BY NORM TOLLINSKY

Dr. Stuart Holtby, a specialist in sleep medicine, is urging the health-care community to wake up and take insomnia seriously.

The founder and director of the Northern Nights Sleep Disorder Clinic in Thunder Bay says 30 per cent of Ontarians have trouble sleeping on any given night and 10 per cent suffer from chronic insomnia.

“That’s a lot of people,” said Holtby.

Lack of sleep ranks low in the health-care system’s priorities, but can have dire consequences, including carnage on our highways, industrial accidents, increased irritability, poor judgment and decreased ability to learn and remember. There is also evidence that lack of sleep contributes to obesity.

Dr. Holtby isn’t a big fan of sleeping pills.

“Many physicians prescribe sleeping medication because it is quick, transiently effective, and because we do not have adequate training and resources for behavioural and cognitive therapy, which has been repeatedly demonstrated to be a better approach,” he said.

“Using sleeping medication without behavioral therapy frequently causes the drug to fail.”

Holtby is concerned about the long-term consequences of sleeping medications, particularly long-acting benzodiazepines such as flurazepam, which has a half-life of up to 250 hours. And some of the most popular benzodiazepines such as lorazepam have dramatic rebound effects that can trap people on medication, he warns.

“Sedating antidepressants can also have serious side effects,” said Holtby. “Zopiclone is probably the safest sedative, but it is not as potent as some other medications and, once again, it often fails miserably without associated behavioural therapy. In some settings, particularly people with behavioural sleep restriction, it increases the risk of sleepwalking and other odd behaviours.”

The solution Holtby proposes is a stepped approach, beginning with a community-based, group counselling program led by a nurse therapist.

“If you go to your family doctor and say, ‘I’m not sleeping well,’ your family doctor will probably not have enough time or experience to elicit a clear history of what’s wrong and may refer you to a sleep lab test.”

But sleep lab tests are just that – tests, said Holtby. “Many people make the mistake of equating testing with clinical medicine. They’re not the same thing, not even remotely the same thing.”

A visit to a sleep lab may, for example, result in a diagnosis of mild sleep apnea and a prescription for a continuous positive airway pressure (CPAP) machine, but that may or may not address the actual problem, “especially if no one at any point in the process has sat down with you and asked ‘What’s bothering you? What are your symptoms? In what way are you not sleeping well? Is the problem that you can’t fall asleep or that you can’t stay asleep? An awful lot of people I see who have sleep apnea also have other problems, particularly insomnia.”

Sleep apnea, a condition characterized by the interruption of breathing during sleep, gets talked about a lot and is the main focus of a sleep lab’s caseload, but insomnia and sleep deprivation are much more prevalent, said Holtby.

“When you have a problem that’s so common and that’s related to dysfunctional attitudes and behaviours, what makes more sense? Forcing everyone to see a high-priced, highly trained specialist, or having a stepped care approach?”

Offering a nurse therapist-led, one-hour, weekly counselling session over a period of four or five weeks would provide people suffering from insomnia an opportunity to learn about good and bad sleep habits in a supportive environment.

“If they aren’t helped at that level, or it’s clear that something more is going on – a severe anxiety disorder, for example – then you refer those people to a psychometrist or psychological counsellor. If it’s still unclear what the problem is, they can be referred to a clinical psychologist, a psychiatrist or someone like me.”

Holtby tries to explain good sleep habits to his patients, but a brief one-on-one session with a patient doesn’t allow for the repetition, reinforcement and support that group counselling provides.

“I can’t do it because I don’t have the time and no one’s funding it. The government doesn’t pay me to have space and staff assigned to do that.”

Holtby, a graduate of the University of Western Ontario School of Medicine, also has issues with the sleep lab centred model of diagnosing sleep apnea.

“For many people who present with clinically straightforward sleep apnea and no other sleep problems, assessment in a sleep lab is not necessary. However, a clear diagnosis is necessary even with straightforward sleep apnea, and that means adequately organized and funded home testing,” he said.

Home testing is in use in many jurisdictions in Europe and the United States, but isn’t funded in Canada.

www.northernnightssleep.ca