Activity Transcript

Hansa Bhargava, MD: Hello, I'm Dr Hansa Bhargava, chief medical officer at Medscape Education. Welcome to this program titled ''Lack of Sleep and the Impact on Mental Health and Wellness.'' Joining me today is Dr Charles Vega, who is associate dean and clinical professor at UC Irvine. Welcome Dr Vega. Can you let the audience know a little bit about yourself?

Charles P. Vega. MD, FAAFP: Yeah, certainly. I am a clinical professor of family medicine. I'm actually right now in our beautiful community health center, the largest safety net clinic in Orange County, California, where I've worked for 26 years. And that's my primary job is taking care of a wide range of patients on a daily basis, but I do some administrative and leadership functions within the School of Medicine here at UCI as well.

Dr Bhargava: Wonderful. Well, thank you for joining us. This is such an important conversation. Audience members also, thank you so much for joining us. We're hoping to speak about several topics around awareness and sleep, as well as its impact on mental and physical health. We will be talking about who's at risk, inequities, why sleep's important, why we as health professionals need to address it, the impact of technology, and frontline interventions.

Let's get started. Sleep is an issue, right, Chuck? It seems that even though the Centers for Disease Control and Prevention (CDC) recommends 9 to 12 hours for children age 12, 8 to 10 for adolescents, and 7 or more for adults, maybe our nation is not really getting there. What would you say?

Dr Vega: Right. I think you're absolutely right. Especially when I see those numbers for children, having school-aged children myself and having once been a child 70 or 80 years ago it feels like, those numbers are intimidating. The next slide is going to say something to the effect of we're not coming close. But especially for kids and especially for adolescents, I think we're really failing them. You probably know that very well for your pediatric practice.

Dr Bhargava: I'll tell you, I'm a parent myself. It is a battle. Seeing that there has been some advocacy around late start times because of the changes in circadian rhythm, but certainly over two-thirds are not getting enough sleep. It is concerning.

Dr Vega: It's also a great area though for intervention, in that when we think about using behavioral techniques to improve sleep, particularly set sleep times and wake times, that is most effective among children. It works okay for adults, but it really works in excellent fashion particularly for younger kids. As you can imagine, it did make sense. It's a great way to improve sleep duration, sleep quality. Really got to enforce those rules. Even though you and I both struggle on a nightly basis likely with the enforcement of those rules, they really do work.

Dr Bhargava: Do you think that physicians ourselves, do you think that we have enough education around sleep as medical students, as residents, as junior faculty?

Dr Vega: No. I don't think that sleep is emphasized nearly enough across the spectrum of healthcare professionals. Maybe a few hours or less in medical school, a couple hours in nursing education. With all that we know now about sleep science and just how important sleep is to general health and preventive care as well because we're really trying to stave off significant issues such as obesity or cardiovascular disease or mental health disorders, we really need to think about sleep more often and instill that training in our learners from an early time.

Dr Bhargava: Let's just go back to a couple of the elements of physical health that you touched on. What is the impact, just as a reminder, for people who are not getting enough sleep? I feel like there's physical impact and mental emotional impact.

Dr Vega: Sure. And of course, they're intertwined. If you're having sleep apnea, if you're having hypertension, all of these are associated with worse quality of life, more stress, and greater propensity towards depression and anxiety, which can in turn, in and of themselves, make sleep worse. But for both adults and kids, obesity is associated with chronic lack of sleep, that leads to higher rates of diabetes associated with poor duration of sleep as well. Cardiovascular disease, interestingly, it's at both sides of sleep duration. Folks who have very short duration of sleep, under 6 hours, as well as those who sleep 9 hours per night or longer are both at higher risk for cardiovascular events as adults.

Chronic insomnia is associated with hypertension as well. There are more subtle things that patients don't necessarily know about in terms of their outcomes, but it's associated with worse immunity, it's associated with chronic inflammation, can hurt libido. A very important group in my practice is folks living with chronic pain. That's another cyclical relationship. When patients have more insomnia, the pain feels worse and then they sleep less. One feeds into the other. My goal as a clinician is to break that cycle, improve the sleep and improve the chronic pain.

Dr Bhargava: Absolutely. You make such a good point about the chronic pain. The perception of pain, as well as the perception of stress probably can be impacted by lack of sleep. But there are certain groups that are probably even more at risk. Can you tell us a little bit about that, Chuck?

Dr Vega: Well, I'd love to hear your perspective, but I'll blanket for your benefit, but it is true that all kids and adolescents should be screened for sleep. That's part of a well-child examination. It should be every time they're in for a well-child, you're getting information about their sleep, because we're not making, excuse me, the mark for really the majority of kids, particularly adolescents, are not getting their recommended amount of sleep. Other groups where I'm very interested and feel like I want to proactively screen for sleep disorders and screen for fatigue are those with known sleep disorders, sleep apnea being the most common in my practice.

Those who have mental health diagnoses, a lot of mood disorders, but thought disorders as well. We take care of everyone here in our clinic. Substance use disorders also obviously associated with more disorganized sleep. And then 2 other special groups that I really look out for, the chronic pain patients I mentioned and then anyone who's a shift worker. About 20% of US adults do some kind of shift work. I think that we've seen that more in the economy that we have where more folks are gigging, doing something on the side of their regular job. If you have a regular job for 6 hours a day and then you drive or deliver or whatever for another 5, your sleep is going to be affected by that.

Dr Bhargava: Yeah, I think the shift work issue is certainly an important one, but then there's other situations as well, such as those who travel across multiple time zones. And also, something we've probably both experienced is a couple with a newborn baby. That can certainly impact sleep as well. It's interesting though, Chuck, because the ramifications of the pediatrician seeing moms with newborn babies and dads with newborn babies, I mean, it really does impact their ability to be fully there for their baby.

But also from the breastfeeding perspective, sleep can actually have direct impact on breast milk production. There's just so many consequences of not being able to sleep. I almost feel like I sometimes recommend to families that just like you have food trains with people delivering food, have somebody come in for shifts so you can actually get some sleep when you have a newborn baby.

Dr Vega: Oh yes, yes. I think that's a good time to get that schedule up and divvy it up. We talked about scheduled sleep. Sure, it may be at 3:00 in the afternoon when you have a newborn, but that could be some precious hours that you get and keeps you well and keeps baby well too. You're absolutely right.

Dr Bhargava: Absolutely. Let's talk a little bit about inequities. There are groups of people who are probably at risk for sleep disorders and barriers to treatment. Do you have any thoughts on that, Chuck?

Dr Vega: Yeah, I have pretty strong thoughts on it. I think that being low income and just living in an unsafe neighborhood, all of these things are risk factors for poor sleep. Just chronic stress, chronic stress is more common among low-income communities of color. They also have less access to things like green space or healthy diet, which are part of good sleep hygiene. In addition, they're more likely to be shift workers. There's a number of factors that stack against folks in those communities.

I would say also in rural communities because they're affected by a lack of access to care. We'll talk about technology, but I think that could be something of an equalizer. Good sleep hygiene is something that once you get folks who can give you good advice, I think it can be very, very effective. It's harder to get in certain situations, especially when you lack a usual source of care. Now, there are some additional tools that we can use in terms of tech to try to help folks reduce stress and improve sleep.

Dr Bhargava: Yeah, absolutely. I would point out, I just want to underline something you said, Chuck, and that's basically that those in lower socioeconomic circumstances may have compounding variables for lack of sleep, right? I mean, they are stressed, as you said, potentially because one-quarter of the kids in this nation don't have enough food on the table. We know that about food insecurity. They may be stressed because of jobs or income issues, but also, they may live with a large group of people in a small home or even in an urban environment where there's noise pollution. Would you agree?

Dr Vega: I absolutely agree. And then there are other risks, especially during infancy with co-sleeping and the risk for sudden infant death syndrome. These are real risks, again, disproportionately found in particularly low-income communities of color. I think that just chronic stress, when a community is experiencing chronic stress. Racism and bigotry are part of that as well. That's another chronic stress that can worsen sleep. I recognize that. I think that that is yet another consideration.

We screen adults for their mental health, but when something seems off... One of the most common symptoms I hear all day are stress and fatigue, definitely have to think about sleep among those individuals as well. Getting an idea about duration of sleep, their timing of sleep, their sleep environment, and symptoms during the day and any consequences of disorganized sleep I think are really important to gather.

Dr Bhargava: Yeah, absolutely. Let's turn to the biochemical basis of sleep. Why is sleep important? Can you walk us through the critical functions that happen during sleep, Chuck?

Dr Vega: It's obviously those deeper levels of sleep that are really the restorative and the healthiest part of sleep. Sleep comes in waves throughout the night. Really you want to get to that deep sleep phase 3 stage. That's where a lot of the I think extra brain type of activities happen, in that that's a time for tissue growth and repair. There's that dip in blood pressure. That's so important to have that dip in blood pressure during sleep. Those who don't have it have a higher risk for cardiovascular events; that's well demonstrated. It's also where we get to improve our immune system, so that's when their immune function is going on.

That's the non-rapid eye movement (non-REM) deep sleep. There are some important elements going on within the central nervous system as well, but it's that deep sleep non-REM where we see more of these important cardiovascular or immune functions of sleep going on. But in addition, there is this concept that the cerebrospinal fluid (CSF) is actually flushing toxins from the brain during phase 3 non-REM sleep. That's also where learning and memory happened, as well as REM sleep is important for long-term memory storage as well. Think of the movie ''Inside Out,'' for example. There's actually a fair amount of science in that movie.

As a parent, you probably saw it. Yes, you can check it out as a fun way to learn a little bit more about how our brain works.

Dr Bhargava: Personally, I've experienced this, I've certainly seen it with my patients, but sometimes lack of sleep can absolutely impair your ability to get words out, for example, to focus. You tend to eat worse. You have difficulty concentrating. There's a lot of, I guess, not soft effects, but certainly a long list that's even outside of the main effects I think, right?

Dr Vega: Those can absolutely mimic major depressive disorder. They can absolutely mimic dementia. If you don't inquire about sleep, you may not know. It's also very important to have a trusted contact. Usually say for sleep apnea, half the time it's not the patient reporting it. It's their partner. Trying to get someone who's witnessed sleep and looking for sleep related events such as apneic events is a very important part of the history as well.

Dr Bhargava: Absolutely. How do we address the lack of sleep in our patients? What can we do? I will just underline 1 other area, Chuck, that you and I talked about a little bit previously, and that's workplace accidents. Workplace accidents are often attributed to the lack of sleep, right?

Dr Vega: I think that absolutely gets people's attention because it's not just you. I think we have a culture, unfortunately, and maybe it's particularly true in the United States of, well, we're just going to tough it out. I'll sleep when I die. Sleep is not really valued as a good health maintenance tool, but it is so critical. The more we know about sleep, boy, we just seem to know more and more how it's involved in all these systems, not just central nervous system (CNS).

But one of I think the most dramatic examples of sleep as a public health concern are major accidents like the Exxon Valdez spill or the Three Mile Island nuclear plant accident, which poor sleep contributed to those accidents because of exactly we said, a lack of attention, a lack of working memory, all of these things. We're impaired when we don't sleep. Unfortunately, that can hurt not just us, in fact, it does not just hurt us, it can potentially hurt others as well. Motor vehicle accidents is another great example.

Dr Bhargava: Yeah, absolutely. I mean, some of the stats are astonishing. For example, in 2005, drowsy driving contributed to 100,000 motor vehicle accidents and 1,500 deaths. That is really something. I wonder if we should have a little bit more attention paid to this factor that it can actually be a public threat in some ways.

Dr Vega: Well, I think that particularly among my folks who do shift work, they do have to realize that they're getting less than 6 hours of sleep per night. Their risk of having an accident goes up by about a third. It's equivalent in terms of the frequency of accidents to folks who have blood alcohol concentration of 0.05%, which in some place is a legal limit. Yes, really poor sleep, especially more chronically, essentially, it's impaired driving. You could hurt yourself, someone else, and you could be held liable certainly for that as well.

Dr Bhargava: Chuck, you and I are both clinicians and we know that doctors and nurses are overwhelmed with all the tasks they currently have to do, but yet this is an important enough problem that we definitely need to make a difference. What can we do? I mean, let me just open that question up. What do you think we can do to make a difference from your perspective?

Dr Vega: Well, I think we keep our attention open. We screen for folks who are appropriate to screen for sleep, the groups I mentioned earlier. For folks with fatigue, we're always going to talk about sleep. Just being aware is a good first step. My patients generally don't understand sleep hygiene at all. It's just as little as education as we have had as healthcare professionals, patients and the public awareness is near zero. They're lying in bed and trying harder to sleep. They're watching television for an inappropriate amount of time. They have really warm bedrooms that really aren't conducive. They're also well-lit and noisy.

Basically, hygiene is always my first intervention, and a little education can go a long way, and also just to reduce the stress and anxiety around sleep. If you follow these techniques over time, they will be successful. I think you will get greater duration and quality of sleep. If not, I think about polysomnography. You could always think about cognitive behavioral therapy if you're lucky enough to have that resource that's close to you. Involving a team here approach is a good idea.

Dr Bhargava: Now, we have seen a lot of growth in new technologies that claim that they could actually help sleep or monitoring of sleep. What are your thoughts about that, and do you think that they could actually have an impact on sleep?

Dr Vega: What I've seen is that I know that some apps and some of the new technologies can result in subjective improvements in stress levels and sense of well-being. I don't know how well they correlate with important sleep outcomes, an Epworth Sleepiness Scale or actigraphy to actually objectively measure sleep latency and sleep duration. Generally, I try the older techniques first. But if patients want to try one of these technologies, I think that's great. But at the same time, we have to recognize that technology is unfortunately also driving up a lot of poor sleep right now because of device use and overuse, particularly at bedtime.

We really want to keep devices out. We want to recognize that that blue light is quite sleep disruptive. If you have your phone right next to your bed, that is not the place to have it. You need a filter, or better yet just put it in a different room. Really make sure that it's in that room and that you've got devices off, all electronics off at least 30 minutes before it's bedtime. I feel like that when applied correctly, I think it's valuable. I think using 6 different interventions at once is going to be disruptive to the sleep process and probably not helpful but introducing serially, one by one.

Anything that improves the sense of stress and well-being is likely to work over time. I'm confident that a lot of these apps and/or devices can be effective.

Dr Bhargava: Yeah, I do agree with you. I think the devices, it's not just the blue light, but also the doom scrolling and also the FOMO where you feel like you have to be checking your emails or your social media constantly. When the phone is sitting by your bed, it just seems so easy to just pick it up and say, "Oh, well, let me see what else is on X social media, and let me see if somebody responded to my email."

I do agree with you, there's so many reasons why the phone really should not be next to your bed. However, most of us unfortunately end up having that. Are there any games or technology that you're aware of that could actually help us not reach for that phone? For example, is there gamification techniques?

Dr Vega: Oh, sure. There are some things you can do. Yes, there absolutely are apps that can help you to calm down, that use some stories and/or even some games that are repetitive and therefore can increase sleepiness. But I just want to clarify, FOMO is fear of missing out. I didn't know this until yesterday. But yes, I think that it's really just a change in mindset. I think it's making individuals, and, in my case, my patients understand the value of sleep. Talking about some of the long-term sequela but talking about their everyday function. Wouldn't you like to be able to focus more? Wouldn't you like to have better energy? It really was scary when you fell asleep at that red light, wasn't it? I think that trying to find some motivational techniques where patients can shift off, of maybe just that high pace and the stress of everyday life and learn to carve out some time, especially for sleep intentionally. I think that's really a key turning moment for a lot of folks.

Dr Bhargava: I do agree with you. I think intentionally is very, very important. It's just something that we need to take as importantly as diet or exercise to have that wellness, because there's all these ramifications from a physical and mental health perspective. As we close out this discussion, I do want to ask you, is there anything else that you have noticed in your practice, Chuck, or you would like to talk about to the clinicians that are watching this about how to make a change for our patients?

Dr Vega: Well, I think that the nice thing about Medscape, and thanks so much for having me on your program, is that it has a broad range of access. For the folks working in the emergency department, seeing somebody who did fall asleep and dozed off and got in a motor vehicle accident, I mean, that patient's going to be very prime to hear about how sleep contribute to the accident. And therefore, they really need to work on their sleep. Follow up with your healthcare team, with your primary care, with your pharmacist. In hospital insomnia is very common. Folks don't sleep well in the hospital. A lot of times they're being observed.

They're usually at home struggling to sleep. Now they're struggling to sleep in the hospital. Nursing has a great role to play here in terms of identification and making sure patients are aware that's not normal. Again, get follow up. The pharmacy as well. There are a lot of over-the-counter sleep aids. Patients who are using those habitually oftentimes without necessarily me even knowing about as their primary care provider, pharmacists can be that link. They can make sure the patient's med list is completed, that this is what they're taking.

They could also advise the patients to come to us, because there very much could be something else going on, sleep apnea, depression, et cetera. Poor sleep is associated with high risk for both suicide and mortality as well. Therefore, we really need to take it seriously, but it starts with our patients and them realizing, hey, this is something quite serious that's affecting my health that I need to address.

Dr Bhargava: Absolutely. Behavioral change is a great challenge for all of us and for our patients too. I mean, we're on the other side as well. It's not easy to adopt the lifestyle measures when you are running around, you might be stressed, and there are a lot of things going on. But I think to your point, Chuck, that opportunity, if there's been a motor vehicle accident or somebody comes in depressed to talk through that is really, really important.

Dr Vega: Yeah, for sure. It can be those moments of clarity when patients... Even if they maybe have ignored the problem for years, but they lock in and they're more willing to make a change. And then it's just having them find the change they really want to start with and going from there.

Dr Bhargava: Absolutely. Well, Chuck, thank you so much for being with us today and helping me and discussing this very important topic. We really appreciate it. And to our audience, thank you so much for being here. I look forward to speaking with you more about mental health wellness and the factors that impact mental health. Thank you.

This transcript has not been copyedited.