Should sleep be considered a vital sign?
“Sleep is the foundation upon which everything else is built,” says Dr. Blair. Both physical and mental health problems impact sleep, and sleep going awry affects both. What’s critical is understanding and acknowledging that there’s a “bidirectionality between all of these aspects of our health and well-being.”
“Sleep is the foundation upon which everything else is built.”
For physicians, understanding sleep and its impact on a patient will make you a better clinician, whether you’re a primary care doctor or psychiatrist. “Poor sleep can tell you something else is going on,” says Dr. Masri. Insomnia, for example, can precede depression by four to five months. In men, losing a night of sleep can drop your testosterone level by as much as 20 percent, according to Dr. Masri.
Sleep is a passive, intuitive process
An effective analogy that Dr. Blair often uses for sleep patients is this: sleeping is a passive process, a lot like breathing. “If you stop, you’re going to die,” Dr. Blair says. But to trick your body into believing sleep is active won’t resolve your approach. “The same way that if you hold a gun to your head and tell yourself to fall asleep, it’s not going to happen.”
Sometimes improving a patient’s sleep is not always about the sleep itself. “When we have folks who are brilliant, type A, hyperactive overachievers and their sleep goes haywire… they put everything in the kitchen sink into solving the problem, which then makes the problem worse,” she explains. So the task becomes figuring out how to make the active problem solver embrace the passive, mindful process of sleep.
Dr. Masri agrees that forcing sleep is futile. “The more performative endeavor sleep is, the less likely you are to succeed,” says Dr. Masri. “This is not a work performance. This is not an athletic optimization program.” Both doctors agree that consistency in sleep is critical.
Sex and alcohol have the opposite effects on sleep
“For many people an orgasm before bed actually causes a relaxation response, and induces sleep, so it can be fantastic for sleep,” says Dr. Blair, whose work overlaps between sexual and sleep health — two of our most vulnerable states of being as humans, she says.
Alcohol is not good for your sleep, says Dr. Masri, but it’s more so related to how it’s connected to socializing that keeps you awake to disrupt your circadian rhythms.
Alarms should be treated more as a backup to your natural wake time
With work and family obligations, the need for an alarm is often unquestionable. However, Dr. Masri suggests using an alarm as a backup to a natural wake time, if possible. “I always say [the] best sleep is organic sleep that’s not disrupted. You want to sleep how we slept thousands and thousands of years ago,” he says.
“I always say [the] best sleep is organic sleep that’s not disrupted. You want to sleep how we slept thousands and thousands of years ago.”
It can take up to two weeks to get to this consistent wake time where the alarm is your backup. You can train your biological clock by getting up at the same time every day, and soon you will start to feel sleepy earlier and earlier in the evening. One tip is to not get into bed until your eyelids start to feel sleepy. “Even if I’m tired – meaning my body wants to sit on the couch or relax, but my eyelids are wide open – I don’t want to be getting into bed,” explains Dr. Blair. “The best thing you can do is make sure you’re getting up at the same time every single day come hell or high water. And what happens as a result, is you start to get sleepy at the same time every day.”
“The best thing you can do is make sure you’re getting up at the same time every single day come hell or high water.”
Dr. Masri suggests using an alarm as a signal to start winding down your day. If you want to go to bed at 11 PM, set an alarm for 9:30 or 10. “The more you’re a night owl, the more you need a longer wind down,” says Dr. Masri.
Sleep aids can be useful when taking the right dosage or if used sparingly
The optimal dosage of melatonin is micrograms as opposed to milligrams, but people shouldn’t become reliant on it. “The best way to use melatonin is actually to help reset your circadian rhythm,” Dr. Masri explains. It can be useful “if you’re having jet lag, or you’re a bit of a night owl and you want to shift your circadian rhythm.” Taking it five hours before your desired bedtime at around 300 to 500 micrograms is the drug’s optimal dose for both use cases. Intermittently, three to five milligrams are fine. However, Dr. Masri suggests never taking more than ten milligrams because it can affect hormones and blood pressure.
Two other drugs that can be used effectively are Xanax and Ambien. Both these drugs are best used once in a while if necessary, but should be used sparingly to prevent developing an attachment.
Benadryl is one sleep aid that can have poor health effects. There are two problems with the drug’s main ingredient diphenhydramine – it affects acetylcholine, an important neurotransmitter that gives us good REM sleep and helps with cognition functioning. Diphenhydramine lasts a long time in our system, so it can set one up for poor quality sleep as well as brain fog.
Sleep studies are less invasive than they used to be and should be used to prevent the range of health effects caused by sleep apnea
If your snoring is loud, if you’re not getting quality sleep and are chronically tired, that’s a “reasonable time to think about a sleep study,” says Dr. Masri.
Snoring, especially, can be a sign of sleep apnea, “which is a severe condition,” explains Dr. Masri. “It can cause things like heart attack and stroke and can worsen your blood pressure, sexual health, and mood.”
The assumption that you have to be overweight to have sleep apnea is not correct, according to Dr. Masri, as it’s ultimately an upper airway anatomy issue. In clinical sleep studies, sleep apnea can be measured by a “number of events per hour” that disrupt sleep. (Note that snoring is “never normal” in children. Sleep apnea should be diagnosed early since even mild apnea disrupts deep sleep, which is key to children’s growth and development.)
Sleep studies are much less invasive than they historically have been. “We can get really robust data with very minimal intervention,” Dr. Blair says, and it can often be done in the comfort of a patient’s home. Both doctors like to get data from at least three nights within a period of a week or two.
A new study shows that most people need just seven hours of sleep, but we sleep best on our own circadian rhythm
While the World Health Organization has said that adults need between seven and nine hours of sleep, a more recent study suggests that most people need just around seven hours. Those who need less than seven and more than nine are “exponentially small” compared to most sleepers.
On the extreme ends of the sleep spectrum, Dr. Blair identifies two types of sleepers: the night owl and the morning lark. The morning larks tend to be tired around 8:30 and 9:30 PM, and bright-eyed and bushy tailed around 5 or 6 AM. On the contrary is the night owl, who doesn’t get tired until later and has a difficult time waking up early. Most of us, however, fall into what she calls a neutral sleep range. “We get sleepy around 11 PM, [and] start to be wakeful around 7 AM,” she says.
The key is understanding where you fit into the sleep paradigm, and not judging or willing yourself into a sleep archetype you’re not. “You’re productive on your own circadian rhythm, and there’s nothing wrong with that,” says Dr. Masri.