Transcription:
Insomnia: Treatment Options for a Better Night’s Sleep

Melanie Cole (Host):  Do you have insomnia?  Today we’re talking about two therapies that complement each other and highlight the expanding services at Allina Health.  My guests today are Mary Beshara, she specializes in integrative complementary medicine at Penny George Institute for Health and Healing Abbot Northwestern Allina and Dr. Michael Schmitz, and he’s a Licensed Psychologist specializing in behavioral sleep medicine at Abbot North Western’s Hospitals Neuroscience Institute.  Welcome to the show, both of you.  So, Dr. Schmitz, I’d like to start with you.  Please give a working definition of how would somebody know, what is insomnia?

Dr. Michael Schmitz (Guest):  Insomnia is defined primarily as difficulty in falling asleep or staying asleep.  With that, even if you have difficulty falling asleep or staying asleep, it’s essential feature is that there are daytime difficulties.  So, people feel tired or have difficulty with daily activities as a result of the sleep problem. 

Melanie:  Would you be the first person to notice that or, like sleep apnea, would someone you love, somebody else, be noticing that you are rolling around and not getting asleep?

Dr. Schmitz:  Typically, in my clinic, the person who notices it first is often the spouse or bed partner, the person with insomnia, the tossing and turning, the concern and the difficulties that tend to mount over time as people struggle to get some control over their sleep.

Melanie:  So, if somebody is suffering from insomnia, how do you diagnose it?  We’ve heard about sleep clinics and sleep evaluations, Dr. Schmitz, so I’m going to start with you first.  Tell how you evaluate this.

Dr. Schmitz:  I think when you talk about insomnia, I think, probably the first place for many people to start would actually be setting an appointment with their primary care physician.  The reason I say that is that the sleep center is not the first place where a person with insomnia would want to visit.  Primary care is the place where an informed, skilled and caring physician can take a look at whether or not and perhaps how other medical problems might be influencing sleep.  It’s also a place where they can seek that first counseling around improving their sleep habits and health.

Melanie:  So then, Mary, if somebody comes to you and they are suffering from insomnia what’s the first thing you tell them?

Mary Beshara (Guest):  Well, usually, we’re seeing them on a consultation basis and they have either come by the advice of their physician or they’ve decided that they want to do something that is out of the box.  When I say out of the box, I say it with regard with integrative medicine.  We look at other approaches to helping with sleep besides the approaches that might be taken with allopathic medicine, like medications or things like that.

Melanie:  So, Mary, why don’t you explain the type of therapies that you’re talking about?

Mary:  Well, we offer therapies ranging from acupuncture, biofeedback, nutrition, massage as well as integrative medicine consults.  So, we’re really looking at the whole person – body, mind and spirit – and how sleep affects all of those aspects, of course, but also, too, how lack of sleep is affected within all of those and all of those become part of the treatment.

Melanie:  So important.  We’re learning more and more about the health benefits of sleep and the problems that come from a lack of sleep.  Dr. Schmitz, tell about some of the differences in the types of therapies that you provide.

Dr. Schmitz:  Well, the therapies that we provide at our Behavior Sleep Medicine Clinic come from about 25 years of clinical experience and research in which a series of strategies and interventions have come together that have been shown to be very effective, actually, equally or more effective, than sleep medication in treating insomnia.  We really look at insomnia, in some sense, as kind of the body having a state of hyperarousal and figuring out ways to change behaviors and habits that will help people get quieter and improved sleep by reducing this level of activation and arousal before bed and during the bed as well.

Melanie:  And, we will talk about sleep hygiene but, Dr. Schmitz, for a minute, speak about a sleep medicine evaluation because people hear about these sleep clinics and they don’t know, “How can I actually get a night’s sleep in a room when I know somebody’s got wires on me and their keeping track of me?”  What happens at those?

Dr. Schmitz:  Great question.  So, after a visit with primary care, there’s been a referral usually to a sleep center when there’s the suspicion of either, we call them “intrinsic sleep disorders: but whether they might be somebody with excessive snoring, possible sleep apnea or other medical issues that might be contributing to sleep.  What you’re referring to is an overnight sleep study or what we call “polysomnography” in which a patient will stay overnight and we will monitor everything from brain wave activity, breathing, even eye movements, to determine how a person is sleeping and determine whether there is something that, essentially, biologically is affecting the quality of sleep.  Now, with insomnia, it’s important to say that for most patients with insomnia, we would not do an overnight sleep study and, instead, we would do a thorough clinical interview based upon what the primary care physician has already determined to see what we need to do to improve patient’s sleep and that’s where a sleep psychologist, such as myself, kind of gets into action to help a patient look at a variety of things that would be affecting the quality of sleep in a given night.

Melanie:  It’s such a multi-disciplinary approach that you two have together.  So, what are the benefits, Mary, of each type of these therapies?  So, your therapy treats the whole person and, as you call it, is integrative and complimentary but, yet, so much of what you’re discussing is sort of sleep hygiene and common sense.

Mary:  So, when you look at sleep, it’s so multifactorial what’s going on with the patient.  They may have an underlying disorder of an entirely different origin that is, then, affecting sleep.  So, really ruling that out and understanding that and integrating that into a plan is going to be important.  The idea, then, of dealing with sleep – there are so many different ways to help it – from the vary foods we eat to the exercise that we get in a day to possible herbs and teas that we could potentially use to treat it.  Each one of these might be an option and in our visits, we really try to develop a tool kit so that people are really making smart lifestyle choices that are going to enhance their sleep.  We also need to address all the other things that are going on as well but we’ve got get the basics right, so that’s why looking at the body, mind and spirit really makes a lot of sense in insomnia.

Melanie:  And, Dr. Schmitz, how do you refer to each other to enhance patient care at Allina?

Dr. Schmitz:  Well, I think building upon what Mary’s saying, when we treat insomnia, we really want to meet the patient where they’re at and, in some instances, patients, after our evaluation or maybe after we’ve tried some treatment strategies, are open to or have a preference for looking at more holistic mind/body strategies.  So, a lot of that comes out in just getting to know the patient and either that they’ve benefited from some of the strategies and offerings that integrative medicine has or just getting a sense of let’s try something different in an effort to reduce symptoms and help the patient sleep better.

Melanie:  Well, speak about cognitive behavioral therapy for insomnia, Dr. Mike, just a little bit and then kind of tie in how, when you talk to a patient, how you consider medication versus cognitive behavioral therapy.

Dr. Schmitz:  Great.  So, you mentioned earlier sleep hygiene and I think that’s often viewed as a common sense approach and it’s important to make a distinction between sleep hygiene and cognitive behavioral therapy.  Part of this is because there are different kinds of insomnia.  For that few nights of bad sleep or first bout of insomnia, straightening out sleep hygiene – eliminating the caffeine and doing some of those common sense things--often do work.  For the person who has chronic long-term insomnia, there are often many behavioral factors that are unintentionally learned and habits that actually make the bed not a very comfortable place for sleep.  So, we utilize strategies that may seem at the front end maybe a little bit difficult or challenging such as utilized sleep restriction therapy. We actually limit the time in bed in an effort to build sleep drive.  We deal with the negative thoughts and worries and fears that often are automatically provoked when the patient gets into bed.  We’ll adjust the timing of their sleep because we want to make sure that the biological rhythms inherent to a particular patient match up with their sleep schedule. Then, we deal with some of the day-to-day things that occur in life that can interrupt sleep and change those so that sleep can be more continuous.  Sleep medications are not necessarily the first line and patients who are typically considered for sleep medications are those that might have significant stress or strain on a short-term basis where a week or two of sleep medication might be the thing they need to get over the initial challenge or stress or medical problem that confronts them.  But, as a long-term strategy, sleep medications are typically not the best strategy unless there’s a long term chronic medical problem that’s determined to exist where a medication might be a longer term approach.

Melanie:  We certainly could do a whole entire show on some of the sleep medications people see in the media but as we’re running out of time, Mary, tell us about shared medical visits.  How do they work and what patients can expect.

Mary:  When patients have a chronic disorder like insomnia, they’ve tried a million different things before they perhaps come into our clinic and we offer a visit that includes multiple people with the same disorder in the same room.  We meet for about two hours and what we do is, we will practice tai-chi in the beginning of the visit.  You’ll also have a time with the physician or advanced practice nurse in that shared medical visit.  But, most of the visit is conducted by this group process where we discuss it and where people are saying, “Hey, that question pertains to me, too.  I’m glad the person next to me asked it.”  So, the idea of building synergy off of the patients and being able to utilize an extended period of time of two hours is a great opportunity to introduce new types of therapies like mindfulness meditation or giving them ideas on the types of foods that are actually going to increase our tryptophan, which is the chemical that helps feed into melatonin.  So, those kinds of things are the types of tools that we can discuss and doing it as a group, people can ask questions and they, oftentimes, will help each other through difficult chronic illnesses like insomnia.

Melanie:  Then, how many visits would it take?   Can they expect to see improvements after going through their first visit with you?

Mary:  You know, I’ve been running the shared medical visits for a couple of years now and what I’ve really enjoyed seeing is how excited patients get.  They get very energized about being able to apply something that very night to what they’re doing.  We may recommend something as simple as a tea and then the next week, as they come back they go, “Hey, this worked or this didn’t work.”  As they compare with the other folks that are in the room, oftentimes, I see progression but the biggest part of progression is that they’re motivated.  So, partnering with patients is a huge deal.

Melanie:  I’m going to give you the last word, Dr. Schmitz.   Give us your best advice on people suffering from insomnia and what other information you really want them to know.

Dr. Schmitz:  I think the first thing for people suffering from insomnia is to not ignore the problem and to start with the fundamentals.  As Mary mentioned, people have often tried a variety of strategies and when we interview patients, they will often try something for a day or two or for maybe a week and they abandon it.  So, getting back to the fundamentals of sleep hygiene and habits, make sure that you get up at the same time every day, make sure you don’t spend more time in bed than you think you need for sleep.  Not everybody needs eight hours but the amount of sleep you think you need. Make sure you wind down before bed and never, never stay in bed if you’re worrying, thinking or ruminating about your next day’s activities or all the things in the world that might be concerning you.  You never want to bring worry, fear and concern about your insomnia into the bedroom – only sleep and relaxation and intimacy should be part of the bed.

Melanie:  Thank you so much, both of you, for being with us today.  It’s really great information.  For more information you can go to allinahealth.org.  That’s allinahealth.org.  You’re listening to The Wellcast with Allina Health.  This is Melanie Cole.  Thanks so much for listening.