As a part of National Sleep Week the National Sleep Foundation just released the results of a new survey. They found that 75% of American adults have at least one symptom of a sleep problem and 25% have symptoms at least several times per week that cause problems with daytime functioning. Insomnia is defined as problems with either falling asleep, staying asleep, or early morning awakening that causes next day consequences like excessive fatigue, daytime sleepiness, poor concentration and/or irritability.

Why are so many people having problems? A physician friend of mine told me recently that he’s reluctant to treat insomnia since it’s just a symptom of depression. But is this true? It is according to the old paradigm, but now we know it’s usually the opposite. The new paradigm is that untreated insomnia causes depression. Of course depression worsens insomnia and then they both snowball. It’s the chicken and the egg.

One study found that only 16% of patients with insomnia were depressed. Another 24% had an anxiety disorder. But 60% had other causes of their sleep difficulties. Many things can cause problems with sleep on a frequent or nightly basis. The most obvious is high stress.

Many medical problems especially chronic pain, gastro esophageal reflux, heart disease, respiratory illness – in fact just about any chronic illness has a negative effect on sleep. Many substances including alcohol, tobacco, and caffeine can cause problems as a direct effect +/- as a rebound effect. Changing schedules, shift work, and jet lag disrupt normal sleep patterns. Specific sleep disorders like restless legs or myoclonus (muscle jerks during sleep) – usually noticed more by the bed partner are common.

Sleep problems tend to increase with age. 50% of the elderly experience significant sleep problems. Women have more sleep problems than men, especially premenstrually, during pregnancy, post partum, perimenopause, and menopause. As if all that is not enough many of the medications that we take worsen sleep, including antidepressants, stimulants, cardiovascular, respiration medications, and others. Medications may interfere with sleep directly and/or cause rebound symptoms as they are wearing off.

Fortunately we have excellent medications for treating insomnia. I believe everyone needs to have available a safe/effective sleep medicine to take at least on an as needed basis. Just this week, we now have a new sleep medication, Lunesta. This new medication might be good for those that don’t have success with Ambien or Sonata. Some people wake up in 3-4 hours when taking Sonata, or wake up in 5 hours when they take Ambien. Lunesta lasts significantly longer and is more likely to provide 7-8 hours of sleep. Lunesta was also well tolerated in research studies. I will still need to see how it works in the real world before we can whole heartedly endorse it. Also, this summer a controlled release Ambien is coming out. This will presumably increase duration of action.

Unfortunately only 7% of people with sleep problems go to their doctor to get sleep medication. Of people with sleep problems who are seeing a doctor for another reason only 1 out of every 3 will bring it up. How amazing is that? 2 out of 3 people with insomnia don’t discuss it with their doctor or ask for a sleep medication.

Insomnia hurts mental and physical health. It interferes with work, study, relationships and hobbies. It reduces quality of life. Insomnia is usually easily treated. The sleep medications Lunesta, Ambien, and Sonata not only are safe and effective but provide normal sleep – both deep sleep and dream sleep. Benzodiazepines like Xanax decrease deep sleep. Antidepressants decrease dream sleep. OTC’s (antihistamines) don’t provide normal sleep and are more likely to have next day side effects. Of course, not every sleep problem requires a sleeping pill. Sometimes cognitive behavioral changes are adequate. See the Sleep Do’s and Don’ts Handout

Why are so many people hesitant to ask for or use medication for sleep? It may be that the importance of insomnia is trivialized or that people are afraid of becoming hooked on "sleeping pills" or still have the old stigma of addiction (associated in the past with barbituates and benzodiazepines).

Current sleep medications, Ambien, Sonata, and Lunesta have a very low abuse potential. Addiction means compulsive use despite negative consequences. This is almost non-existent with the new sleep medications. Physical dependence means physiologic adaptation resulting in serious withdrawal symptoms if a medication is abruptly stopped. This is also extremely rare with the new sleep medications.

As always we want to compare possible risks with probable benefits. This one is a no brainer. Do whatever it takes to ensure quality sleep every night. Your health and longevity depend on it!

See Sleep Newsletter

That’s certainly the implication of the headline appearing yesterday on the popular Drudge Report website. It read, "School Killer was on Prozac …" The story then goes on to describe a very disturbed and isolated teen who had tragically lost both parents. The only information available about Prozac was in paragraph seven and just comments that he was on it.

But was he really taking it – likely not. We won’t know until we get the final coroner’s report. Many questions need to be answered before we can speculate about what role, if any, Prozac played.

So, why would a headline want to jump so quickly to insinuate that Prozac was the real killer? Because this is America, and the main purpose of our dominant news sources is to build as large an audience as possible – it’s all about the money.

Recently a 15 year-old was found guilty of maliciously murdering his grandparents. The jury rejected the defense that his behavior was caused by Zoloft, a medication similar to Prozac. The evidence was overwhelming that in his case a long history of pathologic violence and absence of normal guilt and remorse had long preceded his taking the medication.

So what about the case in Minnesota? He had a long history of deviant behavior and fascination with violence. He had been in a psychiatric hospital because he was suicidal.

When was he put on Prozac? Did it precede his deviant behavior? We don’t know. But hey, let’s not wait for the facts. Let’s exploit the possibility. How else are we going to get over 9 million hits per day?

Besides, we need to move on to planning the made-for-T.V. movie. I can see it now … ratings week … Slaughter in Minnesota goes head to head with Terry Schiavo.

Listen to Dr. Jones explain what it means that clinical depression is a “deficiency state.”

[Audio clip temporarily unavailable]

I just received an email from a man who has been diagnosed with ADHD and is afraid to try stimulants because of some of the bad press and unfavorable articles he has read. He wants to try the medication Amantadine (Symmetril). Amantadine is being used successfully by a clinician named William Singer at Harvard Medical School for his ADHD patients. His positive results in 400 patients, (all children) were reported in Hallowell’s book Delivered from Distraction as a potential treatment for ADHD.

Amantadine has been around for many years, first as a treatment for Parkinson’s Disease and then as a treatment for Parkinson-like side effects to the old antipsychotic medications. More recently it has also been used to treat early flu symptoms. The latest pharmacology text says it has enhancement effect on dopamine, but it is not known exactly how it works.  In contrast, lots of scientific data and studies explain how stimulants work, a reassuring fact when using them.

I certainly don’t question that Dr. Singer is getting good results with Amantadine in ADHD patients, but could his positive results be linked to factors other than the Amantadine itself? What if a randomized placebo controlled study compared active Amantadine to an inactive placebo and found that the placebo group did about as well as the Amantadine group?  In other words, they both showed improvement.  What would that mean?  It would mean that all the things that go into a patient’s involvement with treatment including the decision to get help, monitoring of symptoms, interaction with the entire office staff, etc., would be contributing to the patient’s improvement, but that the Amantadine itself was not contributing much if any.  Possibly, Amantadine could even make ADHD worse.

One of my favorite examples of this phenomenon was an open study showing that progesterone helped PMS.  An open study, in comparission to a contolled study, records the patients response to treatment, but does not compare their response on an inactive form of the medication.  Later, a placebo controlled study was conducted and patients taking placebo reported better response than those taking progesterone.  This meant that progesterone actually made PMS worse in these patients, but not enough to neutralize the placebo benefit inherent in any treatment.

What am I saying by all this?  Amantadine may be a beneficial treatment for ADHD.  I hope it is.  But I have been burned many times in the past by the promise of treatments that under rigorous study "didn’t pan out."  What if you try it and it seems to work great?  How do you know it’s not a placebo response?  You don’t, but if you’re doing great and you think it’s helping, what difference does it make?

You would think that I would be sick of the seven habits of highly effective – you can finish the sentence with people, dieters, psychopharmacologists, zoo keepers. (I’m kidding about the zoo keepers). Now comes doctors Hallowell and Ratey with their new book Delivered from Distraction. They include a chapter called "The Seven Habits of Highly Effective ADDers." As in their first book called Driven to Distraction, they have broken new ground. From their perspective of being ADD and treating ADD they are able to put into a few words principles that instantly ring true with those of us who live in an ADD world. It helps to have at least a modicum of mindfulness tuned into self and others to intuitively know they are on target.

THE SEVEN HABITS OF HIGHLY EFFECTIVE ADD ADULTS

By Edward M. Hallowell, M.D., and John Ratey, M.D.

1. Do what you’re good at. Don’t spend too much time trying to get good at what you’re bad at. (you did enough of that in school).

2. Delegate what you’re bad at to others, as often as possible.

3. Connect your energy to a creative outlet.

4. Get well enough organized to achieve your goals. The key here is "well enough". That doesn’t mean you have to be very well organized at all – just well enough organized to achieve your goals.

5. Ask for and heed advice from people you trust – and ignore, as best you can, the dream-breakers and finger-waggers.

6. Make sure you keep up regular contact with a few close friends.

7. Go with your positive side. Even though you have a negative side, make decisions and run your life with your positive side.

I appreciate that they have organized these important principles into a simple prescription for improving the quality of life not just for people who are ADD, but secondarily for their families. It is hard being ADD – it’s harder living with someone who is ADD.

Change starts with awareness of a problem or alternative course of action. The next step is a decision to change – in behavioral terms like – I’m going to get certified in a particular skill to expand my career options. The last step is the hardest – the process of change – you have to do it.

With new insights from Dr. Hallowell and Dr. Ratey we are better equipped to evaluate our current life course and make adjustments where appropriate. "It’s great being ADD!"