Night and Day: The Essential Role of Sleep Medicine

Sleep is generally more complex than how many hours you slept last night.

Posted Jul 23, 2019

Sleep is truly the other half of our waking lives, as well as an essential half of modern psychiatry. During sleep, our brains recharge the neurotransmitters that are so important to our mood and thinking—dopamine, norepinephrine, and serotonin, to name a few. Training in both psychiatry and sleep medicine has allowed me a unique perspective on these two highly related fields of medicine, which, unfortunately, tend to be practiced in isolation of each other. Through this unique perspective, I have seen some truly remarkable breakthroughs in difficult, treatment-resistant cases. A careful analysis and understanding of sleep and sleep architecture has made this possible. “If there is no gas in the tank, you can’t push the gas pedal,” is something I often say to my clients, because indeed, if you are not well-rested and recharged, not much will work.

The effects of sleep on psychiatry cannot be understated. In a study by the Gallup organization, “Sleep in America,” people with impaired sleep suffered some significant daytime consequences. Individuals with frequent sleep difficulty, had a 3- to 5-fold higher incidence of problems coping, accomplishing tasks, and suffering from low mood. Their family and relationships suffered as well, with a similar worsening in personal relationships, as well as social and family life. 

Besides having a marked negative impact on emotional and mental well-being, sleep can also be a warning sign for more serious psych-related conditions. In my experience “sleep, sex, and drugs (including alcohol),” are all the “tips of the iceberg,” and when something is wrong in one of these domains, it usually points to something deeper below the surface. In a large scale analysis of about 1,000 patients, insomnia was a strong predictor of increased risk for depression, anxiety, and substance use. In the case of depression, insomnia was associated with nearly a four-fold increased risk of depression at follow up, in 3.5 years. The graph below illustrates what a warning sign insomnia alone can be.

The bad news is that we live in an ever busy, 24/7 society in which our days have effectively squeezed out our nights. We are sleeping less than ever, and while some have questioned how much sleep we really need, the line at Starbucks and popularity of energy drinks illustrates we probably need more than we’re getting. The rise in the use of stimulant drugs further supports this point.

The good news is that for most healthy sleep-deprived people, allowing the time for our minds and bodies to de-stress and have a chance to sleep, does a lot of good. Our bodies do this quite well, naturally, and it’s a matter of allowing our biology a chance to do so. Regular sleep schedules, no screens in bed, and getting some exercise can do a tremendous amount of good. In the words of Alan Watts, “Muddy water is best cleared by leaving it alone.” The human mind, is not much different. Leave it alone, and it will settle itself. But you have to leave it alone – and this may take practice and patience.

For those working with either a sleep doctor or a psychiatrist, or planning to do so, it is so important to realize how connected these two fields are. Make sure your psychiatrist is aware of any sleep issue—whether its sleep apnea, insomnia or restless legs syndrome. Certainly make sure your sleep doctor is aware of any psych issues or medications. Ideally have your doctors be able to communicate about your care, given the tremendous overlap between these two. As there are so few practitioners of psychiatry and sleep, it might be up to you to learn more on this topic. Sleep is generally more complex than how many hours you slept last night, and at minimum quality is as important as quantity. My hope is that these articles will be a good starting point.

Copyright Alex Dimitriu, M.D.