Sleeping Sickness

The hour hand has turned full circle, but Snehlata Mattoo, 24, is still sleeping like a log. As usual, she has missed her classes. She just can't wake up, despite the loud exhortations of the alarm, and finds herself unable to tackle her responsibilities.

KATRE and Mattoo are just two of the more conspicuous victims of the hide-and-seek games that sleep plays on many of us. Look around and you will discover a legion—people with dark circles under their eyes, lethargic people who struggle, zombie-like, to get through their day. Or just ask psychiatrists and they will tell you how the numbers of sleep-disorder patients have been rising steadily. Says Datta Ray, a psychistrist who runs a clinic in Chittaranjan Park: "Ten years ago not many patients came to me with sleep disorders. But over the last few years they have been coming in hordes."?

But does that mean sleep disorders are actually rising? Maybe it's just that more patients are visiting clinics; maybe earlier they didn't take it seriously enough to go looking for a cure. "That's quite possible," admits J.C. Suri, a chest physician who also runs a sleep clinic at Safdarjung Hospital, "but it's also true that changing lifestyles, food habits, work patterns, and many other environmental factors have increased the incidence of sleep disorders. There's no estimate of how many suffer from sleep disorders in our country, but I guess it would be an appreciable number. In the US, there are an estimated 40 million patients with sleep disorders. Here in India, we don't know about them simply because sleep disorders are still taken very lightly by most people."

?Like many other aspects of normal human activity, the industrial revolution has disturbed—perhaps irrevocably—the rhythms of sleep acquired over millions of years of living harmoniously with nature. Round-the-clock operations are now commonplace, and the time tradition-ally reserved for sleep has been usurped by the need for higher productivity, by business, war, entertainment, and so on. Therefore, an average individual has to cope with a work schedule that interferes with normal bio-patterns. Even today, as hitherto agrarian societies like ours go through the birth pangs of industrialisa-tion, some of the more dramatic changes—whether you call it 'cultural' or 'natural'—that occur involve sleep. For example, siesta is usually outlawed, and shift work is the norm. The advent of highly technological societies has turned poor sleep and substandard levels of wakefulness into a matter for grave concern.

If cultural trends are anything to go by, India is jetlagging, if you will, the American way. Life in the fast lane is becoming the norm—late-night conferences, late-night revelries, late-night duties, late-night travel, and so on—they are all seriously disrupting age-old rhythms of sleep and wakefulness. Though there is as yet no systematic study in India that establishes that changing lifestyles and job profiles are abetting sleep disorders, there is sufficient anecdotal evidence to suggest that this is happening.

Take the case of Ravi Kumar, a 30-year-old factory worker. Till eight years ago, he enjoyed normal, regular sleep patterns. But soon after he took up this job, which often had him working night-shifts, he discovered he was falling asleep at unearthly hours. "I was miserable. I would just go to sleep while on the phone or driving the car or even eating food. To keep myself from falling asleep inadvertently, I started keeping a pin or a knife with which I would prick myself the moment I would begin to doze off. For nine long years I lived in a veritable hell, desperately and undiscerningly seeking help—from roadside healers to homeopaths to general practitioners. But to no avail. Finally, I landed in Suri's lab, and I think I'm improving."

Manisha Gupta, 31, a business executive, is another typical case. The tribulations of a divorce she went through recently and job pressures left many scars on her psyche. She often went into bouts of depression and couldn't sleep for days. When her insomnia became chronic, she began taking sleeping pills. But before long, her body got used to the pills and she was back to sleepless nights. Like Ravi, she too began a frantic search for help, a treacherous path which finally led her—like many others—to sedatives. Now she is under treatment at Suri's lab.

About nine out of 10 patients visiting Suri's lab are like Ravi or Manisha—apnea-afflicted people and insomniacs. Sleep apnea is a condition in which a person repeatedly stops breathing during sleep. The person's airway collapses, blocking the flow of air into the lungs. Explains Suri: "The person who experiences such interruptions probably doesn't remember them. There can be hundreds of interruptions and may last only long enough to interrupt sleep patterns. The person is not consciously awake, but the deep sleep that we all need to function is not sustained. The result—a sleepy or fatigued person who may experience intellectual deterioration, mood disturbances, diminished libido, and be at increased risk of high blood pressure."

Fortunately, apnea can be cured. The most common treatment is called CPAP (or continuous positive airway pressure). In this therapy, a constant, gentle flow of air is kept up through the nose or the mouth or both. This airflow helps keep the airway from collapsing and, hence, allows breathing to become regular. The patient also ceases snoring and gets back the ability to have reposeful sleep. The therapy is provided via a device that blows the air through a tube to a mask which the patient has to wear before going to sleep. It is a surefire cure. The only problem is that not everybody can afford this device—it has a prohibitive cost of nearly Rs 60,000.

Apnea victims at least have a tangible cure to look forward to. Insomniacs are not so fortunate, however. They have to be treated symptomatically, with a combined therapy of sleep hygiene, drugs, and relaxation techniques such as bio-feedback and light therapy. Of these, sleep hygiene is perhaps the most important—it provides a regimen that controls when and where you sleep, when and what you eat and other seeming trivia that eventually determine the quality of your sleep.

Equally important are environmental factors like temperature, light intensity and noise. Explains N.G. Desai, a psychiatrist at All India Institute of Medical Sciences, New Delhi: "The human biological clock has been tuned over millions of years to ever-changing environmental stimuli. Any abrupt disagreement between the two often leads to a sleep disorder. And each body clock is unique, with varying inherent vulnerability to changes in the environment. So some are more likely to suffer than others."

Relaxation techniques come in all sorts of varieties. More popular among them are bio-feedback, meditation, even transcendental meditation, and light therapy. Biofeedback is based on the reasoning that lack of sleep is reflected in muscle tension. The tenser your muscles are, the more elusive you find sleep to be. So patients are taught some tension-relieving exercises. As your muscles unwind, sleep returns. In light therapy, patients who tend to fall asleep earlier than usual, or later than usual, are exposed to varying degrees of light brightness—corresponding to different times of the day. This way, the biological clock can be fine-tuned back to its original rhythm.

Ravi and Manisha were lucky to find their way to Suri's clinic. Pratap Pandey, a 29-year-old college lecturer; Revathi Agnihotri, 35, air-hostess; Shalini Gupta, 35, freelance writer; Chandan Bakshi, 35, jetsetting corporate executive; J. Ramesh, 18, IIT-aspirant; Naresh Satyanarayan, 28, a resident doctor in a hospital. All of them suffer from sleep problems but are, sadly, too complacent or ignorant to seek medical help. And most of them are hooked on sedatives or stimulants.

Says Suri: "By the time they come to us, many of them are addicted to anti-depressants or stimulants, which are routinely prescribed by general practitioners. These drugs are freely available over the counter, sans prescription. I am sure the sale of tra-quilisers has shot up significantly over the last decade." Suri's hunch is confirmed by users and druggists alike.

And here ignorance is no bliss. In fact, it's the gravest danger, primarily because it's so widespread. Policy makers, the medical community, and citizens have no idea of the damage this menace might cause. Desai explains: "Our society is getting increasingly dependent on the alertness of key individuals—drivers of public transport vehicles, supervisors in nuclear power stations, health-care workers, military personnel. Catastrophic disasters that have occurred on the night shift, such as the uncontrolled scam at Three Mile Island nuclear power plant and the grounding of the Exxon Valdez oil tanker, have undermined public trust in these industries."

Regrettably, very few Indians have examined the consequences of altered sleep patterns in high risk groups such as bus drivers, pilots, and healthcare workers. A few years ago, a study conducted by the Bangalore-based National Institute of Mental Health and Neuro-Sciences showed how the constabulary, subjected to long hours of work, developed all sorts of psychiatric problems. Likewise, an ongoing study by the Voluntary Health Association of India shows how loss of sleep is causing psychological distress to Latur relief workers.

Even in the US, of the 40 million sleep disorder victims, over 90 per cent will never be made aware of their problems. They might go undiagnosed and untreated. But there are some people losing sleep over the situation. On May 29, the American Sleep Disorders Association will stage a 'sleepwalk' on Capitol Hill. Sleep disorder victims and healthcare professionals will fan out across Congressional offices and hallways to let elected federal lawmakers know about the increasing need for educating medical personnel and the public about the gravity of sleep-related problems. They will also campaign for easy access to care and affordable testing and treatment as well for funding for research. When will the sleep disorder victim realise the need for therapy? And when will the Indian medical community wake up to the alarm bells?