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Summary: Guest: Dr. Wallace Mendelson, author of Understanding Sleeping Pills:
- Mendelson gives an example of a young engineer with insomnia that used a combination of sleeping pills and Cognitive Behavioral Therapy for Insomnia to solve his sleep problems.
- Why Dr. Mendelson put sleep art in his book on sleeping pills and why he remains an active sleep advocate into his retirement.
- How to be an equal partner with your doctor when making decisions about your health care and how to prepare before going in to see you healthcare provider about sleep.
- Things to know if you are trying to solve sleeping issues on your own.
- What to do if your sleep medication is not working and how to improve your chances of success.
- What are reasonable expectations for sleeping pills.
- Why alcohol should never be used with sleeping pills.
- Melatonin as a sleep aid.
- What Dr. Mendelson would put on billboards to get his message out.
- His recommendation for something you can do today, to sleep better tonight so you feel and function better tomorrow.
Note: We encourage you to listen to the podcast with a portable device (via a podcast app is best) rather than sitting in front of the computer.
Links mentioned in the show:
Dr. Wallace Mendelson’s website: https://www.zhibit.org/wallacemendelson
Twitter: @TheScienceofSleep, https://twitter.com/ScienceofSleep1
Book: Understanding Sleeping Pills
https://www.amazon.com/Understanding-Sleeping-Pills-Wallace-Mendelson/dp/1718039980/
Book: Understanding Antidepressants:
https://www.amazon.com/Understanding-Antidepressants-Wallace-B-Mendelson-ebook/dp/B07B4GWKSN/
Show notes with approximate time they occur in the episode:
(Note: For your convenience, the following is paraphrasing from the interview, not exact quotes. For exact wording, listen to that part of the episode)
Introduction (the host, from the audio):
Humans have been trying to improve their sleep with sleeping aids for thousands of years. It is only natural to seek out solutions to insomnia. It is unpleasant laying awake for hours and the daytime consequences can be equally undesirable. The wish for an instant, convenient, effortless, effective solution to our sleeping problems is enticing but not necessarily the right answer or achievable.
Sleeping pills have been with us for decades, and recent advances have seen new medicines that are more targeted for specific sleep issues and, equally importantly, less detrimental during our wakeful hours. But what are reasonable expectations for these pills?
When deciding if sleeping pills are appropriate, many factors need to be considered such as:
– The root cause of the problem being solved. For instance, is the sleep issue caused by stress or is there a biological basis?
– Interactions with other medicines or herbal products, or even supplements,
– Relevant medical issues such as weakened kidney function or sleep apnea,
– How long the chemicals stay in our system and its impact during the daytime,
– What other issues the person is dealing with and how urgently intervention is needed,
– And which non-medical interventions are appropriate.
All this, means, that it is in your best interests to be well educated when you think about taking a sleep aid to help with your sleep problems. The issue isn’t whether sleeping pills and their cousins are good or bad, but whether medication is appropriate, and if so, which one. Uneducated choices can prove problematic such as using a sleep medication that suppresses breathing when you already suffer from sleep apnea.
Fortunately today we have the person who wrote the book on sleeping pills. Dr. Wallace Mendelson who recently wrote the book “Understanding Sleeping Pills.” He is a retired professor of Psychiatry and Clinical Pharmacology at the University of Chicago. Dr. Mendelson’s credentials are too numerous to list here but includes being the director at the Sleep Disorders Center at the Cleveland Clinic, publishing over 190 peer reviewed papers and is a past president of the Sleep Research Society.
In his book, in addition to sleeping pills, Dr. Mendelson covers other treatments for insomnia such as Cognitive Behavioural Therapy for Insomnia and he covers non-prescription sleep aids.
Interview:
3:50 – Dr. Mendelson gives an example where somebody struggled with a sleep problem but worked their way out of it. His example is of a young engineer who had trouble getting to sleep, found himself thinking about issues and problems he was dealing with during the day at night, he would wake up during the last half of the night and the result was in the morning he would not feel well rested. At work he was less enthusiastic than he used to be and he thought that his memory was not as good as it used to be. It’s important to focus on issues outside of sleep, so he found out in his personal life that he was unhappy with his marriage with some tensions with his wife,. He had tried over-the-counter sleep aids but that didn’t seem to help. They looked to see if there was any illnesses that he had that might have caused the sleep difficulty but there didn’t seem to be anything there. They looked at other medications, and noticed that he was on a decongestant for a chronic sinus condition, so we talked to his doctor about alternative types of medicines that would not be as disruptive to his sleep. He was also taking a thyroid medication so they tested to make sure that that was at the proper level, which it was. They looked at psychiatric illnesses and he didn’t appear to have any other than a slight depression but not a severe depression. He suggested that he try cognitive behavioral therapy for insomnia or CBTi, which is a non medical intervention. Has patient was skeptical of that approach, wanting something that would be faster and not take such a long time. He informed him that it usually only takes 2 or 3 months with six or eight visits. So they made a compromise in combining CBTi with sleeping pills. This gave them a relatively quick short-term solution while working on the longer-term solutions. And that solution worked well for him.
10:20 – Dr. Mendelson talks about The Sleep art which is included in his book on sleeping pills. While he believes strongly in the scientific approach, it doesn’t always express the feelings and emotions around the subject whereas art is a better medium to do that.
13:30 – Dr. Mendelson talks about why he remains enthusiastic about sleep education even into his retirement. Insomnia is not just something that impacts at person while they are laying in bed unable to sleep, it affects them 24 hours a day. People with insomnia are more likely to get into accidents, have problems at work, and have problems in their personal lives. Also he wants people to know that it’s not hopeless and there are a lot of treatments options out there.
15:00 – What are the risks and side effects of sleeping pills? In the book he tries to make people aware of the benefits and the risks so they can make a balanced and informed decision. He thinks that you should not be a passive recipient of treatments for your condition, but that you should be an equal partner with your doctor. But to be an equal partner means that you must be informed. You also must balance the risk of the medication with the risk of not treating insomnia has there are issues such as mentioned earlier and also health effects.
17:50 – What to know if you are trying to solve sleeping issues on their own. The first one would be to educate yourself about sleeping issues, the consequences of not treating it, and what treatments are available. He thinks that it is important to work with a caregiver and look at the effects of other medications and illnesses. Also to look at potential psychiatric issues which really need the help of somebody else who is qualified. There are online methods of cognitive behavioral therapy for insomnia or CBTi, but the jury is still out whether they are as effective as getting help from a professional. They can be helpful if you are also seeing a professional.
19:00 – Dr. Mendelson talks about how to prepare before going to see a doctor or speak sleep specialist. One thing is to come into the appointment prepared and educated. That was one of the purposes of writing the book so that people understand they medical issue with the insomnia as well as some of the solutions with their benefits and risks. The bottom line is to prepare, prepare, prepare.
22:10 – What things should you make sure your medical practitioner it’s aware of? It is important to tell them how about any medications you’re taking, including any over-the-counter medications. Another is to be honest and forthright about your alcohol consumption as there is a tendency to minimize this aspect. Alcohol is important because it can directly impact the quality of your sleep, especially in the ability to be able to stay asleep. Even in moderate amounts.
24:10 – Dr. Mendelson talks about his main message in “Understanding Sleeping Pills”. The first is that sleeping pills are just one of many different alternatives to deal with the issue. The second is to have an appreciation of why insomnia needs to be treated, why it is important that it be treated. And the third is that if you decide to go with the route of sleeping pills, that you have realistic expectations and understand the benefits and consequences.
25:50 – Dr. Mendelson talks about what to do if your sleep medication is not working. The first thing is to use it as an opportunity to go back to the very beginning and make sure something important has not been missed. For instance, if you are suffering from depression, it is important to solve the depression as sleeping pills will not do this, and may in fact make it worse. Although antidepressant medications in combination with the right sleeping medication can be very effective and beneficial. Also it is a chance to see if there are stressors in your life that need to be dealt with.
29:00 – Dr. Mendelssohn talks about how common it is to have to try a few different medications before you find the one that works for you. The response to sleeping pills is analogous to the response rate for medications for severe depression. The first medication may only have a success rate of 40 to 60%, so there is a pretty good chance you will need to try and alternative medication. Eventually the rate of success is in the 80 to 90% range. But you may need to try several different medications to get there. There is no research to give exact numbers, but the numbers reflect his general experience.
30:50 – Other things to do if the sleeping pills are not working: It is a good opportunity to go back to the beginning and see if anything has been overlooked such as other medications, or illnesses that might be interfering with sleep such as pain, or depression, He makes a point about not increasing the dose as it will not affect the effectiveness but will increase the side effects. Switching to a different medication is likely to be an incremental improvement, not to expect a big change. It might also be time to consider non-medical solutions such as Cognitive Behavioral Therapy for Insomnia. That’s about 34:30 -.
35:10 – Do people give up too quickly on medication before they giving it a fair chance? It is important to recognize that your interaction with your medical provider is a process that may take some time. It’s also important to know that insomnia usually doesn’t just happen, it may have been going on for years. It is usually related to what’s happening to you during your waking time. And sometimes these connections may not come out for a while you are working with your healthcare provider.
37:30 – What are some reasonable expectations for sleeping pills? The first is to not go into the appointment with an expectation of instant 100% success. It’s not realistic to think that an issue that has been going on for years and possibly decades is going to be solved in a brief time. What is realistic is that if you are willing to identify and work on issues that have been identified or neglected in the past, that you will likely be able to improve the situation with time.
39:10 – What should we know about over-the-counter sleep medications? Most over-the-counter medications or sleep aids, are not very effective but can still have their own risks. Many people think that because it is over the counter that it is benign, but is that that is not the case. The most common ingredient in the over-the-counter sleeping aid is his chemical called Diphenhydramine (Benadryl)which is an antihistamine. It is designed to help with allergies, and although it can make you sleepy during the day time, it doesn’t necessarily help you sleep at night. There is some data that it can disturb sleep in a number of people. There is a risk that long-term use, over years, can lead to an increased risk of dementia. And the elderly it can cause confusion all states and delirium which is serious. It is on the list of medications that is to be avoided by the elderly.
42:20 – Why should alcohol not be mixed with sleeping pills? Sleeping pills and alcohol are both central nervous system depressants. So when they are combined the results can be bad. For example if you have sleep apnea then the results can be very bad. If the sleeping medication is taken in excess, then the combination can be deadly.
44:10 – Is melatonin a good sleeping aid? It is a substance that is naturally secreted by the pineal gland at night. It is helpful for very specific conditions having to do with disorders of the body’s biological sleep clock. But if you give it to people with insomnia who don’t have one of these very few specific conditions, it is showing that it is not beneficial. The American Academy of Sleep Medicine does not list melatonin on their list of medicines for treatment of insomnia. It also has side effects including daytime sleepiness.
46:40 – What he would put on a billboard? To get his message across. The first message would be to take insomnia seriously, that affects you 24 hours a day. The second is that it is not hopeless, that there are many solutions out there. To educate yourself of the options available and avail yourself of them.
47:10 – What listeners can do today to sleep better tonight so they can feel and function better tomorrow. The solution is a process and the first step in the process is education, so learn, learn, learn.
Key Take-away points:
One thing that struck me about this episode and episode 10 with Dr. Stephanie Silberman, is that both sleep medicine experts continually point towards non-pharmaceutical interventions as the preferred route. Sleeping pills have a role to play, but doing the work to identify and correct the root cause is the preferred option.
The second point is Dr. Mendelson’s recommendation that you become an equal partner with your health care professional through continual learning. I think that medical professionals are often under-trained in sleep health and need a balanced perspective from you, their patient.
The final surprise was melatonin. It seems like a very popular sleep aid for insomnia, but its application is much more limited. Please use it wisely.
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