What it takes to get better sleep
By Anna C. Christensen, College of Medicine – Tucson
In June, Patel visited Baltimore to participate in the 40th annual meeting jointly held by the American Academy of Sleep Medicine and the Sleep Research Society.
When Dr. Salma Patel was an internal medicine resident, her own lack of sleep led her to take an elective in sleep medicine. She fell in love with the specialty, and her patients inspired her to pursue a career as a physician-researcher.
"We kept telling our patients, 'You shouldn't sleep with your pets. They're going to disrupt your sleep,'" she recalled. "I kept hearing, 'I can't sleep without my dog! They make me feel so much more secure and I have fewer bad dreams.' I asked myself, 'What is the evidence behind that recommendation?' I looked, and there was nothing that supported that, absolutely nothing."
So Patel conducted a study on 40 humans and their 40 dogs – and found that the two species could share sleep space without compromising sleep quality. Her study challenged some conventional advice that doctors might give to patients.
That early foray into patient-centered research inspired her to continue to seek answers that would directly improve care. Now, as an associate dean of curricular affairs at the Mel and Enid Zuckerman College of Public Health and a clinical professor of medicine at the College of Medicine – Tucson, she has helped develop national treatment guidelines for chronic insomnia.
There are two main ways to treat chronic insomnia: cognitive behavioral therapy for insomnia (CBT-I) and medication. After sifting through available evidence, the American Academy of Sleep Medicine task force Patel served on recommended CBT-I as the first treatment for chronic insomnia.
"Cognitive behavioral therapy for insomnia addresses the underlying causes," Patel said. "If it doesn't work, you can consider adding a medication, but medications do not address the underlying causes and can have side effects. The effects of a pill last only as long as you take it, so you would only go to medication alone as a last resort."
Drug-free treatment for chronic insomnia
Patel (right) shared her findings at a national sleep medicine conference alongside another taskforce member, Luis Buenaver, PhD, from Johns Hopkins School of Medicine.
When Patel helps a patient with chronic insomnia, she incorporates the two key components of CBT-I: stimulus control and sleep restriction. Both hinge on the idea that healthy sleep patterns develop when we associate the bed with sleep, rather than working on our laptops, watching television, or tossing and turning.
"If you're awake for more than 15 or 20 minutes, you need to get up, do a boring activity and come back when you feel tired enough," Patel said, explaining the concept of stimulus control. "You don't want to associate the bed with being awake, because that leads to anxiety, worry and stress."
Sleep restriction relies on the counterintuitive notion of spending less time in bed, not more.
"If you were to restrict someone's time in bed to five hours a night – let's say midnight to 5 a.m., no daytime napping – within a few days, they will fall asleep and wake up with an alarm clock," Patel explained. "Then you extend it slowly until you've hit your sweet spot."
Simple steps for better sleep
Patel shares some advice for those hoping to get a better night's sleep.
- Have set bedtimes, wake-up times and nap schedules. Consistency is key. You have to keep doing it if you want to feel great the next day.
- Get plenty of light during the day to train your circadian rhythm for good sleep at night.
- When we suffer from insomnia, it feels important to increase our time in bed. However, you probably want to decrease your time in bed so you don't associate it with staying awake. If you can't fall asleep within 15 or 20 minutes, get up and do a boring activity. Go back to bed when you're tired enough to fall asleep.
- Cognitive behavior therapy remains first-line treatment for insomnia because it addresses the underlying causes of insomnia.
Marshaling evidence
Treatment guidelines were in place for CBT-I and medication on their own, but there were none for using them in combination, which is a common approach.
To help fill the gap, Patel joined an American Academy of Sleep Medicine task force. The task force's review and recommendations were recently published.
"We all put our heads together to come up with good guidelines for our patients," she said. "It was humbling to realize that not one of us has the answers, but if we were to work together, we'll come up with better answers."
Inspiring tomorrow's physician-researchers
Patel says she'd love to see one of her students or residents work on a follow-up study to the research she conducted during her own residency – perhaps looking at cats or multiple dogs.
These days, Patel has come full circle, from asking research questions as a resident to guiding medical students, residents and fellows to incorporate research into their clinical work.
"Keep the best interests of the patients in mind," she said. "That's something I try to model for my students and trainees every day."
A version of this story originally appeared on the College of Medicine – Tucson website.