the 'rabbit hole' of chronic insomnia: sleepless nights and short-term solutions
9 minute read
insomnia isn’t a minor inconvenience, but a serious health issue that needs to be recognized and better treated.
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this article was produced by the healthing editorial team with the support of a grant from idorsia pharmaceuticals. while idorsia pharmaceuticals made the production of this article possible, they did not have any editorial influence or control over the content, including review prior to publication.
if you’ve ever gone through a few endless nights—and dismal days—without sleep, imagine what that feels like if it doesn’t stop. living with chronic insomnia is not just an annoyance, it’s a disorder that takes a heavy toll on mental health and quality of life.
andrea rich can trace her sleep deprivation back to her early teens. “i remember a night where i complained to my mom that i couldn’t fall asleep. that was the first time i learned the word ‘insomnia.’”
it wasn’t a passing phase of her adolescence and a flurry of hormones, but the start of a difficult journey to push herself to function as expected in her job and family life. she’s a 46-year-old realtor and mom of three in milton, ontario.
“i’m a full-time realtor, so i’m responsible for people making the biggest financial transaction of their lives. i need to be cognizant. i need to be aware. i need to have all my faculties. and when you’re not sleeping, you don’t have all your faculties,” she explains, adding she has to keep going in a cycle—get up, drive 25 km to work, be there for her kids, take care of the dog, and make peace with the quiet hours through the night.
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she hasn’t slept a solid six hours in years. she can get to sleep most nights, but then wakes up two hours later, feeling alert as though she could get up and start the next day. she dozes for another hour or two, then wakes up again. by 4 a.m. she can’t get back to sleep.
“a lot of it can be anxiety related too, because the more you get yourself amped up, you know you’re not going to sleep. your brain is just all over the place,” she says.
“you have to find a way to live with it because there’s no cure for it. there’s no quick easy fix. you know, doctors who have studied this for decades can’t explain it.”
chronic insomnia that lasts for more than three months—and can go on for years—is commonly attributed to life events, stress, or habits that disrupt sleep like late-night eating, screen time before bed, caffeine and alcohol.
but there are myriad other related factors, including prescription medication, pain from other health conditions, mental health struggles and neurological disorders like epilepsy, parkinson’s disease, stroke and alzheimer’s disease.
with the growing emphasis on good sleep hygiene as critical for health, looking at the impact of lack of sleep has also gained momentum in scientific research.
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scientists have suggested that insomnia may speed up the progression of alzheimer’s disease and that treating sleep disorders may help improve symptoms. neuroimaging studies have shown structural differences in the brains of people with chronic insomnia, like reduced gray matter volume in areas involved in sleep regulation. there’s also emerging science on chronic insomnia causing inflammation and brain aging.
anxiety and drug dependency become a downward spiral
experts say as many as 30 per cent of canadians struggle with getting to sleep or staying asleep at any given time. the prevalence of chronic insomnia seems to be higher among women with fluctuating hormones during the menstrual cycle, pregnancy and in menopause with night sweats and hot flashes.
what can make the situation worse is worrying about getting enough sleep. you dread bedtime long before it comes, and the expectation of not being able to sleep coupled with the anxiety can keep you in a constant loop of restlessness. the anxiety can become a vicious cycle.
dr. diane mcintosh, a vancouver-based psychiatrist, works with patients who live with chronic insomnia who are understandably desperate for help. she talks about the stigma associated with mental health where people who are suffering are dismissed and their concerns are not validated by healthcare professionals. they’re told about the list of sleep “fixes,” like breathing exercises, consistent before-bed rituals and having a dark, quiet bedroom.
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“when someone has chronic insomnia and they have gotten that list and gone over it and done it, it’s infuriating for them to be told in a word, it’s you. if you could just stop doing whatever, you’d be fine,” she explains. “sometimes people need medication because you can’t yoga your way out of severe depression or make that fix your insomnia.”
her approach is to discuss treatment options with patients and help get them on a path to recovery. this includes patients across the country. she’s the co-creator of the switchrx platform which equips healthcare professionals with information to support clinical decision-making for adjusting psychotropic drug treatments for patients.
for rich, she reached a point where she needed medication, but it backfired. “i’ve had periods where insomnia has really taken over. i’ve just submitted myself to it because i can’t fight it. the more i fight it, the more crazy i get.”
a couple of years ago, she went down the “dark rabbit hole” of sleep aid dependency that was completely unintentional.
she started with an over-the-counter antihistamine that reduces histamine effects and helps with occasional sleeplessness. it didn’t help, so she called her family doctor who prescribed the z-drug, zolpidem, intended for short-term use. “it worked, it literally knocked me out and i slept all night. it was like mind-blowing.”
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after several months of use, it became less effective, but she needed it.
“the pharmacy will only dispense it to you after 30 days, so you get 30 pills, and if you’re short, they won’t dispense it. so i think i was on the 28th day and i was like, oh, my god, i don’t have any. so i called the pharmacy. i was like, ‘hey, i need a refill.’” the pharmacist refused.
“we got into an argument and my pharmacist was very hostile with me. and he’s like, ‘you know, you’re drug-seeking.’ i started to cry. i said, ‘you don’t understand, i need to sleep.’ so that was very ugly. after that i was like, no, i’m just not going to do it anymore. i stopped taking them cold turkey.”
she’s not interested in medication and makes a conscious effort to appreciate the quiet and stillness of the long night hours when she’s awake.
how does she cope, really?
“i just do. i don’t have a choice. i would love nothing more than to just retire and live my life, but i can’t,” she says. “i just don’t want to go down the rabbit hole of dependency and that mania.”
treating chronic insomnia: benzos and z-drugs highlight short-term flaws
the first-line treatment recommended is cognitive behavioural therapy for insomnia (cbt-i). it is meant to help people restructure their thoughts, feelings and behaviours that are contributing to insomnia.
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although cbt-i is highly effective, it can be difficult “because it’s expensive. it requires you to be able to learn, remember and practice, so it’s hard work. it requires a lot of motivation,” mcintosh adds. the therapy demands also aren’t straightforward if you’re cognitively impaired by sleep deprivation.
when medication is appropriate for a given patient, the options have long been problematic. traditional sedative-hypnotic medications have a lot of side effects and are intended only for short-term use because of the high risk of dependency and impaired function. antidepressants and antipsychotics are also prescribed off-label as a sedative for insomnia, but many cause weight gain and daytime fatigue.
benzos and z-drugs
the class of medication called benzodiazepines, or benzos, is the only publicly funded sleep medication available across canada. it’s a type of sedative that slows down brain activity, leading to feelings of calm, drowsiness and muscle relaxation.
another common medication is zopiclone, known as a z-drug, which is less widely available. it’s a sedative that causes depression or tranquilization of the central nervous system.
benzos and z-drugs work as rescue medications for acute insomnia, intended for short-term use. these traditional medications are addictive and come with a burden for patients, says mcintosh.
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“they have risks for developing tolerance so that you need higher doses. older people are at risk of falls, so they could break their hip. it’s a disaster having daytime sedation that can affect your driving or your performance at work or home.”
doras
the newest drugs for insomnia are dual orexin receptor antagonists (doras) that block signals to the brain that stimulate wakefulness. they are considered safe for long-term use and don’t carry the same burdens of traditional drugs prescribed for insomnia. they may cause side effects like nausea, dizziness, headache, and possible inflammation of the nasal passages. they’re also not suitable for people with narcolepsy. as well, doras come with the risk of some daytime drowsiness the next day if people can’t get a full night’s sleep.
“doras have a unique mechanism of action that basically decreases that wakefulness rather than sedating, and they have safety data, including driving data in the elderly,” she says.
there are different dora formulations available, so if one doesn’t work, another can be tried. “the aim is to use the safest, most effective long-term treatment for that individual and they have worked very effectively in my patients.”
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stigma and the barriers to better interventions for chronic insomnia
the prevalence of long-term use of hypnotic sedative drugs is high. as the canadian journal of public health reports, between 1996 and 2019, five to 10 per cent of the population in canada and the united states were using benzodiazepines and z-drugs.
health canada has worked with manufacturers to update the safety labelling for these drugs to provide patients and healthcare professionals with prominent and consistent messaging about the severe and potentially life-threatening risks associated with these drugs.
however, a recent observational study of ontario data in the journal of clinical psychiatry found that inappropriate medication use in patients with chronic insomnia was noted in 52.5 per cent of adult patients aged 18 to 65 years and 69.5 per cent of senior patients older than 65.
why isn’t canada supporting new drug innovations like doras that are safe, effective and designed for long-term treatment of chronic insomnia?
mcintosh says that the stigma of mental health means that patients are underserved with healthcare providers keeping up the status quo of traditional drugs. and while the new doras can be life-changing for people, they are expensive and not covered under public health. “psychiatry has the lowest coverage across the board for medications,” she says.
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the mood disorders society of canada published a report in 2023 that revealed substantial delays, a significantly higher rate of negative reimbursement recommendations for mental illness medications compared to medications for other medical disorders, and an inequality of publicly funded medications across canada’s most populated provinces.
as mcintosh points out, “provinces will say we’ve got lots of antidepressants, so why do you need another antidepressant? well, it’s because no one wants to take the ones that are covered because they suck. because they cause weight gain or because they cause discontinuation reactions, or because they make you excessively sedated.”
insomnia isn’t a minor inconvenience, but a serious health issue that needs to be recognized and better treated. as mcintosh emphasizes, traditional benzos and z-drugs are meant to be used in the short-term; they’re not suitable for chronic health issues.
“you’re only supposed to use them for a few weeks and reassess constantly. but what about people who have chronic insomnia? i’m not wanting to hit people over the head with a rubber mallet. i’ve got to give them something,” she says. “it’s a mess.”
rich is disillusioned with medication and the checklist of good sleep habits. she’s on autopilot, existing and keeping her life together as best she can. “most nights i fall asleep. but then i wake up two hours later, so it’s a really short two hours. it’s ridiculous. it’s like this every night.”
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