Your Health

Can't sleep at night? There's a website for that!

Thousands of Manitobans struggle with insomnia, a disorder that prevents them from getting a good night's sleep. Now, a Winnipeg Health Region psychologist has created a website that is helping many of them get the rest they need.

Can't sleep at night? There's a website for that!
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About insomnia

How insomnia affects you

Do you need help?

Understanding the sleep cycle

BY JOEL SCHLESINGER
Winnipeg Health Region
Wave, November / December 2010

Della Cogar could have been the poster girl for burning the candle at both ends.

For years, she would go to bed at 11 p.m. only to wake up a short time later completely alert.

"I would sleep about four to five hours a night," says the 47-year-old office manager at a dental clinic in Portage la Prairie.

"I would go to bed, get an hour's sleep and wake up and be wide awake, so I'd get up, do some things and then go back to bed and get a couple more hours."

This would happen a few times a night, every night - for years. Her mother was the same way, so Cogar thought it was only natural that she was becoming a night crawler just like her Mom.

"We joked about it a lot as a family, but I didn't mind it," she says about how her husband, Larry, daughter, Amber, 26, and son, Chad, 22, reacted to Cogar's odd sleeping habits. "I saw it as a little bit of a bonus; we all thought of it as a bit of a bonus. They'd all wake up to fresh baking in the morning, for heaven's sake. How could that be a bad thing?"

But her sleep patterns did turn out to be a "bad thing" after all. About five years ago, Cogar's health started to suffer. She had been diagnosed with hereditary angiodema, a rare blood disorder that causes airways to close and is often exacerbated by stress. "It's a systemic illness where I get these attacks where everything goes out of whack and I need special medication," she says.

Cogar became a frequent visitor to the Emergency Department, being rushed to hospital a few times a month. "I needed to get as healthy as I could to minimize the effects of the illness."

And getting a good night's sleep was part of the prescription. But after years of waking up, getting up and then staying up cleaning, baking and doing other chores, Cogar found she couldn't get a full night's sleep without the aid of sleeping pills.

"I used to like (insomnia) because I got more hours in the day than anybody else, but as my health deteriorated, it just wasn't a good thing."

Like thousands of Manitobans with insomnia, Cogar carried on with her life as best she could.

But with it now becoming a problem that was affecting her health, she needed help. The less sleep she had, the more stress that lack of sleep put on her body. The more stress she had in her life, the more likely it was she would end up in the Emergency Department with abdominal pains, a result of her blood disorder.

Then, about two years ago, she saw an ad in the newspaper looking for participants in an online study program for insomnia, a project funded by a grant from the Health Sciences Centre Foundation and run through the Winnipeg Health Region's Clinical Health Psychology Program and the University of Manitoba.

The study, which is ongoing today, aimed to test the effectiveness of a new and innovative website called return2sleep.com, also referred to as the Online Treatment Program for Insomnia.

The brainchild of clinical psychologist Dr. Norah Vincent, the online program provides treatment for sufferers of insomnia anywhere in Manitoba at any time. Vincent came up with the idea after realizing a growing number of people with sleep issues were in need of help.

One study estimates that a third of the adult population suffers from insomnia. And a 2005 Statistics Canada study found that almost one in five Canadians over the age of 15 sleep less than five hours per night. That's more than three million Canadians, the report stated.

Insomnia is characterized by a persistent inability to get to sleep, stay asleep or experience refreshing sleep. Generally, people need at least five to nine hours of sleep a day. Each person's need for sleep differs, Vincent says. And in many cases, sleeplessness isn't a problem until a person perceives it as one.

In fact, about 30 to 40 per cent of the general population will suffer from the occasional bout of sleeplessness. It could be a result of stress - worries about work, family or financial issues.

"There are lots of different reasons, and stress is one of them, but it's not the only one," Vincent says.

Some people can experience insomnia if they are taking medication for hypertension, asthma or allergies, which have stimulating effects, making it difficult to get to sleep and have restful sleep.

Others may have problems with their internal clock, also known as the circadian rhythm. They can't physically fall asleep at the time they need to be in bed getting rest - often a problem for shift workers.

"It's not a mental health kind of situation for a lot of people in which they are very depressed or anxious," she says. "It's just that this problem started and now it's being maintained. They kind of condition themselves not to be able to fall asleep."

Two or three sleepless nights turn into several in a row, and lying awake in bed at night, instead of falling asleep when the head hits the pillow, becomes the norm.

And the problem builds as it persists. Insomniacs fret about the day ahead and the fact that they're not sleeping. They may wake up during the night several times, unable to fall back asleep - and worry even more about not sleeping. And in the morning, they may feel exhausted, believing they've hardly slept at all.

As the problem continues, they may begin to see themselves as poor sleepers. Instead of the bedroom being a place of rest and relaxation, it's associated with anxiety, frustration and insomnia. And the health risks associated with chronic insomnia are many.

A 2002 Canadian Community Health Survey found 20 per cent of people who suffer from asthma, arthritis or rheumatism, back problems or diabetes also suffered from insomnia, compared to just 12 per cent of people without those conditions.

"Sleep is vital for everything," Vincent says. "It regulates our hormones, protects us by strengthening our immune system, and restores cognitive functioning and our ability to heal from injuries."

Without a good night's sleep, our memory, attention and concentration are all diminished the next day. "Sleep provides us with the ability to control our impulses," she says. "Have you ever felt when you haven't slept very well that you're more impulsive?"

Insomnia has been linked to obesity, bouts of depression and even substance abuse. "Alcohol and substance abuse can become a long-term problem because the person is just desperate to sleep, and will start to over-consume alcohol in order to sleep," she says.

"What starts off as a solution for sleep becomes a big league problem in its own right."

Insomnia affects people's ability to be productive both at work and at home. Insomnia sufferers are more likely to take time off work with disability. Marriage and family life can become strained because the sufferer has less ability to deal with the challenges of daily life, Vincent says. And because those with insomnia are generally perpetually fatigued, they are often less alert and more prone to accidents at work, in the home and behind the wheel.

Vincent says there are two main ways to treat insomnia. "There's medication and then there's something called behavioural therapy," she says.

Family doctors often provide patients with sleeping pills to deal with occasional insomnia, but medication is often just a band-aid for long-term problems with sleeplessness. "It's expensive and a lot of people don't like to take pills, so many people are interested in other ways to deal with the problem," she says. "Behavioural therapy teaches people to reduce their level of tension before bed, and when you wake up at night, it teaches you how to curb an anxious or busy mind."

Behavioural treatment has been available for a number of years in the Department of Clinical Health Psychology at the University of Manitoba's Bannatyne Street Campus at the Health Sciences Centre. There, Vincent and other clinical health psychologists provide individual and group treatment programming to patients from across the province. Through therapy, they help sufferers uncover the psychological, physiological and environmental causes of their insomnia.

The Region also funds the Sleep Disorder Centre at Misericordia Health Centre, which receives patients with physiological- based problems such as restless leg disorders or sleep apnea.

Vincent says the Region's HSC program has a good track record in helping patients improve their sleeping habits. But the problem was there were just too many with insomnia in Manitoba for the program to handle.

The wait time for behavioural treatment - or therapy - was about a 1½ years, and getting longer. Vincent estimates she gets about 15 referrals every week.

"I thought that putting on a website some of the materials I use when I see people to work with them here in the hospital would allow more people to start working on the problem without having to wait," she says.

Vincent started work on developing the site in 2005. The first patients started using the website in 2006. A six-week online course, it provides patients the opportunity to treat themselves for insomnia, using the same methods offered in single-patient or group therapy at the centre. From keeping a sleep diary chronicling their sleep patterns to learning relaxation techniques to helping them develop better sleep habits, the return2sleep.com website has brought cutting-edge sleep behavioural therapy into the homes of Manitobans.

Initially, individuals need to be screened and provided with a user name and password prior to accessing the online program. Next, the online treatment program takes patients through six modules, one to work on each week, starting with creating a sleep diary. Each day, participants are asked to enter into a webpage survey when they go to bed, how long it took them to get to sleep and how many times a night they wake up unable to get back to sleep. They're also asked to provide information about sleeping pill and alcohol consumption, as well as rate how they feel in the morning and how satisfied they were with their sleep for the past night.

"Once you enter some information in your sleep diary for awhile, a sleep calculator will tell what time you should try to go to bed," Vincent says.

It may sound like a lot of work just to figure out something that sounds obvious. After all, most people assume they go to bed when they're tired. But it's often not as cut and dried as that for insomnia sufferers, Vincent says.

"A lot of times, people get so divorced from knowing what's normal because their sleep has been so messed up for so long that they just go to bed when their bed partner does, and sometimes that can be a bit of a problem."

But more than anything, the online treatment program helps patients learn how their sleeping habits and attitudes regarding sleep often play a large role in perpetuating their insomnia.

In module four, for instance, Vincent - who appears in most of the videos on the website - leads patients through the basics of how their thinking habits about sleep can be at the heart of the problem.

She says cognitive therapy is a means to unravel these thought patterns and develop more helpful ways to look at sleep and insomnia. This involves a three-step process: first, they must identify their thoughts about sleep; then, they need to examine those thoughts and challenge their validity. Step three involves developing helpful alternative ideas about sleep to replace those existing thoughts about sleep that were unhelpful.

Donna Dyer, a 66-year-old retiree, was one of the first participants in the study more than three years ago. The module on cognitive therapy helped her overcome years of frustration, lying in bed awake for hours. The online program helped her realize how negative thinking about her sleeping habits was fuelling her insomnia because she was becoming increasingly frustrated and anxious about not sleeping.

"Before the study, I would have said, 'Oh, poor me! I didn't sleep well!' But I learned not to worry about getting enough sleep," says Dyer, a former cashier at the public swimming pool in Thompson.

"Now, if I can't sleep, I just realize that tomorrow will probably be a better night, whereas before I wouldn't have thought about it that way."

Dyer, like Cogar and many other insomnia sufferers, always figured her lack of sleep was a fact of life. In her case, she worked the 3:30 p.m. to 10:30 p.m. shift at the pool, and she always assumed she had difficulty getting to sleep and staying asleep because she worked odd hours.

After all, experts say shift work can be a cause of sleep problems. "But the thing is, when I retired, I didn't sleep any better," she says.

Dyer, too, saw the ad in the newspaper about the online sleep study. "I thought, 'Wow, this is for me!'"

And once she started using the website, she soon realized her hunch was correct. She obviously lived too far away to make the trip for treatment in person, but more importantly, the online program worked.

Besides teaching her ways to reduce her anxiety about her sleeplessness, she also realized her condition wasn't as problematic as she had thought it was.

"If I hadn't participated in that study, I would have thought that I slept hardly at all, but I realized that I probably did get more sleep than I thought I did because you can kind of tell by the way you feel the next morning," she says.

Many participants are actually surprised to realize they are in fact sleeping every night, says Vincent, even though they at first believe they hardly sleep at all. Whether they do or don't is somewhat beside the point, she says. It's about changing their attitude regarding sleep, bringing down their level of anxiety and frustration, and associating sleep once again with the bed.

But it's not just about changing how they think about sleep. It's about changing their sleeping habits, and even their bedtime environment. Often referred to as sleep hygiene, these are the dos and don'ts of getting a good night's rest.

"One of the simplest things was getting rid of my alarm clock," says Cogar.

Most insomnia sufferers find their sleep improves when they can't see what time it is when they wake up at night.

But Cogar's problem differed from most people who wake up in the middle of the night and become anxious about not being able to get back to sleep.

"What I would do is I would see the clock and think, 'If I got up now, I would do this, this and this,'" she says. "When I got rid of the clock, I would wake up late at night and have no idea what time it was, and then I would just tell myself to go back to sleep."

Dyer, too, found she was a clock watcher, but she also realized she had fallen into some other bad sleep habits. "I used to have a bath at about nine o'clock at night with a glass of wine," she says. The bath would raise her body temperature, which can make it hard to sleep because the body's temperature typically decreases at night to facilitate sleep. And alcohol, contrary to popular belief, can also cause insomnia.

Both women learned that good sleep hygiene involves developing lifestyle habits that promote healthy sleep at bedtime and abstaining from actions that may make it more difficult to sleep. These include the obvious, such as avoiding coffee and other stimulants, and the lesser-known ones, like not having pets sleeping in the bed.

They also learned that good sleep hygiene means controlling the amount of stimulus they experience when going to bed. In fact, Vincent even discusses stimulus control in the online study before hygiene is discussed in the last two modules. "Certain cues or stimuli can produce arousal or wakefulness when you are in the bedroom," she says in the web video on the site.

At the top of the list of stimuli to avoid in the bedroom are television and reading. "Although many individuals find these help them to unwind and relax, most people with insomnia are unaware that these activities may be actually maintaining the problem of insomnia," she says. "Simply put, these activities require attention and are stimulating." Instead, she says insomnia sufferers should unwind outside the bedroom.

Program participants also learn relaxation exercises, such as focusing on their breathing. Dyer says she still uses this exercise today. "Instead of thinking about something, I just become really conscious of my breath coming in through my nose, going down into my lungs, my stomach rising, and the breath going out my mouth." And when she finds that isn't working, she will occasionally go back to the website for a refresher.

"I really like it being at my finger-tips because you forget a few things, but you can go back and look at the program," she says. "It's always there."

One of the other reasons the site has been so successful is its ease of use, says co-ordinator Kate Walsh.

"I usually don't hear a lot of problems that come up because it's been pretty user-friendly," says Walsh. "For the people who aren't as computer literate, I will walk them through the process and show them what they will need to do each week."

For the most part, most e-mails and calls she receives from users are to express how pleased they are with the online program. "Because it is so flexible, that's something that really is attractive for them. It's not like there is a set time that they have to do this module or that one," she says. "They can work it around their lives and still get the help that they need."

And word is getting out, Vincent says.

"We're getting referrals from family physicians specifically for the program," she says. "That's when you know we must be on to something."

Of course, even without those specific referrals for the online program, Vincent and other researchers were aware of the site's benefits for insomnia sufferers. Early results from the study to test its effectiveness were published in 2009 in the U.S. medical journal SLEEP.

It found that more than 35 per cent of participants stated their sleep had much improved, and another 46 per cent of participants stated their sleep had minimally improved.

The study didn't go unnoticed. The Mayo Clinic in the United States approached the centre about using the site for its patients. And it wasn't just the medical community that took an interest. Soon after it was published, Vincent was fielding calls from the New York Times, Time Magazine and ABC News. The program also received a leading practice designation from Accreditation Canada - which is responsible for reviewing health-care practices in this country. The designation is generally given to programs that the agency deems to be "exemplary organizational practices that demonstrate high quality leadership and service delivery."

Despite the attention the study garnered across North America, the program is available only to Manitoba residents. And while the program is administered by the Winnipeg Health Region, Vincent says it has been particularly helpful for residents in rural areas and municipalities outside Winnipeg. "Probably 40 per cent of our referrals are living in rural areas," she says.

In fact, the online program is ideally suited for out-of-town patients. "Coming in for a program is just really very challenging to drive on a highway in the winter and take care of children and so forth."

Cogar says she found it convenient she could work on the program at any time, and she didn't have to drive into Winnipeg for treatment. A two-hour commute for an hour or two of therapy a week would have proved as stressful as it would have been helpful, she says.

While all online patients have the opportunity to follow up with one-on-one and group therapy, a good number say the online program improved their sleeping habits enough that they didn't need further treatment, Vincent says.

Cogar says she certainly found the online program beneficial. Her days of night crawling are behind her. And most importantly, her overall health has improved. Since taking the online program, she has had fewer Emergency Department visits because of her illness, and she rarely takes sleeping pills.

She says she finds she now has control over a problem she once believed was part of her genetic makeup. Before, Cogar believed being a bad sleeper ran in the family, and she feared her children may suffer the same fate. But after taking the online program, she now understands insomnia is not a fact of life to be endured. For her, it was a bad habit that needed to be broken.

"I know my children will not follow in this pattern because - like me - they know how to break it now."

Joel Schlesinger is a Winnipeg writer.

Wave

About Wave

Wave is published six times a year by the Winnipeg Health Region in cooperation with the Winnipeg Free Press. It is available at newsstands, hospitals and clinics throughout Winnipeg, as well as McNally Robinson Books.

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