A Crisis of Sleep

How much sleep do we need?

“A recent study came out in Nature, one of the world’s top science journals, and the conclusion was that the sweet spot is around 6.8 to 7.4 hours. We used to say eight hours or longer, but now, it’s around seven. We don’t want anyone to sleep less than six hours because you’ll have more health risks, but we don’t want anyone to get more than nine hours either. Some people say five hours of sleep is enough for them; they can just drink coffee and be perfectly fine. But you can perform better if you have an optimal amount.” —Dr. Keisuke Miyamoto

What exactly is quality sleep?

“There are several measures for quality sleep. One is sleep efficiency or how long you were in bed divided by how long you were able to sleep. If the sleep efficiency is 85% to 95%, it’s good. Then we look at how much REM (rapid eye movement) sleep you have; usually, we want patients to have around 20% to 25%. (REM sleep is the state where the most vivid dreaming takes place. It plays a significant role in helping the brain process new information and ensure better mental concentration and mood regulation, according to the National Sleep Foundation.)” —Dr. Keisuke Miyamoto

When do sleep problems become serious?

“I ask patients whether it’s taking longer than 30 minutes to fall asleep, or whether they’re experiencing disruptions that are hard to go back to sleep from. If you’re getting up to go to the bathroom but then get back in bed and immediately fall back asleep, I’m not worried. But if it’s taking longer than 30 minutes to fall back to sleep, that’s a significant disruption. I also ask patients whether they’re waking up feeling restored. Even if they’re falling asleep well and staying asleep, but every single day, they’re waking up with no energy, that would be worrisome. I start getting worried about any issue that happens multiple times a week and persists beyond a month. It’s normal to have sleep disruptions after jet lag or major stress, but it’s when it pushes past four weeks, your body is habituating poor sleep patterns.” —Courtnee Nunokawa

If you wake up frequently in the night but can get back to sleep, is that OK?

“It depends on how you feel the next day. We all go through sleep stages. We hit light stages of sleep, then go to deep stages and slowly come back out of it. So fragmented sleep could be normal as you’re coming out of those cycles. If you’re able to get back to sleep, even if it’s fragmented, and you feel rested when you wake up and can function fine, it’s probably OK. It becomes an issue if you have fragmented sleep and you feel like you’re not fully rested. You may be getting interrupted out of deep stages of sleep, and you’re not completing your sleep cycle. You need to understand what is waking you up from deep sleep. Is it sleep apnea and snoring? Or is it your environment, like chickens outside making noise, or it’s too hot in the room? Cooler temperatures are always going to be more comfortable for sleep. You need to be aware of your sleep environment.”  —Dr. Halley Tsai

Who should you talk to about your sleep issues?

“I would start with a primary care physician because there are things medically we need to make sure aren’t going on. For instance, for perimenopausal or menopausal patients, their sleep issues could be due to hot flashes or just hormonal changes, and they can consider hormone replacement therapy to address their symptoms. But if after routine labs and general interviewing, we don’t find medical issues or pain that could be waking a patient up, then the primary care doctor can think about sleep-specific interventions, which would mean a referral to a sleep center or for cognitive behavioral therapy for insomnia.” —Dr. Halley Tsai

“When it pushes past four weeks, your body is habituating poor sleep patterns.”

—Courtnee Nunokawa

What is the first-line therapy for insomnia?

“It would be cognitive behavioral therapy for insomnia, looking at the behaviors of our lifestyle. What time are we going to sleep? What are we doing before bed? How are we building sleep pressure during the day? Then really trying to change our lifestyle and our behaviors to support a healthy circadian pattern, sleep pressure and sleep drive. For those who haven’t slept well for years and their circadian pattern is really disrupted, we may go with pharmacological approaches to help the person reset their cycle so they can have some normalcy in the circadian patterns. Then we’ll focus on the behaviors around the circadian pattern and supporting that 24-hour clock. CBT-I is highly effective, but it takes a lot of effort and motivation. It can be really hard. For instance, one of the strategies of CBT-I is no screens and no TVs in your bedroom. It’s very effective, but it can be challenging to stick to it.”  —Courtnee Nunokawa

Have you seen good results with CBT-I?

“I definitely have. If you give someone a pill, they can always fall asleep, but they’ll build tolerance to it, it will stop working and they’ll be back at square one. Whereas with CBT-I, it’s a lot of work to go through that program, but they are left with better tools to keep insomnia at bay.”  —Dr. Halley Tsai

What are the options if CBT-I is not working?

“CBT-I is not just a one-shot thing. If you fail one time, you can repeat a program of CBT-I later on. The next best option is to supplement CBT-I with a sleeping pill, to do it in tandem. And the reason for that is that you can ideally work with a sleep coach to notice patterns of when you may need the sleeping pill in the week more than other times, so you’re not relying on the sleeping pill every single day, because that can lead to a faster incidence of tolerance. But using those in conjunction can help make CBT-I more effective. Apart from that, you should also look into medical issues, if you haven’t done so already, that could be contributing to the problem.”  —Dr. Halley Tsai

Are there any new sleep medications available?

“If you have tried everything, all the lifestyle suggestions, there are some new medications, but they’re expensive. One is called Belsomra, which is an orexin receptor antagonist. Belsomra has a very good profile with fewer side effects compared to other medications like Ambien, so that’s why it’s getting popular. Ambien can sacrifice sleep quality in the long term. It’s always better to continue with the lifestyle part because even if medicine can help you get better sleep initially, at some point, probably, the medicine will not work anymore. So it’s better to develop good sleep habits.”  —Dr. Keisuke Miyamoto

If you take a power nap during the day, will that compromise your nighttime sleep?

“There are many sleep disorders, and napping recommendations can differ between them. For those who suffer from insomnia, the general recommendation is to avoid napping because it can reduce your nighttime drive to sleep. While napping is a perfectly understandable strategy for trying to combat the consequences of poor sleep, it often becomes a self-perpetuating factor in the insomnia cycle, where napping is maintaining the poor sleep. For other types of sleep conditions, we may utilize longer, more frequent, or regularized napping as an intentional intervention.”  —Julie Takishima-Lacasa

“CBT-I is highly effective, but it takes a lot of effort and motivation.”

—Courtnee Nunokawa

Is taking melatonin helpful?

“Understanding what melatonin does and does not do is usually helpful for patients who are interested in it (or very commonly, frustrated that it is not fixing their insomnia). Melatonin is not a sedative or a sleeping pill, and it does not create sleepiness. It is a hormone that tells your body that it is nighttime. As such, it helps to signal sleep timing but does not influence sleep quality or quantity. It also does not address the actual cause of chronic insomnia, which is conditioned hyperarousal (nervous system overactivity). This is why there is little medical evidence to support the use of melatonin for chronic insomnia, and U.S. sleep guidelines recommend against melatonin use for insomnia. Based on the research, the only defensible role for melatonin for otherwise healthy adults is as a circadian tool for jet lag, shift work disorder, or sleep-wake phase disorder, and prolonged-release in adults 55 years or older, the only insomnia population with reasonable randomized clinical trial evidence supporting melatonin use.” —Julie Takishima-Lacasa

What supplements would you recommend?

“There are no OTC supplements or alternative sleep aids that have strong enough scientific medical evidence for long-term insomnia benefits without significant risks and side effects for me to directly recommend, but there are many products that my patients ask me about. So I have informed discussions with them about the current evidence pertaining to, and the pros and cons of, whatever they are curious about.”  —Julie Takishima-Lacasa

“I always tell my patients that no supplements are FDA-approved. So you may be consuming something that sounds organic, but we don’t know what else is in there and how they formulated the pills. One supplement that I do generally recommend is magnesium glycinate. There are various forms of magnesium, but magnesium glycinate is the one supplement that’s well studied for sleep, is generally very safe and well tolerated and could be helpful.”  —Dr. Kimberly Kho

How much alcohol is it OK to drink if you have sleep issues?

“Alcohol is not healthy for sleep in general, whether you have insomnia or not. However, a lot of people who struggle to fall asleep use a drink or two (or more) before bed to help them fall asleep, and because alcohol is a sedative, people think it is helping because they are mistaking sedation for sleep. Sedation is not sleep because when your brain is sedated, it is not generating as much of the big, slow waves necessary for deep sleep. To add insult to injury, the metabolic byproducts of alcohol disrupt the production of REM sleep. These crucial stages of your sleep architecture are fragmented, resulting in lighter and more fragile sleep that is more easily disrupted, and as alcohol is metabolized, it activates your sympathetic (fight or flight) nervous system, causing more frequent wakenings. This means that the trade-off of being sedated into a light sleep at bedtime is giving up much of the nourishing, restorative quality sleep throughout the night (and impaired growth hormone release for cellular reparation and repair). That is why people do not feel refreshed, restored and rested when sleeping after drinking alcohol.” —Julie Takishima-Lacasa

Why do so many women struggle with sleep?

“Sleep disturbances are prevalent, and they don’t just start in perimenopause. We see it also among women who are taking care of small children and their sleep is disrupted. There’s something very physiological happening, and it starts with the thermostats in our brain that regulate temperature, which sit next to areas of our brain that monitor sleep. All of that gets twitchy around the time of perimenopause. A lot of it has to do with estrogen declines and a lack of consistent estrogen. It impacts the thermostats in our brain, and that’s why women sometimes have hot flashes. But outside of hot flashes and night sweats, it impacts sleep because it impacts the area of the brain around sleep and wakefulness. The signals in our body are starting to change, and that can become dysregulated.”  —Dr. Kimberly Kho

Should women consider hormone replacement therapy for sleep disturbances?

“It’s a great thing to discuss with your physician, starting a conversation and getting to the cause of the sleep disturbance. Frequently, it can be attributed to hormonal changes, but not always. When it is, hormone therapy can be really helpful. One of our nurses who sees me said, ‘I’ve been spreading the gospel of my great sleep.’ I started her on HRT, and she’s proselytizing about hormone replacement therapy.”  —Dr. Kimberly Kho

Is there a cutoff age for when women can start HRT?

“With HRT, you want the lowest dose of hormones for the shortest amount of time, and 60 was generally thought of as when we should start transitioning women off of it. I think that’s becoming more nuanced. The Women’s Health Initiative came out in the early 2000s and made everyone worried about the long-term and short-term impacts of HRT. Now, we’re swinging to this other place. I want to emphasize that HRT during menopause and perimenopause isn’t for everybody. The rules about who can and cannot have it, when you should start it, and when you end it are really nuanced based on individual risk profiles, needs and symptoms. There’s no hard rule on age. The beauty is that there are so many different kinds of estrogens and progesterones, and we can titrate and customize them.”  —Dr. Kimberly Kho

While there’s no “hard rule” on when to begin HRT, at what age is it most commonly or safely prescribed?

“There is a healthy and safe window to start menopausal hormone therapy, and that’s usually in that perimenopause attrition transition to early menopause. When we start to take it in the 60s and 70s, which is what they studied in the Women’s Health Initiative, we see higher risks of stroke and other catastrophic events. Women who are in their 60s and super vital and living a great life may not be on it because their doctor said no to them 10 years ago. And now they ask if they can get on it. It’s hard because the risks increase if you have not been on it.”  —Dr. Kimberly Kho

Why is there such a focus on sleep issues?

“People are more aware of their mental health and sleep hygiene. From a medical standpoint, even for sleep apnea, there’s a lot more awareness. So there is a bigger movement to look at sleep. I do get the sense too that anxiety in general is becoming more of an issue. And those two are linked. So as people become more aware of their anxiety and mental health issues, sleep issues come up.” —Dr. Halley Tsai

“As people become more aware of their anxiety and mental health issues, sleep issues come up.”

—Dr. Halley Tsai

Should people struggling with sleep turn to AI and Google for information?

“My general opinion is to stick with guidelines from the National Sleep Foundation and the American Academy of Sleep Medicine. Those are good, evidence-based, major societies whose websites provide good studies and well-known data. There’s always going to be something that pops up on Instagram about some new intervention, but I’m always skeptical.”  —Dr. Halley Tsai

What is your take on wearables and tracking devices that measure sleep?

“Sometimes, the more we think about insomnia, the worse it gets. If you notice that a device gives you more anxiety about your sleep, I would not wear it. My approach to wearables is that you won’t really know if you’re having deep sleep without brain-wave measurements, which none of these wearables do. They listen to sounds and take your vitals from your heart rate and oxygen level. They use that information to make their best prediction. Wearables are good if you want to compare how you’re doing if you apply sleep hygiene, for instance. But I wouldn’t use them specifically to measure the amount of deep sleep.” —Dr. Halley Tsai

Diane Seo is the editorial director of HONOLULU Magazine.