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Posted February 22, 2021
Listen to this episode of the Healthy Vitals Podcast.
Ketan Deoras, MD shares his insight on understanding insomnia and tips of treating the difficult disorder.
A sleep medicine specialist, Ketan S. Deoras, M.D., FAPA, has clinical interests in Sleep Apnea, Narcolepsy, Hypersomnia, Insomnia, Restless Legs Syndrome and REM Sleep Behavior Disorder. He attended medical school at the University of Toledo, completed a residency at the University of Arizona and received fellowship training at the Cleveland Clinic Sleep Disorders Center. Dr. Deoras is board certified in sleep medicine and psychiatry.
Scott Webb (Host): According to the National Sleep Foundation, more than 60% of adults report having some sort of trouble sleeping more than once a week. Insomnia is also considered one of the most difficult conditions to treat, since it's both a disorder and a symptom of other issues. So, it can be difficult to make an accurate diagnosis of an underlying issue that's causing it. Oftentimes, a medical condition can cause insomnia. Common examples include pain, acid reflux, shortness of breath, nocturia, or frequent need to urinate at night, or really anything that causes pain or discomfort. Insomnia is also common in people who experience a lot of stress, like during COVID-19, worry a lot, or experience racing thoughts right before bed.
The good news is that insomnia is treatable and that the occasional night of poor sleep does not mean that you're an insomniac. And joining me today to discuss insomnia, both the causes and treatment options is Dr. Ketan Deoras. He's a Board Certified Sleep Medicine Specialist at Summa Health. This is Healthy Vitals, a podcast from Summa Health. I'm Scott Webb. So, Doctor, so great to have you back on again, today we're talking about insomnia. So, let's do that. Is insomnia a long-term problem?
Ketan Deoras, MD (Guest): There are actually two types of insomnia. There's a short term version, which they say up to two thirds of the population actually experiences. And that's considered insomnia that has lasted less than three months. And then chronic insomnia is defined as insomnia going on for longer than three months, which they say about 10 to 15% of the population experiences.
Host: Yeah, we're going to go through that and talk about causes for both short-term and long-term, but upfront here, what are the risk factors for any type of insomnia?
Ketan Deoras, MD (Guest): So, they found, from demographic studies, that women and the elderly report insomnia more often, and then the other big risk factors we see are psychiatric. So, for example, there's a higher proportion of insomnia in patients with anxiety or depression. And then there can be genetic factors as well. Definitely stressors play a big role, too, which everyone's got a lot of stress in their life right now.
Host: Yeah. And from doing my research for this, it seems to me that, from what I read, that insomnia can be, or what causes insomnia for people can be difficult to diagnose. Is that right?
Dr. Deoras: Yeah, exactly. In the short term insomnia we'll often see more kind of an acute stressor. So, it can be something with a job, a relationship, loss of a loved one. It's pretty common to experience difficulty sleeping after something like that. But then as it goes on for longer periods of time, it's hard sometimes to pinpoint exactly what led to the insomnia to begin with.
Host: Yeah. I was thinking, I know in my experience, I have daily ocular migraines, they call them and very difficult to diagnose and difficult to treat. And it's just gone on for so long and I've just kind of learned to deal with it. And I, I was wondering and thinking that maybe insomnia is similar in that way, in that the longer it goes on, the more chronic it is, the more difficult it is for someone like yourself to diagnose.
Dr. Deoras: Yeah, it definitely can be. And so that's why we have to always take a look back and try to see if we can identify some sort of trigger or is there another medical condition that can be playing a role too. We look at medications that might be contributing, and even simple things like alcohol, caffeine, what role are they playing? So, yeah, it definitely can be difficult.
Host: Yeah, I don't know that I necessarily suffer from insomnia, but I'm definitely somebody who likes a late-night cup of Joe, you know, and I know that there's caffeine even in decaffeinated coffee, right. So, a lot of this stuff we may just do to ourselves. And I'm wondering, have you seen higher incidents of insomnia during the pandemic, during COVID-19?
Dr. Deoras: Oh, yeah, for sure. It's played havoc with people's routine, their normal functioning. So, we definitely have seen the anxiety levels go up and kind of a corresponding increase in the insomnia too. I guess on the flip side with more people working from home, and less commute time, there's a certain set of the population that's actually getting a little bit more sleep from that. But overall we've been seeing definitely a lot of insomnia throughout this pandemic.
Host: When we talk about insomnia, and so we've established that it can be difficult to diagnose, especially the more chronic it is for people. How do we remedy insomnia? How do we treat insomnia? So, let's go through all the possible causes and then what you do to treat insomnia for folks.
Dr. Deoras: So, yeah, I mean the first part of assessing the causes is doing a clinical interview or visit where we'll ask a lot of questions about patients' sleep history, kind of define what type of insomnia is this. Is this difficulty falling asleep, staying asleep, waking up too early, or a combination of those things. And then, like I said, we look at what role alcohol, caffeine, nicotine, medications might be playing. One thing we typically don't do is order a sleep study if we just think its insomnia. If we think that someone might be waking up in the middle of the night, cause they're stopping breathing, then we will order a sleep study to make sure it's not something like sleep apnea that's actually contributing to it. Once we get all that information, we'll also use scales, for example, to grade patient's level of insomnia.
We sometimes have them fill out what's called a sleep diary, which is basically just tracking their sleep over the course of a couple of weeks. So, we can see if there's a pattern. Then we'll go into the treatments. And there's kind of two main arms. One are behavioral treatments and then the other are pharmacological. So, medications that we'll use for insomnia. In the longterm, all the studies have shown that patients benefit more from the behavioral treatments over lengthy periods of time. Medications can be really helpful in the short term, but they sometimes lose efficacy over time or patients become tolerant to them. And then sometimes they can have their own side effects as well.
Host: Yeah, let's talk about that. What are some of the side effects that could also contribute to persisting insomnia or perhaps other conditions?
Dr. Deoras: Yeah. So, the most common side effects we'll see with the medications for insomnia is that people can feel more tired or sleepy or groggy the next morning, especially. And it's basically just the medication hasn't fully worn out of their system. They haven't fully metabolized it. So, they're still feeling the effects of it when they wake up when they'd like to feel awakened, refreshed, ready to go. But sometimes, they'll use medications from different classes, like antidepressants even for their sedating effects. And those can have other kind of effects on mood, which can be beneficial, but some people will develop some side effects that way too. So, those are the main kinds of things we see with the meds that we use. Some can have effects. Sometimes we use things like anti-histamines, prescription strength, those can really dry out patients. So, it can be a kind of a variety of things, depending on which class of medications we're using for the insomnia.
Host: When we talk about the behavioral aspects of insomnia, what are we doing to ourselves and how do we fix it?
Dr. Deoras: Usually there are a few components to the behavioral modifications for insomnia. One, everyone's pretty much familiar with sleep hygiene.
And that's what people will usually have already read about or heard about before they come in. And those will be the kind of common knowledge tips about keeping a cool dark room and trying to avoid caffeine or alcohol right before bed. And just basically making it an optimal sleep environment. The other components, they really work on are relaxation techniques. So, patients oftentimes will wake up in the middle of the night feeling really anxious. And so they can benefit from using techniques to try to calm down or just feel more relaxed, get them in a better state, to prepare for sleep.
They'll also focus on what they call cognitive restructuring. So, just reframing people's thoughts, when they can't sleep to try to get them to normalize it a little bit more and not feel like it's the end of the world that they can't sleep. And then they also will work on stimulus control. That basically means trying to keep the bed only for two things, sleep or sex. And so they don't want patients lying in bed looking at their phones, looking at the TV, doing other things where their brain starts to associate the bed with kind of these non-sleep related activities. And then the last part is actually where they temporarily will restrict your sleep. So, they try to modify it to where you are spending less time in bed and hopefully the time you do spend in bed is spent more sleeping because of a mild sleep deprivation. And as you start filling that time with sleep, they start extending the amount of time you're prescribed to sleep. And this is usually done by like a sleep psychologist. Or because there aren't a lot of those around, there are online programs that also, patients can use to do this form of therapy.
Host: Yeah, and I think you're so right. And I think so many of us are guilty of it if you will, I hate to judge, but I'm guilty of it myself in that one of the last things I do before I try to go to sleep is watch a little TV or watch a YouTube video or check out Facebook or news headlines. And I worry about that with my kids as well. So, much screen time and stimuli right before bed, watching YouTube videos, playing video games, and then you try to close your eyes and go to bed and it's almost impossible and we're just kind of doing it to ourselves aren't we?
Dr. Deoras: Yeah, exactly. And so, there's so many patients that bring up this exact same issue and we have to go through the concept of kind of a wind down or a buffer zone before trying to go to sleep. Sometimes you're watching the late-night news, seeing not the most optimistic things or you're hearing about depressing things and then it's hard to fall asleep right after that. So, we talk a lot with patients about transitioning where there's a little relaxation or meditative period between kind of the last things you were doing for the evening before you are trying to go to bed. And just like when people wake up in the morning, we don't tell them to go straight to work. They've got this routine of brushing their teeth, showering, whatever it is. So, at night too, we try to develop this more relaxing routine to transition to sleep.
Host: Doctor, I love speaking with you. So great to have you on again, as we wrap up here, anything else you want to tell people about insomnia? It is a real problem and of course there are things that we can control. There are behavioral aspects to it, and there are lots of treatment options. So, what else can we tell people here as we wrap up?
Dr. Deoras: So, it's a very common issue. One thing we've found with insomnia patients is they sometimes feel like they're the only ones who can't sleep. It somehow always happens that a patient experiencing insomnia, their spouse sleeps wonderfully, or fast asleep the minute they hit the pillow. So, one of the big things is, letting people know that this is a very common thing. It's experienced by a lot of people. And there are treatments, in primarily the medications or the behavioral route or a combination of both. A lot of the studies have shown very few people sometimes just 10 to 13, 15%, of who experienced insomnia actually seek treatment for it. So, the big thing is getting the word out there. There are treatments. See a doctor about it if it's disrupting your sleep or making you feel bad the next day. And try to get it better so you can feel better.
Host: Yeah. As you've talked about, there's acute or short-term insomnia, and then that can become chronic. And we want to try to address that before it goes that far. And as you say, it is very common. It is highly treatable. People just need to reach out. We hope they do. Doctor, great having you on again and you stay well.
Dr. Deoras: Oh, thank you. Great to talk to you again, Scott.
Host: For more information on insomnia, visit Summahealth.org/sleep. And if you've found this podcast helpful and informative, please share it on your social channels and be sure to check out the entire podcast library for additional topics of interest. This is Healthy Vitals, a podcast from Summa Health. I'm Scott Webb. Stay well and we'll talk again next time.