Insomnia: costs to lose sleep over

Business & Health, June, 1997 by Marilyn Dix Smith, William McGhan

Counting sheep into the wee hours can be an expensive activity. The annual medical and reduced productivity costs associated with insomnia among U.S. workers is estimated to be $92.5 to $107.5 billion, according to a survey conducted by the Washington-based National Sleep Foundation.

An estimated 60 million Americans suffer from insomnia, and this figure is expected to grow to 100 million by the middle of the 21st century. Some 47 percent of the people surveyed by the Sleep Foundation reported having sleeping problems, and the majority of those respondents claimed that sleep deprivation hurt their job performance. This suggests that the impact on overall health status has largely been ignored by both physicians and patients.

Nighttime insomnia goes hand in hand with impaired daytime functioning because of physical and mental fatigue, the latter demonstrated by memory loss, difficulty concentrating and irritability. The annual cost of insomnia-related productivity losses was estimated at $41 billion, based on a 4 percent reduction in productivity among the 42 million working Americans affected by insomnia. This amount is conservative as it only considers loss of productivity among those earning an income.

Accidents--some catastrophic--also increase with insomnia. A report prepared for the National Commission on Sleep Disorders Research explored the economic implications of sleepiness in relation to accidents. Accidents are the fourth leading cause of mortality, and motor-vehicle accidents account for 51 percent of all accidental deaths. Sleep-related accidents were linked to over 23,000 fatalities and as many as 2.5 million disabling injuries a year, along with annual costs of $43 billion to $56 billion.

WHAT IS IT, WHO'S AT RISK?

Insomnia is not defined by the number of hours of sleep a person gets. Rather, it is the perception or complaint of inadequate or poor-quality sleep because of one or more of the following:

* difficulty falling asleep

* waking up frequently during the night with difficulty returning to sleep

* waking up too early in the morning

* unrefreshing sleep

The condition is found in men and women of all age groups, although it seems to be more common in women (especially after menopause) and in people over 60. The ability to sleep, rather than the need for sleep, appears to decrease with advancing age. A history of depression increases the likelihood of insomnia, as do conditions such as stress, anxiety, chronic medical problems and the use of certain medications.

WHAT KEEPS YOU UP--AND LETS YOU REST?

Short-term insomnia lasting from a single night to a few weeks is referred to as transient. If episodes of transient insomnia occur from time to time, the condition is said to be intermittent.

Both classifications are often triggered by temporary changes in an individual's environment or by sleep/wake schedule disruptions such as jet lag. Stress and medication side effects are common contributing factors, as are environmental noise and extreme temperatures. Respondents to the Sleep Foundation's survey also cited pain as a frequent cause of sleep deprivation.

Transient and intermittent insomnia may not require treatment since episodes last only a few days at a time, and the person's biological clock will often get back to normal on its own. For some people who experience daytime sleepiness and impaired performance, short-acting sleeping pills may improve sleep and next-day alertness.

Insomnia is considered chronic if it occurs on most nights over a span of a month or more. This more complex condition often results from a combination of factors, including underlying physical or mental disorders. One of the most common causes is depression. Other underlying causes affect all of the body's systems and include arthritis, kidney disease, heart failure, asthma, sleep apnea (cessation of breathing during sleep), narcolepsy (chronic falling asleep during the day), Parkinson's disease and hyperthyroidism.

Chronic insomnia may also be due to behavioral factors, including the misuse of caffeine, alcohol or other substances, disrupted sleep/wake cycles as may occur with shift work or other nighttime activity schedules and chronic stress.

Habits also come into play. For instance, expecting to have difficulty sleeping and worrying about it evidently perpetuates insomnia in some people. So can ingesting too much caffeine or drinking alcohol and smoking cigarettes before bedtime. Excessive napping in the afternoon or evening can prolong existing insomnia, as can irregular or continually disrupted sleep/wake schedules. These behaviors may also be responsible for causing the sleeping problem in the first place, and simply stopping them may be the most effective solution.

Treatment for chronic insomnia begins with diagnosing and treating underlying medical or psychological problems and stopping or reducing behaviors that may worsen the condition.

Sleeping pills may be prescribed, but long-term use is controversial. Clinicians generally favor the lowest dose for the shortest duration needed to relieve the sleep-related symptoms. For some of these medicines, the dose must be lowered gradually when treatment is complete, as abrupt discontinuation can cause insomnia to recur. See the table at left for a list of drugs used in treating insomnia.