The longest nights of the year fall this weekend, and they will be long indeed for those of us who do not sleep well. Kim Dungey looks at what it can take to get a good night's rest.
Malcolm Macleod almost wrecked his car, his business and his marriage.
For both Dunedin men, sleeping problems have had a major impact on their lives.
And for every person like them with a diagnosed sleep disorder, there are many more battling insomnia.
More than just a nuisance, poor sleep is increasingly being linked to medical issues such as diabetes, depression, high blood pressure and cardiovascular problems, and to driver and workplace errors.
Last month, New South Wales researchers announced sleep apnoea suffers who snore may be severely impairing their brain function as a result of a lack of oxygen reaching the brain during extended pauses in breathing.
In the United States, a third of adults are reportedly losing sleep over the state of the economy and personal finances, while longer workdays are causing many to feel sleepy at work, drive drowsy and lose interest in sex.
In New Zealand, a 2001 study showed chronic sleep problems to be a major health issue affecting up to a quarter of adults.
Experts claim tiredness is the "smoking gun of the modern age".
And the problem may get worse, with increasing obesity linked to the rising prevalence of obstructive sleep disorders and our 24/7, activity-driven society said to be contributing to insomnia.
Malcolm Macleod, who has obstructive sleep apnoea, and John Graham, who has narcolepsy, are both veterans of the recently-enlarged sleep laboratory at Dunedin Hospital where staff measure patients' brain waves and breathing.
Those sleep tests showed Mr Macleod stopped breathing 138 times in an hour and for up to two minutes at a time.
His oxygen saturation level was just 58%.
The tissues in Mr Macleod's throat repeatedly blocked his airway when he was sleeping, preventing the normal flow of air to his lungs.
His brain sensed this and would briefly interrupt his sleep to allow him to resume breathing.
It was a condition that could have had disastrous consequences.
One day when driving home from work appointments in Wanaka, he felt himself getting tired.
The next thing he knew there was a pole in front of him.
The former rally driver managed to spin his car around and miss the pole but the vehicle careered 54m back in the direction it had come and 16m up a bank before stopping.
"The next thing there was a knock on the window and a woman standing there, asking me what happened," he recalls.
"She said, `God, you could have killed us'.
Then I looked over and saw three kids, all in the back seat of her station wagon in baby seats."
Mr Macleod told the distraught woman he had been mucking around with the car stereo: "I knew damned well I'd gone to sleep but didn't want to admit it".
Asphalt had been ripped from the road.
The four brand-new tyres on his car were down to canvas.
And it wasn't the first time he had fallen asleep at the wheel.
On another occasion he was driving his family home from holiday when the car crossed the centre line and wife Anne had to grab the steering wheel.
Incredibly, the incidents did not faze him.
Mr Macleod says like many people with a sleeping disorder, he was in denial.
Getting up seven or eight times a night meant he was constantly lethargic, having headaches and feeling as if he was hung over.
"You're not thinking, not in control. You're doing things on autopilot."
Vitamin B injections helped but only for a couple of weeks at a time.
The broken sleep affected his memory and concentration so badly his agency dealing in hardware was close to collapse.
When friends went to his house for dinner, he would sometimes fall asleep and only wake after they had gone.
For five years, his love life was extremely strained.
Anne Macleod suffered sleep deprivation, staying awake in order to shake her husband when he stopped breathing, and once had to intervene when he was having an altercation with their son about who would unload a trailer.
"I had him around the neck, off the ground, and was going to lay into him. It was something that became concerning because it was out of character. Mentally I was so tired, I wasn't able to cope."
Then, a couple of months after his car crash, he was on an aeroplane when he picked up a magazine left in the pocket in front of him.
"There was a little piece in it, no more than 150 words, about a guy who had been diagnosed with sleep apnoea . . ." he says.
"Some of the symptoms it talked about were me to a T."
Mr Macleod went to his GP and asked if it was possible he had the disorder.
"I ended up getting into the sleep clinic at Dunedin Hospital within two weeks and being diagnosed as one of the most severe cases they'd had," he says.
"It immediately changed my life."
Doctors sent him home with a CPAP machine that blew a stream of air through a face mask and kept his airway open when he slept.
The next morning, he woke so refreshed his family thought he'd been on "happy pills".
Fourteen years later, Mr Macleod is vice-president of the Sleep Apnoea Association of New Zealand, still uses the pump nightly and owns Sleep Apnoea Services, a company that supplies similar equipment to more than 1300 patients in Otago and Southland.
His ongoing health problems include arthritis, gout and kidney stones, but the 55-year-old is convinced that if sleep apnoea had not been detected, he would have had a heart attack or a major stroke.
"If I hadn't been diagnosed, I wouldn't be here to talk to you."
Adequate sleep should be seen not as a luxury but as a necessity, GP Karen Falloon says .
A researcher in the Auckland University department of general practice and primary health care, Dr Falloon says part of the problem with insomnia is our 24-hour society.
"We don't expect infants to sleep well when they have erratic routines, yet we somehow assume we will sleep well as a `default' condition.
"We haven't viewed sleep as this thing we put a priority on . . . We're perceived as not as hard-working [as others] if we don't burn the candle as much as everyone else. And I predict it will become more and more of a problem."
This view that sleep is a luxury means that many people think a lack of it is just "unlucky", rather than a medical condition which often has well-prescribed management options, she adds.
A recent study in which she was involved showed 40% of people approached in Auckland GP waiting rooms had a chronic difficulty sleeping and of those, up to 10% might have primary insomnia (primary insomnia was defined as having daytime consequences but no apparent cause).
Dr Falloon says many of the patients did not tell their doctors about their sleeping problem because they thought it was not important enough, thought nothing could be done, or worried about being put on medication.
GPs do prescribe sleeping tablets but usually only in the short term so patients don't become tolerant to the effects or form a dependence on them, she says.
Many herbal remedies are scientifically unproven, while alcohol and sedating antihistamines may help people "drop off" but the sleep will be of poor quality.
Overseas, the treatment of choice for primary insomnia has been cognitive-behavioural therapy, a package of behavioural treatments usually administered by a psychologist, but here there is a shortage of people trained in the techniques.
Doctors do urge people to look at their sleep schedules and practices - things like making sure the bedroom is cool and dark, and avoiding caffeine and exercise before bed.
People can inadvertently contribute to the problem by changing their usual sleep schedule - taking naps during the day or trying to catch up on sleep at weekends, Dr Falloon says.
Others become frustrated when they don't get eight hours sleep, not realising that some people function perfectly well on less.
Once they are sleeping poorly, many people give themselves extra opportunity to sleep, she explains.
They go to bed when they are not sleepy and spend more time awake, worrying.
The next day they get more and more anxious as night-time approaches: "It's a vicious cycle".
Fiona Johnston, an occupational therapist with an interest in sleep issues and rosters, says people who sleep fewer than five hours in a 24-hour period are usually considered unsafe.
But many shiftworkers manage on that much as a matter of course and have accrued a "huge sleep deprivation" by the end of the week.
Sleep-deprived people, like those who have been drinking alcohol, will have slow reaction times and difficulty concentrating and processing information, she adds.
This is a particular concern for people in high risk occupations such as manufacturing, aviation and driving.
The Ministry of Transport reports that driver fatigue was a factor in 127, or 12%, of fatal crashes from 2005 to 2007.
And fatigue has contributed to many other serious accidents, including the Exxon Valdez tanker crash, the Chernobyl nuclear reactor disaster and the Challenger shuttle tragedy.
When John Graham tells people he can nod off any time, many of them are envious.
But the 50-year-old Dunedin man says it is not as good as it sounds.
People with narcolepsy can suddenly fall asleep while they are talking, working or driving a car.
Other symptoms can include a feeling of paralysis on falling asleep or waking, and sudden muscle weakness triggered by stress or excitement.
Mr Graham says he is lucky to have only a mild form of the disorder - he sleeps about four hours a night, nods off only when he is sitting down and has no problem driving: "I don't just have an attack. I can feel it coming."
But the rare condition still has a significant effect on his life.
Two years ago, he and his employees were at his Hyde crib when it burnt to the ground.
Mr Graham says he sleeps so soundly that if it were not for one of his workers waking him, he would have been a "goner".
"The smoke alarm was going off and the fire was roaring and cracking and I didn't hear a thing."
An apiarist with his own landscaping business, he traces his problems back to the chemicals he sprayed on gorse in his teens.
Each time he used them, his glands swelled and he would struggle to stay awake on breaks.
Wife Ulli found it frustrating to see him dozing on the sofa instead of helping out with the children when they were small.
And the youngsters were offended when they saw him sleeping during their school play, he says, smiling.
"I had to say I'd closed my eyes to soak in the atmosphere."
The problem became progressively worse but his GP told him he was simply working too hard and getting run down.
Then one day his regular doctor was away and he saw another who had just been to a seminar on sleep disorders: "She said, `I think I know what you've got'. And it changed my life."
Tests showed Mr Graham went into rapid eye movement sleep within two minutes, which may explain why whenever he sits down to watch the 6pm news on television, he misses it.
He has also nodded off in bars, at restaurants and while talking to people at parties.
"If it's a warm room and I sit down, I'm toast."
Although narcolepsy cannot be cured, it can be controlled with medication.
Mr Graham is on a "relatively strong" one which makes him feel better within minutes, but tries not to take the full dose because it also makes him irritable.
He believes many people have a mild form of narcolepsy without being aware of it and is willing to speak to anyone who identifies with his symptoms.
"If I can make one other person realise they've got it, it will be worthwhile, because it was so difficult doing it on my own and not knowing what was wrong."
Mr Graham suspects that despite the fact he worked 10- to 12-hour days, some people used to think he was "just lazy".
So getting a diagnosis and then medication was a relief.
"It's like not having a hangover every morning."
• A few tips for the sleepless
Napolean Bonaparte and Margaret Thatcher (who each survived on less than four hours sleep a night) are among many famous people who suffered insomnia - an inability to fall or stay asleep.
The others include actor W. C. Fields who, on his worst nights, could only fall asleep under a beach umbrella being sprinkled by a garden hose.
Comic actor Groucho Marx phoned people up in the middle of the night and insulted them.
Artist Vincent van Gogh rubbed camphor into his mattress and pillow, while US president Theodore Roosevelt took a shot of cognac in a glass of milk.
Other people who often experience sleep problems include shift workers, sleep-deprived new mums, night owls who can't fall asleep until early morning, sleep walkers and those with restless leg syndrome.
People with sleep apnoea stop breathing because their throat is blocked.
This can result in sleep disturbance and reduced oxygen delivery to vital organs.
When the person stops breathing, the body's defence mechanisms are alerted and stimulate the brain to wake the sleeper.
In severe cases, this can happen every few minutes.
Common symptoms include snoring, daytime sleepiness and weight gain.
The most common treatment for sleep apnoea is continuous positive airway pressure (CPAP), a machine consisting of a face mask with a generator that blows air through the nose and mouth to prevent collapse of the upper airway muscles.
Some health boards supply these but Otago people have to buy their own machines at an average cost of $1200 to $3500.
EXPERTS RECOMMEND THE FOLLOWING FOR A GOOD NIGHT'S SLEEP:
> Have a realistic expectation of your sleep needs.
> Try to have a relaxing bedtime routine. This could include a warm bath, meditation or listening to relaxing music. Avoid getting into an argument or an important family discussion just before bed.
> Go to bed and get up from bed at the same time each day.
> Try to spend part of the day in natural light as it helps the body to produce the sleep-promoting substance, melatonin.
> Make sure your bedroom is dark, cool and quiet and that your bed is comfortable.
> Avoid caffeine, alcohol and exercise just before bedtime.
> Use your bedroom only for sleep and sex. Remove computers, televisions and work material.
> Don't stay in bed if you are awake. If you don't fall asleep in about 20 minutes, get up and do something relaxing in another room. Go back to bed when you are tired.
> See your doctor if insomnia happens more than a few times a week and affects your days.
