Transcript HMN Webinar #11 - Healthy Minds Network

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Interventions to Promote Healthy
Sleeping Habits in College Populations
The Healthy Minds Network Webinar Series
Session #11, March 2015
Welcome and About The Healthy
Minds Network
The Healthy Minds Network
Research-to-practice network based at University of Michigan
Public health approach to mental health among young people
HMN Research-to-Practice Objectives:
(1) produce knowledge (research)
(2) distribute knowledge (dissemination)
(3) use knowledge (practice)
HMN Announcements
▪ Currently enrolling colleges and universities for HMN
survey studies
▪ Enhancements for 2015-2016
▪ Menu of “modules” that schools can select from
▪ After completing the survey, student respondents receive
2 things:
▪ Personalized feedback from mental health screens
▪ Customized resources
▪ HMN data interface: http://data.healthymindsnetwork.org/
Today’s Webinar: Sleep, Health,
and Optimal Performance
▪ Presenters: Dept. of Psychiatry and Behavior Sciences
Stanford University School of Medicine
Mickey Trockel, M.D., Ph.D. Clinical Assistant Professor
Britney Blair, Psy.D., CBSM Staff Psychologist and Adjunct Clinical
Faculty
▪ Discussion
Please submit questions at any point throughout the webinar using
the chat box!
Disclosures
● Dr. Trockel and Dr. Blair are compensated as part-time
consultants for SleepRate. SleepRate is a local start-up
developing a mobile sleep improvement program for
consumers.
Learning Objectives
● Why is sleep important?
● Sleep and physical health, mental health and performance.
•
How does sleep work?
● What gets in the way of good sleep?
● Sleep-Health Promotion
● Sleep Resources
● Q&A
Why is sleep important?
Health
Sleep and Health
Sleep and Health
(Taheri et al. 2004)
Sleep and Health
Long term
Habitual short sleep is associated
with increased risk for:
• Stroke
• Coronary heart disease
• Diabetes
Short term
● <7 hours sleep = THREE
TIMES greater risk for cold
compared to 8(+) hours
sleep
● Restricting sleep to 4 hours
/night turns healthy adults
into pre-diabetics
• Cardiovascular morbidity and
mortality
• All cause mortality
Cohen et al., 2009; Spiegel et al.,
1999; Kurina et al., 2013
Why is sleep important?
Performance
Sleep &
Academic Performance
● 200 first year college students (> 90%
response rate):
● Beginning of semester survey of health
behaviors, including sleep (number of hours
and timing of sleep on typical weekdays and
weekends)
● End of semester GPA obtained
(Trockel et al. 2000)
Sleep &
Academic Performance
Consistent wake-up times seem to
matter:
● Each one hour earlier average weekend wake
up time predicted a 0.11 point higher end of
semester GPA, controlling for weekday wakeup times, and employed/volunteer work hours.
(Trockel et al. 2000)
Sleep and Cognitive Performance
● Attention-intensive performance is unstable
● Errors of omission (lapses)
● Errors of commission (wrong responses)
● Performance deteriorates as task duration increases
● Psychomotor response time slows
● Cognitive slowing occurs in subject-paced tasks, whereas time
pressure increases cognitive errors
(Goel et al., 2009)
Objective and Subjective Effects
Of Sleep Deprivation
Objective
Subjective
PVT performance lapses
KSS subjective sleepiness
4h TIB
4h TIB
6h TIB
6h TIB
8h TIB
8h TIB
deficits
(Van Dongen et al. 2003)
Sleep and Cognitive
Performance
● Sleep quality and quantity associated with
learning capacity.
● Sleep affects: memory, attention, verbal
fluency, abstract thinking, and problem
solving capacity.
(Curicio et al. 2006)
Sleep and Sports Performance
Stanford men’s varsity basketball players:
● 5 to 7 weeks sleep extension
● (≥ 10 hours in bed).
(Mah et al. 2011)
Sleep and Sports Performance
After sleep extension, players had:
● Faster sprint times
● Improved shooting accuracy
● Decreased fatigue
(Mah et al. 2011)
Functional Impairment
● Effects of sleep deprivation are similar to
alcohol intoxication
● 0.05% BAC equivalence occurred after
● 17-19 hours of wakefulness
● 0.1% BAC equivalence occurred after
● 28 hours of wakefulness
(Williamson et al., 2000)
Catastrophic Consequences
January 28, 1986—American space shuttle
Challenger exploded, killing all 7 astronauts
on board just over a minute into their flight
from Cape Canaveral in Florida.
October 15, 2003 - The Staten
Island Ferry crashed into the
dock at full speed. 11 people
were killed, 71 were injured.
4:09AM March 24, 1979
Three Mile Island nuclear power plant
undergoes loss of coolant water to
core – half of the core melted. Steam
blows from TMI’s cooling towers
during the first 24 hours of the March,
1979 accident.
Drowsy Driving
• Estimates by US National Highway Traffic Safety Administration
– 100,000 police reported crashes
– > 1,500 fatalities and 71,000 injuries
– $12.5 billion in monetary losses
• Risk factors for drowsy driving crashes:
– Late night/early morning driving (0000-0700 hr)
– Patients with untreated excessive sleepiness
– People who sleep ≤ 6 hr per day
– Young adult males
– Prolonged work hours
– Night shift workers
(NHTSA, AAA)
The Magnitude of the Problem
● 60% of adult drivers say they have driven a vehicle while
feeling drowsy in the past year
● 37% have actually fallen asleep at the wheel
● 4% admit they have had an accident or near accident
because they dozed off or were too tired to drive
● 2013 UPDATE – 1 in every 24 people admitted to
falling asleep or nodding off briefly while driving in
the last month
(National Sleep Foundation’s 2005 Sleep in America poll; CDC,
2013)
Total vs. Chronic Sleep Deprivation
● 2 weeks of 4 hours time in bed per night:
● Performance deficits equivalent to 2 nights of total sleep
deprivation
● 2 weeks of 6 hours time in bed per night:
● Performance deficits equivalent to 1 night of total sleep
deprivation
● Insufficient sleep affects domains of functioning differently
● Subjective sleepiness
● Fatigue
● Objective performance
(Van Dongen et al. 2003)
How does sleep work?
Sleep is Universal
Sleep Stages
Sleep Across the Lifespan
Total Sleep Time (minutes)
700
600
500
Total time in bed
400
Awake in bed
NREM stage 1
300
REM
200
NREM stage 2
100
NREM delta
0
10
20
30
40
50
60
70
80
Age (years)
Adapted from Williams RL et al. Electroencephalography (EEG) of Human Sleep: Clinical Applications. 1974.
Sleep Wake Regulation in Humans
Sleep Drive
Wake
Circadian
Rhythm
Sleep
9am
3pm
9pm
Wake
3am
Sleep
9am
Adapted from Edgar DM, et al. J Neurosci. 1993;13:1065-1079. Courtesy of Phyllis C. Zee, MD, PhD.
Determinant of likelihood of Sleep
Behaviors
Cognitions
Conditioned arousal
Arousal
Somatic
Experience
Likelihood
of Sleep
Sleep Drive
Negative emotions
Circadian
Rhythm
Circadian Phase Type
8pm
11pm
2am
7am
10am
Neutral Sleep Phase
Tmin⇓
Delayed Phase
Difficult to
Stay awake
Still Alert
Biological Sleep Phase
Tmin⇓
Advanced Sleep Phase
Tmin⇓
Difficult to
wake up
Cannot
Sleep
Advanced Phase
What gets in the way
of good sleep?
Possible
Poor Sleep Predictors
● Caffeine / Stimulants
● Worry about Sleep
● Working until Bedtime
● Sleeping Against Bio Clock
● Alcohol
● Rigid Sleep Beliefs
● Tobacco
● Some Medications
● Eating Late
● Exercise Late
● Stress
● Kids
● Depression
● Anxiety
● Napping / Dozing
● Irregular Sleep Schedule
Morning / Afternoon / Evening
Anytime Coffee
•Effective ‘countermeasure’
against sleepiness
Caffeine blocks sleep inertia
• Long half life (5h)
Van Dongen et al. (2000)
Coffee is one of the most traded
commodities.
US imports more of it than any other
country.
Sleep Disorders
● Insomnia
● Obstructive Sleep Apnea
● Narcolepsy
● Restless Legs
● Parasomnias
● Circadian Rhythm Disorders
Insomnia
● Difficulty initiating or maintaining sleep, or non-restorative sleep for
at least 1 month.
● 30-40% of population has at least one insomnia symptom
•Rates of insomnia are higher in
• Women than men
• Older than younger
•Quality of life
• Fatigue and sleepiness
• Mood disturbances
• Impaired concentration and
cognitive performance
• Increased absenteeism
How to Get Good Sleep
Healthy Sleep Habits
Daytime
● Avoid caffeine after lunchtime
● Increase physical activity
● Light exposure in early morning
Evening
● Limit alcohol consumption in late evening
● Avoid exercising in late evening
● Protect a one-hour wind down time before bedtime
Nighttime
● Maintain a dark, quiet, and cool sleep environment
● Keep electronics out of the bedroom
● Avoid watching the clock
● Protect adequate time for sleep
When to See a Sleep Specialist
● Persistent difficulty falling asleep or staying asleep
● Daytime fatigue or sleepiness even with:
● Adequate sleep opportunity
● Reasonable sleep habits
•
•
•
Difficulty maintaining desired sleep schedule
• Difficulty managing jet lag
Witnessed apneas (gasping for air/choking)
• Chronic and/or loud snoring
Other unusual (or interfering/distressing) sleep-related symptoms
Treatment Options for Insomnia
● Cognitive Behavioral Therapy for Insomnia
● Non-Pharmacological Approach
● 4-6 Sessions - Effective
● The ‘Gold Standard’ for Insomnia Treatment
● Medication
●Prescription (e.g., Ambien, Lunesta)
●OTC (e.g., Unisom, Benadryl)
Sleep-Health Program
Sleep-Health Program
Treatment Options for Insomnia
Adapted from Sivertsen et al, 2006,
JAMA
VA Patient Cognitive Behavioral Therapy for Insomnia (CBT-I)
Outcomes: Insomnia Severity Index (ISI)
VA – CBTi Outcomes
Intent-to-Treat Analysis (Mixed Effects Model using all session scores available)
n = 696
VA – CBTi Outcomes on
Depression Scores
VA CBT-I Patient Outcomes: Beck Depression Inventory-II
Completer Analysis: n = 385
BDI-II Score
VA – CBTi
Outcomes
Quality of Life
VA CBT-I Patient Outcomes:
WHO Quality of Life-BREF
Completer Analysis: n = 374 to 395
VA – CBTi Outcomes
Suicidal Ideation
VA CBT-I Patient Outcomes:
Suicidal ideation
Completer Analysis: n = 405
• At baseline, 32% of patients, compared with 21% at final
assessment, endorsed some level of suicidal ideation [χ2
(df = 1) = 125; P < 0.001].
• Each 7-point decrease in Insomnia Severity Index (ISI)
score achieved during CBT-I treatment was associated
with a 65% reduction in odds of suicidal ideation.
• After controlling for change in depression severity, the
effect of change in insomnia severity on change in
suicidal ideation remained significant.
Resources / Bibliotherapy
SleepRate can help:
● Identifies causes of poor sleep (assessment)
● Individualized CBT strategies to address
identified causes
● Smart-phone guided CBT self-help (no human
delivery)
● Combines objective biofeedback with CBT
Sleep Assessment
● Track your sleep for 7 nights
● Identify sleep problems
● If environmental or medical conditions are
suspected
● Resolve these problems before initiating sleep
improvement plan
● Start Sleep Improvement Plan
● Individually tailored strategies are based on
assessment results
SleepRate Cognitive and
Behavioral Strategies
A Sequence of “goals” that “reboot” sleep
● Sleep schedule goals
● Strengthen circadian clock
● Consolidate sleep
● Goals to prepare for sleep
● Calm the mind
● Relax the body
● Acquired habits are reinforced while new goals
are introduced
● Success metrics include compliance and sleep
parameters
About Participating
To pose a question, please submit your question using the “Chat
Room” in the bottom corner of the screen. A moderator will then
read your question to the group.
Discussion
More Information
The Healthy Minds Network: www.healthymindsnetwork.org
[email protected]
Mickey Trockel, MD, PhD: [email protected]
Britney Blair, PsyD, CBSM: [email protected]