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Rx for a Better Night’s Rest

by Edward Stepanski, PhD

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Difficulty sleeping, or insomnia, is a frequent problem for people being treated for cancer. People experience insomnia in many different ways: trouble falling asleep at the beginning of the night, waking up in the middle of the night and being unable to return to sleep, or having many brief awakenings throughout the night, leading to unrefreshing sleep.

Insomnia generates many possible daytime consequences, including fatigue, decreased concentration and memory, increased depression, and increased perception of pain. In addition to these direct effects of insomnia, a potential indirect effect is a reduction in the ability to engage in cancer treatment. A rested person is in a better position to endure the rigors of cancer treatment. Since there are safe and effective treatments for insomnia, seeking treatment is appropriate for anyone experiencing daytime impairment related to insomnia.

Treatment for insomnia can be in the form of medication (e.g., sleeping pills) or cognitive-behavioral treatment (CBT). CBT requires adjusting habits that can affect how well you sleep. In general, medication is recommended for short-term, or transient, insomnia, and CBT should be used for long-term, or chronic, insomnia. For example, medication would be best for someone who is anxious about upcoming surgery and develops insomnia related to that anxiety. Medication can be used to allow improved sleep prior to surgery and then discontinued afterward.

A rested person is in a better position to endure the rigors of cancer treatment.

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Dr. Edward Stepanski

Although sleeping pills have gotten a bad reputation due to the risk of dependence, they are often appropriate and effective, especially when used for short periods. Short-acting medications are preferred as they increase the ability to sleep during the night but do not continue this effect into the day.

Several research studies have shown that CBT improves sleep in people with insomnia who have been diagnosed with cancer. The ability to attain restful sleep is related to many habits, such as keeping a regular sleep/wake schedule, taking naps during the day, consuming caffeine or alcohol, and worrying about sleep quantity or quality.

When people become ill, they commonly change many of their habits, including their sleep-related habits. For example, a person on medical leave from work may stay in bed later in the morning while keeping the same bedtime at night. This simple change means the total time in bed may go up to nine or ten hours, but the quantity of sleep may stay the same. The person may be sleeping seven or eight hours each night but will spend two to three hours awake during the night. Because of the time spent awake, this person is more likely to get out of bed, get something to eat, check e-mail, or engage in other activities, further worsening his or her quality of sleep. As time goes on, this person will begin to worry about his or her lack of sleep, which can lead to increased tension at night and poorer sleep quality.

In this example, a simple change in arising time leads to a cascade of additional changes that will likely end in disrupted sleep. This is why adopting good sleep habits is important in solving a problem with insomnia.

Choosing between sleeping pills and CBT can be complicated for a person being treated for cancer. For instance, a person receiving chemotherapy may experience extreme fatigue and other symptoms that would make it difficult to seek out a sleep specialist or to follow a CBT program. Therefore, administering sleeping pills might be the preferred method of improving sleep during cancer treatment, and CBT could be implemented after completing chemotherapy if the insomnia returns.

There is no single approach to dealing with insomnia. The best treatment will depend on individual aspects of the problem. Perhaps the most important factor is the severity of insomnia-related impairment during waking hours. For example, if a person notes substantially increased pain on days following very poor sleep, the advantages of using sleeping pills – improved pain control and decreased use of pain medication during the day – may outweigh the possible side effects.

If you are struggling with insomnia, you should discuss it with your doctor so, together, you can create a treatment plan that works for you.

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Dr. Edward Stepanski is chief operating officer for the Accelerated Community Oncology Research Network in Memphis, TN.

For a list of certified specialists in CBT for insomnia, visit the American Academy of Sleep Medicine Web site,

This article was published in Coping® with Cancer magazine, September/October 2008.