This is the eighth of a nine-part print and online series looking at the science of sleep and the vital role of sleep in maintaining overall health.
Sleeplessness affects everyone differently. The ability to get treatment can also be vastly different.
"There are tremendous discrepancies in access to sleep care in Canada," said Doug Bradley, a respirologist specializing in sleep apnea and director of the sleep research laboratories at the Toronto Rehabilitation Institute and Toronto General Hospital.
"In Ontario, we are very well endowed with sleep laboratories and sleep physicians, because the government pays for the sleep studies and pays for the [procedure] to treat sleep apnea, for example."
But if you're in British Columbia, for instance, Dr. Bradley said, "you may wait anywhere from one to two years just to get a sleep study done, and another one to two years to get on treatment, because the government only funds very few sleep laboratories in British Columbia."
It's a concern heard throughout the field. "The message is not that Toronto has too much, it's that the rest of the country is woefully behind," said Brian Murray, a neurological sleep specialist at Sunnybrook Health Sciences Centre and the University of Toronto. "The numbers for Ontario are about right. The numbers across Canada? Way behind."
The Canadian Sleep Society, a national organization promoting sleep research and clinical care, lists nine, full-equipped Level 1 sleep laboratories in British Columbia, including just three in Greater Vancouver. (A Level 1 sleep clinic has full sleep measurement capabilities with a technologist in attendance. It does not include portable sleep monitoring and lesser diagnostic services.)
In the Maritimes, only three centres are listed, with two in Halifax and one in Saint John. On the other hand, Southern Ontario has 75, and Southern Quebec 35.
Part of this may have to do with medicine's general conservatism, say sleep specialists. Sleep medicine has grown rapidly in the past few decades. Yet sleep apnea, a relatively common disorder caused by the obstruction of breathing during sleep, was only formally discovered in 1965. And it was around that time that Ontario starting becoming a leader in sleep research, helping to spur the opening of clinics just in that region.
One of Canada's key research facilities, started by Harvey Moldofsky at what was then the Clarke Institute of Psychiatry, now Toronto's Centre for Addiction and Mental Health, opened in the mid-1970s. Another was the Sleep Medicine Centre at the University of Ottawa, led by neurologist Roger Broughton. In Montreal, Jacques Montplaisir was a major researcher at the Hôpital du Sacré-Coeur in restless leg syndrome, in which people have a compulsion to shake or move their leg and which can chronically interrupt sleep.
"As a consequence, a lot of people got into the field in the early 1980s, and the sleep laboratories proliferated here," Dr. Bradley said, adding "that sleep medicine in Canada started in the usual two places, Toronto and Montreal." Whereas in other corners of Canada, a similar boom in research-led sleep care didn't happen.
Demand for sleep medicine has greatly increased since then and there's a wide acceptance that sleep is directly linked to overall health. Yet diagnostic and treatment facilities remain few in most of Canada.
An important distinction to make, though, is the difference between sleep clinics and sleep laboratories. At a clinic, a doctor examines a patient and recommends, largely based on a patient's description of symptoms, a certain course of treatment. Some sleep clinics are general treatment facilities, accepting all patients with all kinds of sleep problems and referred from family doctors. Some clinics are more specialized, however, such as Dr. Bradley's clinic focused on sleep apnea. Most of those referrals will come from other specialists such as cardiologists who are dealing with a patient with related sleep issues.
At a sleep laboratory, though, a patient's sleep can be studied fully with a polysomnogram recording an assortment of vital signs, including heart rate, breathing, movement and sleep stages to determine abnormalities during sleep. This involves spending the night hooked up to 12 to 16 electrodes.
Most Canadian sleep centres focus on sleep apnea and are run by respirologists, said Sunnybrook's Dr. Murray. His centre concentrates instead on neurological issues such as parasomnia (or unusual sleep behaviour), which can indicate neurodegenerative disorders, and narcolepsy, which effects one in 2,000 people. (For a neurological condition, that's relatively common, Dr. Murray said.) Restless leg syndrome is also neurologically linked and carries cardiovascular risks affecting about 6 per cent of the population, he said.
Many conditions can be diagnosed easily without a sleep study, such as restless leg syndrome. "That being said, a sleep study is important and critical for the management of many conditions. People may be unaware of the problems they are experiencing," Dr. Murray said.
The reason is that a number of different conditions can occur at once, preventing sleep in a variety of ways. "Most patients have multiple contributors to their sleep scenario," Dr. Murray said. "You have to be holistic about the approach to the individual. You have to appreciate all aspects, the psychological and physiological components of the sleep problem."
There is a push to have more mobile sleep studies, such as activity monitors, which can screen for some easily diagnosable conditions. This could help patients across Canada get at least somewhat closer to diagnosis and treatment.
"If a person is very sleepy, they have a very impaired quality of life. And if we treat those people quickly, they can have a tremendous improvement in just 24 hours," said Dr. Bradley, the sleep apnea specialist.
"So when I say urgent, it may not be life threatening, but from their quality-of-life point of view, it can be a dramatic improvement if we get them treated quickly."