Podcast: Sleep’s Relationship to Mental Health
Jenn talks to Dr. John Winkelman. They talk about the importance of sleep for our mental health, how our sleep cycles impact our quality of life, as well as ways to treat sleep disorders and mental health conditions.
John Winkelman, MD, PhD, is a psychiatrist and chief of the Sleep Disorders Clinical Research Program at Massachusetts General Hospital.
Winkelman previously was medical director of the sleep program at McLean Hospital and subsequently medical director of the sleep laboratory at Brigham and Women’s Hospital. He has lectured in and directed national and international post-graduate medical education courses on sleep disorders.
Jenn: Hey everyone, welcome to Mindful Things.
The Mindful Things podcast is brought to you by the Deconstructing Stigma team at McLean Hospital. You can help us change attitudes about mental health by visiting deconstructingstigma.org. Now on to the show.
So, hey folks and welcome. I would like to introduce myself. I’m Jenn Kearney, and I am a digital communications manager for McLean Hospital. Wherever you’re joining us from today, whatever time you’re joining us today, I hope you’re having a great day.
So, today’s discussion is all about sleep and its relationship to our mental health. And as it turns out, there’s actually a science to getting quality sleep and there’s even more science behind how our health impacts our sleep and vice versa. And even though many of us are sleep deprived, myself included.
Those of us with mental health conditions are more likely to feel the impact of less sleep. In some research I was doing before the session, I discovered that about sleep problems tend to affect just about 80% of patients in psychiatric practices. So, the impact is there.
Over about the next hour-ish, maybe a little less, I will be talking with Dr. John Winkelman about the relationship between sleep disorders and our brains. We’ll take some time to talk about the importance of sleep cycles for our mental health and functioning, chat about how we can treat sleep disorders and mental health conditions and talk about ways to improve our quality of life through getting a good night’s sleep. So, I’m super excited to introduce John to all of you.
So, John Winkelman, MD, PhD, is a psychiatrist and the chief of the Sleep Disorders Clinical Research Program at Massachusetts General Hospital. He’s also currently a professor of psychiatry at Harvard Medical School and his research has primarily focused in two areas. Number one, epidemiology, physiology, cardiovascular consequences, and treatment of restless leg syndrome and two, the neurobiology and the treatment of insomnia.
So, John, hello, I’m super excited for you to be here today and thank you for joining. I did have a few questions that I wanted to get started with. So, let’s dive in. First and foremost, can you provide some insight into the short and long-term importance of getting a quality night’s sleep?
John: Sure, of course, Jenn. Obviously the, probably the essential or key question and it gets to maybe even a more fundamental question, which is what is the function of sleep? What does it do? And I have to say that after 30 years in the sleep field, I’m embarrassed to still say, I don’t know. Sleep clearly has many functions.
We’re not exactly sure how they work, how sleep interacts with these functions, but it serves metabolic purposes for the body. It clearly serves functions of memory consolidation, it is involved in learning and recent data suggests that during sleep, we are most able to clear toxins from the brain.
So, if we think about the reduction like Jenn had last night and seems to have on a regular basis of sleep, not getting enough sleep, they’re going to be a variety of negative consequences in each of those areas.
In terms of those people with psychiatric illness, it generally is destabilizing, so that it makes it harder to manage mood, anxiety, and psychotic disorders and potentially substance use disorders as well. In the short term, people will find that if they don’t sleep enough, they’re going to be sleepy, they’re going to probably be more irritable, have difficulty concentrating.
In the long term, there’s probably an association, as I said, with metabolism, so harder to control blood sugar, harder to control weight, more difficulty with memory consolidation, learning new things. And there’s a variety of evidence suggesting that chronic sleep problems increase the risk for mood disorders like, bless you, like depression.
And we’ll probably have an opportunity to talk about this bidirectional relationship between sleep and psychiatric illness. Sleep problems can cause or increase the risk for psychiatric illness. And the reverse is true, psychiatric illness can increase the risk of sleep problems. So, it’s kind of a chicken and egg phenomenon.
And so, I generally try to treat both, rather than choosing, oh, which one should I choose? Which one should I treat? The depression or the sleep, I generally would say treat both. So, at that I’m going to stop and let Jenn and others ask other questions.
Jenn: So, I didn’t realize my camera’s still on. So, I sneezed for people who were confused as to why John said, “bless you,” but thank you. So, I’m curious about how common sleep disorders co-occur alongside mental health conditions? And which ones are most commonly occurring together, or does it tend to vary by person, age? What factors are there?
John: Yeah, well, the most common sleep disorder is insomnia. So, 10 to 15% of the general population will have chronic insomnia, meaning at least three times a week for at least three months. That’s what chronic insomnia disorder is.
And as I said, the most common sleep problem, it is much more common in those people with psychiatric illness, then the general population and, in particular, anxiety and mood disorders, but psychotic disorders as well, some of the substance use disorders in addition.
The second most common sleep disorder is obstructive sleep apnea which is a disorder in which the upper airway collapses during sleep and our bodies have to choose whether to breathe or sleep. And so, you wake up very briefly, a few seconds, take a few breaths, go back to sleep.
And this is more common in people with psychiatric illness as well, when I ran the sleep disorders lab and clinic at McLean, which was from 1991 to 1996. When I was just a young man, I did a lot of consultations to people on the psychotic disorders unit, and recognized that there was a lot of sleep apnea in this population of individuals.
And some of that was probably related to the weight gain that is produced by some psychiatric medications, but it also may be influenced by those medicines themselves. So that’s an important relationship that we should think about.
Next, I’m going to think about circadian rhythm disorders, in which there’s really not a problem with sleep per se, but rather it’s the timing of sleep. When does it happen? So, there are people who have a delayed sleep phase, they can’t go to sleep till really late, then they can’t wake up until late in the morning.
And then there are people with advanced sleep phase, they may fall asleep super early and then wake up kind of what some other people might call the middle of the night. And those sleep disorders, those circadian rhythm disorders also can be associated with various psychiatric illnesses.
Finally, I’ll just mention restless leg syndrome, which is a disorder in which people’s legs feel very uncomfortable, tingly, creepy-crawly at night and they have to move them to get them to feel comfortable. And that is also probably a risk for psychiatric illness, as well as having psychiatric illness cause it. And some of the medications, particularly the serotonergic reuptake inhibitors, SSRIs, can produce restless leg syndrome.
Jenn: So, we had someone write and I know that you were talking about circadian rhythms and just like when you can be asleep. Someone wrote in saying “I never seem to be able to sleep more than four hours at a time without waking up. Is this common? And do you have any suggestions for staying asleep for longer periods of time?”
John: Sure, so that’s a classic insomnia complaint or description where people have problems maintaining sleep. Now, to some extent, this could be normal depending upon age, as people get older, it becomes more and more difficult to maintain sleep throughout the night.
The secret that I’ll tell you is that and I know this from looking at thousands and thousands of sleep studies is that we all wake up many times, not only per night, but many times per hour, it’s normal to have five to 10 three to five second awakenings per hour of sleep.
That’s totally normal. Sleep is not a static state. It’s not like turning off the lights and eight hours later you come and turn back on the light. There’s a lot going on during sleep and that involves fluctuations from sleep to wake.
But it’s clear that these awakenings are long enough for you to remember them. And it sounds like it’s bothersome to you. And there are many ways that we can address insomnia. When I see patients with insomnia, I spend a full one hour just trying to understand what’s going on.
So, for me to kind of come up and say, I can see through my computer screen here that the cause of your problem is X and that the treatment is Y. That would really be misleading.
But I can tell you that the most common causes of insomnia are mood and anxiety disorders or other psychiatric illness, medications, pain, things that cause shortness of breath, difficulties needing to pee overnight.
And then any neurological disorder is going to interfere with sleep as well, because the brain makes sleep. And so, what we generally try to do is treat underlying causes of insomnia, if they’re present, if we can identify them.
If we can’t identify any co-occurring psychiatric or medical reasons, then the two main approaches are either cognitive behavioral therapy for insomnia, CBT-I and this is different than CBT for mood or anxiety disorders, it’s CBT for insomnia. And if that doesn’t work, because CBT-I is first-line treatment, if that doesn’t work, then we will use medications.
So that’s kind of a general overview of how we treat insomnia. One, we try to identify underlying medical and psychiatric causes. And if those are present, we address them. If we can’t find what we would call comorbid or concurrent problems, then we will turn to CBT-I. And if that doesn’t work, then we would use medications.
Jenn: So, thanks to the internet, there’s a ton of varying advice out there. And I would love some clarification on this. If we’re having trouble falling asleep, should we stay in bed or should we get up and do something?
John: Yes, well, the psychologists would call this stimulus control, which is a fancy way of saying that over time, people with insomnia start to associate the bed and even their bedroom with anxiety about being awake. And so then if you didn’t have that anxiety, then you’d wake up and you might be able to go right back to sleep in a minute or two.
But if you have that conditioned anxiety, if it’s happened many, many, many, many times and you start associating the bed with, “Oh my God, I’m awake again,” “How long am I going to be awake?” “I don’t want to have another night like last night, that was terrible” or “I was up for an hour and I got a big day tomorrow. And I’m going to mess up in my interview with Jenn and it’s going to be so embarrassing.”
And all these thoughts start to develop in your head. And all that anxiety, whether it’s physical anxiety, mental anxiety, starts to be associated with the bed and the bedroom. So, stimulus control means that you get away from that conditioned stimulus, the stimulus being the bed, because now the bed after years of insomnia or even weeks of insomnia, you start being anxious just being in bed awake.
And so, some people will say “you have to get out of bed, go to another room and read.” I’m not so strict about that myself in my own practice with patients. I think what produces the anxiety for many people is not necessarily the bed or the bedroom, but it’s the trying to fall asleep.
And the kind of quiet that’s in your head when you’re trying to fall asleep or hopefully it’s quiet. In fact, what rushes into that quiet is all the nervy things that are going through your head. And so, I can say to people, you don’t necessarily have to get out of bed, but I want you to try to stop falling, don’t try to fall back asleep immediately. If your mind is going, you know, like a gerbil on a wheel.
Once your mind starts going like this, you have to say time out, let’s take a break, stop trying to fall asleep so hard and let’s get a little book out or do a Sudoku, something that I call R and D, relaxation and distraction. And this is the opposite of the anxiety gerbil kind of thing.
And whatever that might be for you. For some people, it might be a podcast, for some people, it could be the sound of waves, even for some people it could be television, because many people associate TV with falling asleep.
And so that is what helps them fall back asleep. So, we try to identify what it is that they associate with falling back asleep or falling asleep, maybe at the beginning of the night and then reintroduce that in the middle of the night.
And then over time, hopefully we break this association that people have developed of the bed and insomnia or the bed and anxiety about insomnia. I call this insomnia phobia, because that’s really what happens over time is people develop insomnia phobia.
And it’s not the pain that they had in their hip that kept them awake, you know, before that’s now keeping them awake right now over time, what happens is this insomnia phobia develops and then that’s what’s keeping them awake. So, we want to break that association.
Jenn: So that actually segues really nicely into my next question, because it sounds like these are some components of CBT-I, maybe that’s part of the treatment. But can you provide a little more insight into how CBT-I differs from traditional CBT?
John: Yes, of course, they have the same letters CBT, but in many respects they’re quite different. And it’s really important if you’re going to do a CBT-I treatment with somebody that you make sure that they know that this is not regular CBT, that they’ve been trained in CBT-I, because the components are different.
It’s a multi-component, I call it really an educational program or also could be considered therapy as well. The first component and this may be the most important one is restriction of time in bed.
So, most people with insomnia, as their insomnia develops, they spend more and more and more time in bed. So, to get eight hours of sleep, they used to spend eight hours and 15 minutes in bed, because it took them 15 minutes to fall asleep and then they’d sleep through the night.
Over time as they were having problems falling asleep or returning to sleep, they realized that they couldn’t get the eight hours just in the eight hours and 15 minutes in bed. So, they start spending more, “I’m going to go to bed an hour earlier, because I know it’s going to take me an hour to fall asleep.
And then I’m going to sleep an hour later in the morning, because I was up in the middle of the night for an hour.” So now they’re spending 10 hours in bed to try to get eight hours of sleep. And unless you’re kind of a teenager or a very young adult, there’s no way you can get 10 hours of sleep.
So now you’ve baked into the night two hours awake, because you can’t get 10 hours of sleep. All their body can make is eight hours of sleep. So now that is established that they are going to be awake two hours in the middle of the night.
So, this time in bed restriction or sleep restriction therapy, returns bedtime and wake time so that they’re eight hours apart. Now, what happens over the first couple of weeks is people get sleep deprived, take somebody with insomnia and now they’re sleep deprived, because they’ve still taken time to fall asleep and they’re still awake in the middle of the night.
But after the first couple of weeks, now they become increasingly tired during the day. And therefore, it’s easier to fall asleep and easier to fall back asleep in the middle of the night. So, the 10 hours’ time in bed now is only eight hours’ time in bed. And now you find that they’re getting most of that time now asleep. So, this is the core feature.
And for most people it’s not eight hours, they say “I’m only getting six hours.” So, I really limit people’s time in bed, oftentimes to about six hours between the time they put their head on the pillow and close their eyes to the time the alarm goes off. And at the beginning, it’s really hard. This is a no pain, no gain approach. And they wake-up cursing the name Winkelman.
When the alarm goes off, they say, “I just got back to sleep an hour ago, now the alarm is going off and Dr. Winkelman is making me get up” I say, yep, just hang in there, over the first few weeks you’re going to find it’s a lot easier to fall asleep, stay asleep, go back to sleep and then we’ll gradually increase it. So that’s sleep restriction.
Next component is the stimulus control that we talked about. If you’re not falling back to sleep and the gerbil wheel is going in your head, take a time out, do the R and D, relaxation and distraction till sleep wants to come back, which it does, it’s a strong drive, just you can’t get in the way of it with your anxiety. So, you have to be thinking other things rather than the worries about sleeplessness.
The third component is relaxation therapies, whether it be a progressive muscle relaxation, the physical part of it or the mind relaxation, whether it be mindfulness or meditation, listening, you know, counting, breaths, that kind of stuff.
And the fourth component is sleep hygiene. And this is the stuff that we all, you know, kind of know, but don’t necessarily follow, no caffeine after noon, no alcohol in the evening, exercise in the morning, but probably not exercise at night, quiet, dark room and very importantly, same bedtime. And even more importantly, same wake time, seven days a week.
Weekends are a social invention. There’s no reason why our bodies should have a different timing two days a week, just because you don’t have to go to work, than the other five days a week.
So, there are many people that would have what’s called social jet lag. On weekends, they go to bed later and they sleep later by two or three hours. And this is really not a good plan for sleep and it really does mess up sleep.
So, bedtime and wake time should be really pretty much the same seven days a week. Most importantly is wake time, because that’s when we get light and light is what sets our internal clock.
Jenn: So I know over the last year or so at this point we’ve had a lot of people having a really hard time sleeping, because of current events, but one group of people that’s been having a hard time, even outside of the pandemic has been teens.
So, is there any correlation with screen time impacting teen and preteen quality of sleep? Or are there other factors at play around kids in that age range, developing sleep issues?
John: Yeah, it’s clearly a time of a lot of change, a lot of stress, a lot of distress these teen years. And the last year has even been more so, because so many of their usual rhythms have been broken up. Now for some people, there’s been a kind of a relaxation of it, because there’s much less FOMO, people aren’t missing out, there’s nothing to miss out on.
So, for teens, they’re less anxious about, what they’re missing out on but for many people, they just feel stuck. And there’s very high rates of severe psychological distress among teens. And this has been documented in a number of ways and the least stress are among people over the age of 55.
And I mentioned this to my son, who’s in his early twenties. And I said, do you see, you know, look at this data, teens, very high levels of distress, people over the age of 55 with the lowest levels of anybody, any subgroup.
And he said, “of course,” he said, you know, “it doesn’t matter if there’s really not much you can do, because you didn’t have a life before this. And so, it doesn’t matter if you can’t do anything.”
Whereas, you know, he was saying “I had a life.” So, I think that there’s a lot of stress, a lot of distress. In particular, I think screens can be a significant issue for a few reasons. One, I think this is most important. They’re associated with psychological activation. What we’re watching on screens is generally not very chill, it’s more stimulating.
So, you know, it’s a movie, and movies may not be so quiet, it’s the news and the news is oftentimes not good or they’re on Facebook or Instagram and they’re looking what other people are doing and there’s anxiety associated with that. So, there’s that psychological distress about what the content is.
Then the other part of it is that the screen itself produces wavelengths of light that may be stimulating. In particular, it is thought that blue wavelengths are more activating whereas the red ones are not activating.
Many people’s laptops at this point have, can’t remember what it’s called, night phase or something like that. Or if you’re laptop or whatever device you’re using doesn’t, there’s a nice website called f.lux, which changes the wavelength of light in the evening so that there’s less blue light.
People can also get blue light blocking glasses, if they want, I think that that really may not be necessary, but it certainly produces a good look, if that’s what you’re into. Although you’re usually in bed at the time, so probably no one’s seeing you.
But if you can just block that from the screen, your phone or your iPad or whatever device you’re using, f.lux is quite helpful. So, I think both the content of what’s coming from the screen as well as potentially the light that’s coming from the screen can be stimulating and interfere with sleep.
The key, as I said before, I think more important than light at night is making sure you get bright light at the same time every day. And I encourage young people to put their shades up.
So when the light comes up in the morning, you are getting light, you’re going to be the early bird who’s getting light in the morning, who’s suprachiasmatic nucleus in the hypothalamus is getting this signal from the eye, even with your closed eyelids that it is light outside and it is now time to wake up.
And after you do wake up, then you get this light and it fixes, it sets our clock. This is morning. So that allows you 16 hours later to say, “okay, now it’s time to sleep.” But you have to have that time zero and that time zero is when you get light.
Jenn: So, I did want to ask, because I know that you said that screens are not great for before sleep. Do you know of any apps that would be helpful to helping people fall asleep?
John: You know, I don’t, I probably should. Maybe I’m a little behind in apps. There’s a lot of different apps that are available that provide all kinds of different sounds or stories that you can... Somebody just told me about one and I’ve already forgotten the name of it.
It depends what you’re going to find most useful, whether it’s sounds like the rain or waves, whether it’s soft music, whether it’s somebody reading you a story.
There are all of these apps, most them free that you can find on the internet or download from the Apple Store. And they should turn off after a certain amount of time, because you don’t want them jabbering all night long while you’re sleeping. You really just want it to go for 20 or 30 minutes and then automatically turn off.
Jenn: How accurate, ‘cause I know so many people wear smartwatches to bed, I mean, I do, I keep my garment on all the time. How accurate are the sleep trackers that are in our watches versus any other devices that you might use in like a sleep lab?
John: Well, I’m not going to diss the sleep lab, because I read sleep studies for 30 years, they’re beautiful, I love reading sleep studies. But they’re inadequate in a number of respects in that you’re not at home. And so, you’re being asked to sleep in this foreign environment, which is difficult, but particularly for people with insomnia.
And further, it’s only one night, whereas these devices are tracking sleep in your home environment, number one and number two, it’s multiple, multiple nights. So, you get a much better picture of what’s going on, it’s like a video versus just a still shot.
That being said, most of these devices are making inferences, or conclusions about sleep from movement, really from nothing else. If you’re moving, you’re awake. If you’re still for long enough, then it’s sleep. And this is not always true, particularly for people with insomnia, because many people with insomnia have learned to just kind of lie there and be awake quietly.
And the equipment is going to think that, you know, your wrist device is going to think you’re asleep. Similarly, for people who move a fair amount during their sleep, but are still sleeping, the wrist device is going to say that they’re awake.
So, I think that they are probably better than nothing. Some of them are including more information than just movement, they may be incorporating heart rate. Some of them that you wear here, may be incorporating information either about eye movements or about EEG. And so, they’re going to be much better. But we do need to be careful about conclusions that we make from them.
I’ll just tell you very briefly about a study that was done in England in the last year or two, it was a really cool study and it tells you something about sleep. They took 30 people with insomnia and gave them all devices like yours Jenn, to wear at home.
And however, they programmed these devices, so that half the people with insomnia would have information in the morning that they slept poorly. And the other half of the people would get information that they slept really well.
And then they asked the people after a couple of weeks, actually they were asking them every day in the morning as well as throughout the day, not only how did you sleep, how do you feel you slept, but how irritable are you? What’s your concentration level like? How much energy do you have?
And remarkably, even though there was no actual difference between the fake watch information and the real watch information, how they actually slept. The people who thought that they had slept poorly said that they were more irritable, had worse concentration, had low energy.
And the people who’ve been told that they slept well said, “I’ve felt much more energetic and much better mood.” So, it’s complicated, isn’t it? So, there’s the effects of sleep and then there’s our conclusions. That then carry on and influence, how we feel during the day about how we slept.
And this is why for people with insomnia, it’s really important as part of CBT-I to actually improve sleep, but also to counteract some of the inappropriate beliefs that people have about sleeplessness, because this is really what gets people, is these inappropriate beliefs. If I don’t sleep seven hours straight, I won’t be able to function.
And so, I’ll say to people, how many times in your life have you, you know, in the last year, let’s say, have you awakened two or three times during the night? And they said, “well, 90% of the time.” And I said, how did you do at work the next day? Or with your loved ones? They said, “well, you know, I basically did fine.”
And so, where do you then you get this idea, particularly these ideas take hold in the middle of night that you’re going to be a total mess? And so, you need to kind of break these beliefs about sleep and how you feel during the day. And you know, at the very beginning Jenn asked me “well, what are the effects of sleeplessness?”
And I don’t like to exaggerate them, because some of those effects are real, but the other part of the effects are our expectations of how we’re going to feel after a bad night’s sleep. And so, you really have to break those expectations that are unrealistic.
And sometimes they’re catastrophic, people have all kinds of really exaggerated ideas about what’s going to happen the next day if they don’t sleep. And mostly those ideas are in our head in the middle of the night.
We don’t think very clearly in the middle of the night, I mean, everybody’s gone through this, the next day you think, “oh my God, why was I thinking those things in the middle of the night, they were way off base.
I was really super preoccupied and worried about X, Y, or Z. And now I realize it’s not that such a thing.” We’re just not able to think clearly in the middle of the night. And it’s important you realize that and this is one of the things that CBT helps with.
Jenn: So, do you have any recommendations for how to find a CBT-I specialist?
John: Even though I said this is first-line treatment for chronic insomnia, you’d think there’d be tons and tons and tons of CBT-I therapists and especially in the great mecca of medicine in Boston. But unfortunately, they’re not, there’s really just a handful. What I would recommend doing is there’s a organization called Behavioral Sleep Medicine Society for Behavioral Sleep Medicine, something like that.
And they have a website and they have a list of people who provide cognitive behavioral therapy for insomnia, CBT-I. And I would go from that list of people who are established providers, because remember, there are people that do CBT-I for anxiety and mood, who think it’s the same thing for insomnia and it’s not. So, I would go to the Behavioral Sleep Medicine list.
There are also now, people should be aware digital CBT online providers. And these are programs that some of them are free, most of them are not free that you can sign up for, they’re not personalized. They are basically algorithms, but it’s kind of like reading a book that’s somewhat interactive.
And you put in some of your information and it may then give you relatively generic feedback on maybe you want to, I see that you’re spending this much time in bed. One, you try cutting down, changing your bedtime and wake time, but it’s basically an algorithm, it’s kind of a bot that’s responding to you, not a person. But the evidence for digital CBT-I for people who engage with it and complete the programs is quite good for treating insomnia.
So it’s a very reasonable place to start is try digital CBT-I, if for some reason it doesn’t work and you feel like you need more individualized feedback, then you may want to go to an individualized, then go to the list of psychologists who provide CBT-I in a clinical setting. These days it’s virtual, but usually it’s face to face. But digital CBT-I has really, I think the wave of the future as the first line approach to chronic insomnia.
Jenn: So how do we know if we need to look for a sleep specialist?
John: I think anybody who has insomnia that is not responded to CBT-I should probably see a sleep specialist for a medical evaluation. Anybody who has excessive, daytime sleepiness, a difficulty staying awake during the day, even though you’re getting adequate, let’s say, seven to eight hours of sleep at night should see a sleep specialist in a medical setting, making sure there’s no sleep apnea making sure that medications are not interfering with sleep or producing excessive sleepiness.
Anyone who has excessive movements during sleep. So, this could be restless leg syndrome, it could be a specific sleep disorder. It’s called REM sleep behavior disorder, where people act out their dreams. So, you’re dreaming, but you’re not paralyzed. So, your moving around a lot, should seek out a sleep medicine evaluation.
Anybody with suspicion of sleep apnea, loud snoring, witnessed a bed partner who says that they hear you stop breathing or people who report shortness of breath awaking and short of breath during the night, there’s strong suspicion of sleep apnea.
Particularly if you have hypertension or you have the physical features that are consistent with sleep apnea, which would mean overweight or obesity, a collar size in men that is, now I’m blanking on the inches. That is more than, you know what, I’m going to leave that aside, because I’m blanking on the exact number there, but we have a large neck or as I said, overweight. So again, sleep apnea risk.
I’d say those would be the main things. And then finally, anybody who has new-onset of sleep walking as an adult, should probably get sleep medicine evaluation. Many kids sleep walk, usually that resolves by the age of 10 or so, if it doesn’t resolve and continues and is problematic, probably a good idea to get evaluation or if it just appears for the first time at the age of 30, 40, 50, 60, that probably suggests an evaluation too.
Jenn: Do you have any good sleep resources that providers can share with their clients? I know several folks have written saying that many of their clients who are struggling with sleep for a variety of reasons.
John: The American Academy of Sleep Medicine, AASM has a number of provider resources and patient resources, both online as well as hard copies that can be distributed. I would say that that’s probably going to be the best resource is through the American Academy, AASM, American Academy of Sleep Medicine. I think that would be really the place to start.
There are sites, so Harvard has a healthy sleep site that those of us in the Division of Sleep Medicine at Harvard Medical School put together, Mayo Clinic has some offerings as well. If people subscribe to UpToDate, which is a resource usually for physicians, there’s good physician related materials there, there’s quite a bit that is available online.
Jenn: I know if you’re a woman and you have the inevitable menopause period, there’s a lot of women writing in saying that they encounter sleep issues during menopause. Can you explain if there’s any correlation between irregular sleep and menopause and what you would recommend to aid poor sleeping during this transitionary period?
John: Sure, this is become quite common over the last 15 or 20 years as women less and less are going onto hormone replacement therapy. And so, the withdrawal of estrogen during the menopausal transition is certainly associated with an increased prevalence of insomnia.
And we don’t really understand the mechanisms of this that, well, certainly one of the things that wakes women up during this period are hot flashes, which can be really quite disturbing and night sweats where people can really need to change all of their clothes, certainly their tops.
And then it’s hard to go back to sleep. And so, for women who’ve been going through this and it clearly started in menopause, I think a big evaluation is probably not indicated.
However, CBT-I can be employed or medications can be employed that can assist with sleep maintenance, waking up less or falling back asleep more easily. There are some specific treatments that can address the hot flashes and night sweats.
So those medications could be attempted at least for some period of time until that’s done. Some women unfortunately continue to have hot flashes and night sweats for years and years and years.
So, the transition becomes kind of a way of life for some people over a period of time. And the last thing is that men’s risk of sleep apnea is much higher than women’s until women go through menopause at which time the risk of sleep apnea goes way up in women postmenopausally.
So, women who start to have snoring, stopping breathing episodes should certainly be evaluated, if this is a nuance after menopause and certainly should be evaluated at any time, really.
Jenn: So, I know that we are starting to run out of time, I would be remiss if I did not ask about the effects of caffeine on sleep. And do you have any best practices beyond stop drinking coffee around noon?
John: That’s really what it is. Caffeine is a great drug, but remember it is a drug, you know, it’s probably the most commonly used drug in the United States and everybody loves it. And it’s a wonderful assistance to feeling more awake, feeling more engaged, feeling more talkative. However, being awake, alert and talkative is not a good plan for when you’re trying to go to sleep.
Some people are more sensitive to it than others. So, the exact time to cut off isn’t clear, to be safe, I generally say noon. I’ll hear people say to me, “oh, I can have a cup of coffee at 10 o’clock and go right to sleep.” And God bless them, that’s wonderful.
My guess would be that their sleep would be better if they didn’t have the coffee then, but everybody makes their own decisions. But in general, I would say noon is the time to cut off.
Many people drink a lot of soda, many people who are taking medications that make their mouth dry need to drink something. So, they’re having lots of diet sodas throughout the day, just make sure that it doesn’t have caffeine in it. Caffeine really should stop at noon.
Jenn: So, I know that if you had a few bad night’s sleep, folks might try to want to catch up or payback their sleep debt, which is one of the like new fun terms around it. Do you have any advice about the best ways to catch up or is that kind of an impossible task?
John: Well, you know, it fundamentally is impossible, because you lost that sleep and you were more tired, you were more irritable, you had more difficulty concentrating on those days that you just did. And so those days already happened. So, by getting sleep tonight, you can’t be less irritable than you were two days ago. That already happened.
However, for people who need to be up at night and not get enough sleep, you’re in a job setting where there’s one or two days a week, let’s say where you’re going to be short-changed for sleep. I do think it’s okay to sleep in after that, probably better, I shouldn’t have said sleep in, probably better to go to sleep earlier and wake up at the same time, rather than going to sleep late and sleeping later.
Because remember that wake up time is really key, getting light first thing in the morning is key, setting our clock. So I would prefer if people were short-changed on sleep a couple of nights in a row, then on that third night, rather than sleeping in the next morning, you go to bed earlier to make up for that sleep and to catch up, because sleep deprivation is cumulative.
If you get one hour less sleep than you really need or want seven days in a row, it’s almost like staying up a whole night at the end of that first week which is seven hours of cumulative sleep deprivation.
So, I would encourage people to try to make up, recognizing you can never really make up, because those days are past when you were sleep deprived. Going to bed earlier, i.e. falling asleep when you’re sleepy, which is probably going to be earlier, but then trying to wake up around the same time.
Jenn: Got time for one more question, any last pieces of advice to get started on resetting our sleep schedule. How do I retrain my body to sleep better?
John: I think keeping sleep diaries is helpful. This way you can really monitor what’s going on and you don’t fill them out at night, for sure you fill them out in the morning. “Okay, what time did I think I tried to fall asleep?
Okay, it was about 10 o’clock and I think it took me about 15 minutes to fall asleep. I think I had two awakenings and I was up for a total of 10 minutes and I got up this morning at six.”
How long did that take? Less than a minute. And you do that every morning. And then you start to see patterns of when you’re sleeping poorly, when you’re sleeping well, when you feel most rested and trying to keep bedtime and in particular wake time stable every night is a really good skill, a really good tool.
And for people who are having consistent problems with insomnia, I would encourage you to try to keep the amount of time that you are in bed, trying to sleep equal to the amount of sleep that you think you’re getting.
If you think you’re only getting 6 1/2 of sleep, I would probably try to make your bedtime and wake time 6 1/2 to seven hours apart, rather than nine hours apart. Keep it short and over a few weeks, you’ll find that it’s easier to fall asleep and stay asleep.
Jenn: I think that’s a really great way to wrap up the session, ‘cause I do know you’ve got to jump off, you have tons of other obligations. And John, I know that you said that you have decades of experience and clearly it shows you’ve given us so much valuable information.
I cannot thank you enough for taking the time to answer all our questions or as many questions as we could get through about sleep, our mental health and everything in between. So, thank you so much for joining and for everybody who joined us for the live session, thanks so much, this actually ends the session.
John: Thank you and hope everybody sleeps well.
Jenn: So, until next time, be nice to yourself, be nice to each other, wash your hands and don’t drink caffeine past noon. Thank you so much, take care everybody.
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The McLean Hospital podcast Mindful Things is intended to provide general information and to help listeners learn about mental health, educational opportunities, and research initiatives. This podcast is not an attempt to practice medicine or to provide specific medical advice.
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