With Professor Dr. med. Ingo Fietze, head of the Interdisciplinary Center for Sleep Medicine at Charite and Advanced Sleep Research GmbH, on sleep disorders and the insomnia pandemic.
Many people have never heard of a sleep doctor. Can you briefly explain your work?
I run a clinical sleep laboratory and a research laboratory. Patients with sleep problems spend a few days and nights in the laboratory and we observe them in various ways. We measure their brain waves, eye and muscle movements, heart rate, breathing, and more while they sleep to try to diagnose the problem. In the research laboratory, we use more experimental techniques to monitor and influence sleep.
What types of sleep disorders do you encounter in your work? And why is insomnia so important?
There are many – from movement disorders (sleepwalking) to hypersomnia (inability to stay awake) to sleep paralysis, to name a few. But insomnia is by far the most common, along with sleep apnea. About 30 percent of the population have it in some form, be it easy or difficult, and up to 70 percent have had symptoms of insomnia at some point in their life. In its chronic form, it affects 10 percent of the adult population. Sleep apnea also affects 30 percent of people.
Wow, those numbers are impressive. Has it always been like this?
No, it is sure to get worse. The number of people with chronic insomnia has doubled in the past 15 years. The prevalence of sleep apnea is also increasing, although not as rapidly.
Why do you think that is so?
One reason for this is the aging population – the older you are, the more likely you are to have a sleep disorder. The increase in obesity has also played a major role in sleep apnea. When it comes to insomnia, stress is the most obvious driver. In the developed world, financial stress and job loss fear are the most common severe stressors, both of which have increased. The situation was of course also exacerbated by Covid.
How do you define chronic insomnia?
There are a couple of criteria. If you have a problem falling asleep more than three times a week (that is, it takes more than half an hour) and this continues for more than four weeks, then it is already considered chronic. The same applies if you have trouble sleeping through the night, at least three times a week, and it takes more than half an hour to get back to sleep. It also counts if you regularly wake up early, for example after five hours, and cannot go back to sleep. However, your life must be decisive for the definition as a disease: your mental or physical well-being or your productivity.
Four weeks appear quite early to classify something as chronic. Why is it like this?
Because once you hit the four week mark, treatment becomes extremely difficult and is very likely to last for the rest of your life. By focusing on sleep hygiene and seeking appropriate medical help, some people can still overcome them completely, but such cases are extremely rare.
So it is best to get insomnia before it becomes chronic?
Absolutely! Then it can usually be cured with cognitive behavioral therapy (CBT). After that, CBT is no longer sufficient and treatment usually requires additional medication. The problem is that this window is extremely small and there is not enough awareness of it among the general public, or even most doctors. As a result, many insomnia sufferers arrive late, if at all: mostly after an accident or a mistake at work.
Part of the problem is that many fail to realize that insomnia is a disease in itself. For a long time it was only viewed as a side effect of other physical or psychological problems and is still understood as such by many doctors today. In reality, it can occur without any other pre-existing medical condition, and it can work the other way around – for example, depression can result from insomnia – not just insomnia from depression.
Why is there such a lack of understanding?
Sleep medicine is a relatively young field. As a result, as far as I know, insomnia is not treated as a topic at any medical faculty in Germany – with the exception of the Charite. This also means that there are very few specialists: there are only around 1200 in all of Germany, and most of them are sleep apnea doctors, not insomnia doctors. This is tiny compared to other areas, especially when you consider the number of people it affects.
That all sounds pretty gloomy. Is there light at the end of the tunnel?
Fortunately yes. The new 11th revision of the International Classification of Diseases, which came into force in January this year, has for the first time classified insomnia as a disease in its own right that should have positive effects on education 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; such as neurostimulation, which tries to improve the quality or intensity of sleep with the help of electromagnetic, light or sound waves.
It’s also important to note that for people with chronic insomnia, there are now numerous sophisticated medical and other treatments – including hypnosis and CBT – that can be combined to address the problem. If you have chronic insomnia, you shouldn’t be afraid to seek medical help. A good night’s sleep with pills is better than persistent poor sleep without it.