Dr. Michael Breus is a clinical psychologist and both a Diplomate of the American Board of Sleep Medicine and a Fellow of The American Academy of Sleep Medicine. He is the author of The Sleep Doctor's Diet Plan: Lose Weight Through Better Sleep. In answer to my questions, he shared his thoughts on the major obstacles to getting a good night's sleep, the steps you can take to improve your sleep, and the future of sleep technology.
What are the major challenges Americans face in getting a good night's sleep today?
I think that there are two major challenges Americans face in getting a good night's sleep: stress and making sleep a priority. People stress about things going on in their lives, and they also stress about sleep, and both of these make sleep more difficult. When it comes to making sleep a priority, a lot of people engage in sleep procrastination, which is to say they put sleep off, thinking they simply have too much to do to sleep. It's the I'll-sleep-when-I'm-dead syndrome. The number one complaint I hear patients say in my office when we talk about an inability to fall asleep is: "Dr. Breus, I can't turn off my brain"
And it is true. Just think about it for a minute. Throughout your day, you are constantly being bombarded with people asking you questions, expecting you to do things, running non-stop from here to there. But when you get in bed at night, and your turn off the light, and your bed partner is not talking, and you finally have just a little alone time, your brain kicks into overdrive.
ￂﾷ What do I need to do tomorrow?
ￂﾷ What did I do wrong today?
ￂﾷ What things did I not get to today that now need to be on my list for tomorrow?
This list can go on forever. But then, in many cases, something else happens. After you've spent some time with these stressful thoughts rolling around in your mind, and you think that you might have a handle on tomorrow, you look at the clock, and then you get stressed about your sleep.
ￂﾷ Oh no, it is 1:00 a.m., and I have not fallen asleep.
ￂﾷ Here we go again, I am going to be exhausted tomorrow.
ￂﾷ Maybe I need to take a sleeping pill, is it too late?
I call this situation Wired and Tired, and it is usually due to stress and anxiety. People tend to forget that sleep is not an on/off switch. It is more like slowly pulling your foot off the gas and slowly putting it on the brake. There is a process that needs to occur and we need to give ourselves the time and tools to reduce stress before trying to sleep. Our lifestyles, in many cases, do not support our own sleep needs. Working to the point of exhaustion, only to do it over and over again, is a vicious cycle and cannot lead to true rest.
Making sleep a priority over work, fun, or other responsibilities, will actually help someone perform better at all the tasks they were doing before bed! This is easy to give lip service to, but putting sleep high on our list compels us to change our behaviors.
We get much of our health information from our doctors. For the past 15 years, the American Academy of Sleep Medicine has worked incredibly hard to educate non-sleep physicians about all of the sleep disorders, but specifically sleep apnea. It's been a great effort, but it is just not enough.
Sleep is the only topic that is absolutely and immediately relevant to everyone's lives. Sleep education needs to be taught in schools and as general education to the masses. I am suggesting a nationwide campaign to the general public. Sleep is the foundation of all wellness. No researcher, educator, politician, or celebrity ought to talk about any aspect of wellness, without also acknowledging that good-quality sleep affects all aspects of health. There is not an organ system or disease state where sleep is not critical. When I post my blogs, do national television appearances, see patients, and write books, I am trying my best to get the word out about the importance of sleep. While this does help change some minds, the true motivator is often personal to each individual. Looking at your story, you actually had your "Wake-up Call" when you smacked your head so hard after falling asleep that you needed stitches. Pain appears to have been a great motivator for you, as it is for most people. But it does not have to be that way. We can all avoid the physical and emotional pain often required to change, and simply open our eyes to the importance of sleep, and integrate it into our own lives as well as the lives of our children, family, friends, and employees. It merely requires us to all take a good long look at our sleep, have credible resources to guide us, and commit to make a positive change.
What trends are you seeing in the sleep industry today? What do you see as the future of sleep technology?
Looking at sleep medicine I see a few really amazing things happening. The current research environment is fast-paced and exciting. We are continuing to learn more and more about all of the sleep disorders. Innovation has infiltrated sleep medicine.
For example, Merck has just completed development and launched a new medication for insomnia, with a completely unique mechanism of action from anything else the research community has ever seen. Historically, most of the pharmaceutical interventions for insomnia have worked in an area of the brain called the VLPO (the sleep switch) and tried to increase GABA (a.k.a, the brakes of the brain). This new medication actually turns off the "wake switch" by decreasing a neurotransmitter called orexin. Orexin turns out to be a neurotransmitter scientists identified when researching the idea of balance, or homeostasis, in the brain. People with narcolepsy have fewer orexin receptors. And orexin influences the wake switch. How amazing is it that we are learning about insomnia from narcoleptics!
Another real breakthrough comes in the area of Restless Legs Syndrome. RLS occurs when a person has a disruptive feeling in their legs -- a sensation of crawling under the skin -- which often prevents sleep. These sensations can only be relieved with potent anti-Parkinsonian medication or by getting up and moving around, something that's hard to do when you want to go to sleep. A small group out of San Clemente, California (Relaxis) has discovered that by using a counter-stimulus not only could they reduce the length of the attack, but in many cases reduce the frequency of attacks. They developed a vibrating pad that is placed under the legs of someone suffering from an RLS attack. The hypothesis is that RLS is a misfire from the brain, and by sending a counter signal (like a noise-cancellation headphone) it helps the brain cancel out the misfiring signal.
In the world of sleep apnea we have seen a technology surge with the rise of the Home Sleep StudyTest(HST). The excuses that many people have for not being evaluated for sleep apnea are that they: 1) do not have time, 2) don't want to spend the night in strange place, or 3) feel confined by all the wires. With the home evaluation, those excuses no longer apply. These small units do an excellent job of measuring sleep apnea, and will allow for diagnoses in more of the supposed 24% of men and 18% of women with sleep apnea. In addition, the number-one treatment for sleep apnea, the CPAP machine (Continuous Positive Airway Pressure machine) has become significantly more sophisticated. These machines help push air gently to open a collapsed throat. But now these machines have become "smart." They can tell when an airway needs increased or decreased pressure based on sleeping position, sleep stage, even compromised lung function. People can also wake up each day to see how well they slept, as can their doctors, who can make changes to their devices remotely. For those who do not tolerate CPAP, the world of oral or dental appliances to treat sleep apnea is also getting more and more sophisticated. These appliances are molded by board-certified dentists and can open an airway without the need for a CPAP. While they tend to work best with more mild cases, these can work well for many people. Finally, the use of EPAP (Provent) has really been nothing short of amazing. Provent is a small band-aid type of valve that is placed on the outside of the nose. While it lets 100% of air in, it closes a little bit when a person exhales and causes a negative pressure system to open up the airway without a dental device or a CPAP. It is also disposable and can be disposed of after every use. Most of the most common sleep disorders have seen breakthroughs in treatment and diagnosis.
In the consumer world of sleep the list is endless for new products but I see new trends in two areas: self-monitoring devices and solutions through invention. I went to CES (Consumer Electronics Show) this year and in health you could not turn a corner without seeing a device to monitor health-related signals, including sleep. There is a sincere interest by consumers to learn more about their sleep. The quality of the devices, and signals being monitored, seemed to vary significantly. Everything from an app (the least accurate) that measures movement and data that the consumer will enter manually to a wearable (more accurate, but can be bothersome) that can measure movement, heartrate, blood pressure, and sleep stages. These devices can also monitor more than just sleep, and can give a comprehensive look into a person's overall health through metrics. There were also a few bedside or inside-the-bed devices that, while only measuring sleep, are very easy to use and very accurate. My only real complaint is that very few devices actually tell a person what to do with their data, to improve sleep.
I also saw an increasing trend of new sleep-related comfort devices on Kickstarter! It has been impressive to see how many inventors are looking into the wonderful world of sleep. I have seen devices to make people sleep warm or cool, have light only on their side of the bed, help parents with night terrors, and help women sleep better based on their menstrual cycles. I am trying, as quickly as possible, to learn more about each of them and their technology. The trend and future is in people wanting to increase the sleep experience. Interest in sleep is growing, and I personally am thrilled to see it. Sleep is on the cutting edge of technology in so many ways.
You treated everyone from athletes to celebrities -- what steps can even the busiest of people take to improve their sleep today?
While most people do not like this answer, the truth is it will depend upon several factors. Genetics play a huge role in sleep improvement. Many people are simply born with the genetic gift of good sleep, while others are not. For example, there is research suggesting that many people with insomnia actually have a significant amount of underlying autonomic arousal, which can prevent them from getting good sleep. Autonomic arousal is like the RPMs that the engine of your body is running while moving around and trying to sleep. We also know that whether you're a morning person (an early bird), or a night person (a night owl) is based on genetics. Furthermore, we know that some people are born with certain genes for sleep disorders like narcolepsy, and other people are born with specific anatomy that can lead to sleep apnea.
But genetics alone will not entirely determine your sleep quality or quantity. Our environment is important as well. I believe that sleep is a performance activity, and the better equipment you have the better you are likely to perform. For example, if you are a genetically gifted runner you can likely enter just about any race. In fact, you could probably race with flip-flops, cut-off shorts, and an old tee shirt, with a radio in your hand and still cross the finish line is decent time. But if you have the right running shoes, dry-fit wear, a heart monitor and some great music, your time, or performance, would be even better!
The same holds true for sleep. We can all benefit from setting up an environment for better sleep. Researching the right mattress and pillow can be a daunting task. I teach people how to do it, and I even go shopping with them to help them find the right bed. It is not about how much money you spend, but rather about understanding your body and your needs and matching those needs to the right equipment. For example, one of the simplest things a person can do is to make sure that they are using the right pillow, understanding that the pillow they need at the beginning of the week may be different by the end of the week. Reducing exposure to light, since it is the biggest disruptor of melatonin, can be a huge factor in improving sleep. Companies like Lighting Sciences have special bulbs that filter out blue light at night, so a person is not reading in bed while telling the brain it is morning out. Reducing sound by using a sound machine is also quite helpful. (Consumer Reports did a study to find sound machines work better than sleeping pills.)
I often tell my busiest patients these five steps for sleep improvement (as detailed in my book: The Sleep Doctor's Diet Plan):
1) Maintain a similar sleep schedule. This is really the number one issue. When a person stays roughly on the same schedule, sleep drive is higher and the circadian rhythm is on track. As it turns out, bedtime is not as important as wake-up time. If you stay up late, or cannot fall asleep, that could actually help increase sleep drive in the case of an insomniac. But if you are a regular sleeper, staying within a 30-minute window each evening and morning (even on the weekend) will be the easiest way to improve sleep quality.
2) Eliminate caffeine after 2:00 p.m. (and stay away from energy drinks in the afternoon or evening). While tough, it really makes sense. Most people do not know it but caffeine can have anywhere from a 6-9 hour half-life. This means that it takes this long for about half of the caffeine to leave your system, which is about when it will stop affecting your sleep. Not everyone is the same. Different people have different sensitivities to caffeine. Stop by 2 o'clock and you will be able to get to sleep around 10:30 p.m. Energy drinks in general should be considered a sign to the user that there could be something that they are missing that's making them need an energy drink. While I understand using these drinks under certain circumstances, such as for a long car trip, if you are using them regularly, this is a real sign that something else may be going on.
3) Stop drinking alcohol three hours before bed. It takes the average human about an hour to digest a single alcoholic beverage. That said, if you want a beer, wine or mixed drink with dinner, even two, that is fine, but make sure that you also drink one glass of water for each beverage, and wait one hour after the last sip (per beverage) before lights out. So if you have two drinks and end your meal by 8:00 you will not want to go to bed before 10.
4) Exercise daily -- but stop about four hours before bed. One of the quickest ways to improve sleep quality is with daily exercise. About 20 minutes of aerobic exercise per day will improve sleep. But be careful and do not exercise too close to bedtime otherwise it may disrupt your ability to "wind down" for bed.
5) Get 15 minutes of sunlight every day. Most people do not know this, but sunlight re-sets your circadian rhythm, since it stops the production of melatonin. Getting just 15 minutes of direct light in the morning is a great way to burn off the "morning mental fog," get some much needed Vitamin D, and re-set your clock.
Looking at the challenges represented by a busy schedule it doesn't matter if you are a celebrity, a mother, a business person, a professional athlete or the president, following a few of these simple steps can make a huge difference.