sleep part 2: interview with dr. amanda swain, sleep specialist

I recently spoke with Dr. Amanda Swain, a family medicine physician and sleep specialist. She had some very important and useful information about how important sleep is and how to improve your sleep. This interview has been edited for length, clarity, and style.
 
HH: I talk to my clients a lot about the importance of getting 7 to 9 hours of sleep. Talk to me a little bit about why that’s important and what may happen if someone doesn’t.
 
AS: I think he first thing people need to figure out, and people can do this with a sleep diary or sleep app (such as CBT-I coach), is how much sleep they actually need. Because not everybody needs 9 or even 8 hours. People can start to track their sleep a bit and get a sense of how they feel throughout the day on various amounts of sleep. They may note that on 9 hours, it may actually be hard to wake up and their energy isn’t as good throughout the day, but wow, if you hit that 7 hour and 15 minutes, that’s a sweet spot that’s just the right amount. So, first, experiment with how much you personally need.
 
Adequate sleep helps to support all these important processes in the body. Like the ability to concentrate, retain information, and new memory creation. All of these things that are really important to academics and work and executive functioning. And you have the impact on mood, managing stress, and anxiety and depression management. We also know that risk-taking behaviors are higher in people who don’t get enough sleep.
 
If you’re not getting enough sleep, you may be using substances as a crutch. Like caffeine to get you up in the morning and alcohol in the evening, when you want to relax and try and sleep. Or tobacco or marijuana. We do worry about people using substances to manage what could be best-managed with getting adequate sleep.
 
And then there are a whole host of physiologic effects. There have been many studies on people who get chronic sleep deprivation, and you can see that their cardiovascular system is not as healthy, so they’re at risk for coronary artery disease, strokes, diabetes, obesity, and a whole host of other medical conditions. It’s not that sleep is the only thing that people need, but it’s hard to overlook how important sleep is in supporting all these other systems. And sometimes people will look and try to figure out what to do about all these other things when you can just take a step back and say, “if we just help you sleep, you’d feel so much better”. Sleep does a lot!
 
HH: Can you say a bit more about how it impacts mood and thinking if someone is not getting enough sleep?
 
AS: Most people can probably think of a time when they were truly sleep-deprived, and they can probably remember that there was just so much more emotional lability. They could turn on a dime, felt more tearful. They were really affected by things that normally wouldn’t affect you. The world just seemed so overwhelming. That’s after only one or two nights or a week of sleep deprivation. But for people who are chronically sleep-deprived, it can really take a toll on their health exacerbating any underlying predisposition to anxiety, depression, or suicidality.
 
HH: This is good. I often talk to people about how not getting enough sleep can affect your mood and your ability to think and remember. Studies show you can be as impaired as if you were drunk if you don’t get enough sleep.
 
AS: It’s true. There are studies that show that driving while sleep-deprived is similar to driving with impairment from alcohol.
 
HH: How do you think COVID-19 has changed sleep for people? Have you seen changes with this pandemic affecting people’s sleep?
 
AS: More people have had concerns about their sleep, in general. This might be because they are spending more time in the home and have more time to focus on sleep and worry about it. It could be that the rise in anxiety in the general population has disrupted sleep. It could be that many people have lost their normal circadian cues that would usually help keep them on schedule. Or it could be due to how so many people are working in the same space where we sleep. This is very confusing for the body in terms of signaling, as the bed becomes part of so many activities. When this occurs, the bed no longer just has a strong association with sleep. If you’re doing many things on the bed, it’s not good. I think there are a whole host of reasons why people have potentially had trouble with sleep during the pandemic. This isn’t just my experience. I went to a sleep conference last month, and this is a recognized phenomenon. In North America, there has been an increase of sleep disturbance and insomnia in the past year.
 
HH: What are the things you think are most important for good sleep?
 
AS: That’s a good question. I think I’ll answer it in a slightly different way. I would say there are a few behaviors that people do to help sleep once it comes apart. If I could do anything, it would probably be to educate people on these few things to avoid doing if their sleep gets off track.
 
One very common misconception is that spending more time in bed is actually good for sleep. The rationale that people come up with, on its surface, is logical- “if I don’t get enough sleep, but I spend more time in bed, I will get more sleep”. But what often happens is that people then spend more time in bed awake, wishing they were sleeping. And so, the first thing I like to tell people is if you’re having trouble sleeping, you actually want to spend the same amount of time in bed you normally do, or better yet, spend less time in bed. What you want to do is really be sleepy enough to take advantage of your time in bed. Resisting the urge to spend more time in bed is key.
 
And the other thing that I think people lose sight of is that the bed should actually just be associated with sleep. This goes back to classical conditioning and the idea of stimulus control. If you think about little kids, you can put a child in a crib or a bed and if they’re not sleepy, they will do anything to get out of that bed because for them the bed is only associated with sleeping. As adults, we lose that association, and it becomes a substitute for a couch and for a desk and for a table to eat upon. We really want to preserve the bed as a place for bedtime. And aside from sex and sleep, we shouldn’t be using the bed for anything else. When sleep isn’t going well, you really want to limit the amount of time you spend in bed to remind your body of that association. And that will take a few weeks most likely.
 
And the third thing is that it is helpful for people to get an idea of how much sleep they need. Again, I think they could do this with a sleep diary and something that tracks how they feel through the day. If people think that 9 hours is the gold standard and that they need to get 9 hours, they may be doing themselves a disservice. It’s far better to appreciate how much sleep is just the right amount. Most people have a sweet spot, kind of like our weight. Most of us have somewhere within half an hour of where our bodies do the best in terms of amount of sleep. It’s helpful to get a sense of that and not attach any good or bad association with it. If you need 9 hours of sleep, that’s what you need. Figure it out. Make it happen. But if you’re someone that needs 7 hours, that’s fine. You don’t need to feel like you’re doing anything detrimental to your health if you don’t get 8. Those would be 3 things that come to mind.
 
HH: What is sleep hygiene?
 
AS: Sleep hygiene is just the basics of supporting your body in sleep. Sleeping in a dark cool quiet environment. Having some sort of routine associated with bedtime. Not overheating in bed because it’s going to disturb your sleep. Try not to have a screen in your face before bedtime because the bright light is going to interfere with your melatonin. Don’t eat a big meal before bed. It won’t feel good and it can set you up for acid indigestion.
 
HH: I find that I’m often talking to my clients about it. And one of the things that I find the most important is having downtime before bed. Allowing yourself to prepare for sleep.
 
AS: I agree. It’s all going back to that stimulus-control thing. You wouldn’t think of doing something high energy and super stimulating before doing something very restful. Like you wouldn’t go jogging around the block before you try to meditate. It feels a little out of sync, and it’s the same with sleep. You want to do some activities that allow you to start to disconnect and slow down and quiet your mind and your body before sleep. Now, some people find a fairly structured routine helps, but for others, they find that to be anxiety-inducing. It’s just important that people find something that works for them. And it doesn’t need to have a lot of bells and whistles. It may be something as simple as showering before bed. Or turning the screen off 30 minutes in advance, washing up, straightening up the bedroom, and getting into bed. I just never recommend that someone powers down their laptop and gets right in bed because those two activities are very different.
 
HH: I’ll often talk to people about how you have to prepare your body for sleep. And slow things down. What are your thoughts on sleep meditations to help you fall asleep?
 
AS: That’s what I kind of reference in terms of people getting focused on a bedtime routine. I kind of like to separate activities that require some concentration, like mindfulness, from bedtime. Just because If people don’t feel like they’re getting where they need to be, they’re anxious about going to bed. I tend to say, “if you want to do a mindfulness activity or a mediation, think about placing it earlier in the evening”. Just because I don’t want people to be like, “I have to relax! I have to relax!” right before bedtime. That said, if people find that’s really helpful, great, I’m all for it. As long as they have the insight about whether or not it’s revving them up or feeling like something they have to accomplish. It just depends on how they feel about it.
 
HH: That makes sense. I really like your approach, how you want to meet the person where they are. What are your thoughts on melatonin?
 
AS: Melatonin is fine for people who use it to support a circadian rhythm switch. It’s not really designed to be used as a sedative, although it can have that affect in people. Often because it’s used in elephant-sized dosages, like 5mg and 10mg doses at CVS. The clinical dosing that’s been studied is .1-.3mg, so we’re talking about much much smaller doses. So people are going to feel sleepy on larger doses, but then that often leads to headaches, some grogginess in the morning
 
HH: Are there any things that you feel are effective and safe to help someone sleep?
 
HH: Yes. There are absolutely times when medication can be helpful, like when someone is really struggling with insomnia. Or someone who, the night before an exam, does everything in their power to sleep well but the anxiety keeps them up. That might be a time that they want to use a medication. There are times to use medication. I just worry about, with melatonin or anything else, that you don’t want someone in a situation where they feel that the only reason that they can sleep is this pill or this oil or whatever it is. Because you’re not doing yourself any favors if you convince yourself that you’re unable to sleep without something that’s external. Sleep is a really really basic bodily process.
 
For most people, they don’t think about their sleep until it goes off the rails, and all of a sudden, it’s a real issue. I would just encourage people to take their sleep seriously, and if they have concerns about it, they should bring it to the attention of their physician, their psychologist, or their coach. It should be low-hanging fruit in terms of a reason to seek support.
 
 
Amanda Finegold Swain, MD is a board-certified family medicine physician who has pursued additional training in behavioral sleep medicine. She practices community-based family medicine at Penn Family Care in West Philadelphia and is a Clinical Assistant Professor in the Department of Family Medicine and Community Health. She also provides Cognitive Behavioral Therapy for Insomnia (CBT-I) through her behavioral sleep medicine practice (www.phillysleepworks.com).