Sleep and Mental Health Disorders An Overlooked Treatment Issue

Foreign. Hey there, everybody. And welcome to today's presentation on sleep disturbances, impact and intervention. I'm your host, Dr. Donnelly Snipes. In this continuing education presentation, we're going to learn about sleep, its functions, the different sleep cycles, how much is really enough, how lack of sleep contributes to feelings of depression, anxiety and irritability. We'll understand the connection between sleep and circadian rhythms. And finally, we'll review some techniques for improving your sleep hygiene. People whose circadian rhythms are off often have difficulty getting restful sleep. Now remember, circadian rhythms are far bigger than just sleep. But when circadian rhythms are off, people often have difficulty getting restful sleep. When your circadian rhythms are off, you usually have higher cortisol levels that stress hormone. And remember, when stress hormone levels are high, serotonin and melatonin levels are going to be low. People whose circadian rhythms are off often report being tired at all the wrong times. Your circadian rhythm tells your body to secrete cortisol at its highest amount in the morning. That's that awakening response. And then it's supposed to decrease throughout the day. And if it's not doing that, then you're not going to know when it's time to be awake, when it's time to be sleepy. They also have difficulty concentrating and often confuse sleep and hunger cues. Now, it's important to recognize that if your sleep is poor quality or inadequate, that's one of many things that will throw your circadian rhythms off. Likewise, as I already mentioned, if your circadian rhythms are off, it will impair your sleep. So it's a sort of a downward negative cycle. What are the prevalence of sleep disturbances, though? How. Why do we care? In 4 to 22% of adults, we see symptoms that meet the criteria for insomnia disorder. So those of you who have difficulty sleeping, you're not alone. 40 to 50% of people with comorbid mental illness report symptoms of insomnia. Now, that's a big number. And we're starting to recognize that adenosine, one of the substances that's cleared out during good sleep, is connected to or maybe connected to mood disturbances. So that's an interesting new avenue of research that's happening here in 2023. But do recognize that these things work? You know, sort of that chicken or egg, which came first, the insomnia or the depression? But it doesn't really matter. We need to treat both of them, and as one gets better, likely the other one is probably going to improve hypersomnolence or sleeping. Too much impacts 5 to 33% of Americans. So that's a big number. And one of the things that we see with hypersol somnolence is somnolence is that people who sleep too much are usually getting poor quality sleep when they are sleeping, and then they're sleeping throughout the day. So their circadian rhythms are a complete mess. Circadian rhythm sleep disorder accounts for about 3% of people. And that's just a one of the labels that we can put on sleep disorders. Obstructive sleep apnea impacts 15 to 30% of males and 10 to 15% of females. Now, normally, I try to give you an idea in terms of numbers instead of percentages, because those percentages don't sound huge. But when you think of it in terms of 1 in 10 or 2 out of every 20 people have obstructive sleep apnea. Wow. You know, look around you and it's really easy to see how quickly that adds up. And 4 to 14% of people struggle with restless legs. Now, these sleep disorders may be ongoing or they may be episodic. So when somebody's having a episode of major depressive disorder, their insomnia may get worse. It's, we're not saying here that everybody experiences this or 33% of Americans experience hypersomnolence all the time, but they have gone through periods where they had hypersomnolence. So there are four things that we really want to look at when we as clinicians, counselors, social workers, do an assessment, do a mental health assessment or a behavioral health assessment that include some sleep because sleep is so incredibly important in the recovery process. The first one is sleep latency. How long does it take the person to get to sleep? And we want to look at sleep latency for the first time they go to sleep. You know, the first time they lay down at night, how long does it take to get them to get to sleep? But then also how long does it take for them to get back to sleep if they wake up during the night? So there are multiple little sleep latency snapshots that we want to get, because if they can fall asleep really quickly at first, but then they wake up three hours later and they're awake for two hours, that's, you know, something to be aware of. The next thing is we want to look at the wake after sleep onset duration. So how long is it between the time they lay down and, and the time they wake up? And for some people it's seven, eight, nine hours more for other people it's two hours. So if they typically fall asleep and sleep for two or three hours and then wake up. That's important for us to know. And then we want to find out how long does it take you to get back to sleep? How many awakenings do you have during the night? And there's a lot of reasons that we're going to talk about that people wake up during the night. Some of them are very preventable through good sleep hygiene. Others may have to do with medical conditions that can be addressed by a physician. And what is your sleep efficiency? And basically, you take the number of hours the person's in the bed and you add up how many hours during that period of time they were actually asleep. So if they were in bed for eight hours and they were awake for a grand total of 20 minutes, then their sleep efficiency would be seven hours and 40 minutes. But if they were in bed for eight hours and they were awake for three hours in the middle of the night, then their sleep efficiency would only be five hours. And that's really important. It's not just about how much time you're into bed. And we'll find it's not necessarily just about how much time that you are asleep if you're not getting good quality, quality sleep. So we want to look at all of these things. I will note here two things. One, it is normal for people to kind of wake up when they cycle through their sleep phases when they're in phase one, non REM sleep. That's not unusual. But most people either don't even realize it or they very quickly go back to sleep. They roll over, they pull the COVID over themselves, they go back to sleep. It's not disruptive. It's also important that we don't have our clients get too hung up on managing their sleep and getting better quality sleep. And I know I sound like I'm contradicting myself, don't I? A lot of fitness trackers, for example, have sleep monitoring capabilities, but they are not very accurate. So unless the person is working with a sleep physician and has actual medical grade sleep monitoring equipment, then trying to monitor their sleep quality, how much deep sleep they're getting versus light sleep is probably in most cases going to add more stress and contribute to more sleep dysfunction than if they didn't look at it at all. So when we are monitoring sleep, what we really want to look at, we don't want to get too far down in the weeds. How long is it taking you to get to sleep? How many, how many times do you wake up? And what is your sleep Efficiency. So we want to have people kind of look at that so we can get a picture. And if it looks like they're having regular difficulty getting adequate amounts of sleep, or if we recognize that they're getting adequate sleep but that's they're waking up and they're not feeling rested, then we want to make a referral. I've talked about the importance of sleep, but I really haven't articulated why sleep is when your body rests and restores. Adequate sleep improves memory and learning, increases attention and creativity, and aids in concentration and decision making. All right, so stop right there. Think about the children that we work with who have behavioral disorders, who have difficulty learning, who have difficulty focusing and concentrating. Now, granted, there are other things that can contribute to that. However, we also want to rule out the obvious. Poor sleep, poor nutrition. Sleep is a time when the body rests and restores. If there's not good quality sleep, the person is going to have brain fog in the morning. If there's not good quality sleep, the person is actually going to be a lot more likely to get sick. Toxins that accumulate in the brain are thought to be cleared out during sleep. Adenosine is one of those that I was mentioning earlier. Healing and repair of cells takes place during sleep. And sleep helps the body maintain the balance of hormones in the body. And this is important to recognize. It's not just your hunger and satiation hormones, but it's also your insulin. It's also your gonadal hormones. So sleep, by virtue of helping the body stay healthy and functioning efficiently, and by virtue of helping maintain that circadian rhythm, we will help manage some of these things. And the hunger and satiation hormones, for example, may impact a person who is having difficulty managing their food intake. We look at the criteria for depression, for example, and it's a significant change in eating habits. Well, part of that could be because they're not getting good quality sleep and their circadian rhythms are off. Sleep also allows the brain to focus on rebuilding and repairing itself. They found that animals deprived entirely of sleep lose all immune function and die in just a matter of weeks. Now, obviously, it's a cruel experiment in my opinion, but this is zero sleep. Prisoners deprived of sleep entirely often develop psychoses. New parents deprived of sleep often have difficulty with memory and concentration. How many of us have referred to and. And in my day we called it mommy mind. But when you have new children at home or even a new puppy that has to go out every three, four hours, you're not getting good sleep. How many of us have difficulty thinking clearly and being on our aame. Well, that's because we're not getting good sleep. Muscle growth, tissue repair, protein synthesis and growth hormone release occur mostly or in some cases only during sleep. And there's been a flurry of advertisements and everything over the past few years about the importance of growth hormone to stave off the aging process and stay young and blah, blah, blah. Well, okay, if that's going to help motivate you to get good sleep, wonderful. But it is important to recognize that poor sleep contributes to the buildup of toxins, oxidative stress, and you're not going to have the same level of release of growth hormone. So you are actually contributing to expediting the aging process. Other rejuvenating aspects of sleep are specific to the brain and cognitive function. While we're awake. Here's that thing I keep talking about. Adenosine. While we're awake, neurons in the brain produce adenosine. That's kind of the byproduct of thinking, if you will. The buildup of adenosine in the brain may lead to our perception of feeling tired. They call it sleep pressure. As adenosine goes up, sleep pressure goes up. And as adenosine goes down, we start to feel more awake and alert. Sleep deficiency is also linked to a higher risk of cardiovascular disease, stroke, diabetes, kidney disease, and just plain old systemic inflammation. When you are sleep deprived, your body registers that as a stressor and in its infinite wisdom tries to help you stay awake and alert. Which means triggering that HPA axis, triggering that stress response. And when that goes on for an indefinite period of time, the cortisol lose its ant, loses its anti inflammatory abilities, you become resistant to the cortisol and you start to see systemic inflammation. And we know that systemic inflammation is correlated with increases in pain, increases in sleep disturbances, increases in mood disturbances. You know, it just kind of spirals from there. So this is all, all connected. Sleep deprivation is also correlated to difficulty concentrating, irritability and fatigue. Now why do I have those three set out in particular? Because those three in particular, and also, I should add, changes in eating. But those are symptoms of a variety of mental health issues. So if we're just saying, okay, you've got depression and we're treating their cognitions, well, that's great. You know, there's probably some work to be done there. But if they don't start getting good quality sleep, if they don't start regulating that circadian rhythm, some of those symptoms may not improve at least nearly as much as they could Sleep disorders are often accompanied by DSM 5 trips diagnoses. So these are official psychiatric diagnoses, including depression and anxiety, cognitive disorders, substance use and non substance use disorders. So for example gambling disorder and other medical conditions. We want to recognize this. There's an entire chapter in the DSM 5TR on sleep disorders and I actually have a video on that when I went through the updates in the DSM 5 trip. So I would advise you to at least peruse the one hour video if you're not going to do anything else. They also may represent early warning signs of an episode of mental illness, providing opportunities for early intervention to stop or reduce the intensity of a full blown episode. So for some people prior to becoming a hundred percent symptomatic, you know, one of the early warning signs of an impending depressive episode or anxiety episode or manic episode may be sleep changes. Likewise, sleep changes, especially sleep deprivation, can trigger some of those episodes. So again, we're back to that whole chicken egg. Either way, you can't remove one or the other, you've got to address it. So we'll go back to that analogy I usually make of the body factory just to kind of bring this all together. During the day in your body factory, the workers and the machines, all of your bodily systems do their thing. When the factory shuts down for the day, when you go to sleep, the maintenance crew clears out the trash, tunes up the machines, restocks the shelves to ensure effectiveness and efficiency deficiency. So hormones are rebuilt, adenosine and other toxins are cleared out the machines, all of your different systems are repaired and restored. So everything's ready when you wake up in the morning to jump out of bed and hit, hit the floor running. If the factory never shuts down, think about these poor workers. Supplies run low, the machines become less efficient and break down, trash builds up and maintenance is trying to work at the same time. And I think most of us have experienced this like before an audit when you're burning the midnight oil, making sure all your ducks are in a row and everything, and you're almost tripping over each other because everybody needs, well, this is back in the days of paper files, but everybody needs the file. The nurse needs the file, you need the file. And we are in the way of the maintenance crew that's trying to get everything cleaned up and cleared out and ready to welcome not only the auditors, but also the clients the next day. So I mentioned we were going to talk a little bit about sleep cycles and again, this is just for your understanding. We're not going to diagnose this. This is something that they can pick up in a sleep study. But during stage one non REM sleep, this is when you drift in and out of light sleep and can easily be awakened. So think of it going back to that analogy of the factory. Non REM sleep is like packing up for the day. You haven't left the office yet, so you can easily be called back into work, but you're ready to go. You know, you've pretty much mentally shut down. Stage 2 non REM brain waves slow. With intermittent bursts of rapid brain waves, the eyes start stop moving, the body temperature drops and the heart rate begins to slow down. This is sort of what I say, akin to clocking out. The machines cool down and it's your decompression time as you drive home. So you've left the office. It's going to be a lot harder to call you back in now. Can it be done? Yes, but it's going to be harder. This stage usually lasts for approximately 20 minutes. Now we've got to recognize that your sleep cycles. The duration of each stage changes a little bit throughout the night, especially your deep sleep in the beginning of the night. Stage three, non REM sleep is a lot longer and because this is when a bunch of stuff is done, but after that stuff's done and then the maintenance crew is just going back and double checking so it doesn't take them as long to go through each floor of the factory. So stage three non REM sleep, also known as deep sleep or delta sleep, is marked by very slow delta brain waves. There's no voluntary movement, you're very difficult to awaken. So at this point, this is like the factory having only maintenance staff doing their job and they're doing it very well, thank you very much. But if all of a sudden you need to reopen the factory for an emergency, it's going to take a minute because you've got to call everybody back into work. So during stage three non REM sleep, during this deep sleep, you're out, as my mother would say, you're out like a light and it's really difficult to wake you. And when you do wake up, sometimes you're disoriented and groggy and it takes you a minute to figure out who, what, where, when, why. This stage usually lasts for about approximately 30 minutes early in the night. And the largest percentage of deep sleep comes in the early part of the total night's sleep pattern. So on a official medical grade sleep study, you're probably Going to see this duration of stage three shrink throughout the night because again, most of the work, all of the hard stuff is done on the first round of the building, then successive rounds of the building is just double checking. REM sleep, or rapid eye movement, is characterized by temporary paralysis of the voluntary muscles and fast irregular breathing, inability to regulate body temperature, faster brain waves resembling the activity of a person that's awake. Most dreams, but not all of them. Most dreams occur during REM sleep. During REM sleep, the amygdala, which is the fear part of your brain, but it's also the part of your brain that processes emotions, activates and processes those emotions. Interestingly, and I'm not going to go into a deep dive on sleep paralysis or REM sleep deprivation, except for to say most antidepressants suppress rapid eye movement sleep. And they found in repeated studies that restriction of rapid eye movement sleep, restriction of dreaming, restriction of the person's ability to turn on that amygdala and process those emotions actually improve depressive symptoms. Now, do not try this at home. Do not try to time this and not sleep. But it is important to recognize that this may happen. And people who begin taking antidepressants or who've been on antidepressants for a long time and weren't aware of this, it may help them understand why they don't dream as much or why they may not seem like they dream at all. So how much is enough? Part of it depends on the person, part of it depends on the quality of sleep. And I, as I said, we don't want clients getting too wrapped up in how much deep sleep they're getting versus light versus rem. We just want to know how much sleep they're getting. Because if they get too far down in the weeds, especially with inaccurate equipment, they may actually cause themselves extra stress. Newborns need 14 to 17 hours of sleep. Most of us know this. 3 months to 1 year old, 12 to 15 hours, 1 to 3 years old, 11 to 14, 3 to 5, 10 to 13 hours, 6 to 13 years old. This is elementary school and middle school. 9 to 11 hours of sleep. So think about what time that child gets up to get ready for school in the morning. If they get up at six, you know, count backwards and figure out what time they need to go to bed. So the median would be, you know, 8 o'. Clock. And if children are staying up until 10, 11, 12 o' clock at night, then obviously they're not getting enough sleep. 14 to 17 year olds need approximately 8 to 10 hours of sleep. And true adults over 18 need approximately 7 to 9. Now, if you're sick, if you're pregnant, if you're undergoing something, you very well may need more sleep than this. And there are times where you may not feel like you need as much. But in general, for your body to do what it needs to do and function most efficiently and effectively, these are the guidelines. Now, the deep sleep needed is approximately 15% of or more of your actual sleeping time. And I did the calculations here for the least amount of sleep. So for four, a newborn getting 14 hours, we want them to have 2.1 hours of deep sleep and so on through, through the chart. This is just for your reference, this is just for you to kind of get an idea. But it also may be helpful for you as an individual to say, hey, I'm feeling groggy. I wonder if I slept well last night. I slept a lot, but did I sleep well? Sleep and hormones. I know I keep going back to some of this physiological stuff, but it's important for us to recognize because if, as we age, our hormones production decreases, which can contribute to sleep disorders when we're pregnant, when we're taking birth control, people who are taking hormone therapy for other conditions, it may and likely will impact their sleep at some level. So we need to recognize that because poor sleep may end up leading them to our office with mood disorders, estrogen at normative levels for that person usually improves the quality of sleep, reduces time to fall asleep, and increases the amount of REM sleep. Now, why do I say normative levels? If somebody's estrogen levels are within normal range for them and they take estrogen, it's not going to improve their sleep. It's actually likely to worsen their sleep because too much estrogen or estrogen dominance is often associated with anxiety. Likewise, not everybody has the same needs for estrogen levels. And so it's important that the person works with their physician in order to determine could this be causing my issue. Too little or too much testosterone may also affect overall sleep quality. And too much testosterone is associated with sleep apnea and reduced sleep efficiency. So we want to look again. Remember, people, regardless of their biological gender, have estrogen and testosterone. The balance is just different. But it's important to recognize that the way we're wired biologically at birth affects how we respond to particular to particular hormones. So that may be a treatment issue we need to consider. Sleep issues may be a treatment issue we need to consider. With people undergoing hormone related therapies, sleep quality may result in alterations in testosterone levels. If you're getting crappy sleep, your testosterone levels may be altered, typically lowered. And I think this is also interesting because there's a correlation between having a newborn at home in the male gender and having lower testosterone levels. And some researchers suspect that that's in order to promote bonding. But it also could be in part because the male counterpart is also not getting enough sleep. Thyroid hormones, which are too high can cause insomnia and too low can cause fatigue and lethargy. Back to that physiological aspect again, no amount of sleep hygiene effort is going to radically improve if somebody is hypo or hyperthyroid. That is a medical issue that needs to be addressed for the person to get maximal gains. And thyroid dysfunction often co occurs with insomnia, restless leg syndrome and obstructive sleep apnea. So we want to also screen for these things. By the way, restless leg syndrome is linked to dopamine levels. So all of this stuff starts to be. You start to see how it's all related. The stress hormone cortisol prevents restful sleep. Higher levels of cortisol can create agitation, insomnia and sugar cravings. Think about when you're stressed, you tend to be a little bit more irritable. You may have more difficulty sleeping, and you may crave sugar. Why is that? When the HPA axis is activated, the stress response, you're in fight or flee. What is sugar? Sugar is a very fast release source of energy, so it makes sense that that may happen. Low levels of cortisol can be associated with inability to handle stress, extreme fatigue, low libido and mood instability. So when people's cortisol levels get too low or when their system becomes resistant to cortisol, glucocorticoid resistant, we may see this happening. Estrogen increases norepinephrine and serotonin and decreases dopamine. So we want to recognize that norm normative estrogen levels can help decrease dopamine. Why is that important? Well, dopamine gives us energy, so that can be helpful to have a slight emphasis on slight decrease in dopamine. What do antipsychotics do? Decrease dopamine. And what is one of the side effects of antipsychotics? Extreme lethargy. Progesterone helps balance estrogen, promotes sleep, and has a natural calming effect. But abnormal levels of progesterone can cause insomnia and contribute to irritability. So many times I've referred to that Goldilocks principle. Too little a problem, too much a problem. We need it to be just right. For that person. And each person's levels are going to be a little bit different. That's what why doctors have ranges. But some people may be within the normative range, but at the very low end and experiencing symptoms. So we need to encourage them to advocate with themselves, for themselves, with their doctor if they feel like, yeah, it's in the normal range, but it's barely there and I'm feeling like crap. In terms of nutrition. Poor nutrition can also impair sleep because we need to have the building blocks for serotonin to make melatonin to help us drift off to sleep. So tryptophan is important and that's a protein that's really, really abundant in just about all the foods we eat. You don't need to take supplements, but it's important that you eat a high quality diet with enough protein. And caffeine is a stimulant with approximately a six hour half life. So half life is how long it takes the body to eliminate half of the substance. Nicotine is a stimulant with a two hour half life. So how long does it take to get nicotine out of your system so you can sleep? Interestingly, and, and this has been updated. Decongestants are stimulants with a half life of between two and six hours. And that's for your rapid acting, if you will, decongestants, not your extended release. Extended release is way longer than that. But it's important to recognize if you're sick and you're taking decongestants, it may impact your sleep latency, it may impact your sleep quality. There's a lot of things that may impact, however, you gotta weigh the good with the bad. How much worse is your sleep gonna be if you can't breathe? Antihistamines are common over the counter sleep aids and also used by people who have allergies. They tend to make you drowsy when you take them, which can help some people fall asleep. But they tend to have rebound drowsiness the next day and often contribute to poor quality sleep. Alcohol. A lot of people drink in order to get relaxed so they can go to sleep. Well, yeah, it does help people get to sleep faster. It reduces their sleep latency. It also tends like SSRIs, tends to block REM sleep. It can also, because it's a system depressant, can worsen sleep apnea and it causes poor quality sleep in the second half of the night. Think about if you've worked in a detox unit, you're familiar with this as People's alcohol gets out of people's system, it leaves their system faster than the body can compensate with its own endogenous depressant substances. So people's blood pressure and their anxiety tend to spike at a certain point during the detoxification process. So if you're drinking, especially if you drink enough to get drunk and you go to sleep well, you may sleep hard, maybe not well, but you may sleep hard the first part of the night, but then you may wake up or you may toss and turn a lot the second half of the night because your HPA axis is activated. Eat a high protein dinner to ensure you have enough tryptophan in the body and make sure you're getting enough selenium, vitamin D, calcium, vitamin A, magnesium and zinc. Again, most people do not need to take supplements if they're eating a relatively healthy diet. However, if you're not getting enough and you can track your meals in a variety of different apps, if you're not getting enough of particular nutrients, talk with your doctor about whether a multivitamin is helpful. Some doctors are very pro multivitamin, some are very anti multivitamin. So you really need to talk with your physician. I've mentioned circadian rhythms and I'm just going to touch on them one more time to re emphasize the fact that it's approximately a 24 hour internal body clock that involves patterns of brainwave activity, hormone production, cell regeneration and other biological activities. It's not just sleep. The circadian clock is set by the light dark cycle as well as temperature. You need to cool down in order to go to sleep and socialization or your activities over a 24 hour period. So when little kids come home from school and they play and then they eat dinner, then they go to bed, then they take a bath, then they read a story, then they go to bed and if you change it up on them, then a lot of times they're going to have difficulty getting to sleep because their brain hasn't been cued in. Circadian rhythms allow organisms to anticipate and prepare for regular environmental changes and best capitalize on the environmental resources available. Circadian rhythm disorders can be caused by many factors including shift work. So you don't have a choice. One day you're working 8 to 4, the next day you're working 4 to 12. Pregnancy or menopause where there's a change in hormone levels and that can impact temperature regulation, serotonin levels and just general comfort time zone changes. Certain medications will impact your circadian rhythms like the antipsychotics that I mentioned because they tend to make people feel very sleepy. Changes in routine medical problems, including Alzheimer's or Parkinson's disease. So your neurodegenerative disorders and a variety of mental health issues. And, and we've seen that there are alterations in the sleep structure of people with mental health issues. So what do we do? As I've mentioned multiple times, we are not dietitians, we are not doctors, we are not sleep professionals. Okay, so if a person is having a lot of difficulty with sleep, we're going to need to make a referral. However, there is a large subset of people who simply have difficulty with sleep because they have really crappy sleep hygiene. And I think most of us have at least a few things in here that we don't do very well. So create that wind down ritual. It doesn't need to be multiple hour involved, but something that you do, like read a book or, or do a crossword puzzle or something before you go to sleep that cues your body in. When I do this, it's about time to get sleepy. Reduce or eliminate exposure to blue light one to two hours before bed. Now remember, blue light comes from the sun, but hopefully you're not going to sleep when it's daylight. If you're a shift worker and you're going to sleep when it's daylight, then it's important to try to get to sleep or try to get inside and not see that sunrise because when the sun rises, it starts triggering that circadian rhythm. You also want to reduce the influence of the blue light from the tv, the computer, your phone, your tablet, and even some light bulbs. I recommend to a lot of my patients to consider using lights at night that are right around 2000 to 2500 kelvin. So those are very, very yellow candlelight bulbs. You don't want to use bright daylight bulbs when you're trying to wind down. Go to bed at roughly the same time time every night. That doesn't mean you can't stay up an hour or two later on the weekends if you know that makes you happy. Or sleep in a little bit on the weekends. But you don't want to sleep till noon on your days off and then have to get up at 5am on the days that you work. Your body has difficulty adjusting to that. Eliminate as much light as possible. And this can even include moonlight, especially on those really bright full moon nights. If you feel comfortable, put on a sleep mask or get the blackout curtains. Those can be extremely helpful to reducing blue light. Also, pay attention to lights on devices in your bedroom, for example, I have an air purifier that for some unknown reason, when it's on, it's on. Light is blue. I'm like, really? I, I have this in my bedroom. So I put a piece of masking tape over top of the blue light so it doesn't illuminate my, Illuminate my room as much. Eliminate as much noise as possible. Now, some people like to have white noise in the background. Some people are comfortable with earplugs. Other people need to be able to hear. They have a trauma history or they have small kids at home and they need to be able to hear in order to be able to actually relax enough to go to sleep. Sleep. So as much noise as possible. And this also includes the dog that is scratching while he's sitting on the floor, ideally or on the bed right next to you, licking his paw insistently. The significant other who has sleep apnea. Now, I'm not saying kick him out of bed, but it's important for them to get that addressed because they are negatively impacting the sleep of anybody around them. My uncle. Oh my gosh. Had sleep apnea. And even if you were in the bedroom next door at my grandmother's house, he snored so loud it felt like it was peeling paint off the walls. Obviously I know it wasn't, but. So it's important to, for the person with apnea to recognize that not only are they impairing their own sleep and mental health, but they're impairing the sleep and mental health of those around them. Don't exercise or take a hot bath. Really hot bath within two hours of bed. Now, some people will argue with this. They'll say I sleep best if I exercise really hard and then come home and go to sleep. Okay, you know what works for you? The sleep foundation recommendations are not too keep the room cool. 72 is apparently ideal. I would disagree. I think that's far too warm. So figure out what temperature is comfortable for you and consider using a cooling pillow or a mattress topper. And the old fashioned foam mattress. Mattress toppers used to hold heat like nobody's business, but they've improved those drama the past decade. So if you can afford it, consider looking into a mattress topper that will help regulate your body temperature and avoid anything that might get you upset. This can include social media. This can include scary movies. This can for me watching. I, I try to avoid watching any television that has commercials because invariably one of those ASPCA commercials comes on and it upsets me. So I don't watch any television with commercials. Before bed, reduce or eliminate caffeine at least six, preferably 12 hours before bed, which means. I know. Which means cutting it down before noon. But you've got to remember that caffeine that's in your system can impair your sleep. Drink the majority of your fluids during the day. If you don't drink the entire time you're at work, or you just sip a little bit here and there and then drink coffee, and then you get home and you drink 64 ounces of fluid, you're going to be a peeing multiple times during the night, and that's not good for your sleep hygiene. Keep an air purifier in the room if you have allergies. And keep animals off the bed. They move, they make noise, and they aggravate your allergies. This is one I violate every single day. So I'm not judging, I'm just telling you what the recommendations are. Make the bedroom a place of relaxation and sleep if you can. You know, obviously, if you live in a studio apartment or a dorm room, that's not going to work. But try not to do your bills in there. Try not to have that be the place where you always come to argue with your significant other. Keep a red light. You know, obviously not a blue light, not a white light, a red light, and a notepad by your bed to write down anything that pops into your head. The red light won't destroy your night vision as much as the other types of light. And for most people, it is easier to let go of ruminations or racing thoughts if they write them down because their brain is like, okay, we've got it written down. Nobody's going to forget, and I can relax. Incidentally, they found that sleep deprivation is associated with more difficulty controlling thoughts and increases in ruminations. So yet another reason to improve sleep. Weighted blankets help some people get to sleep easier. And for kids, they actually have these special stretchy sheets now that the kids can kind of slide into, and it provides that pressure without the heat of a weighted blanket. Unfortunately, most of the sheets that I found only came in twin sizes, but that may be another consideration. If you like that feeling, if that feeling is terrifying to you, then obviously no. Keep daytime naps under 20 to 45 minutes and before 3pm and 20 minutes is recommended by some. Less than 45 minutes is recommended by other places. So 20 to 45 minutes, you know what works for you. Interestingly, for some people, naps may actually boost cognition and norepinephrine levels in the last half of the day. These quick little naps, not anything where you're actually falling asleep and dreaming and you're out hard. Consider diffusing essential oils if you're not sensitive to smells or hypersensitive to smells, including lavender, chamomile, pachuli or even catnip. Now obviously if you've got cats, don't do this, don't, don't, don't do catnip. But catnip is actually a sedative for humans even though it's a stimulant for cats. So interesting. And select the right pillow. If your neck is all whopped up, it's going to be a lot harder to relax and get good quality sleep. Address any ongoing pain issues, address apnea. Obviously that's something you've got to do with your those with your physicians, allergies, you know, talk with your physician, find ways to reduce the allergens so you're not sneezing, coughing, stuffy during the night, address restless leg syndrome and be aware. Sometimes there's nothing you can do about it. But if you've had a head injury, especially in the front part of the brain, it can impair sleep. Quality exercise also helps reduce cortisol levels, increases serotonin and can help reduce aches and pains which keep people awake. Now that's gentle exercise. That helps so you don't get stiff and achy and those sorts of things. That's not going to the gym and trying to power lift and stress management. I know that's kind of a catch all term. Can also help with sleep hygiene. If you have racing thoughts, write it down. That way you know it's there and you can attend to it in the morning. If you have ruminations, practice thought stopping. Find other techniques to address those ruminations, including writing them down. And do whatever you can in order to try to reduce your levels of stress hormones at night. Insufficient quality sleep contributes to mood disorders, inflammation, difficulty with learning and memory, fatigue and more. And again, I'm going to restate it for like the sixth time. Many of the symptoms of poor quality sleep are reflected in the diagnostic criteria for mood and cognitive disorders. So we need to figure out chicken egg we need to address regardless of what caused it in the first place, we do need to make sure that the person starts getting good quality sleep to help them improve or at least ensure they don't worsen their current condition. During deep sleep is when researchers think the brain rests and rebalances. And over time sleep deprivation can cause changes in neurotransmitter levels and immune and immune functioning. Frankly, most of us, even if you don't have a mood disorder or an autoimmune issue or something, most of us could benefit from auditing our sleep quality as part of our overall wellness plan.