We spend one-third of our lives asleep and yet know so little about the phenomenon. The number of Taiwanese experiencing difficulty sleeping has risen substantially in the last five years, as has the economic burden on the national health insurance (NHI) system. Funding for research is almost non-existent, according to local physicians who say the government and public can no longer afford to ignore what is becoming a serious issue.
Data obtained from the Office of Statistics at the Department of Health (DOH) found that number of outpatient visits to a hospital or clinic jumped from 52, 657 in 1998 to 681,146 last year, causing an increase of NT$120 million in NHI medical expenditures within five years.
"Sleeping disorders do not only effect individuals, they cost society as well," said Lee Yue-joe (
ILLUSTRATION: MOUNTAIN PEOPLE
Lee is one of the nation's leading researchers in the field of sleep disorders. The most common condition, he said, is insomnia. It is defined as difficulty falling asleep, unable to maintain sleep, or waking up too early. This can happen as the result of a change in one's life or daily routine caused by surgery, moving, or a new job. After a period of adjustment, a normal sleeping pattern usually resumes.
"When one's regular sleeping behavior does not return then one should be alarmed," Lee said.
Chronic insomnia is understood to be a sleeping problem that occurs at least three times a week and persists for one month. Lee said studies conducted in Taipei showed 20 percent of the population suffer from chronic insomnia, and up to 40 percent of those will do nothing about it.
"If someone is having a problem sleeping they don't want to spend their days worrying about it too. Most people believe when their body gets tired enough they will sleep. But if you ignore a medical condition, it doesn't go away on its own," he said. "If insomnia continues for more than a few nights, it can become chronic and cause a sleep deficit that is extremely detrimental to the sufferer's well-being."
The consensus among the Taiwanese medical community is that chronic insomnia is not a disease but a symptom of other physical or mental ailments that leads to wakeful nights. Left untreated it can lead to additional psychiatric, or anxiety disorders and likewise without proper diagnosis the underlying causes cannot be sought out and diagnosed.
"Before prescribing any medication or further treatment the first step is to determine the reason behind the inability to sleep," Lee said. "But for many people this won't be clear."
Better than counting sheep
Yuan Hsu-hu (
"Suddenly, all the things I never had time to think about during the day would start playing over in my mind."
After a few weeks, however, the wakeful nights became agonizing.
At first he tried reading, exercising, meditation and eliminating caffeine from his diet. Finally he reduced his work hours, which was successful for a short period of time. After a year, when the sleeplessness resumed, he went to see a doctor who prescribed a sleeping sedative. Three years later, Yuan continues to use sleeping medication two or three times a week. It might not be the best solution, he said, but it's better than counting sheep.
According to Lee, Yuan is a common example of stress-related chronic insomnia that is common among employees with low-impact, high-stress occupations. Another common cause of restless nights is, shift work, which according to Lee has increased by 30 to 40 percent over the last 10 years in Taiwan.
"Establishing a daily routine with set meals and bed times is the best means to sleeping well, but it's not that simple for most people," he said. "This is a 24-hour society and people need to work various schedules."
All brands of prescribed sleeping pills are hypnotics -- drugs that depress the central nervous system and put users to sleep. In the past barbiturates were prescribed but nowadays are rarely used. Most doctors prefer to treat patients with benzodiazepines, which are considered less addictive and safer than barbiturates. Not all hypnotics are the same, some work faster, longer or are eliminated from the body sooner; therefore the drug prescribed depends on a person's particular problem and need.
The most commonly prescribed sleeping medication in Taiwan and the US is zolpidem tartrate, distributed in Taiwan under the brand name Stilnox. It works to put users to sleep and wears off within three to six hours. It has become the drug of choice for insomniacs who can't fall asleep at night and doctors who claim it has less liability for physical dependence.
"While taking hypnotics for an extended period of time (years) is not an ideal situation," said Lee, research also shows that drugs such as Stilnox can be taken four to five days a week over a period of many years without negative repercussions.
"It's a popular misconception that if a person takes sedatives that in the long run they will become addicted," said Lin Keh-ming (
"The [national healthcare] system is both good and bad. You can see a doctor right away and the costs are negligible, but then the doctor can only spend three or four minutes with you," he said.
Other Sleeping Disorders
Not all sleeping disorders are non-organic. Insomnia is also a major symptom of people with bipolar disorder or chronic depression. Likewise, it can also be a sign of hyper-thyroidism, respiratory problems, or other serious physical ailments. Additionally, there is a rare genetic condition that is permanent and eventually fatal called Fatal Familial Insomnia.
A major concern for studying both sleeping and respiratory disorders is sleep apnea -- when a sleeping patient stops breathing for brief periods while sleeping. To accurately diagnose a patient, however, they must be observed in a sleep lab, which can monitor if a patient has stopped breathing in his or her sleep and for how long. Two percent to 4 percent of Taiwanese suffer from sleep apnea, a disorder that left undetected or combined with sleeping sedatives can be fatal, said Lee, who has observed and successfully diagnosed a number of patients in his sleep lab at the NTUH.
Chinese medicine doctor and CCMP member, Zheng Sui-zong (鄭歲宗) said six out of every 10 patients he sees experience sleeping problems, a major jump from the two to three he saw a decade ago. His biggest concern is the age of the patients, many of who are in their teens he said. It is an increase he attributes to entertainment and technology. "Too many children are sitting in front of the television, or computer for hours, not eating, not exercising, and now not sleeping."
The majority of Zheng's patients, he claimed, are looking to find an alternative or addition to the prescription medication they are already taking. His first step, he said, is to wean people off the prescription drugs before giving them any herbal medication to take, because a combination of the two can be harmful. His approach includes massage, acupuncture, herbal medicine and a magnetic bead that is placed on the ear at night time that works to relax the nervous system.
The road to recovery, Zheng said, is to locate the source of the sleeping problem and make a diagnosis from there. "Most sleep disorders, whether caused by physical or mental factors, can be treated or managed effectively once they are properly diagnosed," Lee said, but for some he added, "the waiting period is many sleepless nights."
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