The Cost of a Good Night’s Sleep

American writer and humorist W.C. Fields once remarked that “the best cure for insomnia is to get a lot of sleep.” While this seems like an obvious remedy, a good night’s sleep is not always so easy to come by. An increasing number of Americans are resorting to sleeping pills to achieve rest (up to 10% of adults by some estimates), but, according to a new study published in BMJ Open, this use of sleeping pills may lead to eternal sleep, not beauty sleep.

The authors of the study conducted a longitudinal review of electronic medical records from a health system in rural Pennsylvania. They examined more than 10,500 patients who received sleeping pill prescriptions, along with nearly 24,000 matched controls. The average age of subjects was 54 years, and they were followed for an average of 2.5 years between 2002 and 2007. Medications taken for sleep included older sedatives and hypnotics, such as benzodiazepines, barbiturates, and antihistamines, and newer non-benzodiazepines, such as zolpidem, eszopiclone, and zaleplon.

The raw data report that the death rate for all sleeping pill users was nearly 5 times as high as the death rate among controls. After adjusting for lifestyle, age, gender, marital status, body mass index, race, and other confounding factors and health conditions, the death rate was still more than 4.5 times higher among sleeping pill users.

When divided into groups based on the number of sleeping pills consumed, the death rate showed a dose-response relationship. That is, the lowest third of sleeping pill consumption (0.4 to 18 doses per year) showed a death rate that was 3.6 times higher than controls; the middle third of consumption (18 to 132 doses per year) showed a death rate that was 4.43 times higher; and the top third of consumption (more than 132 doses per year) showed a death rate that was 5.32 times higher.

Further, the middle third of consumption exhibited a 20% increase in the risk of a new major cancer and the top third exhibited a 35% increase. The risks of lymphomas and lung, colon, and prostate cancers among people who used sleeping pills were higher than the risks among current smokers.

The authors ruled out the possibility that the increased risks of death and cancer were due to pre-existing conditions, but the mechanism by which sleeping pills increase morbidity and mortality are unclear. Possibly, the association may occur due to the use of sleeping pills in combination with alcohol or other drugs, increased levels of depression and suicide associated with insomnia, increased risks of accidents and falls, increased sleep apnea, and night eating syndromes.

Owing to the nature of the study, researchers were unable to verify if the sleeping pills prescribed were actually consumed. They were also unable to account for the possibility that people without prescriptions for sleeping pills took over-the-counter sleep aids or sleeping pills prescribed to other individuals.

Insomnia is a difficult clinical entity; it is complex to diagnose and complex to treat. Most sleep complaints involve difficulty falling asleep, difficulty staying asleep, and not feeling well-rested upon awakening — all of which lead to professional and social consequences, preventing individuals from performing activities of daily living and work-related tasks. Insomnia may be acute or chronic in nature and is often attributable to anxiety or stress, inadequate sleep hygiene, the use of other medications or substances, or a medical condition.

Medications should not be the first line of defense against sleep-related ills, and a complete evaluation should include an investigation of the precipitating and perpetuating factors related to insomnia. Cognitive-behavioral therapy is often an effective tool to teach sleep hygiene, relaxation techniques, and other cognitive restructuring techniques to aid in sleep. Pharmacological management of insomnia poses risks of drug interactions, memory disorders, daytime drowsiness, falls and accidents, and dependence and withdrawal symptoms.

No sleep aids are intended for long-term daily use, and the risks associated with their use are downplayed by the soft music and floating butterflies in the consumer advertising for newer, presumed-to-be-safer, sleeping pills. As a let-the-sleeper-beware caution, the study raises important concerns about the costs of a good night’s sleep and the use of even infrequent doses of sleeping pills.