Why Can’t You Sleep? How Insomnia Is Plaguing America

BIANNA GOLODRYGA, ANCHOR: Now, we know we all need our beauty sleep, and there’s nothing more frustrating than tossing and turning in bed and able to drift off.

 

Well, millions of Americas suffer from insomnia, including our next guest, the Atlantic staff writer Jennifer Senior. She speaks to Hari Sreenivasan

 

about her recent piece on the struggle for some shuteye and why she believes it’s becoming a, quote, “public health emergency.”

 

HARI SREENIVASAN: Bianna, thanks. Jennifer Senior, thanks so much for joining us. You wrote an article for The Atlantic recently, “Why Can’t Americans Sleep?” My first question is, how big of a problem is sleep that it requires this much attention?

 

JENNIFER SENIOR: I feel like that story, the name is a little deceptive. 

 

SREENIVASAN: Yeah. 

 

SENIOR: That really, it should have been called, “don’t feel bad if you can’t sleep.” I was trying very hard not to write a scary sleep story, but I definitely wanted to convey the scope. Yes. ’cause so many people have trouble.

So the answer is 30 to 35% of Americans report at least temporarily, some forms of inso, some form of insomnia, which is to say either they can’t fall asleep, they can’t stay asleep, or they wake up far earlier than they would like. 12% of Americans, at least, report this as a complete, as an obdurate, enduring condition. That number pops up to 15% if you’re a millennial.

And another way to think about this – which I think is very interesting – is that 18.4% of Americans take some medication to fall asleep either every night or some nights. And when I mentioned this to a giant in this, the field, this woman named Suzanne Burdish, she wrote back to me, that’s impossible. The number has to be much higher. Which makes you wonder, are people under reporting? Are because they’re ashamed? Do they not consider melatonin a drug? Do they not consider weed a drug? I mean, I don’t know.

 

SREENIVASAN: You share a lot about how this is such a, a personal story for you because you said “Then one night, maybe two months before I turned 29, that vaguening sense that normal sleepers have when they’re lying in bed, their thoughts pixelating into surreal images. Their mind listing toward unconsciousness completely deserted me. How bizarre I thought, I fell asleep at 5:00 AM” And this was, do you, do you remember that kind of transition from a person who got great sleep to just, you know, no longer having it?

 

SENIOR: it’s such a good question and it’s so visceral when I even think about it. I was just thinking the other day that that sensation that you have, not just of like the pixelating stuff, you know, but that sense that you cannot stay up another minute. You just have to roll over and you’re out. I used to have that every night at one o’clock on the nose. I haven’t known that sensation for over 25 years, and I still know what it, I can still remember what it felt like. That tug into unconsciousness. There’s such a giant discontinuity in my personality or my body between then and now. But yeah, I do remember that transition. And it was abrupt. It was terrifying. I mean, at first it was just weird. But in short order, you were thinking something broke. Was I poisoned? Like what happened? 

 

SREENIVASAN: Yeah. What are some of the reasons that, that we, we haven’t been able to get a handle on this?

 

SENIOR: I mean, some of them are, I mean, a lot of them are things that are intuitive, but a lot of them, the numbers are really fascinating. You can start with the fact that electrification laid waste to our circadian rhythms.  

SREENIVASAN: Yeah. 

SENIOR: Right. That, that was the first thing. So that midnight was no longer mid-night <laugh>, you know, something a lot of us stayed up until. But let’s see, 16.4% of Americans work non-standard hours, which is to say really night shift work. So they’re driving home during the day, which is confusing their internal clock. They can’t really–

SREENIVASAN: Yeah. 

SENIOR: Right. So that’s part of it. People work second jobs, that’s part of it. They’re, if you’re working, if you’re white collar, you are gonna have these constant, constant kind of like woodpeckering incursions from your bosses and your colleagues and everyone else asking you about work. There’s no such thing – you know, the boundary between home and work is completely dissolved. Yeah. Adolescents, they socialize online. They, they do homework online. We read online. The blue light online does everything. I mean, it’s horrible. 

SREENIVASAN: Yeah. 

SENIOR: I could go on, but those are –

 

SREENIVASAN: So, you know, I was my, my fascination with sleep is partly because I don’t get good sleep. And I’m sure you – as a person that, you know, you’ve described yourself as, as someone who doesn’t get good sleep, who kind of lost that ability – it’s amazing how people who get good sleep have the best advice for people like us. Right? I mean, they’re just like, have you tried, I don’t know, X, Y, Z,A but you’re like, yes, I’ve gone through all those things and it’s still not working.

 

SENIOR: I love you for saying that. The amount of insipid tips that we have to endure. Yeah. And all the listicles we’re given. It’s like, oh, I hadn’t thought of that. So don’t drink caffeine at nine at night. Crazy. Or, you know, if you’re, sleep in a room, that’s the right temperature. As if we don’t instinctively, you know, throw a blanket off if we’re too hot. And also all the kind of dopey stuff like spray your pillow with essential oils. And I mean, these are not, if you really have trouble sleeping, and it’s very interesting. I mean, I almost, in your case, I wonder whether your body learned a new trick. I mean, eventually not sleeping becomes a repetitive stimulus and it’s a negative. And so you have to relearn sleep to some degree.

And cognitive behavioral therapy for insomnia is one of the best tools out there. And almost no one knows about it because general practitioners don’t really hear about it much, and not enough people are trained in it. And for a lot of people, you know, it’s, it doesn’t really, there’s also a substantial number of people for whom it doesn’t work. So people take medication and then they don’t wanna talk about it because there’s something shameful about it. I mean. But yes. Agreed. And also my favorite thing is when people say, I could never not sleep. I love sleep too much. I mean, I love sleep more than an insomniac. Are you kidding? Like, I’m voluntarily deciding to forego my sleep? Blah. Anyway.

 

SREENIVASAN: Yeah. Yeah. I’m not choosing this. Trust me. 

 

SENIOR: No. Trust me.

 

SREENIVASAN: I wonder, I there is you talked about cognitive behavioral therapy in this article, and there’s this idea of sleep restriction. Explain, explain what is happening for our audience.

 

SENIOR: I will. It is really one of the main pillars of cognitive behavioral therapy for insomnia. It, it kind of is the pillar. And it’s really hard. I couldn’t swing it. I couldn’t hack it, but if people can hack it, it is supposed to work. Okay. So what do you do? Let’s – you keep your sleep diary and or you, you have your wearable, right?

SREENIVASAN: Right.

SENIOR: And it tells you how much you sleep. And you discover that you go to bed at let’s say 11, and you wake up at eight and you’ve only slept five out of those nine hours. You compress all of that sleep into a five hour block. This is a discipline you do. And which means, let’s say you wanna still choose eight as your wake up time. Okay. You have to go to bed at three and that’s it. You are allowed only those five hours in bed. That is it. 

And once you have slept a majority of those hours, you still have to do it two more nights. And only after you’ve done it for three nights, then you can reward yourself with 15 more minutes of sleep. And you have to do that for three nights. And then you get to, you add 15. So it’s really hard because your sleep doesn’t just contract obligingly. Yeah. Like an accordion into a case. This is just, it’s really hard to do. Yeah. and it makes you really hysterical with exhaustion if you can’t pull it off.

 

SREENIVASAN: Well, you know, as you described this process, I can, I can hear people in the audience who have trouble sleeping saying, oh my God, that sounds like the most anxiety inducing things on earth. Because part of the problem so many people have falling asleep is when they don’t fall asleep, they’re thinking about not falling asleep, and then all of a sudden they’re checking their watch, oh my God, it’s now five hours. Now it’s four and a half. Oh no, I only have three hours left. How am I gonna – and then they’re thinking about their next day and how their life is gonna be a wreck. And I mean, there’s just, so, I, I wonder how much of sleep is our physiological need to rest, right. And then our sort of managing all the psychology around it to allow our brain to relax.

 

SENIOR: You are exactly right. In fact, you have isolated what basically keeps insomnia, airborne, if that’s the right way. It doesn’t matter what lofted it. I mean, at a certain point, whatever the precipitating factor, if you can even figure out what it is, kind of becomes beside the point because you start doing insomnia math as you’ve said, oh my God, now I’ve got five hours, now I’ve got four, now I’ve got three. And part of what the behavioral component of cognitive behavioral therapy is, is to not look at your watch. 

 

What they sometimes say when you’re doing sleep restriction is you take a medication in order to make sure that you do fall asleep at the prescribed hour. And people are often very reluctant to do that. But if you only take it for a short period of time, it’s pretty easy to, wean, I mean, you can wean. In fact it, you can wean at any time really. You know, you just have to taper slowly and under the supervision of a doctor. And the idea is that you build up enough sleep pressure if you do this. 

 

So that is one, I refused to take sleep medication. I was so afraid of it, and it just made me worse. But – for all the reasons you said. Right. So you have to manage your actual anxiety about sleeping and fact check your beliefs. Yeah. I mean, will you really not function the next day? Will you really get, get fired? Or will you just be really bad at your job for a day or two? You know what I mean? You have to sort of rightsize your beliefs.

 

SREENIVASAN: I also wonder whether there’s this sort of connection which way the connection is between the anxiety that the lack of sleep is giving you and depression, because there’s a lot of overlap for people who seem depressed. They say, well, I can’t sleep because of the depression. And then some people are like, well, I don’t, I think I’m getting depressed because I can’t sleep. Which way is it?

 

SENIOR: I I’m so glad you asked that. That is one of the things I found most fascinating, the, about my research on this. The most recent wave of studies seem to suggest that actually, of course, they’re bidirectional as any analyst or clinician would say. But it used to be that if you fell asleep for some kind of mysterious reason, just this idiopathic onset of sleeplessness, they would say, oh, it’s depression in disguise. You’re probably depressed and you don’t know it. This is how it’s manifesting. It’s what I was told. And I kept looking at people and saying, you don’t understand. My day, my week is no different from the week, month, two months I’ve had before. There’s nothing different. And everyone insisted I was depressed. Now the thought is actually that sleeplessness more often causes depression than vice versa. Now, depression can certainly cause sleeplessness, but there’s a thought that, it more often is the reverse. It certainly predicts depression in a way that depression is not quite depre– predict sleeplessness as consistently.

 

SREENIVASAN: Maybe in America, we are in a place where there’s a larger conversation about mental health. There’s maybe a little less stigma around taking antidepressants. Have we been kind of scared away from pharmacological solutions around sleep? 

 

SENIOR: I‘m very glad you asked that because I do think that unlike people are very free with saying that they’re on their Prozac or whatever, but people don’t like to talk about whether they take things for sleep. And a lot of people do. And the question is why there’s so much shame around it when, as you said, with some lifestyle alterations, perhaps people wouldn’t need statins, maybe they wouldn’t need the ozempic, which everyone considers miraculous. They wouldn’t need their hypertension drugs. And no one says that they’re addicted to them, but people say that they’re addicted to their sleeping pills, and they call them drugs as opposed to medication, often. There’s this kind of stench of stigma surrounding it. And I think some of it is cultural. 

 

And also there’s a difference between dependence and addiction. People are taking this because they’re seeking relief. And contrary to what most people think, most people don’t go beyond their prescribed doses, even though they’re on it for years. A Danish study showed only 7%. That’s not much.

 

Melatonin in the high doses that we have here in the United States, three milligrams, five milligrams, even two, that’s regulated. You can only get that by prescription in many European countries. So it’s really interesting. People take it without realizing that it’s really a circadian signaling hormone. It’s good for jet lag. It’s probably good for shift workers. It sort of tells people when to go to bed. 

 

SREENIVASAN: We have heard for so long, you need eight hours of sleep, right? As you went and talked to all these different researchers, I mean, what were the kind of things that they said, yeah, you don’t have to worry about that, that thing that you’ve heard for 20 years, that’s not supported by the science that I’m doing, or maybe you should think about this or that more.

 

SENIOR: Right. So I asked every single researcher I interviewed, tell me the dogma about sleep that you think ought to be debunked or that you think is just totally wrong. And eight hours came up the most. So it’s, I’m glad you mentioned it. Because there is actually, there are a number of analyses, many that say that really the right amount is 6.5 to 7.4. And it’s tricky to do because what it is, is those numbers are associated with the best health outcomes. But what that means, you don’t know why people are sleeping more. Maybe it’s because – you can’t, you can only control for the things you can control for, you can control for age, for weight, for yeah, I’m trying to think besides – sex, you know, all the, do you smoke? But you know, the preexisting conditions that you might know of, it’s hard to control for all of them. So it’s a little hard.

But there are many studies that say seven, this said, there are many that say seven. Also, this is gonna change over the course of a lifetime. Older people don’t sleep as well as younger people. They just don’t. And they have more broken sleep. They just do. So when people who are 75 come into a sleep clinic and say, I’m not sleeping eight hours, the clinicians have to look at them and say, well, I hate to break it to you, but at this age, you’re probably not gonna.

 

SREENIVASAN: What’s your suggestion for who to reach out to? Because you know, as you describe in this story, I mean, the infrastructure is uneven and the experts might differ in their opinions.

 

SENIOR: Right. It’s a great question. And certainly some people need sleep studies overnight. Maybe they have apnea. There’s all sorts of things that they could, you’re right. I would say to people, number one, if it’s been a persistent condition, get yourself on a list for a sleep clinic to see, yes. If they can give you cognitive behavioral therapy, if you feel like you’re taking meds and they’re raging out of control, they may be able to help you manage them, taper them, reassess what you’re taking, you know, see if it’s conflicting. There are apps, there was two developed by the DOD and the VA that are quite – one is kind of, and one doesn’t include sleep restriction. And one does, I can’t remember what the name is, but if you just type in cognitive behavioral therapy for insomnia on Google, and you write Department of Defense and Veterans Affairs, you’ll find two apps and you’ll be able to see very quickly which one has the draconian sleep restriction one, and it is in fact the one you want. And that will be available to you immediately. Acupuncture is great. It doesn’t re– it just relaxes you. I would say that meditation does help. 

 

SREENIVASAN: Yeah.

 

SENIOR: It does. 

 

SREENIVASAN: Jennifer Senior, this has been a fascinating conversation. Thank you so much for, well, one you know, turning your personal nightmare into something that people can learn from and, and writing about this. And thanks so much for your time. 

 

SENIOR: Thank you. Thanks for the great questions.