Approaches to Integrative Sleep Medicine – Dr. Nishi Bhopal – HPP 93
Sleep health is one of the most overlooked and essential factors for physical and mental health, as well as longevity. Yet, so many people worldwide suffer from sleep disorders, and this issue seems to only be increasing in modern times. Although sleep aids may help people fall asleep, they don’t necessarily support sleep efficiency which is a better indicator of restfulness and rejuvenation.
In this episode, we explore many important questions related to what goes into a good night’s sleep and why we are facing an increasing rate of sleep issues globally. We discuss integrative interventions, the role of wearables and where they fall short, and a map to understand the root causes of sleep disturbances. This is a great episode if you’ve been trying to optimize your sleep personally or working with clients professionally.
My personal struggle with sleep – 04:06
“I was always that kid who was kind of drowsy in class and had trouble staying awake. I’d go home after school and take a nap. I really struggled with getting to my college classes on time, and I lived off campus. So that was kind of like an ongoing issue for me and I could never really get a handle on it”
Defining sleep health – 06:02
“We actually don’t have a great definition of what it means to get healthy sleep, but there’s a few things that I would look at. One is how do you feel during the day? Are you feeling sleepy? Do you have brain fog? Do you have trouble concentrating? Are you irritable? Do you feel like you need to take a nap or grab an espresso at two o’clock? Those are all signs that maybe you’re not getting great sleep quality”
Insomnia is a global problem – 11:15
“It’s a huge issue and it’s become sort of more prominent during this pandemic. We’ve seen more issues with sleep, even excessive daytime sleepiness. So I want to emphasize that the issue is not just about insomnia, but excessive daytime sleepiness is an issue that many people struggle with”
Sleep and Nutrition: what you need to know – 18:34
“You don’t want to eat anything that’s too heavy, or too fatty or too spicy. It’s a good idea to avoid those things anyway, right? You don’t want to be eating too much food within three hours of bedtime, because then your body is now shifting its attention to digestion, rather than to the physiological process of sleep”
Sleep Interventions – 22:42
“So there’s a couple things that I recommend starting with. One of the most high yield things you can do is to get up at the same time every single day and get bright light, no matter how much sleep you had gotten the night before. And what this will do is it’s going to help regulate your circadian rhythm, and it’s also going to increase your sleep drive”
Sleep and mental health disorders – 25:44
“And what’s really interesting is that when you start working with people on their sleep, a lot of the principles we use for improving sleep are the same tools that we use with patients to improve depression or anxiety. So there’s elements of CBT-I, and mindfulness, and relaxation, and stress management and so forth. And so it kind of goes hand in hand, but it’s really interesting that you say that it’s hard to really assess for a mental health condition if there is a sleep condition”
How does exercise support sleep – 31:23
“One of the issues with exercising too late in the day, though, is that it increases your core body temperature. And one of the physiological changes that we see when we’re falling asleep is the core body temperature decreases, and that’s also associated with production and secretion of melatonin. So to get good quality sleep, you want to make sure your core body temperature is nice and cool”
Keith Kurlander, Dr. Will Van Derveer, Dr. Nishi Bhopal
Dr. Nishi Bhopal 00:00
The other aspect of healthy sleep is not needing to take sleep aids to be able to sleep. So if you are relying on sleep aids, and these include things like medications, so benzodiazepines, even over the counter medications, like anything that has PM, so Tylenol pm or Benadryl, or even if you’re relying on supplements in order to induce sleep, that’s a sign that you’re probably not getting good quality sleep.
Keith Kurlander 00:30
Thank you for joining us for The Higher Practice Podcast, I’m Keith Kurlander with Dr. Will Van Derveer. And this is the podcast where we explore what it takes to achieve optimal mental health. Hey there, welcome back, we’re super excited about today’s episode because we’re going to dive into sleep. So if you’ve ever struggled with sleep, you obviously know how complex it can be to solve your sleep issues, and obviously if you’ve worked with clients or patients that are dealing with insomnia, then you’ve probably seen that sometimes you can knock it out of the park, but often it’s a long kind of windy road of figuring out what’s going to solve the issue. So today, we’re definitely really focused on talking to amazing sleep expert, who’s really involved in integrative sleep medicine says something that’s not often practiced when you go to traditionally when you go to a doctor, you’re going to be offered some medication, maybe CBT I for insomnia, and a few other things. And there’s so much more to know here, so today is exciting, because we’re gonna dive in with Dr. Bhopal who’s really focused on what you need to know. And as you’ll hear on this episode, there’s actually a lot of different root causes to sleep issues, and there’s a lot of different types of sleep issues. So feel free to re-listen to this episode multiple times, if you’re intrigued by how to conquer sleep issues or work with people that we do cover some hacks. Here we cover some overview material. We talked a little bit about why so many people right now have sleep problems globally, which you’ll hear about on the episode. It seems like we have a modern disorder, basically that is increasing in modern society. So we’re going to dive in Dr. Bhopal is a Board Certified psychiatrist, and also in sleep medicine and integrative holistic medicine. She received training through the Maharishi Ayurveda Association of America and integrative psychiatry Institute. Having grown up in an Indian family in Canada and lived in several different countries, Dr. Bhopal understands what it means to be multicultural, and is attuned to the unique challenges faced by immigrants and expats. She’s also a meditator and brings her experiences with yoga meditation to clinical practice blending the best of ancient wisdom and modern medicine. Dr. Bhopal is the founder of Inter Balance, Integrative Psychiatry and sleep in San Francisco. And she’s on a mission to make mental wellness and the science of sleep easy to understand, and accessible through her YouTube channel and online programs. Let’s welcome Dr. Bhopal to the show. Hi, Nishi. Welcome to the show.
Dr. Nishi Bhopal 03:34
Thank you for having me.
Keith Kurlander 03:35
Yeah, it’s great to have you here, and as I was just saying to you before, like we’ve never actually focused a full episode on sleep. So we’re super excited to have you here to share some wisdom about how people can get better sleep and the impact not getting good sleep has, and obviously it’s a very big issue. I mean, insomnia is obviously clearly a huge issue, so we’re excited to get in there with you.
Dr. Nishi Bhopal 04:01
Thanks. Well, it’s one of my favorite topics to speak about, so I’m excited to get into it.
Keith Kurlander 04:06
Maybe start us off by just saying why it’s one of your favorite topics to talk about, like why are you so into sleep and understanding sleep and helping people with sleep? And is it a personal thing? Is it just more of a professional interest or?
Dr. Nishi Bhopal 04:19
It’s kind of a little bit of both, so personally I struggled with sleepiness. For most of my life, it’s still something that is kind of a day to day consideration for me. But I was always that kid who was kind of drowsy in class and had trouble staying awake, I’d go home after school and take a nap. I really struggled with getting to my college classes on time, and I lived off campus. So that was kind of like an ongoing issue for me and I could never really get a handle on it. And I didn’t really understand what was going on with me, either. And so from a personal standpoint, he’s always really interested in the science of sleep and how it works. But then when I was in my psychiatry residency. Almost all of my patients at one point or another struggled with sleep in some way, either with hypersomnia, or excessive daytime sleepiness or insomnia, not getting enough sleep or experiencing poor quality sleep. And I felt like I didn’t have a good handle on how to really help them beyond prescribing the usual medications that we might use. And when I was in my internal medicine rotations, one of my senior residents was actually going to sleep medicine fellowship. And at that time, I had no idea that was a thing. I was like, Oh, that’s something that you can do. And she opened me up to this whole world of sleep medicine. And I actually did my residency at Henry Ford Hospital in Detroit, where they have a very prominent sleep department. Dr. Thomas Roth, who’s the big name in sleep medicine, ran that lab. And I had no idea about any of this, but I was really lucky to be able to do rotations with them, do some research with them, and that really kind of sparked my interest in sleep. So I went ahead and did a sleep medicine fellowship after my residency.
Keith Kurlander 06:02
Terrific, thanks for that. What is healthy sleep? What are the metrics we’re looking at for healthy sleep? And why do we need to get what we would call efficient sleep? Like what does it do to the body to the brain, Like? What are some of the kinds of reasons people want to pay attention to getting good sleep? And what is it?
Dr. Nishi Bhopal 06:23
So healthy sleep is kind of a subjective idea, we actually don’t have a great definition of what it means to get healthy sleep, but there’s a few things that I would look at. One is how do you feel during the day? Are you feeling sleepy? Do you have brain fog? Do you have trouble concentrating? Are you irritable? Do you feel like you need to take a nap or grab espresso at two o’clock, those are all signs that maybe you’re not getting great sleep quality. The other aspect of healthy sleep is not needing to take sleep aids to be able to sleep, so if you are relying on sleep aids, and these include things like medications, so benzodiazepines, even over the counter medications, like anything that has PM, so Tylenol PM, or Benadryl, or even if you’re relying on supplements, in order to induce sleep, that’s a sign that you’re probably not getting good quality sleep. And then another measure is the sleep efficiency that I mentioned before, so if your sleep efficiency is less than 80%, or even more than 90%, that could be an indication you’re not getting enough sleep, that’s another metric to look at.
Keith Kurlander 07:33
Can you maybe go a little into sleep architecture and stages just in terms of because when I guess, when you’re talking about sleep efficiency, it also refers to some of that, right? So could you maybe just give a quick, just a very light handed quick overview of sleep stages and what we’re looking to achieve there?
Dr. Nishi Bhopal 07:50
Yeah, absolutely, so there are four main sleep stages. So there’s non REM, and then there’s REM, and then within non REM, you’ve got stages one, two, and three, and then REM is considered kind of like the fourth stage. so non REM stage one is your transitional stage, and this accounts for about 5% of your sleep architecture, so this is when you’re going in and out of sleep. then you have non REM stage two, which accounts for about 50% of your sleep architecture. So this is still a light stage of sleep, but it’s a little bit deeper than stage one. And this is kind of where you see things slowing down, heart rate, respiratory rate starts to slow down, and then also your muscles start to really relax. Then there’s non REM stage three, which is deep sleep, this is the really deep restorative sleep, where you see a lot of growth and repair in the body, and this accounts for about 20% of your sleep architecture. And then REM sleep is what most people have heard of. This is your dream sleep, rapid eye movement sleep. And this accounts for about a quarter so 25% of your sleep architecture, and so healthy sleep includes all of these sleep stages in the right proportions.
Keith Kurlander 08:59
Got it, and can you just say a little bit about when you said like growth and repair happens in a stage and like what what actually is happening in the body, either physically to the body or psychologically like to the memory banks, or anything that people should just be aware of, of like, this is the reason we really want to concentrate on hacking our sleep and getting better sleep.
Dr. Nishi Bhopal 09:22
Yeah, so all of the different sleep stages have different functions. And this is the great mystery of sleep, and this is why I find this field so fascinating, because we don’t actually know all of these answers yet. But we do know a few things, we know that in stage three sleep, that deep restorative sleep that I was talking about, you get these really beautiful, big Delta brainwaves. And what happens with that is you get synchronization of those brain waves across the brain, and that helps to increase the flow of CNS through the glymphatic system. So what is happening here is that your brain is actually clearing out toxins that build up through the day as byproducts of cellular metabolism, it also clears out amyloid beta. So getting good quality sleep and getting enough restorative, deep sleep is really important to reduce the risk of Alzheimer’s and dementia later in life. But there’s so much more than happens during sleep as well, as you mentioned, Keith, you consolidate memories during sleep. So, and this happens in various stages, including REM sleep, and stage two and stage three, but we encode the information that we’ve taken in during the day. And when you sleep, the brain actually then goes in and takes all that information and files it into the right filing cabinets, and then stores it away and compartmentalizes that information in the right spots. So if you’re not getting adequate sleep, it’s going to be really hard to retain information, it’s going to be hard to learn, it’s going to be hard to recall information. And so that’s a really important aspect of sleep. We also know there’s a bi directional relationship with mood disorders. So when people are not getting enough sleep or good quality sleep, it increases the risk of anxiety and depression and vice versa, anxiety and depression increase the risk of sleep issues.
Dr. Will Van Derveer 11:15
Let’s talk about your mention of your psychiatry residency hearing, really having loved patients who are struggling with sleep, probably across the board, regardless of their diagnosis and what they’re dealing with, and just the scope of the problem in our society and our culture. How big of an issue is insomnia just for our listeners who may not be as familiar with these statistics?
Dr. Nishi Bhopal 11:37
Yeah, so it’s estimated that about one in 10 Americans experienced chronic insomnia. That’s a pretty big number. That’s like 10% of all. And it’s also estimated that worldwide issues with acute and chronic insomnia could be as high as 60% globally, it’s a huge issue and it’s become sort of more prominent during this pandemic, we’ve seen more issues with sleep, even excessive daytime sleepiness. So I want to emphasize that the issue is not just about insomnia, but also excessive daytime sleepiness is an issue that many people struggle with. And as we see a psychiatrist people might get placed on stimulants or other medications, which can lead to its own sets of issues. But there’s also an issue with just not prioritizing sleep, sleep deprivation is a huge issue globally. And it’s estimated that most people around the world are getting maybe six or seven hours of sleep on average, which generally is not enough, and sleep deprivation can cause a whole host of issues downstream as well.
Dr. Will Van Derveer 12:38
Well, those are huge numbers, and so, we have a cultural issue, we have people struggling with mental health issues and their insomnia, or their excessive sleepiness. And just as a kind of a global overview of our medical treatments for insomnia, outside of that we could go down the rabbit hole of sleep apnea and obstructive sleep apnea and sleep apnea and so forth. How do you feel about the results that you get or what we’re seeing in terms of response to the kind of usual sleep aid medications?
Dr. Nishi Bhopal 13:14
What I see is that patients are looking for solutions beyond just medication, and we see this as integrative psychiatrists as well as they want to know what else they can do outside of taking the medication. But oftentimes, as clinicians, we don’t have a lot of time with our patients. And so at the end of the appointment, a patient might get prescribed a prescription sleep aid to treat the insomnia. But what’s really important, in my view, is that you need to get to the root cause of what’s causing the sleep issue in the first place. There’s actually over 80 different kinds of sleep disorders, so this goes beyond just insomnia, and insomnia can there’s lots of different conditions that mimic insomnia. So things like circadian rhythm disorders in up to 16% of adolescents have delayed sleep phase syndrome, which often gets misdiagnosed as insomnia in young adults and teenagers. This is something that I do in my practice, and this can carry over into young adulthood, and even older adulthood as well. So I’ll see people in their 20s, 30s, 40s, and 50s, who have been diagnosed with insomnia are placed on medications for the duration of their life, essentially, when they actually had a circadian rhythm disorder that could have been treated without medication. Restless leg syndrome and periodic limb movement disorder can look like insomnia, that’s something that’s often missed. And then you mentioned sleep disordered breathing as well, about 20% of patients with depression. So one in five patients with depression have undiagnosed obstructive sleep apnea.
Dr. Will Van Derveer 14:40
Wow, yeah. So it’s not a one size fits all situation when you’ve got 80 different types of problems and you’ve got just a handful of medication to try to knock people out. What would you say to providers in the audience who are going to be in a position if they’re working with people with mental health challenges? What should they know in terms of screening? Or referrals? Or what would you say to those folks?
Dr. Nishi Bhopal 15:07
Yeah, so what I would say to them is that it treating sleep issues doesn’t have to be as hard or as complicated as it might seem, it can be really frustrating when you’re the provider, you’re the therapist or the doctor, and your patient is coming to you with sleep issues, and you only have a limited amount of time. And you feel like maybe medications are the only tool that you have available to you, and that can be incredibly frustrating and inducing a sense of helplessness as the doctor, but also for the patient as well. So the first thing I would say to people is that it doesn’t have to be complicated, I use a very simple four step process. And I teach this to my colleagues as well, to help identify your patients’ sleep issues, and then also to create a roadmap to treatment that could either help prevent them having to use medications or to help them get off medications. And the first step in this four step framework is to really just track the sleep patterns, and track their sleep efficiency, sleep efficiency refers to the amount of time that you’re sleeping while you’re in bed. And an ideal sleep efficiency is about 85%, 80 to 85% is considered good. So if that sleep efficiency is less than 80% that’s usually an indication that people are spending way too much time in bed. And that’s a common problem that you see with people who have insomnia, and we can maybe come back and talk more about that. But oftentimes, the tendency is to spend more time in bed hoping you’re going to get more sleep, and that just feeds into this hyper arousal response to insomnia, so that’s step one, in this four step framework.
Dr. Will Van Derveer 16:46
Having talked a little bit more about the first step in your process of evaluating sleep problems, can you tell us about step two and what you recommend there?
Dr. Nishi Bhopal 16:58
Yes, so in step two, this is where I really like to identify root causes for the sleep issues. So you can identify the root causes, and then create a treatment roadmap based on that, and I really love the Ayurvedic view of root causes of sleep issues. So Ayurveda the ancient healing system from India, it’s over 5000 years old. And there’s a lot of wisdom there about health, but also about sleep and the circadian rhythm. And so they have broken down root causes into four main categories, which I find really practical to use in clinical practice. So the first category is food. And this includes things that might induce reflex, which we know is also linked with sleep apnea. So foods that are too hot, we’re learning more about the impact of macronutrients on sleep. So when people are eating too much saturated fat, or there’s a diet that’s hard to find carbohydrates, that actually causes more sleep disruption, and more symptoms of insomnia. But a high fiber diet is associated with fewer symptoms of insomnia, and more consolidated sleep. So that’s a really easy thing you can assess for in clinical practice. And then in the food category, we also have dysbiosis in the microbiome. And there’s some really fascinating research coming out on how dysbiosis can contribute to circadian rhythm dysfunction, and therefore sleep issues. The second category in the Ayurvedic framework of root causes is the environment. Should I talk more about that or?
Dr. Will Van Derveer 18:34
Well, I’m curious, I’ve got a question for you about food before we move on to the environment. Can you say anything about the timing of that meal in the evening, and because I hear different things about, you could bottom out your blood sugar if you don’t have a snack before bed, and then I also hear about this high carb thing and how that can be a problem for people, what’s your thought there, in terms of that last meal of the day?
Dr. Nishi Bhopal 18:59
A good rule of thumb is to have your dinner at least three hours before bedtime. Because you don’t want to eat anything that’s too heavy, or too fatty or too spicy, it’s a good idea to avoid those things anyway, right? only be eating too much food within three hours of bedtime, because then your body is now shifting its attention to digestion, rather than to the physiological process of sleep. But for people who do struggle with blood sugar and sort of maintain that throughout the night, it’s a good idea to have a light snack, maybe an hour or so before that time. So this could be something like a banana with some nut butter, or maybe some vegetables with hummus or something like that, something that’s light and not too heavy.
Dr. Will Van Derveer 19:40
Okay, thank you. Let’s talk about the environment.
Dr. Nishi Bhopal 19:43
The environment is a huge factor to take into consideration when you’re helping a patient with sleep. And the way that I approach this is I really like to imagine what their sleeping space looks like, so I ask patients to give me as much detail as possible about what their bedroom looks like and what their living space looks like in the evening. And I’ll just give a quick story about a patient of mine who struggled with sleep for decades, and she came to me with complaints of insomnia and poor sleep quality. And so I went through this root cause analysis with her. And it turned out she was sleeping in a small closet in her studio apartment, because that was the only space that she had in her apartment. We’re in San Francisco, we have small spaces here. So she was sleeping in this tiny little closet that was unventilated, it was hot, it was stuffy, the air was stagnant. So I had her simply move the bed out of the closet into another area in her apartment near the window where there’s better ventilation. And literally overnight, her sleep improved. That wasn’t the only issue we did discover she had sleep apnea and issues with her diet and nutrition and things like that, but that one simple change had a huge impact. So I always recommend asking patients about what their room is like where they’re sleeping, even the types of sheets that they’re using, natural fiber sheets are more breathable. So switching from a synthetic blend to 100% cotton sheets can also have a huge impact on quality. So that’s the second category that I highly recommend assessing that is often missed.
Dr. Will Van Derveer 21:21
Great examples, thanks for sharing those. And I get marketed, it seems like on Facebook quite a bit to these cooling devices that people sleep, I guess people sleep on mattresses that have like a water cooling setup. And it occurs to me as a clinician, that there’s so much that needs to happen around environment and sleep hygiene and just sort of getting the basics right nutrition. And like you said, before going into a big tech investment or so to speak upgrade, thoughts about that.
Dr. Nishi Bhopal 21:53
Yeah, I mean, I think that’s a really important point, because I get all these ads on Facebook and Instagram, as well for all these different gadgets, and people can end up spending 1000s of dollars on these things. And then forgetting about the basics of just eating a healthy diet, regulating their circadian rhythm, just maybe switching out their sheets, that could be a really, really simple sort of strategy. And interesting because when you look at how humans have slept for millennia, we didn’t have beds for a long time, right? Like we sleep like kings would have hundreds of years ago, humans still in some places, humans still sleep on like strong maps, or even just on the ground. So biologically, we actually don’t need all of those things, we really need to get back to basics, and that’s what I emphasize in my practice.
Keith Kurlander 22:42
What do you like to work on? So if we just imagine that these lifestyle behavioral interventions are a big chunk of many people’s issues, and there’s so many things you said at different diagnoses on top of all the different root causes, how do you even work with the behavioral changes hard, right? So, especially with sleep hygiene, we’re talking about a lot of different things that happen throughout a day, in order to cultivate good habits, and so if we just pause here for a moment around, where do you start helping people make these critical changes, and over time, there’s probably lots of detail of changes that could happen, that could go really far. And it could be diet, and when you eat and when you exercise and how you exercise and what your habits are before bed, and all these different things can break down into so many behavioral changes. So I’m just curious, like, where do you start? And how do you help people actually make changes, since that’s typically, people have really poor sleep habits, they have trouble typically making any sleep changes. And that’s why they just want the pill, right?
Dr. Nishi Bhopal 23:51
That’s exactly right, and people get frustrated, because there’s so much information out there. And you could find hundreds of articles with hundreds of different tips, and then people just don’t know where to start. It’s overwhelming. So there’s a couple things that I recommend starting with one of the most high yield things you can do is to get up at the same time, every single day, and get bright light, no matter how much sleep you had gotten the night before, and what this will do is going to help regulate your circadian rhythm. And it’s also going to increase your sleep drive, and then make it easier for you to fall asleep at night. So getting up at the same time, every single morning, within about an hour is okay. But if you’re getting up three hours later, on a weekend, you start getting into a jet lag effect that we call social jetlag. So at the same time every day, getting bright light in the morning, there was an interesting study in nature recently that actually showed that a regular sleep schedule increases the risk of depression. So if you’re seeing a patient who has depression and sleep issues, this is a super high yield thing that you can help them with.
Keith Kurlander 24:55
Great, and so obviously, there’s a lot you can do in your environment with your environment. So many things and I can relate to this, it’s like I remember my sleep got like twice better when I got a new mattress for instance and like I didn’t even realize it. There’s just so many factors, and I think that was the second category in the Ayurvedic system, is that right? So what’s the next one?
Dr. Nishi Bhopal 25:17
Yes, that’s right. So the second is food, the second is the environment, the third category is mental health. So making sure that you’re assessing for anxiety, or depression, or bipolar disorder, but also stress related conditions, and really getting a good psychosocial history. So addressing those things, of course, it’s really important in improving sleep. We know this as well as mental health professionals. And the fourth category is.
Keith Kurlander 25:44
Let’s actually pause at mental health for a second. So mental health, so I know just from my own training, but also from obviously being like a patient. Sometimes I have been told, let’s not assume any mental health disorders until we get your sleep fixed. And then let’s see what’s going on, like, I’m curious about your perspective. I know you said it’s bi directional, I’m just curious about your perspective on people’s mental health. And like, if there’s an obvious sleep disturbance going on, how far down the rabbit hole of the mental health disorder framework, do you go? Or do you really just try and fix sleep first, and then return to seeing what’s left over? Like, what’s your perspective on that?
Dr. Nishi Bhopal 25:50
My approach to that is, I kind of do a little bit of both at the same time. So I’ll help patients work on their sleep, but I’ll also help them with therapy for depression or anxiety or for stress, because you can’t really address one without the other. And what’s really interesting is that when you start working with people on their sleep, a lot of the principles we use for improving sleep are the same tools that we use with patients to improve depression or anxiety. So there’s, you know, elements of CBT I, and mindfulness and relaxation and stress management and so forth. And so it kind of goes hand in hand, but it’s really interesting that you say that it’s hard to really assess for a mental health condition if there is a sleep condition, because as I mentioned before, a delayed sleep phase syndrome is really common, often misdiagnosed as insomnia, but it may also be misdiagnosed as depression, because people are sleeping late in the day, and then they have trouble getting to sleep at night, and that can look like depression. Narcolepsy is often diagnosed as depression, because of low motivation and fatigue, and narcolepsy doesn’t show up like it does in the movies, you know, where people are just randomly falling asleep and having sleep attacks. That’s kind of the Hollywood version of narcolepsy, but in real life, it can really look like depression, because people may come into the flat effect, they may endorse low motivation, or sleeping during the day, or even apathy or anhedonia, so that’s a really important diagnosis to consider as well.
Keith Kurlander 27:58
Great. What’s the last category?
Dr. Nishi Bhopal 28:02
The last category is medical. Okay, the last category is medical, and this is a huge category, because this includes basically anything and everything that you might see. But a few big things that I recommend screen for if you’re a mental health clinician in practice, one is obstructive sleep apnea. As I said before, about one in five patients with depression have obstructive sleep apnea, so you can use something like the stop bang questionnaire to help you with screening for that, I just do it by history, I don’t use the questionnaire because that questioner might miss patients like women who are thinner, or patients who are just generally smaller, they might not be caught on that stopping questionnaire, so that’s something to think about with your patients. Another one is restless leg syndrome, I mentioned that earlier as well, and that you can screen for by history, you can check iron levels, and ferritin levels to sort of support that diagnosis. Other things include thyroid conditions, or even certain types of medications can cause sleep issues. So again, this is a huge category, but it’s important to really take a thorough history to see what might be driving your patient’s sleep issues.
Dr. Will Van Derveer 29:11
It sounds terrific, very thorough and it’s really helpful to have four categories to keep our minds oriented in the assessment process. And there’s another piece that Keith and I’ve been exploring and talking about a lot lately, which is the kind of advent of these tracking devices. And there’s different ones out there, and my understanding is this summer, more research validated than others. And I’m curious, your thoughts on them in general, and also what you’re seeing in terms of. How can people get tripped up with these devices?
Dr. Nishi Bhopal 29:47
Yeah, so these sleep tracking devices, they’re kind of a double edged sword because they can give you some really good information on sleep efficiency, and also the person’s general sleep patterns. So I do find them useful for those purposes but you want to be careful because there’s this thing called orthosomia, which is kind of a preoccupation with getting good quality sleep or getting perfect sleep. That’s actually what that term means, and this can feed into anxiety and stress and even worse than issues with insomnia over time. So you want to be careful with your patients who are using these sleep tracking devices, because there can almost be an obsessive compulsive type of component that can come with that. But as far as what the devices can tell you, they’re usually pretty good at telling you total sleep time and total wake time, the Fitbit, ionic and the aura ring are thought to be the most accurate. This was based on a report that came out just a few months ago, what the sleep trackers are not so good at though is telling you the sleep stages, it’s really hard to do that without an eg or an actual polysomnogram. So that data I take with a grain of salt, because I’ll have patients come in and say, Oh, I only got 10% REM sleep last night, or I didn’t get any deep sleep. And so I explained to them that well, these devices are not very accurate at assessing that. So let’s not worry about the sleep staging. But let’s look at your sleep patterns, and I recommend tracking over two weeks, over a period of two weeks, because one single night isn’t going to be very useful. So you want to look at the trends rather than individual night night variations.
Dr. Will Van Derveer 31:23
That makes a lot of sense, and that brings up for me also this question about exercise and the relationship between activity levels and sleep. How would you recommend that people kind of frame that relationship and when the right time is in terms of sleep quality to get that workout?
Dr. Nishi Bhopal 31:41
Exercise, as we know, helps to increase sleep drive, and that’s going to also help increase your sleep quality and just make it easier for you to fall asleep and stay asleep. And of course exercise has many other benefits for physical and mental health. Now, one of the issues with exercising too late in the day, though, is that it increases your core body temperature. And one of the physiological changes that we see when we’re falling asleep is the core body temperature decreases, and that’s also associated with production and secretion of melatonin. So to get good quality sleep, you want to make sure your core body temperature is nice and cool, and you mentioned a sort of cooling device on the mattress before that’s kind of how these things work. So I usually recommend not doing vigorous exercise within at least four hours of bedtime, because of the impact on your ability to fall asleep and your sleep quality. Now for people who do prefer to work out in the evening, I’m one of those people myself, I’m a bit of a night owl and I have more energy later in the day, you just want to be really mindful about not doing anything too vigorous, too close to bedtime. So I usually recommend, you know, at least by six or 6:30pm to be finished with your workout.
Dr. Will Van Derveer 32:50
Keith Kurlander 32:52
Yeah, I’m curious, if we kind of zoom out for a second. Do you feel like sleep disturbance is becoming more and more prevalent over time in the course of history that we’re actually dealing with a more modern problem and the problems getting worse. I mean, we know that obviously, some of the mental health disorders are getting worse. We know that do you feel like sleep is in that category that we’re actually sleeping less than less as a species over time at this point?
Dr. Nishi Bhopal 33:26
I think that’s such an interesting question, because insomnia, I think, in some ways, is a modern kind of problem and I think that’s true for a few reasons. One is I think we just have different sorts of maybe even sometimes unrealistic expectations of sleep, and what sleep should look like, what healthy sleep should look like, and also how much sleep we actually need. Because if we go back in time, we see that there may have been cultures where biphasic sleep was pretty normal. So sleeping for a chunk of time at night, waking up for a couple hours in the middle of the night, and then going back to sleep again in the morning hours, or in other cultures, the siesta is pretty normal. So that aligns with our natural circadian depth around two or 3pm, so taking time off of work, shutting everything down, going home and taking a nap for an hour or two and then continuing with your evening activities. That’s not something that we do in modern society, we have this expectation that we should be on first thing in the morning and then completely on until the end of the day. And that’s totally misaligned with her natural body rhythms, and so I think for that reason, we’re seeing more sleep issues and sleep disturbances. But the other thing is exposure to artificial light disrupting our circadian rhythms. That’s not something we had centuries ago, so that’s another aspect of it. But there’s also a notion in our culture that sleep when I’m dead kind of thing, that we don’t actually prioritize sleep, that’s changing I think because companies like Google and Huffington Post and Ben and Jerry’s, NASA, they all have nap pods in their offices, because they’re seeing the data on how sleep is so important for productivity. And for just cognition and memory, and they’re seeing that in their employees at night, even the insurance company, they actually have an employee wellness program where they pay their employees to get more sleep. So they actually incentivize that, so I think we’re starting to see the culture shift towards making sleep a priority and understanding that it is a pillar of health. And then one last thing I’ll just say about that is, interestingly, during the pandemic, we’ve seen this phenomenon of Coronasomia, so just insomnia related to the stressors and various other changes that many of us have experienced during the pandemic. But there was a report recently that showed that on average, globally, people are getting 25 minutes more sleep, because of the sheltering in place, and not having to commute and such. So yeah, I think you’re right, Keith, I think that this is kind of a modern issue, but I think the pendulum is starting to swing the other direction.
Dr. Will Van Derveer 36:06
I’m gonna keep going with this idea of sleep, awareness of sleep quality being becoming a more of a phenomenon, which is really good. So okay, so we’ll start back in now, one of the things that I’ve noticed in some of the channels that I follow the podcasts that I listened to, there’s a much bigger awareness and emphasis on recovery, and not focusing so much on this kind of maniacal drive for more productivity, more focus, more attention more, getting more done. And actually acknowledging, like you were just saying, with the program like that, actually, there’s more productivity or more health or more capacity, the more we focus on recovery. It seems like sleep is such a critical element of that. Is it a completely crazy idea that getting more than the physiologic amount of phase three sleep would offer you more recovery, or more glymphatic clearance of amyloid plaque and so forth, is that completely crazy to think that way?
Dr. Nishi Bhopal 37:15
Well, I hesitate to say that it’s completely crazy, but I think what’s important to remember there is that all the stages of sleep are important. And I think oftentimes we get fixated on getting enough REM sleep or getting more deep sleep or what have you, but all of these stages work in concert, it’s like a symphony, right, you’re not just going to have a symphony playing with only a violinist, right, you need all of the other instruments for the symphony to make beautiful music, that’s how I think of sleep as this beautiful Symphony. When you look at a sleep study, you see all these beautiful brain waves in the different stages, and so I hesitate to say that you should focus on getting more deep sleep, I think we should focus on getting an adequate amount of deep sleep, not necessarily more than normal, more than that 20%. Deep Sleep is incredibly important for recovery, and growth and repair and immunity and repair of our muscles in ourselves. But also, if you’re thinking about athletic performance, REM sleep is really important for encoding motor memories, so when you’re working on your golf swing, or your tennis swing, or whatever activity you’re learning, I was learning how to ice skate figure skating A few years ago, and I noticed how when I didn’t sleep well, it really impacted my performance. So that REM sleep is also really important for recovery in a different kind of way, so all of the sleep stages are necessary.
Dr. Will Van Derveer 38:37
Thanks for that Nishi, yeah, it’s really helpful, it’s sort of like the message I’m hearing from you is maybe we need to be less obsessive about optimizing. And actually, it’s kind of like cognitive therapy for insomnia, like, probably less helpful to focus so much on optimizing, and probably a lot more helpful to just relax, let the sleep machinery operate in its own Symphony, but create the right conditions for that to occur essentially.
Dr. Nishi Bhopal 39:06
That’s exactly right, and the great paradox is that the more you try to do it, the more elusive it becomes. And so the thing I say to my patients is, well do you know, kind of just don’t think about it. And the less you think about it, the easier it actually will come. It’s like digestion, right? You’re going to make sure you eat the right foods, you set yourself up to optimize your digestive capabilities, but you’re not going to be thinking about it. 24 seven, but that’s what happens when people have sleep issues. They’re always thinking about it, they’re researching, they’re talking to people about it, they’re on Facebook groups. And so that’s a really important thing that I tell my patients is like, you know, we need to just take a step back and let it happen, but set yourself up during the day, so you could sleep at night.
Keith Kurlander 39:50
Thanks. Can we could wrap up for a few minutes on the role of trauma, historically and how that may be a big factor in a person who’s struggling with sleep, it may not be it may be, but just maybe we can just say a little bit about trauma and a nervous system that’s basically operating in a traumatic pattern. And how that could be something to be really looking out for, and how much of an issue is that even?
Dr. Nishi Bhopal 40:19
Trauma has a big impact on one’s ability to sleep, your sleep quality, and even Of course, in the types of dreams and experiences that people have during sleep. One of the aspects of sleep is this hyper arousal response, and the parasympathetic nervous system is dominant during sleep, except for during REM sleep for the sympathetic nervous system is dominant. So if a person is experiencing a trauma response, they’re in sympathetic mode, most of the time, and that in itself is going to affect their sleep quality. But another aspect of sleep is feeling safe, so if you’re not feeling safe enough to move into this other stage of consciousness into a stage of sleep, then that, of course, is going to impact your ability to sleep and fall asleep and stay asleep. Now, our bodies have evolved to experience a hyper arousal response when we are not feeling safe or when we’re experiencing trauma. And that is why many people experience insomnia, right? So if you think about back when we were living in villages, if there was some sort of attack or something traumatic that was happening, our bodies would naturally respond by staying awake at night, to be hyper vigilant to look out for danger. And that is what is happening to people when they are experiencing traumas, there may not necessarily be an external sort of stimulus for that. But that response is perpetuated, so this ties back to the interaction between mental health and sleep. And so it’s really important to address any underlying trauma that is exacerbating or perpetuating this hyper arousal response if you’re trying to help someone improve their sleep.
Keith Kurlander 42:03
Great, thanks. Well, let’s wrap up on a question we asked everyone. And this doesn’t have to be related to sleep Nishi, unless you want it to be, which is if you had a billboard that every human being would see once in their life, and there was a paragraph on it, what would you want to say to them?
Dr. Nishi Bhopal 42:20
I would say to them, you are loved.
Keith Kurlander 42:25
Great. Thanks so much, Nishi for being on the show. It is really informative.
Dr. Nishi Bhopal 42:33
Thank you for having me. That was so fun. I hope I didn’t talk too much.
Keith Kurlander 42:39
I definitely am going to take to heart a lot of what Dr. Bhopal said, looking at getting further hacks for my own sleep, and many of you probably feel the same way. Well, maybe I’ll go try a couple different things with my exercise routine or something along those lines. I also wanted to mention that if you have not yet scheduled a call to apply to our psychedelic therapy training, and if that’s something you’re interested in doing, it’d be a great time to do that. We already have 200 applicants and basically two weeks, so obviously, it’s a training that people have really been waiting for. We’re super excited about this training, if you haven’t heard about it, we’ve developed a year long comprehensive training for psychedelic assisted therapy, it’s going to be extremely fun to be engaged in this new cutting edge modality. We’re going to really cover ketamine assisted psychotherapy, which can already be used in medical settings, and we’ll also be covering the protocols behind the MDMA research and psilocybin research. So very exciting, and we’d love to see you apply if you’re interested. So if you want to apply to that program, it’s psychiatryinstitute.com/psychedelic so again, that’s psychiatryinstitute.com/psychedelic. Again, if you want to apply, it is a great time to do it, just because we’ve gotten so many applicants in such a short period of time and we have limited spaces. We look forward to connecting with you again on the next episode of The hire practice podcast where we explore what it takes to achieve optimal mental health.