The appointment was for his annual physical, and to review his well controlled hypertension and gout. After we had addressed these issues, I asked if there was anything else he was concerned about.
“I need some sleeping pills. I can’t sleep, and I’m so (expletive) tired during the day I’m having a hard time at work. It’s been a problem for a couple years and it’s gotten real bad in the last 2 months.” From his perspective, this was a simple problem with a simple solution. From my perspective (and based on a large amount of research), chronic sleep problems are neither simple nor easy, and medication is rarely the answer.
He hadn’t had trouble sleeping as a child or young adult. The problem began slowly when he started a business and had gotten worse as the business grew in size and success. (He was doing very well designing and building both personal and commercial storage solutions.) It had gotten dramatically worse after his twins were born 8 months ago. He had tried various over-the-counter medications including antihistamines (Benadryl) and melatonin, with no benefit.
He was not having night time pain or trouble breathing, was thin and did not snore, was fatigued but not hyper somnolent (did not fall asleep inappropriately) and importantly noted that he had slept fine last month during the week he and his wife were on vacation. He drank 2-3 cups of coffee daily, always before noon, did not exercise regularly (his work week was routinely 65-70 hours), and he had 3-4 beers every evening while he watched TV and used his laptop to do estimates, inventory, and other business tasks.
He described being unable to get to sleep, often lying awake with racing thoughts for 3 hours, then awakening to use the bathroom (beers at bedtime will do that), and being unable to get back to sleep but increasingly aware that it was going to be time to get up soon.
As is often the case, a good history made the problem pretty clear, but a solution was not going to be easy. I explained the role of evening alcohol, stressful tasks and screen time in disrupting the complex neurology of sleep and suggested a limit of one beer with dinner, a 30 minute walk daily, and some quiet family activity, reading, or listening to music but no screen time or business activity in the 90 minutes before bed.
“Can’t happen, doc. Please, all I need is some pills to help me get to sleep and I’ll be fine.”
It was clear to me that I could tell him medication would not work but he would not hear me. Instead, I told him that we could try some medication for up to a month, but that if it didn’t work, we wouldn’t continue it and would need to try something else. He was sure it would work.
It didn’t. He called in a month for a refill, but told my nurse that he was getting to sleep a little sooner but still waking up and unable to get back to sleep for hours, averaging 3-4 hours of sleep a night, and still constantly tired and irritable. I called him back and reminded him that we had agreed to this as a short trial with the plan to do something else if it didn’t work. (I was good and didm;t say ‘when’ it doesn’t work.)
I told him my back-up plan was to have him see a local psychologist who did cognitive therapy and had an interest in both stress-related illness and insomnia.
“No way, doc. I don’t have time to do my work now, and I can’t see wasting good money talking to some touchy-feely guy who thinks I’m a nut case. Isn’t there a stronger sleeping pill?”
At this point his wife (who was on the other line) jumped in: “Excuse me for butting in, doctor. This is a big problem. He yells at the twins and is rude to customers. He forgets things all the time and gets upset over little things. We need to fix this. What’s the name of he psychologist. I’ll make the appointment and make sure he gets there.”
There ensued a brief back and forth between the two of them, culminating in her taking the psychologist’s name and phone number and promising to call me back if there was a problem. The last thing he said was: “No way. I’m not going. Don’t waste your time.”
When I saw him for his annual visit this Spring, I asked him about his sleeping problem.
“Sleeping great, doc. I’m not so tired anymore.”
What fixed it, I asked.
“Oh, that head-shrinker was fantastic. One visit. Best $100 I ever spent.”
What did he do?
“He convinced me to hire an assistant at work to cut my work load. I get home for dinner, now. And I have most of my weekends off. And we can take more jobs so I’m making more money. It’s all good.”
What made you change your mind about seeing the psychologist, I asked?
“My wife. She made me.”
I know this couple pretty well. He is a bit over 6 foot, heavily muscled, and wrestled in college. She is barely 5 foot 4 and has to hold on in strong winds to avoid being blown into the next county. He is full of bluster and often sounds like a dockworker on a bad day. She is soft spoken, a literature and theater buff, and very articulate.
“How did she MAKE you?”
His enthusiastic bluster vanished when I asked this. Looking down, he cleared his throat, shifted a bit in his chair and said, almost inaudibly:
“No sex unless I went. I argued, but she said something about some Greek guy named Aristo-something.”
Ahhh, I thought. Lysistrata by Aristophanes. But all I said was: “Whatever works.”