by Margaret Wahl

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Dealing With Depression

Depression is a close cousin of insomnia. Almost everyone with depression has some sleep abnormalities, but the reverse isn't always true: Not everyone with sleep abnormalities is depressed.

It's become commonplace for physicians to assume the person with insomnia is depressed and to prescribe a low dose of an antidepressant without further evaluation, says Merrill Mitler, a neuropharmacologist at the Scripps Research Institute in La Jolla, Calif. Mitler doesn't think that's a good idea, since antidepressants can have undesirable effects and aren't as good as some other drugs at treating insomnia.

Karl Doghramji

Karl Doghramji, a psychiatrist and sleep specialist who directs the Sleep Disorders Center at Thomas Jefferson University Hospital in Philadelphia, says that when he feels a sleep problem is related to a depression he takes care to prescribe antidepressants that are "sleep-friendly," which not all of them are. "It's a bit of an art" to determine whether depression is the underlying cause of insomnia, he says, one he practices on a daily basis.

Sleep Hygiene Tips

Sometimes, a sleep problem can be caused by bad sleep-related habits. A field known as sleep hygiene has developed to study these patterns, and experts advise the following routines:

• Avoid caffeine within four to six hours of bedtime.
• Avoid the use of nicotine close to bedtime or during the night.
• Don't drink alcoholic beverages within four to six hours of bedtime.
• While a light snack before bedtime can help promote sound sleep, avoid large meals.
• Avoid strenuous exercise within six hours of bedtime.
• Minimize light, noise and extremes of temperature in the bedroom.
• Try to sleep when you're drowsy.
• If you're unable to fall asleep or stay asleep, leave your bedroom and engage in a quiet activity elsewhere. Don't permit yourself to fall asleep outside the bedroom. Return to bed when - and only when - you're sleepy. Repeat this process as often as necessary throughout the night.
• Maintain a regular time to arise, even on days off from work and on weekends.
• Avoid napping during the day. If daytime sleepiness becomes overwhelming, limit naptime to a single nap of less than no hour, no later than 3 p.m.

From the American Academy of Sleep Medicine. Used with permission.

The Other Side of Midnight - Daytime Sleepiness

The most common cause of excessive daytime sleepiness is insomnia: If you don't sleep well at night you'll be sleepy the next day. Once the nighttime insomnia is treated, drowsiness in the daytime usually decreases. However, there are other causes for daytime sleepiness.

Here again, myotonic dystrophy is a special case. In this disorder, the part of the brain that controls the level of arousal and alertness is often involved. People with myotonic dystrophy, even after their respiratory problems have been brought under control with assisted ventilation, may need additional help in the form of a stimulant medication.

David Rye, a neurologist and sleep specialist at Emory University in Atlanta, has used pemoline (Cylert), methylphenidate (Ritalin) and modafinil (Provigil) for this purpose when patients with myotonic dystrophy and daytime sleepiness come to him from the MDA clinic. He says recent breakthroughs concerning proteins involved in narcolepsy (a brain disorder that causes people to fall asleep frequently during the day) may have application to the daytime sleepiness of myotonic dystrophy.

Rye uses a multiple sleep latency test, in which the subject is asked to take four or five naps at two-hour intervals, as "a way of putting a number" on daytime somnolence. The test measures the kind of daytime sleep experienced (REM sleep is unusual in the normal napper) and the time it takes to fall asleep during the day.

Another evaluation sometimes used is the Epworth Sleepiness Scale (see "How Sleepy Are You?,"). You can take this test yourself as a way of assessing how sleepy you are during the day.

In addition to the underarousal of myotonic dystrophy, depression and severe cardiac or respiratory impairment can also lead to excessive sleeping during the day. If nighttime insomnia has been adequately treated, these are factors to examine.

Knee wedges and body pillows are among the items that may help someone find a comfortable sleeping position. Photos courtesy of InteliHealth. Others find relief in an adjustable bed such as this Völker bed from Hertz Supply.

Getting Help

"Going to the prescription pad" may be the first impulse of the average overworked doctor whose patient complains of insomnia, says Doghramji, but it may not be the best route, especially for people with neuromuscular disorders. (See "Sleeping Pills: Fact and Fiction.")

In neuromuscular disorders, the causes of a sleep problem can sometimes be clearly related to the underlying disease: a problem with positioning, muscle pain or obvious respiratory impairment, for example. But they can be more subtle. That's where certified sleep specialists and overnight sleep studies can be useful. To find a sleep disorders center or a sleep specialist in your area, you can contact the American Academy of Sleep Medicine or its associated Board of Sleep Medicine (see "Resources"). Chances are, you'll soon be on your way to better nighttime sleep and better daytime functioning.

Additional consultants for this story were Norma Cooke, neuropsychologist at Baylor College of Medicine and consultant to Baylor's MDA/ALS Center; Adrienne Schwarte, publications assistant at the American Academy of Sleep Medicine; Jeremy Shefner, neurologist and neurophysiologist, director of the MDA/ALS Center at SUNY Upstate Medical University, Syracuse, N.Y.; and Edward Sivak, pulmonologist, consultant to the MDA/ALS Center at SUNY Upstate Medical University.

Resources

Sleeping Pills: Fact and Fiction > >