Rachel Salas, MD, a Johns Hopkins Associate Professor, spoke about insomnia, a very individualized disorder, and the need for moving toward precision medicine.
Rachel Salas, MD
Insomnia is a very individualized and it can either be diagnosed as a disorder or a symptom, which is where the difficulty in the diagnosis lies.
Rachel Salas, MD, Associate Professor, Neurology and Nursing at Johns Hopkins Medicine, spoke with NeurologyLive about the difficulty treating insomnia and the need to move to precision medicine-based approach. Inching closer toward precision medicine, Salas mentioned that Johns Hopkins and other sleep clinics are utilizing pharmacogenomics, asking patients to complete tests to determine which treatment method best suits each patient. In the future, Salas envisions moving toward precision medicine so that clinicians can prescribe specific treatment regimens for patients.
Even though insomnia is quite common, it lacks the funding needed to be studied in clinical trials especially when competing with other diseases like heart disease, dementia and stroke. The best thing Salas advises is to keep the conversation going and continue moving forward.
Rachel Salas, MD: Insomnia, that’s an interesting thing in itself, because insomnia can either be a disorder, but it can also be a symptom. With patients in our clinic, insomnia is the most common presentation that we see, then we have to determine is this patient reporting insomnia the disorder or do they have the symptom of another disorder like apnea, that’s causing their insomnia—it’s complicated. Then you can have 10 patients with insomnia the disorder but it’s very variable. Everybody has stress, everybody has things in their sleep environment that could probably be improved, we can all improve our sleep behaviors and practices, but everybody’s different. We all handle stress differently, there’s just all these different factors and insomnia becomes really unique in each individual. Therefore, it’s more difficult to treat and even though it’s a very, very common sleep disorder it’s difficult to get funding to support research in insomnia when we have things like heart disease and dementia and stroke that are out there, but we’ve seen very severe cases in patients with chronic years and years of it, and I can tell you these people suffer.
Where are we with that? I think that it’s critical just to determine is this insomnia the disorder versus the symptom, because if it’s the symptom we need to be aggressive about finding out what’s causing their insomnia, is it a pain syndrome, is it apnea, is its restless leg syndrome, things in their environment?
RS: The gold standard therapy for insomnia is cognitive behavioral therapy for insomnia, so it’s a specific therapy aimed at sleep and insomnia, and for that, we have a sleep behavioral psychologist. These are people who have PhDs and are trained specifically in sleep and are part of our health care team. Typically, I’ll determine that this patient has a primary sleep disorder specifically insomnia and so I’ll refer the patient to our sleep behavior psychologist to initiate this cognitive behavioral therapy. Unfortunately, that’s not a quick fix, and the patient has to come 6—8 times to visit with them and a lot of it’s on them, they have to make changes and these people eventually have developed conditioned behaviors, so now their brain sees their bed and is like sure I sleep there, but that’s where I don’t sleep, it’s where I worry, it’s where I think about things, it’s where I watch TV, you know it gets associated with all other things not just sleep. The behavioral sleep psychologist essentially needs to retrain the brain not to do that—it can be difficult. Then there’s a lot of people running out in the streets that suffer from insomnia, but they haven’t really suffered maybe the consequences enough to make it to our clinic. If you pull those people from the street and say, you need cognitive behavioral therapy the success rate is not going to be that high, but usually by the time they make it to our clinic they have negative consequences—maybe it’s affecting their relationships, maybe its impacting their work or their mood, so they usually are very motivated to make changes, and that’s what we’ve seen that works the best and what the research shows. In our society people are looking for a quick fix, and they’re desperate sometimes, and it could be very difficult for us as providers to see patients who have very severe insomnia, so we are looking for other strategies to combine with their therapy.
There’s also cranial electrical stimulation, there’s actually a device that was FDA approved for depression and anxiety and a lot of times insomnia goes along with anxiety and depression, so this is something that we are looking into as well and trying. Patients are very interested in non-medication options, so you know I’ve had success with patients who try acupuncture or schedule massages, especially if they have pain that interferes with them at night, meditation is another thing that may be of benefit. It’s very individualized on the patient and right now a patient can’t come and I can’t say I’m going to put you on this specific medication regimen or this acupuncture regimen, so where we stand is saying this could be helpful, you could go look into that.
In terms of the medications out there, some are FDA approved for insomnia, others are not and are used off-label—honestly by the time they make it to our center, many patients have already tried sleeping pills and they usually don’t work. In a rare case maybe we’ll have a patient here or there where it works for them, but these medications, hypnotics, come with side effects as well and you don’t want to be on those long term. People are often using over the counter things you know, Nyquil, or ZzzQuil, or alcohol, or street drugs—people are really interested in trying to get better sleep.
I guess what’s coming and what some of us are doing in sleep clinics is called pharmacogenomics, so we can actually have patients complete a test and see which medication, should want to do a medication, which one would be a better fit for them, so moving toward precision medicine where you want to identify for the patient in front of you, what’s the best medication with the less side effect profile, and not really waste time on something that is not a good fit, so that’s something that we’ve started.
Moving forward we’re thinking about ways to kind of roll that for patients so that we could essentially prescribe something specific. I think you’re going see a lot more of that moving forward, it’s probably the most difficult sleep disorder to manage, just because again, it’s very variable depending on the person and it’s definitely an area of sleep that warrants more attention, but it’s again fighting for funding amongst other medical disorders. We just have to keep doing what we’re doing and keep talking about it.
RS: The circadian rhythm sleep-wake disorders many times can go hand-in-hand with insomnia. Kicking the society we live in back to the 1600s, we didn’t have the internet, TV, lights, so people had rhythms, they had natural bedtime routines, so I think going old school and remembering you should have a bedtime routine that’s kind of relaxing, don’t read anything interesting, but stay consistent—I think the timing of our sleep-wake patterns is so important.
People often focus on the quantity of sleep, which is definitely important, but I think what might be even more important in individuals is the timing. The more consistent people can be with their bedtime and their awakening time, the better. Then also naps can be helpful, but they also may not be helpful. If people are taking long naps, anything over an hour definitely is not a nap, it’s like a sleep period, and by taking naps in the evening then you’re actually negatively interfering with our other sleep process—the homeostatic drive—so taking naps earlier in the day is best. I think timing is very important and if you’ve experienced jet lag that gives you at least a sense of how your sleep-wake cycle can be off but imagine being a shift worker, shifting back and forth, people have jobs like that and people can be pushed out, especially with all of the light. We have people whose circadian rhythm is out and even though they’re so tired they can’t go to sleep until 3 a.m. or 4 a.m. and they have to be up by 7 a.m. for work. Circadian rhythm sleep-wake disorders are very common and sometimes can look like people with narcolepsy for instance, so I think we need to put that on the radar. I don’t think sleep-wake syndromes or disorders get enough attention, but I think they’re very common. Timing is key and there are a lot of things that we can do, feeding back to melatonin practices and working with a sleep behavioral psychologist and assessing for other things.
Transcript edited for clarity.