Dreamland: Adventures in the Strange Science of Sleep (20 page)

The worst of the conditions linked to Halcion was something called traveler’s amnesia, which often took place during international travel. Typical patients who experienced traveler’s amnesia would take a dose of Halcion while on a red-eye flight, to ease the adjustment to the time difference. When they woke up at their destination, however, their memory would be blank. Patients lost track of who they were, where they had landed, and why they were there. Others would wake up in their hotel rooms and realize that they had no memory of their plane landing, of walking through customs, or of riding in the cab that picked them up from the airport. The United Kingdom banned the drug in the early 1990s, while several other countries severely restricted its availability (it is still legal in the United States).

The sleeping pill market changed in 1993 when a French company now known as Sanofi introduced a new drug called Ambien, also known by its generic name
zolpidem
. Ambien worked in essentially the same way as the benzodiazepines, though with far fewer side effects. It appeared safe enough, in fact, that many doctors broke their long-standing refusal to prescribe a medication for run-of-the-mill insomnia. Ambien quickly dominated the sleeping pill market and rang up more than a billion dollars in sales a year. At one time, Ambien accounted for eight out of every ten sleeping aids prescribed in the United States, a near monopoly enjoyed by few other drugs in history.

It wasn’t until 2005 that its first real competitor emerged. That was when a small biotech company in Marlborough, Massachusetts, called Sepracor introduced Lunesta, also known as eszopiclone. Though in the same class of drugs as Ambien, Lunesta had two advantages over it. One was the fact that the FDA approved it for long-term use, which meant that patients weren’t advised to forgo taking the drug every couple of days like they were with Ambien. The second was a branding campaign that featured a little green moth that floated onto the faces of happy, smiling actors pretending to be asleep in the company’s commercials. “The word ‘nest’ is hidden in Lunesta so people think of their nests when they sleep,” one brand consultant said while praising its launch. Sepracor made sure that everyone saw its moth by spending $230 million on advertising the year Lunesta was introduced, making it the most-promoted drug of the year.

All told, sleeping pills accounted for more than $1 billion in advertising between 2005 and 2006. The sheer number of commercials may have caused as much insomnia as the drugs treated. Just like in Wegner’s instructions to his test subjects to fall asleep as quickly as they can, constant reminders and advertisements about obtaining good sleep would be enough to push anyone into the cycle of insomnia, beset by worries over whether his or her sleep measured up to what the commercials offered. In one year, the total number of sleeping pill prescriptions written in the United States jumped from 28 million to 43 million. Every week, 120,000 new patients asked their doctors for a sleeping pill, a growth rate that rivaled the spread of Facebook. After it brought in almost $100 million in sales in its first quarter on the market, Wall Street analysts declared that Lunesta could do for the insomnia market what Prozac did for depression.
Brandweek
awarded Sepracor its Marketer of the Year Award and proclaimed that, thanks to the company, “insomnia is sexy again”—though, to be fair, it was never technically sexy in the first place. By 2010, about one in every four adults in the United States had a prescription sleeping pill in their medicine cabinets.

But here’s the twist. A number of studies have shown that drugs like Ambien and Lunesta offer no significant improvement in the quality of sleep that a person gets. They give only a tiny bit more in the quantity department, too. In one study financed by the National Institutes of Health, patients taking popular prescription sleeping pills fell asleep just twelve minutes faster than those given a sugar pill, and slept for a grand total of only eleven minutes longer throughout the night.

If popular sleeping pills don’t offer a major boost in sleep time or quality, then why do so many people take them? Part of the answer is the well-known placebo effect. Taking any pill, even one filled with sugar, can give some measure of comfort. But sleeping pills do something more than that. Drugs like Ambien have the curious effect of causing what is known as anterograde amnesia. In other words, ingesting the drug essentially makes it temporarily harder for the brain to form new short-term memories. This explains why those who take a pill may toss and turn in the middle of the night but say the next day that they slept soundly. Their brains simply weren’t recording all those fleeting minutes of wakefulness, allowing them to face each morning with a clean slate, unaware of anything that happened over the last six or seven hours. Some sleep doctors argue that this isn’t such a bad thing. “If you forget how long you lay in bed tossing and turning, in some ways that’s just as good as sleeping,” one physician who worked with pharmaceutical companies told the
New York Times
, voicing what is a widely held opinion among the sleep doctors and physicians that I spoke with.

Serious problems can arise when people taking a drug like Ambien don’t actually stay in bed. Some have complained of waking up the next day and finding things like candy wrappers in their beds, lit stoves in their kitchens, and bite marks on the pizzas in their freezers. Others have discovered broken wrists that came from falling while sleepwalking, or picked up their cell phones and seen a list of calls that they have no memory of making. Ambien was part of a kinky footnote in the Tiger Woods saga. One of his mistresses said that the pair would take the drug before sex because it would lower their inhibitions. Visitors to Sleepnet, an Internet forum, have noted their own troubles with sleeping pills. “Many people have tried to convince me that Ambien is a good drug. Maybe it works for some people, but I have to tell you it has been one big nightmare for me and my family,” one person wrote. “I have done the most dangerous and humiliating things after taking the drug. To provide some examples, I have called people, who I never would have called and said things that I would never have said, leading to very uncomfortable relationships and explanations of why I called. I have had sexual encounters that I barely remember. I have left my apartment in pajama-like attire to go shopping in the middle of the night. Once I wrote all over the walls of my apartment with nail polish. That was a nightmare.” Not long after a member of the Kennedy family blamed a car accident on the effects of Ambien, the Food and Drug Administration issued new rules that require pharmacists to explain the risk that taking certain sleeping pills could lead to things like sleep eating, sleepwalking, or sleep driving.

Those warnings have done little to tamper with the popularity of sleeping pills, especially since the most popular one is cheaper than ever. Ambien went off patent a few months before the FDA issued its new requirements. While the total number of dollars spent on sleeping pills fell by more than $1 billion a year because of the availability of cheaper generic versions, the number of patients filling a prescription for them remained steady. Many people who take sleeping pills find that their sleep quality reverts to its previous, poor state the night they decide to go without medication, a vicious cycle that increases their dependency on a drug approved only for short-term use. Facing a night of sleep without backup produces the same form of stress that originally caused the insomnia cycle to begin.

Yet there is a way to treat insomnia without setting patients up for a letdown as soon as the prescription runs out. Charles Morin is a professor of psychology at Université Laval in Quebec. For more than ten years, he has studied whether modifying behavior can be as effective at treating insomnia as taking medication. His research focuses on a type of counseling called cognitive behavioral therapy, a treatment that psychologists often use when working with patients suffering from depression, anxiety disorders, or phobias. The therapy has two parts. Patients are taught to identify and challenge worrisome thoughts when they come up. At the same time, they are asked to record all of their daily actions so that they can visualize the outcome of their choices.

When used as a treatment for insomnia, this form of therapy often focuses on helping patients let go of their fear that getting inadequate sleep will make them useless the next day. It works to counter another irony of insomnia: Morin found that people who can’t sleep often expect more out of it than people who can. Patients with insomnia tend to think that one night of poor sleep leads to immediate health problems or has an outsized impact on their mood the next day, a mental pressure cooker that leaves them fretting that every second they are awake in the middle of the night is another grain of salt in the wound. In the inverted logic of the condition, sleep is extremely important to someone with insomnia. Therefore, the person with insomnia can’t get sleep.

In a study in 1999, Morin recruited seventy-eight test subjects who were over the age of fifty-five and had dealt with chronic insomnia for at least fifteen years. He separated his subjects into four groups. One group was given a sleeping pill called Restoril (temazepan), a benzodiazepine sedative often prescribed for short-term insomnia. Another group was treated with cognitive behavioral therapy techniques that focused on improving their expectations and habits when it came to sleep. The members of this group were prompted to keep a sleep diary and meet with a counselor to talk about their patterns, as well as carry out other actions. The third group was given a placebo, and the fourth was treated with a combination of Restoril and the therapy techniques.

The experiment lasted for eight weeks. Morin then interviewed all of the subjects about their new sleeping habits and the quality of their sleep each night. Patients who had taken the sleeping pill reported the most dramatic improvements in the first days of the study, sleeping through the night without spending any of the lonely hours awake they had come to expect. Subjects who were treated with the cognitive behavioral therapy began to report similar results in sleep quality a few days later. Over the short term, sleeping pills had a slight edge in sanding down the rough edges of insomnia.

But then Morin did something extraordinary in the field of insomnia studies: after two years, he contacted all of his subjects and asked them about their sleeping habits again. It was a novel approach to investigating a disorder that often appears solved as soon as a patient sleeps normally for a few nights. Morin wanted to determine whether sleeping pills or therapy would do a better job of reshaping the underlying causes of persistent insomnia. Subjects who had taken the sleeping pills during the study told him that their insomnia returned as soon as the drugs ran out. But most of those who went through the behavioral therapy maintained the improvements they had reported in the initial study. Lowering patients’ expectations of sleep and helping them recognize what contributed to their insomnia combined to be more powerful over the long run than medication. “In the short run, medication is helpful,” Morin told the
New York Times
. “But in the long run, people need to change their actual sleep habits — that’s what [therapy] helps them do.”

Therapy is also helpful at breaking a person’s reliance, either real or imagined, on sleeping pills. In a 2004 study, Morin found that nine of every ten subjects who combined a gradual reduction in their medication with cognitive behavioral therapy were drug-free after seven weeks. Only half of those who tried to stop using the pills by reducing dosage alone were as successful. Further tests revealed that subjects who relied on therapy experienced better sleep quality as well, with longer amounts of time in deep sleep and REM sleep. A separate study the same year found that one of every two subjects who began a cognitive behavioral treatment plan no longer felt the need to take sleeping pills. The results from these and other cognitive behavior therapy studies have been compelling enough that organizations ranging from the National Institutes of Health to
Consumer Reports
recommend therapy as the first step in treating insomnia.

Advice that comes remarkably close to cognitive behavioral therapy is what ultimately helps Bunce, the sleep-starved sailor. The off-screen doctor tells Bunce that he needs to channel the energy he spends worrying about being awake into improving his ability to relax. “Get this first,” the doctor says. “Relaxing is a skill, like hitting a target. It takes practice, concentration, and more practice.” Bunce is then taught the basic skills of progressive relaxation therapy. He is told to first release the tension in his feet. Then, to stretch out his legs and sink into the bed. He continues to relax his body, unfurrowing his brow and unclenching his jaw, all as part of a strategy to convince his mind to let up from its intense focus on sleep.

Yet some people with insomnia may never respond to therapy like this, simply because their sleeplessness isn’t a reflection of the mind putting pressure on itself. Instead, it may be due to nothing more than age. As we get older, the structure of our sleep undergoes subtle changes. The amount of time that adults spend each night in REM sleep begins to decline at around the age of forty. At that age, the brain begins a process of readjusting its sleep pattern and devoting more time to the lighter stages of sleep. Soon, the loud of a barking dog that someone was able to sleep through at the age of twenty-five is a nuisance that makes sleep impossible. These changes, a decade in the making, often become more apparent once someone turns fifty. By the time a person reaches sixty-five, he or she usually settles into a pattern marked by falling asleep around nine o’clock at night and waking up at three or four in the morning.