‘What People Really Want is Better Sleep’

SEATTLE, WA—“Where in the brain is insomnia? How in the world should we treat it?” was the compelling title of one of two plenary talks at SLEEP 2015.

In answering those questions, Daniel Buysse, MD, Professor of Psychiatry and Clinical and Translational Science and Director of the Neuroscience Clinical and Translational Research Center at the University of Pittsburgh School of Medicine, Pittsburgh, PA, told attendees they must first listen to how their patients describe insomnia.

This is important, he said, because “the current sleep medicine delivery system focuses on sleep testing and sleep disorders, but what people really want is better sleep.”

For example, from a sleep medicine perspective, the focus is on diagnosing and treating sleep disorders from a medical “disease” perspective, and categorizing patients as either having or not having a disorder. In contrast, a sleep health perspective focuses on sleep characteristics, such as measuring sleep dimensions and optimizing sleep, from a “health promotion perspective” using a dimensional approach: “everyone has a degree of sleep health,” Dr. Buysse said.

And, there is no doubt that sleep health matters. Aspects of sleep such as quality/satisfaction, alertness/sleepiness, timing, efficiency, duration, and regularity have been linked to increased mortality as well as to metabolic syndrome and obesity; diabetes and impaired glucose metabolism; hypertension, coronary heart disease; depression, and impaired neurobehavioral performance.

In determining where in the brain insomnia may reside, physiological studies have shown that patients with insomnia have intact homeostatic and circadian function. For patients with sleep deprivation, therefore, cognitive behavioral therapy for insomnia (CBT-I) “may utilize intact regulatory mechanisms rather than ‘fix’ broken regulation,” he said.

PET studies have characterized insomnia as alerted patterns of regional metabolism in resting state network (Default Mode, Executive Control, and Salience) during sleep; CBT-I and benzodiazepine receptor agonists “may ‘normalize’ metabolism in these networks,” Dr. Buysse said.

Dr. Buysse acknowledged that “we know how to treat insomnia.” Patients who receive CBT-I, for example, are told to “reduce your time in bed,” “get up at the same time every day,” “don’t get in bed unless you’re sleepy,” and “don’t stay in bed unless you’re asleep.”

A major challenge, however, is supply and demand: for the more than 12 million U.S. individuals with insomnia, there are only 213 certified behavioral sleep medicine providers, for a ratio of 57,409 to 1.

In the second plenary presentation, Masashi Yanagisawa, MD, PhD, Center Director of the International Institute for Integrative Sleep Medicine at the University of Tsukuba, Tsukuba, Japan, explored, “Toward Solving the Mystery of Sleep: From Reverse Genetics to Forward Genetics in Mice.” He described the “long-term and challenging” project that led to the approval of the only currently U.S. Food and Drug Administration-approved orexin receptor antagonist, suvorexant. Dr. Yanagisawa, a former Investigator of the Howard Hughes Medical Institute at the University of Texas Southwest Medical Center, who specializes in molecular genetics of sleep/wake regulation, also previewed his ongoing work with mice with “dreamless” and “sleepy” mutations.