We spoke with Professor Dr. med. Ingo Fietze, Head of the Interdisciplinary Centre of Sleep Medicine at the Charite and the Advanced Sleep Research GmbH, about sleep disorders and the pandemic of insomnia.
Many people haven’t heard of a sleep doctor before. Can you briefly explain your work?
I run a clinical sleep lab, and a research lab. Patients with sleeping issues will come and spend a few days and nights in the lab, and are observed by us in a number of ways. We measure their brain waves, eye and muscle movements, heart rate, breathing and more, while they sleep, to try and diagnose the problem. In the research lab we use more experimental techniques to monitor and also influence sleep.
What kinds of sleeping disorders do you encounter in your work? And why is insomnia so important?
There are many – from motion disorders (sleep walking), to hypersomnia (inability to stay awake), to sleep paralysis, to name just a few. But insomnia is, along with sleep apnoea, by far the most common. Around 30 percent of the population have it in some form, whether mild or severe, and up to 70 percent have experienced insomnia symptoms at some point in their lives. In its chronic form, it affects 10 percent of the adult population. Sleep apnoea also impacts 30 percent of people.
Wow, those numbers are impressive. Has it always been this way?
No, it’s certainly getting worse. The number of people with chronic insomnia has doubled over the past fifteen years. The prevalence of sleep apnoea is also increasing, although not as rapidly.
Why do you think this is?
One reason is to do with an ageing population – the older you are, the higher the probability you have a sleeping disorder. For sleep apnoea, the increase in obesity has also played a large role. For insomnia, the most obvious driver is stress. In industrial countries the most common powerful stress factors are financial stress and anxiety about losing one’s job, which have both increased. The situation was of course also magnified by Covid.
How do you define chronic insomnia?
There are a few criteria. If you have a problem initiating sleep (i.e. it takes longer than half an hour) more than three times per week, and this goes on for more than four weeks, then it’s already considered chronic. The same applies if you have a problem maintaining sleep throughout the night, minimum three times a week, and take longer than half an hour to fall asleep again. It also counts if you consistently wake up too early, for example after five hours, and are unable to fall asleep again. Crucially though, for it to be defined as a disease, it must have a negative impact on your life: on your mental or physical well-being or performance.
Four weeks seems quite early to classify something as chronic. Why is it so?
Because once you’ve reached the four-week mark, treatment becomes extremely difficult and it’s highly likely to persist for the rest of your life. By focussing on sleep hygiene and seeking proper medical help some people are still able to overcome it completely, but such cases are extremely rare.
So it’s best to catch insomnia before it becomes chronic?
Absolutely! Then it can usually be cured with cognitive behavioural therapy (CBT). After this, CBT is not enough, and treatment usually requires medication in addition. The problem is this window is extremely small, and there is not enough awareness about it amongst the public, or even amongst most medical doctors. As a result, many insomnia patients come too late, if they come at all: usually after having an accident or making mistakes at work.
Part of the problem is that many don’t realise insomnia is an independent disease. For a long time it was thought to be merely a secondary effect of other physical or psychological problems, and many doctors still understand it as such. In reality it can occur without other prior conditions, and it can also work the other way around – for example depression can result from insomnia – not only insomnia from depression.
Why is there such a lack of understanding?
Sleep medicine is a relatively young field. As a result, to my knowledge – with the exception of the Charite – insomnia is not covered as a topic in any medical school in Germany. This also means there are very few specialists: there are only around 1200 in the whole of Germany, and most of these are sleep apnoea doctors, not insomnia doctors. This is tiny compared to other fields, especially when considering the number of people affected by it.
This all sounds rather dire. Is there any light at the end of the tunnel?
Thankfully yes. The new International Classification of Diseases 11th Revision, which came into effect in January this year, has classified insomnia as an independent disease for the first time, which should have positive impacts in terms of awareness and treatment.
There are also some promising technological developments on the horizon. In five to ten years we may have the first non-drug treatments for insomnia; like neuro-stimulation, for example, which seeks to improve the quality or intensity of sleep using electromagnetic, light, or sound waves.
It’s also important to mention that, for those with chronic insomnia, there are now numerous sophisticated medicinal, and other, treatments – including hypnosis and CBT – which can be combined to tackle the problem. If you are affected by chronic insomnia, you should not be afraid to seek medical help. Good sleep with pills is better than lasting bad sleep without.