode of the Insomnia Coach Podcast. I’m Martin Reed, and as always, I’d like to leave you with this important reminder — you can sleep.