3: PRIOR TREATMENT ATTEMPTS                                               [Rev 12-23-2017]

            This issue follows the judgment that a patient has chronic insomnia [Section 2 in Step A]

It generally pays to ask how people have tried to cope with their issues, including insomnia. If their methods have been effective, they will say so. Usually they haven’t been effective, or were only slightly so, and there are commonly undesirable side effects.

An early question could be, “When did you first have trouble sleeping?” with a clear implication that we are looking for a long-term answer, like, “As far back as I can remember,” or “I think it started in high school.” According to Morin (p. 15) the average person going to a sleep clinic has had insomnia issues for about 12 years. People in therapy for other issues may or may not have suffered that long.

The person’s answer can help identify age or life-style, or circumstantial causes of the problem. It is also very different from the issue of Section 2, which is directed toward the current insomnia episode. The two sets of circumstances can be connected, as when a light sleeper moves into a noisy environment.

As for treatment attempts, a question of “How have you tried to deal with this?” or “What have you done to try to sleep?” can be very informative. It’s not unusual for a patient to say “everything!” and believe that it’s true. Or be able to come up with a list of things tried.

It can be helpful to ask for details about anything – or things – the person has tried, including, for each…

  • When, how consistently, and for how long
  • What the circumstances were
  • How well it worked
  • If it wasn’t continued, what happened.

 

It is possible that the person’s previous attempts were ineffective because of a failure to follow the most effective procedures – to take a medication regularly, to give a new habit long enough to actually become habitual, to realize the reason for a procedure and not be adequately motivated, etc. It might pay to try a previous method with a variation or with greater awareness of what the procedure requires to be effective.

Many people have tried watching television to fall asleep, or various relaxation programs, taking naps, staying in bed in the morning, and so on. To ask may be to open up a person’s frustration: “I’ve tried everything. Nothing helps.” This may continue as you suggest possible treatments. “Systematic relaxation?” “Tried that.” Well, maybe. Or maybe they tried a treatment in a haphazard and ineffective way. The information is in the details of what they did, and for how long.

Most people have tried some kind or kinds of medication. Try to get an inclusive list, along with the benefits and problems of each. Clearly, anything that the patient has tried wasn’t fully effective or satisfying, or the issue would never have come up. If the problem was that the person used an appropriate treatment ineffectively, you may eventually have to recommend that he/she try the same treatment for a longer time or in a modified way.

 

3a Medications

If the person is currently using medication, ask about his/her experience of the medication’s effectiveness and possible side effects that commonly accompany it. Merely discussing the problem can be a motivator to get the person off medications and on to better self-management.

At this point the goal is greater awareness rather than discontinuance of the drug.  At a later point, the person may spontaneously reduce or eliminate drug use, or you can help plan for him/her to do so.

Common sleep medications include

  • Alcohol
  • tobacco
  • Marijuana
  • Benzodiazepines
  • Other sleep-inducers – Ambien
  • Sedating antidepressants
  • Over-the Counter meds typically include an antihistamine – Sominex, Unisom, Sleep-Eze, Nytol, Tylenol PM, Bufferin Nitetime, Anacin PM, Excedrin PM
  • Melatonin

There are problems with each kind of sleep medication. In general, they

  • Lose their effectiveness over time [Jacobs 31]
  • Lead to dependence – the belief that one can’t sleep without them. This also affects self-esteem, as the user feels inadequate.
  • Are expensive – the cost of medication and possibly doctors’ visits
  • Have undesirable side effects, including drowsiness the following day.
  • Can lead to rebound insomnia on discontinuance
  • Only treat the symptom and not the causes of insomnia, which are thoughts and behavior [Jacobs 31]
  • May be illegal or illegally obtained

Alcohol, tobacco and marijuana are discussed in Section 8. Prescription and over-the-counter medications are discussed in Section 36.

Another possibility is that the person was at one time using a medication that seemed effective without side effects, and only wants to get more of it. Here, there are several possible responses:

  • Encourage him/her to try it again and keep track of the results.
  • If it really works, fine. Move on to other therapy issues. Check back from time to time for long term effectiveness.
  • If it doesn’t work, suggest that the person try something else, either with the valued medication or instead of it.
  • If the person can’t find a prescriber for his/her medication of choice, then a different approach may be necessary.

3b: Other Prior Treatments

Once you have considered all the medications the patient has tried and their consequences, the question, “What else have you tried?’ may reveal a variety of other self-treatments, including use of the bed for other activities, such as…

  • Watching television
  • Listening to music
  • Playing cards
  • Playing on-line games
  • Doing exercises
  • Going to bed earlier and hanging out
  • Staying in bed after awakening

The person may also have tried

  • Relaxation techniques. These are often suggested in magazines and the Internet. Details are important here – the same questions as above. It often is difficult for people to be consistent, especially when a technique is difficult to carry out and results aren’t immediate.
  • Taking naps. For some people, taking a short midday nap can be refreshing. However, taking several naps or a long nap each day can reduce the need for sleep at night, thus perpetuating the person’s insomnia.
  • Using will power to get to sleep. Often the increased effort leads to greater wakefulness and frustration, which can make it harder to fall asleep.
  • Hot baths or showers
  • Self-hypnosis tapes
  • Here the details matter, along with the person’s ability to carry out an exercise plan. It can help to explore the plan and how it helped or failed to help.

A patient’s list of prior insomnia treatments could be interesting and diagnostic. For example, there might be a mismatch between the patient’s psychological issues and the sleep remedies tried – the wrong medication, or a relaxation technique that he/she couldn’t stick with.