Sleep & Mental Health

How many of your clients have sleep issues?

Or maybe the real question is how many of your clients don’t?

With more than a third of Americans not getting enough sleep, there's a high likelihood that many of your clients are struggling to get enough rest, even if they're not bringing it up in their sessions with you.

Where we used to think mental health problems caused insomnia, we now know that the relationship is more circular than casual. And without addressing sleep issues, and intervening in this vicious cycle, your treatment plans for mental health issues will likely be less effective.

As a clinician, you’re uniquely positioned to help clients get better sleep… and you don’t need to be a sleep expert to do it!

Catherine Darley, naturopathic doctor and leader in integrative sleep medicine, shares her clinical insight.

Why should clinicians be asking clients about sleep?

Sleep health has been minimized in our society, but we’ve seen it gain much broader appeal to people over the last five years.

One of the things I’m concerned about is the number of people who don’t get sufficient sleep: about 35 percent of Americans. If more than one in three adults is not getting adequate rest, this has an impact on their health and ability to interact with others.

The other reason clinicians should be asking clients about sleep is the high number of people who have insomnia. It’s correlated with mental health issues; about 75 percent of people who have depression also have insomnia. Plus, when you're not sleeping, it can promote depression.

We want to treat both sides of the equation by combining some depression-focused treatments with some sleep and insomnia-focused treatments. Sleep problems generally don’t resolve on their own just because you’ve resolved depressive symptoms.

What are some of the key questions that clinicians should be asking to assess their clients’ sleep?

One of my favorite questions to ask is this: How much sleep do you do best with? What’s interesting is that people will often say, “I can get by on X hours of sleep,” but we’re not asking how much they can get by on. We want to know how much makes them feel at the top of their game. That’s what we should be going for: the amount of sleep that makes them feel well.

Next, find out if they consistently get their optimal amount of sleep. There’s this myth that you can make up your sleep on weekends. One of my colleagues gave an analogy once: You wouldn’t feed your teenager only 70 of the food they needed Monday through Friday and then assume they could just binge on the weekend. That wouldn't make any sense at all, and sleep is the same. You need to get sufficient sleep night after night.

Lastly, find out if your patients are night owls or morning people and if they can sleep at the hours that are natural for them. People who are night owls are at increased risk of mental health problems. It's unclear yet whether it's an inherent feature of being a night owl or a result of being out of rhythm with their natural sleep times and having to grapple with being chronically sleep deprived.

Can you tell us a little bit more about the negative consequences of not getting enough sleep?

I think about the negative consequences in five domains: social-emotional intelligence, mental health, physical health, physical performance, and cognitive performance.

Social-Emotional Intelligence: If your client is sleep deprived, they’re not going to be able to judge as accurately whether the people around them are happy or angry. If they can’t accurately assess and respond to the people in their lives, that’s going to have ramifications in the social sphere.

Mental Health: If someone has a panic disorder, their panic attacks are going to be increased with inadequate sleep, and they may not be making that connection. As an informed clinician, you can help them see that pattern and address their sleeping habits. That’s probably not going to be the entire solution to their problem, but it’s certainly going to help.

Physical Health: Many people struggle with their weight, and one of the things that happens when we're sleep deprived is our appetite changes. We tend to eat about 300 calories more a day, which may not sound like a lot, but over the course of a year it’s equivalent to 30 pounds. Lack of sleep also contributes to many other common concerns, including cardiovascular disease, hypertension, and even cancer.

Physical & Cognitive Performance: An example of physical performance would be when someone’s driving and has a hard time keeping their eyes open because they’re sleepy on the road. In terms of cognitive performance, we all have a broad spectrum of cognitive tasks we need to do every day, from simple things like remembering someone’s name to more complex problem solving. All of that is going to be impaired when we’re not getting enough sleep.

Can you give us an example of one or two strategies that clinicians can use to address their clients’ sleep issues?

One of the recommended treatments for insomnia is called cognitive behavioral therapy for insomnia. It involves several components, which I cover in greater depth in my training:

• Sleep Restriction: This is a bit of a misnomer and could be more accurately called time in bed restriction. We’re limiting the amount of time a person spends in bed and making sure they actually sleep during this time.
• Cognitive Reframing: I think about people's sleep thoughts in two camps: sleep-promoting thoughts and sleep-disrupting thoughts. What we need to do is reframe those sleep-disrupting thoughts into sleep-promoting thoughts.
• Stimulus Control: This is based on Pavlovian principles. You want people to have a strong psychological physiological response to their bed and associate it with sleep.
• Sleep Hygiene & Relaxation: The idea of a sleep-healthy lifestyle isn’t very prevalent in our society, but there are ways that you can design your lifestyle, including how much light you get during the day.

I like to challenge clinicians to create a sleep-healthy lifestyle for themselves and document how it goes for 10 days. This helps them see the impact it has on their own health so they can speak from experience with their clients.

It also helps them identify barriers that come up, like a change in work schedule or a sick child. Having ways to skillfully anticipate and address those barriers goes a long way in helping clients have success improving their sleep.