The room is dark, the air is crisp and cool. Under the covers, the bed is cozy and warm. Perfect conditions for drifting off to sleep—which just makes it all the more frustrating to be wide awake. It’s hard not to roll over and repeatedly check the glowing digital time, watching the night slip by. Finally, the day starts with a wave of exhaustion.
Almost everyone has lived through some version of that torture. A Gallup survey once found that 95 percent of U.S. adults have had at least one episode of insomnia in their lives, making it a near-universal experience. About a third of adults have regular bouts of sleeplessness, and for one in seven people, falling asleep is a nightly struggle.
Sleep is a biological need, so it seems like it should just happen when you’re tired. But shutting down the brain isn’t as simple as putting your computer on hibernate. We have plenty of ways to sabotage the pathways that recharge our brains and renew our energy. “Our brains and bodies were wired for us to sleep,” says Anne Bartolucci, a Decatur psychologist specializing in insomnia and author of Better Sleep for the Overachiever. “We end up getting in our own way so much, or modern life gets in our own way.”
There are 24-7 alerts pinging on our cellphones; all-night opportunities to eat, drink, dance, study, or work; and a heap of stressors to think about when we finally lie down. Georgia is the seventh most sleep-deprived state, according to the Centers for Disease Control and Prevention. Fortunately, if you want to find help, metro Atlanta has that, too—people who study sleep, specialists who treat sleep disorders, and places where you can escape the chaos of your home for a night to get some glorious slumber.
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Dayna Johnson grew up in Detroit, where she had family members who worked rotating shifts in the auto factories. Those were well-paying jobs, but workers often had to sleep during the day so that they could stay awake all night, and then switch back to a typical day/night cycle on weekends. They battled drowsiness and brain fog from chronic sleep deprivation, which is linked to health risks such as hypertension and diabetes.
Watching people she loved struggle with both sleeplessness and sleepiness inspired Johnson to become a sleep epidemiologist. As an assistant professor at Emory University’s Rollins School of Public Health, she studies the barriers to healthy sleep, with an emphasis on identifying the underlying causes of sleep disparities. As a Black woman, Johnson is also concerned that Black Americans get less sleep than any other racial group.
Sometimes sleep problems are triggered by surroundings—too much noise or bright outdoor lights shining through windows. The stress of daily life plays a role, too, Johnson says. The pandemic worsened sleep, as essential workers worried about the risks of staying on the job, families suddenly spent every waking hour in close quarters, and some people grieved over lost friends and relatives.
For many, the death of George Floyd in Minneapolis in the spring of 2020 sparked outrage over police brutality and stirred long-simmering anger over racial injustice. “What we’re hearing from individuals in our studies is that they’re ruminating [at night] on these different experiences of discrimination that occur during the day,” says Johnson.
But even in the midst of inequities and anxieties, can’t we get a decent night’s sleep? Johnson is studying that, too, and has learned that mindfulness offers a path. In a pilot study with 17 Atlantans—a diverse group that was about half Black and mostly women—Johnson found that using the Headspace app at bedtime to guide meditation and breathing improved sleep. Those who used it at least half the nights for 30 days reported falling asleep faster.
Having good sleep habits also matters, Johnson says. That means turning off electronics before bedtime—preferably an hour or more; sleeping and waking at about the same times every day; and sleeping in a quiet and dark room. “Do things that are nourishing and help to reduce stress and manage anxiety,” she says.
When sleeplessness becomes entrenched, though, the standard sleep advice may not be enough. People with chronic insomnia often have already tried meditation apps, soothing nature sounds, deep-breathing exercises, counting sheep—there are even light projectors that cast stars, ocean waves, or patterns on the ceiling that are meant to induce sleepiness.
If you have troubling falling asleep or staying asleep at least three nights a week and your sleeplessness has been going on for three months or more—the definition of chronic insomnia—it’s time to seek professional help.
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Ellen Orenstein, 39, never was a good sleeper. As a child, she would sleepwalk, and as a young adult she would wake in the night, her heart pounding, with the sensation that there were snakes in her bed. It took a few moments to realize she had been dreaming.
The Dunwoody mother of two soldiered through, using a meditation app, limiting caffeine, and trying to follow a healthy lifestyle. But in early 2020, even before the pandemic began, her insomnia worsened. She and her husband separated. She discovered a lump in her breast, which turned out to be an aggressive form of cancer. She went through 12 weeks of chemotherapy, a double mastectomy, and long-term treatment with tamoxifen, which sent her suddenly into menopause.
At that point, Orenstein was barely sleeping and struggling to function in her job as therapy manager at Emory Rehabilitation Hospital. Her days are full, with no time for restorative naps.
“You know you need sleep. You know you’re exhausted. And for your body not to do what you want it to do is extremely frustrating,” she says. “When you go to sleep with dread of the night being long and anxiety-ridden, it’s just really, really, really difficult.”
Her first visit to the Emory Sleep Center was with director Nancy Collop and involved a long interview, a physical exam, and a review of blood tests. Orenstein turned out to have low iron levels, a condition that can affect both sleep quality and quantity. Supplements, including vitamin C to improve iron absorption, made a huge difference.
“I fall asleep, and I sleep until my alarm goes off,” Orenstein says. “I’m actually sleeping better now than when I was a teenager.”
She also worked on managing her stress with Wendy Baer, director of psychiatric oncology at Emory’s Winship Cancer Institute, but notes that she couldn’t have fixed her sleep problems with behavior changes alone. “I really don’t think I could have gotten better without getting my iron levels back up,” she says.
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Seeing a primary care provider is a good first step if you have frequent sleepless nights, particularly if you have chronic pain or conditions associated with insomnia, such as diabetes, digestive disorders, or bladder or prostate problems. Sleep medicine physicians, who have specialized training, take a comprehensive look at a patient’s physical and mental health, checking for potential causes. Sometimes, people with insomnia have an underlying condition such as circadian rhythm disorder (an out-of-sync body clock) or sleep apnea (in which breathing stops and restarts repeatedly throughout the night).
Hypertension and a high concentration of red blood cells can be signs that your body is trying to compensate for the loss of oxygen due to sleep apnea, says Collop, who is a past president of the American Academy of Sleep Medicine and the editor-in-chief of Journal of Clinical Sleep Medicine. Sleep doctors look for anatomical clues, such as an enlarged tongue or large tonsils. And then there’s snoring. “Not everybody who snores has sleep apnea. But almost everybody who has sleep apnea snores,” Collop says.
Insomnia alone isn’t typically a reason to undergo sleep studies, which involve either wearing at-home monitors or spending a night in a sleep center, where technicians observe breathing patterns, oxygenation, and brain waves. These studies are used to detect sleep apnea, narcolepsy (a form of disrupted sleep that includes attacks of intense daytime sleepiness), and abnormal sleep movements or behaviors, known as parasomnias.
Sleep doctors are also experts in the use of sleep medications commonly taken in a short-term, targeted way. Those include the popular go-to zolpidem (Ambien and similar drugs) and newer ones such as daridorexant (Quviviq) that work on the sleep-wake cycle. Hitendra Patel, a pulmonologist specializing in sleep medicine and medical director of the Wellstar Sleep Program in Marietta, sometimes gives patients prescriptions to help them through a particularly stressful—and sleep-sapping—period in their lives.
For chronic insomniacs, Patel may ask patients to rotate their medications, to avoid dependence or tolerance, but drugs are usually a bridge to cognitive behavioral therapy for insomnia (CBT-I). It’s important to treat any underlying anxiety or depression, as well as to address behaviors that may make it hard to fall asleep, he says. “You’re taking a medication to treat a symptom,” Patel says. “You’re not getting down to the root cause.”
He also educates his patients about good sleep habits. Some are obvious: Don’t exercise vigorously or drink caffeine right before bedtime. Some require lifestyle changes: Don’t eat a late dinner (close to bedtime) or drink alcohol too late in the evening.
Patel knows that some people drink a glass of wine or hot toddy before bed because they think it will help with sleep. Alcohol might make them relax, but he cautions his patients that it will harm the quality of their sleep, due in part to the byproducts created as alcohol is metabolized in the liver. “I just want people to sleep well and better because it translates to better quality of life,” he says.
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Joanna Kobylivker, 44, was the sort of sleeper who needed complete darkness and quiet to fall asleep. But she remembers the moment when insomnia took root and it seemed like she lost the ability to fall asleep at all.
One night, when she was in her late 30s, Kobylivker heard some upsetting news from a friend and kept thinking about it. She ended up tossing and turning most of the night. As she dragged through the next day, a thought came to her: What if that happened again?
The fear became a prophecy. At first, she had a few bad nights a week, and then every night was sleepless. What if I never sleep again? she recalls thinking. “You can really talk yourself into a scary place,” Kobylivker says.
She tried valerian, an herbal supplement that is often touted as a mild sedative, and an antihistamine that causes drowsiness, with mixed results. Her doctor prescribed a sleeping pill, but she knew that wasn’t a lifelong answer. If she didn’t take the sleeping pill, she couldn’t fall asleep.
Kobylivker, a mother of two who lives in Atlanta, was working part time, running a small baking business, and taking naps to get through each day. About seven years ago, she read a book called Say Good Night to Insomnia that guided her to relieve her anxiety with relaxation techniques and a sleep-friendly bedtime routine. Getting personal coaching and encouragement through CBT-I at Kaiser Permanente relieved her dread of having insomnia—and the insomnia itself.
By the time someone seeks help for chronic insomnia, they have been working hard at falling asleep—too hard. “They do things like spend more time in bed to try to get themselves to sleep more,” says Bartolucci, the Decatur psychologist. “Of course, that means that you’re spending more time awake in bed, which then feeds into the underlying problem [of being anxious about sleep].”
CBT-I is a short-term treatment of about four to eight sessions; the American Academy of Sleep Medicine gives it a “strong” recommendation as the therapy that is “most supported” by research. It is built around five elements: stimulus control, sleep consolidation, cognitive restructuring (changing thoughts about sleep), sleep hygiene, and relaxation techniques.
Basically, that means keeping a sleep diary and working with a therapist to create a better routine, such as going to bed only when you feel sleepy—not just tired, but heavy-lidded. Relaxation techniques help reduce the stress that keeps you alert or agitated.
With sleep consolidation, you begin by figuring out how many hours of sleep you usually get. You then set your bedtime by calculating backward from your wake-up time—allowing for at least 5.5 hours of sleep. So, if you usually go to bed at 10:30 p.m., toss and turn, and finally manage to sleep six hours before your alarm goes off at 6:30 a.m., your new bedtime is 12:30 a.m. Gradually, you may move the bedtime earlier, extending the hours of sleep but still focusing on going to bed only when you’re sleepy. That allows you to associate the bed with sleep, not with sleeplessness, explains Leah Farrell-Carnahan, an Atlanta psychologist who specializes in CBT-I.
“It’s not a passive treatment, like a pill,” she says. “The therapist is teaching the person how to facilitate healthier sleep, but they have to take the action. And the action is hard to do. It’s breaking unhelpful habits and developing new habits.”
You can’t just will yourself to sleep, but you can remove the barriers that come from your own thoughts and behaviors. “The point is to recondition the brain and body to be more likely to sleep or get sleepy in this environment at this time,” says Farrell-Carnahan. “So, you’re not directly causing the sleep to happen, but you’re creating the ‘garden’ that’s conducive to sleep.”
Those benefits are lasting. “People not only feel more confident in their ability to sleep, but they’re more confident to weather the rough nights that are an inevitable part of being human,” says Bartolucci.
Kobylivker uses these CBT-I strategies if she has any trouble falling asleep—reassuring herself that a night of light dozing or shorter sleep won’t hurt her—and she usually falls asleep within 20 minutes. “I thought I was just cursed to have this condition,” she says. Now, she feels empowered to do something about it.
• • •
For many years, tossing and turning at night was just a way of life for Brent Henderson, a school counselor from Decatur. About 10 years ago, his mother died after a long decline with Alzheimer’s, and he decided he needed to focus on his own health. A sleep doctor diagnosed mild apnea, and he started using a CPAP machine. The steady flow of oxygen helped, but he still felt he wasn’t sleeping soundly. He woke up tired and never had a hint that he had been dreaming.
When the CPAP broke, Henderson didn’t get it fixed and made up for lost sleep with daily naps. His path to better sleep came unexpectedly. Recently, Henderson, 58 and retired, developed a case of tinnitus—a loud, high-pitched trill in his ears that he called his “cicadas”—after he fell and hit his head. The ringing persisted night and day and created a constant distraction.
Seeking a nonmedical solution, he decided to try acupuncture. Henderson completed a lengthy health questionnaire at Intown Acupuncture Center in Decatur, and acupuncturist Judith Kenen began asking questions. The sleep issue came up. “Getting up, I’m very tired,” he told her. “I don’t sleep soundly through the night.”
As Henderson lay on the massage-style table, Kenen placed thin needles just beneath the skin—with a light tap that produced a painless sensation, one Henderson hardly felt once they were in place. He lay still and relaxed until she returned and removed the needles.
That night, “I lay down and slept. I slept hard and I dreamed,” he says. He didn’t think about it at first, since he had gone to an acupuncturist for his tinnitus. But then he slept well the next night.
He recalls thinking: “Wait a minute—this is two nights in a row that nothing has changed in my daily routine, but I am going to bed, and I am just asleep and dreaming.”
Henderson went back to Kenen every 10 days. “I’m dreaming, I wake up and can recall a dream,” he says. “I’m not finding myself tired and exhausted within a few hours of waking up.” His tinnitus has not gone away, but he says it’s episodic now instead of constant.
“It’s amazing how much better I feel now that I can just sleep. It’s a beautiful thing, really,” he says.
Acupuncture, a treatment that has been part of Chinese medicine for at least 2,500 years, is widely accepted as a tool to control chronic pain. Studies comparing acupuncture to placebo or no treatment show that it can also help improve sleep.
Wei Huang, an Emory rehabilitation physician who is trained in acupuncture, studied acupuncture and insomnia in patients with some of the most challenging cases—veterans with insomnia that had continued at least six months after a traumatic brain injury. Some had had persistent insomnia for years, and some also had been diagnosed with PTSD. Sleeping pills weren’t an option for these patients, says Huang. “All the medications for sleep can cause cognitive effects,” she says.
The study of 60 veterans, comparing real acupuncture to a sham needling procedure, found that acupuncture significantly improved sleep. “Even though they have PTSD, they can still benefit,” she says.
Acupuncture may work by synchronizing the autonomic nervous system, which controls the body’s vital functions and maintains well-being, Huang says. “In insomnia cases, acupuncture calms the excitatory pathway and stimulates the resting pathway,” she explains.
Kenen describes acupuncture to her patients in the language of Chinese medicine: It balances yin and yang, two interconnected forces in the body. Yin is darker, cooler, quieter, she says, while yang is light, awake, fiery. “Yin is about substance and form, and yang is about energy and warmth. You combine that together and you get life, you get this embodied form that is enlivened,” Kenen explains.
She also takes into account the five elements of Chinese medicine—wood, fire, earth, metal, and water—as they’re reflected in a client’s personality, emotions, and symptoms. She may feel a client’s pulse or even look at the tongue—its size, shape, and color provide her with clues about the body’s energy and health. From an in-depth introductory conversation, Kenen develops a plan for where to position the needles to impact the body’s energy flow. She may change the needle positions from one visit to another, or even during the same visit.
The placement of the thin needles usually just feels like a quick prick or pressure; if it feels uncomfortable, the acupuncturist may adjust the needles. Acupuncture rarely causes significant bleeding, but the acupuncturist should be aware if you are taking a blood thinner, are pregnant, or have a pacemaker. The needles will stay in place for about 10 to 15 minutes. For people with a fear of needles, an acupuncturist may use an alternate way to stimulate the acupuncture points.
Kenen’s goal is not just to resolve a complaint, such as insomnia, but to promote a holistic sense of wellness. “One of the things that people will often describe with acupuncture [is to say] ‘I feel more like myself,’” she says.
Sleep by the Numbers
- Black Americans are more sleep-deprived than white, Hispanic, or Asian Americans. About 44% get too few hours of sleep.
- Women are more likely than men to have trouble falling or staying asleep (59% vs. 49%).
- People in Forsyth County are the most rested in Georgia. About two-thirds of adults (69%) get the recommended seven or more hours of sleep.
- Most people who say their sleep is “excellent” go to bed at the same time every night.
- One in seven U.S. adults reports chronic insomnia, or trouble falling asleep most days or every day of the past month.
- Young adults are more likely than older adults to say they don’t sleep well, but older adults have more trouble staying asleep.
- Clayton and Rockdale are metro Atlanta’s most sleepless counties. Forty-four percent of adults get less than seven hours of sleep.
Where to find help
How to find a sleep doctor
Sleep doctors get their initial training in another field, such as internal medicine, otolaryngology (ear, nose, and throat medicine), or neurology, and then complete a fellowship in sleep medicine. They can receive certification in sleep medicine as a subspecialty of their main field of medicine. The American Academy of Sleep Medicine certifies sleep centers and clinics.
Is sleep medicine covered by insurance?
Sleep disorders are generally covered as a medical condition, but treatment may require preauthorization or referral from a primary care provider.
How to find a CBT-I therapist
A directory of CBT-I providers is available from the University of Pennsylvania’s Perelman School of Medicine. Therapists may be certified by the Board of Behavioral Sleep Medicine or the American Board of Sleep Medicine. (Some therapists may have training in CBT-I but not certification.) The Society of Behavioral Sleep Medicine has a state-by-state list of its members. CBT-I therapists from other states may be able to offer telehealth in Georgia, and sleep centers have CBT-I therapists on staff or by referral. You can also try CBT-i Coach, a free app that provides a sleep diary, tips, and tools for better sleep. It was created for veterans with PTSD but works for anyone. Download from the Apple or Android app store.
Is CBT-I covered by insurance?
State and federal laws require parity between mental and physical health, so CBT-I, which is a form of psychotherapy, is typically covered. However, there’s a shortage of CBT-I providers, and many don’t participate in insurance networks. Check with your insurance company to determine your coverage, whether it has CBT-I providers in its network, and if it provides reimbursement for out-of-network providers.
How to find an acupuncturist
The state of Georgia licenses acupuncturists and provides an online searchable database (look for “acupuncturist” under “license type”). The National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM) also provides a directory of certified practitioners.
Is acupuncture covered by insurance?
Acupuncture is not routinely covered, and insurance plans that do provide coverage may have some restrictions. Contact your insurance company for details of your plan. Expect to pay about $70 to $125 per session out of pocket, with a higher charge for the initial evaluation. Judith Kenen, an acupuncturist in Decatur, usually advises clients to have weekly treatments for about three or four weeks before deciding whether it is helping.
More stories from this issue
This article appears in our January 2024 issue.