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- Hello and welcome to this Focus On Wellbeing session on sleep. My name's Sarah Phillips, and I'm one of the team working on the National Wellbeing Hub. This session promises to be very interesting, giving you tips on how to improve your sleep. And I want to hand over now to Dr. Dimitri Gavriloff who's a clinical psychologist and sleep medicine specialist. Dimitri is a clinical engagement lead for Sleepio at Big Health. So over to you Dimitri.- Thanks Sarah. And happy New Year to everyone. I'm gonna sneak it in there because I think it's still okay to say happy New Year. I know that people have very particular views on when you have to stop saying it, so. Glad to be here and thank you very much for having me back again. And I hope you're all well and ready to kick off 2022 with some good sleep. We're gonna spend probably 20 to 30 minutes today, maybe a little bit more talking about some basic sleep stuff, and then tips on how to kind of improve your sleep, or maybe just how it's hard to get back to sleeping well. And we'll leave some time at the end for questions as well. So hopefully we'll have plenty of time to discuss them, but if you pop your questions into the chat, as we go, then members of the team here can collect them, as we go, and we can try and sort of aggregate them at the end. So I'll kick off by jumping into the next slide. And talking about sleep. So I always start, this is something that, for those regular viewers out there, of our stuff, will know that I start by by contextualising stuff a bit. And it's worth thinking about sleep in its natural context. So sleep is something that we see pretty much in all complex organisms. But we certainly see differences in how things behave during the day and during the night, in the absence and presence of light. For example, in plants or bacteria, we see differences in how they do things, not sleep as we would say in complex organisms. But it is a differentiation. And so if we think about our animal cousins, certainly in our mammalian cousins, we all sleep. There's some mammals here on the screen. And you can see we sleep for different amounts, and these are all kind of averages. And in this kind of group of organisms, you have predators, you have animals that are sort of more prey animals, you herbivores, carnivores, et cetera. And you have animals that have a relatively big brain relative to their size, you know, and so on and so forth. It doesn't really seem to be any kind of correlation between any of these variables in how much sleep something needs, but you can see that actually the amount of sleep required per species is highly variable. And in fact may happen, with the brown bat there, it happened mainly during day, which is not what we experience as humans. But what we do have as our experience as humans is diurnal activity and nocturnal sleep. So we sleep during the night and we are awake during the day. And you know, I feel like recording a cover of, you know, "War, what is it good for?" Sleep, what is it good for? Absolutely everything, would be the next line. Because really sleep is something that has an effect on actually every single piece of our physiological machinery, our function. And we don't get enough sleep, it impacts us negatively and across many domains. But you can see here that it is part of, well it has a role in our cardiovascular system, in terms of metabolism, our metabolic system, immune system, thermoregulatory system, endocrine system, reproductive system and more. Emotional reactivity is greatly impacted by sleep as is mood regulation, learning and memory, attention, glymphatic cleaning, which is the kind of janitorial process that goes on in the brain every night. So when we could asleep cerebral spinal fluid comes up into the brain and washes out the metabolic waste of the day and prepares it for the next day. A bit like an office cleaning team, might go into an office and cleared away all the gunk and the coffee cups and stuff that had been left out, in order for the office to work optimally the next day. It's also important to things like creativity and decision-making, you know, you name it, sleep is important for it. So we've kind of established that sleep is kind of, it has an essential function across what we do as humans. And we can think of it a bit like eating, a bit like drinking, breathing, these are things we don't have much choice about. We don't have much opportunity to either do with or without, we either do them or we don't and we suffer the. But sleep is one that we tend to get involved with more. So we wouldn't routinely stop ourselves breathing. And the way we breathe naturally, and in the same way, sleep is something that we can kinda let it go back to, we'll try as much as we can in general terms to allow it to go back to how it's just naturally gonna take place, rather than tweaking it too much. So what does it look like, this sleep thing that we're talking about? Well, here's a hypnogram. A hypnogram is a sleep diagram. And you can see that across the bottom there, we have this cubic to six hours, and we'll talk about that in a bit, but you also have the stages of sleep. This is an old histogram, so it has four stages of sleep. We only really have three these days, so I've got them on the right hand side there. But we go from a period of wakefulness into the first stage of sleep, light sleep, which is called Non-REM, Stage 1 sleep. So Non-REM just means Non-rapid eye movement sleep. Stage 1 is very short, Stage 2 is relatively short. And then we're down into deep sleep, which is that Stage 3 sleep, which is quite quite a lengthy period. So we get this deep sleep at the beginning of the night. We have this notion that the deepest sleep happens closer to morning, but actually the reality is that it's the opposite. We go to sleep, we get the deep sleep that the brain craves, and we're able to just sleep through that. The brain is able to have this stuff done, the body's able to have the stuff done, that it needs doing, the maintenance bit, and then we're up into lighter sleep again. But we cycle through these sleep stages routinely. This is what's known as Sleep Architecture. And what's crucial about this is that it happens in a very natural way, we don't have to get involved with it. But you can see there that the pink bits or the red bits pertain to what we call REM sleep, so Rapid Eye Movement sleep. This is the sleep that happens at the end, typically the end of the sleep cycle. And that is really strongly associated with narrative dreaming, with emotional dreaming, emotion processing. And you can see that after those periods of REM sleep, sometimes you also have brief nocturnal awakenings. We wake up very briefly. We might sort of scramble around a bit in bed and find a comfortable position, then go back to sleep again. And in fact, that's what most of us do every night. And if we don't care about it, if it's not something that has any meaning for us, we just ignore it, we go back to sleep. And in fact, many people will say,"I didn't wake up at all last night." But in fact, they may have done several times and just not realised it. So one of the things to say about sleep is that this is not this deep freeze of consciousness that just kinda goes throughout the night. It's a very dynamic state. And we have periods of light to deep sleep. We have periods of REM sleep. And then of course we have these punctuated periods of awakening, which are totally normal. The point at which they become kinda problematic is when they become problematic, when they become longer, more protracted periods of waking from which one finds it difficult to return to sleep. So if they're very brief and they punctuate the night, that's not necessarily, when they punctuate the night relatively infrequently, that's fine, that's normal. So that's what sleeping looks like. And how much of it do we need? Well, that's a great question. It depends how old you are, and it depends what stage of life you're in. But it also depends, you know, potentially on what season is in swing. It depends on how stressful your life is. It depends on lots of things. Broadly speaking, we talk within a range for a particular age group. And you can see there that newborns may need as much as 19 hours in a 24 hour period, which is a huge amount of time, if you think about it. But that kind of gradually reduces to where I find myself now, around 40, there in that bracket, 26 to 64. And you expect someone at that age to sleep for roughly seven to nine hours, roughly, roughly. Might be a little bit more. And some people might get a bit less than some people, that's fine. But the reality is that we will all have our own sleep need. And if we allow ourselves to sleep naturally without getting involved with too much, then we tend to kind of have an average. But you can see that even teenagers there, at 14 to 17 years old, may still need up to 10 hours sleep a night, some of them, maybe a little bit more, some of them. And so this is actually quite important when we're thinking about how sleep may affect people around us, such as our teenage children or people we know, school children, who may not be able to get enough sleep in the nocturnal period,'cause they have to get up really early and they go to bed very late. Which is again, a natural thing that happens during adolescents, they begin to get later, their body clocks get later. So we tend to think of it a bit like a shoe size. It's a strange thing to do to go online and look up, you know, a 40 year old man, living in Oxford in the UK, how big should my shoe size be? That's a ridiculous way of doing it. In fact, the best thing to do is go to a shoe shop, try on a couple of pairs of shoes and then get a sense of how big your shoe size really is. And it will change from brand to brand, presumably. But the idea is that it's my shoe size and I fall within a range. Now, people at my age and who are in my situation, who have slightly different shoe sizes and that's okay. So one of the most important things to understand, I guess, is about, if we're talking about sleep, is how it works, how it was regulated. So sleep is regulated by what we call the two process model. And I'm gonna simplify it a bit here, but it's fairly straightforward to understand. On the bottom here, we have a 24 hour period, six o'clock in the morning, day one, to six o'clock in the morning, the next day. In the middle there, we have midnight. And you can see that across the waking period, we developed what we call sleepiness. It's the sleep drive. It's the drive to sleep. The basic equation is the longer you stay awake, the more sleepy you'll become. And eventually you get to the point where you're very sleepy and you go to sleep and sleepiness dissipates. You can think of it a bit like a pressure valve, once the pressure is built up, when the pressure is allowed to dissipate, which is what happens during sleep, then it releases, only to be built up again the next day. So that's the first process. But you can see that actually it needs a little bit of a tweaking for it to fall within a more regular pattern. And that's where the second process comes in. This is called the Body Clock or the Circadian Rhythm, the Circadian Process. And here we have daylight being the main signal, but we have a Body Clock Rhythm that is pertinent to alertness to what we call, Circadian Mediated Alertness. And you can see that we become more alert throughout the morning until we peak in the middle of our biological day. It may not be six o'clock or in this case may not be midday, it may be earlier or later, depending on when we get up, depending on when our body clock is, we'll look at whether we have an earlier body clock, an earlier chronotype, or whether we're a later body clock, a later chronotype. But you see that, that rhythm, it balances against the offsets the accrual of sleep pressure that we build during the waking day, such that we're able to stay awake despite being, you know, being sleepy, gradually getting more and more sleepy. So that Circadian Rhythm keeps us awake and it gradually starts to change in the evening or afternoon and evening, and then comes down and down and down, such that we're able to fall asleep. So you see the period just before midnight there, the sleep pressure is very high and the circadian mediated alertness is low, and so the person can fall asleep. If they try to fall asleep at midday, when the sleep pressure isn't high enough, and this circadian mediated alertness is too high, then it wouldn't be able to fall asleep, probably. So that's kind of how sleep is regulated. If we think about tips for good sleep, trying to help people optimise their sleep, one of the main things to realise, and it goes back to the first slide we had, was that we evolve to sleep in a very specific way. We've evolved asleep at night and at night we have three characteristics of the nighttime environment, which are very different to the daytime environment. And the first one is that it's a lot quieter at night than it is during the day. So people outside at night, and you compare that to going outside during the day. Of course you have human activity, but even animal activity is noisy and you noticed that there's a big difference in terms of how much noise we experience. The second one and most obvious one probably, is that it's much darker. We have the absence of light. And the importance of light here cannot be overstated. Light has the strongest signal on our body clock. When we wake up in the morning, it is light exposure in the morning that sets the clock for the rest of the day. And so when we see that, kind of across a period, if you get up at the same time every day, what you do is you give yourself the same stimulus for your circadian process in a consistent fashion across that period of time, that helps regularise sleep. But if we live in an environment like the one in which we live here in the UK, where it's dark most of the time during the winter, it's quite bright during the summer, occasionally. And we want to kinda maximise that. What we can do is you can make stark differences, so we can have thick curtains to keep out light at night, where light maybe problematic. And we can have bright light during the day, particularly on days like today, when it's a bit sort of grey and cloudy, as it is down here in Oxford. Not sure how it is in Scotland, but I imagine it's not too dissimilar. So the idea is that we try and work with the natural context of the nighttime characteristics. And the third one is temperature. So temperature is something that drops a lot at night, in the absence of sunlight. And what happens interestingly to the body is that in accordance with our circadian rhythms, we have a core body temperature drop. So the body temperature actually reaches its lowest point a couple of hours before you'd wake naturally, if left to sleep to kind of a natural rhythm. And so what we see is that core temperature minimum is important because it's the circadian marker, it's something before that time, if we get lots of bright light, it's not helpful, after that time, if we get lots of bright light, it's very helpful. It keeps the sleep regular. In fact it keeps it tight. So allowing, especially in the winter when we turn our heating up, allowing the ambient temperature to drop to about 18 degrees, probably something around that's helpful, there's no absolute number of course, it's just to a suggestion, at night. That's probably a useful place at which to hold the temperature, to allow for your natural drop in body temperature that happens across the sleep period, having good mattresses, having good bedding's really important too. I know this sounds very obvious. But the number of people I've seen over the years who have spent lots and lots of money on, say, a great telly, that they may sit and watch for an hour in the evening. And then they spend nothing on a horrible old mattress that they've had for 20 years with springs poking them in the back. Spend the money where it's gonna be, you know, most helpful, buying a nice mattress. They don't even cost a huge amount these days. But getting a good quality mattress with good bedding and good, you know, appropriately comfortable bedding, warm bedding, whatever it happens to be, that's gonna be important for your sleep. And keeping the room tidy, keeping it somewhere that is enjoyable in which to be. So thinking about a bedroom as a place to drop everything, to drop all the concerns, the worries about the day, you know, piles of laundry you haven't done, not a helpful place to leave it in the bedroom, it just reminds you of stuff you've got to do. So keeping the bedroom a kind of an oasis of calm an oasis of relaxation, a space where you don't bring any work, you don't bring any any of the hassle of the day, is also helpful. Thinking carefully about eating and drinking. You know, we all enjoy, or most of us do anyway, a caffeinated drink during the day. That's something that's quite a British thing for us to do, to have a cup of tea or a cup of coffee. Caffeine has an interesting effect on sleep. What it does is it blocks the ability of the brain to detect sleepiness, that sleep drive, the sleep pressure that we talked about, the first of the two processes. And so if you have caffeine, which may hang around in the body for quite a long time. So the half-life of caffeine, the amount of time it takes for caffeine to reduce by half in the bloodstream is between three and seven hours, roughly. So you have quite a lengthy period of time before caffeine is kind of eliminated completely. And if you have a couple of cups of coffee in the morning, three cups of coffee in the morning, you say, "Well, they're all in the morning." What we don't take into account is that, that load, that caffeine load then takes longer to be dealt with by the body because there's more of it to get rid of. So thinking about alcohol, you know, alcohol is a central nervous system depressant, so it puts us to sleep very quickly. Some of us may remember from the Christmas period that that's what it does. And one of the things that's important to understand about alcohol is that although it may put us to sleep quickly, it doesn't keep us asleep. In fact, once it's been metabolised, then our sleep architecture changes and not only does it change, but it's also a diuretic. So it increases our likelihood of needing to go for a pee in the night, which may wake us up and make us feel uncomfortable. And of course you may be in bed thinking,"Oh I don't wanna get out of bed,"'cause I don't have a pee, 'cause it's cold." And you get caught up in your mind too. So thinking carefully about when you have a drink, you know, when's the latest you're gonna have a drink, if you're noticing that it is a problem. If it's not a problem for you, you knock yourself out, do you do your thing. But if it is a problem, then just spending some time reflecting on it, thinking carefully about it is helpful. Eating is also something that we want to take into account too. So big, heavy meals before bed. Again, if they're not a problem for you, you do your thing. But if it is a problem, if you notice that actually you feel uncomfortable, you know, you're not necessarily sleeping as well, maybe moving that need a little bit earlier, having a lighter meal instead of a heavy meal or having your main meal, your supper, maybe earlier in the evening and having a snack before bed. These are ways of thinking about how you can change it up a bit, to experiment with what works for you. The question I often get asked, by, I don't know, when I'm on the radio or something, people say, you know,"What's the most helpful thing we can do for our sleep?" And it's a difficult one to answer easily and quickly. But what's really clear is, if we get up at the same time every day, we give ourselves the best opportunity for regularising our sleep and making it consistent. Now, if you get up at different times each day, you have longer and shorter periods of wakefulness. It doesn't kind of lend itself to a particularly predictable pattern. And so what we want to do is remember that light is that primary signal that helps us sleep, or helps our circadian rhythm function or entrain to the cycle outside. We want it to be fairly consistent, fairly rhythmical. If you think about where we evolved, outside in the African Savannah, or for loss of it, you know, nice regular sunrises, regular evenings, we're kind of, we're able to sync to that naturally. That's what our brains do, they've evolved to do. So if we try and limit that by getting up at the same time every day and letting the other end fall where it may. So when you get sleepy you go to bed and you get up at the same time every day, then you go to bed when you're sleepy again. You've anchored one end of it and the other end can be a little bit, you know, it's easier to work that way. Much easier to get up at a regular time than it is to go to sleep at a regular time. We can't force ourselves to go to sleep. We can force ourselves to get up. So that's kind of one of the things that I would say has been most helpful. So here we have an example of essentially a messy rhythm. This is an individual who's getting up at different times, going to bed at different times. And you can see that actually, because they're awake or that they're getting into bed, not quite ready for sleep yet, they're awake for a bit, they fall asleep, they have a bit of a period of wakefulness. And then they overshoot when they're getting up time is, they eventually have a bit of a lie-in too. It's all a bit arbitrary. It's all a bit ambiguous. If we just told this person,"Right, cut it here, six o'clock,"don't get up any later than six o'clock."

Or whatever it is, 6: 21:45

30, seven o'clock, whenever you want to schedule it, then we can let that bit sort of, that can be one of the bookends and the other end can kind of fall into place of its own accord. But what we want to try and do is make sure that we're getting into bed when we're sleepy and when we're ready for sleep, and we're getting out of bed at a consistent time, that's, you know, early enough to mean that we keep sleep tight, but not too early so that we cut sleep. We don't want to cut it unnecessarily. So one of the other really important things to mention is keeping the bed just for sleep. Making sure that sleep is the main thing with which we associate being in bed. So they always say, there's two things you can do in bed, or two things that we can kind of associate bed with. One of them is intimacy with your partner because it's a practical place to do that kind of thing. And the second thing is sleeping. So if we start to associate bed with other things such as being awake or being irritated or not being to get to sleep or, you know, worrying about sleep or working or eating or watching telly or whatever, then the signal, the association, the paired association between being in bed and being asleep, that starts to crumble. And I can illustrate this with an example of some tennis. So if I said to Sarah, Sarah, grab a racket, let's head down to the tennis courts. Sarah wouldn't have to think very hard to work out what it is that we were gonna go and do on the tennis court. She would assume, because of the association that we're gonna go to the tennis courts. What do you do on a tennis court? Well, you play tennis and I've got a tennis racket. So she'd assume we're gonna go and play tennis. And of course she'd be right. However, if I decided in my, sort of Machiavellian scientific madness to say, yeah, we're not gonna play tennis, instead we're gonna play hockey, right. Or we're going to, course of a week. The next time, the next week I say to Sarah, grab a tennis racket, let's head down to the courts. She wouldn't necessarily be thinking we're gonna go and play tennis. Now she'd be thinking,"Well, do you know what?"I don't know what we're gonna do."We might play tennis."We don't really play very much tennis"on the courts anymore."We spend time playing hockey."And actually, he's been making cakes there too."He's kind of a strange guy." And so the reality is that we've absolutely degraded that relationship between being on the courts and playing tennis. And we've now made it very, very ambiguous, very arbitrary. If we spend time in bed, not sleeping. If we spend time in bed being actively frustrated, actively irritated at not sleeping, actively worried about the effects of not sleeping, doing other things as a means of trying to get to sleep, listening to whale sounds or whatever it might be, what we end up doing is we end up associating the bed with that frustration, with that lack of predictability, with that battle, if you like it. And bed becomes a battleground, is what some people say. And invariably then we don't have this strong paired association. So what we often suggest is, if that happens and you notice that you're in bed, not asleep, the first thing is to say, if you're not sleepy, don't get into bed. When you're sleeping, you notice you're sleepy, get into bed. If it doesn't happen for whatever reason, within a few minutes, if you lie there and it's not happening. You sigh to yourself, "Gosh, not again." Then that's the point at which to get out of bed. And all we do is we go downstairs again, or we go into the living room, we go and sit down in an armchair, snugly armchair, blankets, pillows, whatever you like, doesn't matter, read a book, watch a documentary, something that's relaxing. Don't try and sleep, don't try and make yourself sleepy, don't try to do anything. Just enjoy doing whatever it is you're doing, just relax. And in doing so, sleepiness will come back again and you can go back to sleep when you feel sleepy. So it's a nice little pattern. You feel sleepy, get into bed. If you're not asleep, get out of bed, relax. When you feel sleepy again, get back into bed and so on and so forth. And what we do in doing this is we retrain ourselves to associate bed with sleep and we stop ourselves getting caught up in patterns of trying too hard to get to sleep. Napping and exercise are also big ones'cause these are things that may have changed over the Christmas period. They certainly changed for me a bit, over the Christmas period. And napping during the day is generally a bad idea if you're struggling to get to sleep at night. There are a couple of instances of people with sleep problems for whom napping is a sensible thing to do, but they are for people with particular sleep disorders, not general and suddenly, or general sleep problems. General sleep problems, what we say is, if you nap during the day, you take away the sleep pressure that you need at night. And so if you have a nap and you try to get to sleep later on, you may struggle to get to sleep later on because you haven't got any of that sleep pressure there. So you have to stay up a little bit later. Now our Mediterranean cousins, you know, they have the siesta in the middle of the day, maybe, but the reason they do that is because often, I mean, culturally one would assume, it's because it's really hot in the middle of the day, often those countries. Not a very productive period of the day, so you have a little rest and then you stay up a little bit later in the cool of the evening with your friends and family and you do your late dinners and stuff and enjoy the cool of the evening. So they've kind of got a different cultural approach to us. But in the UK, we don't do that, so it's a napping is not such a great idea during the day. And exercise is one that's interesting too. So very often I hear people saying,"You know, I went on a run to try and tyre myself out." Or, "I did lots of exercises"as a means of trying to make myself sleepy." So tiredness, physical tiredness, lethargy, exhaustion, fatigue and sleepiness are two different things. And it's very important to differentiate them. Because working hard to feel exhausted in a kind of, in terms of activity won't necessarily make you sleepy. And it may even make you more alert, more awake. And so what's important is understanding that if you do your exercise earlier, often in the presence of some sunlight, that's quite a helpful thing to do, Difficult, of course, in this kind of weather, but do it earlier in the day, rather than later in the day. That's the general advice. Again, if you do it later in the day and you don't have a problem with your sleep, you do it, don't worry, no problem at all. But it's if you notice that the exercise is getting in the way of sleep, then probably that's something to change. Another sort of more therapeutic piece, I guess, might be thinking about winding down before bed. So if we think about driving a car, if we were gonna slow a car down from 50, 60 miles an hour to zero, to stop, we wouldn't do that in a metre. You wouldn't be able to do it in a metre, it'll be a very big mess, and it would be quite uncomfortable for people. So what we want to do is we gradually decelerate the car as we get towards the stop. And that's the same thing we do at the end of the day, we gradually wind-down. Remember your circadian system's already at play, it's already working. Melatonin's probably starting to be secreted. And you gradually start winding down in terms of your alertness. But mentally, we also want to help ourselves to shut down a bit. So maybe that includes things like relaxation exercises. It might include things like meditation. It might include things like, you know, watching your favourite programme on telly to help you laugh and relax and putting the day to rest. So putting those work laptops away, making sure you've got your phone on no notifications or whatever it is, or putting your phone away and just enjoying the part of the day that's just for you. And one of the ways in which people often find this helpful to facilitate is to use something called putting the day to rest, which is a technique that Colin Espie, our Professor of Sleep Medicine at the university of Oxford and our chief medical officer at the Big Health, kinda talks about it a lot. So we get a journal or a diary or a piece of paper, and earlier in the evening, maybe about seven o'clock, we note down all the stuff we've got to do for the next day. We'll make it to do list for the next day. We'd be pedantic, we'd put down everything. So I got to call so-and-so and I've gotta do it on that number and I've gotta do it with this. I've got this in mind, I've got to talk to them about that. And so on and so forth. And you write it all down. Tip all the contents of your head onto that piece of paper and allow that to hold the weight, the metaphorical weight, of all that information. You don't need to hold it anymore. Write it all down, go through it again, be pedantic, add extra bits in, if you think it's helpful. And then when you finished doing that, five or 10 minutes later, grab your phone, put on an alarm for the next day and maybe put the alarm on for eight o'clock in the morning and make a mental note to say,"I'm gonna come back and deal with this"tomorrow at eight o'clock."When the phone goes off at eight o'clock,"I'll come back and deal"with everything that's on this piece of paper."But until that point, I'm gonna rest."I'm not gonna deal with any of it." And if any of your thoughts come up in the run up to sleep, you can put them down on the piece of paper, that's fine, you can go and add to the piece of paper. But we're not taking off that piece of paper, we're just putting on the piece of paper. And of course the next day at eight o'clock, you can sit down and you've got it all laid out there for you to follow. So another option for those of you with difficulty with sleep is what we're very pleased to say is now available to everyone in Scotland and that's Sleepio. So Sleepio is a digital CBT for insomnia, cognitive behavioural therapy for insomnia. And it's something that is available to you through the internet, so you can access it. And I'll put the link at the end of the, I've got the link at the end of the slides. It's essentially what you'd experience doing a face-to-face therapy for insomnia, but done through a virtual therapist. The prof, who's there on the screen there with the dog. And the idea is that this provides the evidence-based, first-line, recommended treatment for insomnia to people, through their computers. And we've found it to be very effective. So it's been through 12 randomised control trials to date. But it's also something that is built upon, a very robust evidence base, in terms of the CBT approach itself. It's something we've used in over a hundred thousand people now. So we've offered to a hundred thousand people in the UK. So it's been used by a lot of people. It doesn't have any waiting time. You can access it straight away, it's safe, it's trusted. And so it's something that I really recommend, you investigate if sleep is still problematic for you. One of the ways in which you can kind of access it, is to go to this website, there'll be a link at the end, and you have a sleep score generated. So what you do is you answer a couple of questions on how your sleep is. And your sleep report is given to you by the programme, so that make sense of your sleep and the programme is then tailored to your needs. So you start these six weekly sessions, which you can do them on your computer, you don't have to do them on a phone, although you can also access some of this stuff on your phone. And you begin to, immediately begin to put into practise the principles of CBT for insomnia, with a view to changing your sleep. So here's some of the tips that we've been through today. So the idea mainly here is to keep a regular rise time and to keep sleep as consistent as possible. Get up at the same time every day, keep a routine that's roughly the same, keep the bed and bedroom dedicated to sleep, develop a wind-down routine to help sleep happen effortlessly and protect sleep from competing demands. So get that mobile phone out of the bedroom. Also get that work laptop off the chest of drawers. We want to make sure that this is something that is just, you know, you don't have to have any intrusions from working life when you get into bed. Keep sleep healthy by being active during the day. And so lots of activity during the day is good. Daytime activity's a good predictor of sleep. And keep sleep for the nighttime don't nap during the day,'cause it's likely to steal away sleep pressure from the time you need it at the end of the day. And keep sleep the same on weekends and weekdays. Remember that the body doesn't have an idea of what a weekend or weekday is. If you need a lie-in on the weekends, it's probably because you're not getting enough sleep during the week. So maybe try and get better sleep during the week, improve the amount of sleep you're giving yourself, the opportunity you're giving yourself to sleep during the week, such that weekend you don't have to sleep in too long. And if you're still struggling with your sleep, then try cognitive behavioural therapy for insomnia delivered by Sleepio. And the two QR codes are here for Sleepio. And for Sleepio's sister programme Daylight, which is very similar, but seeks to help people with anxiety. So particularly with mild to moderate symptoms of generalised anxiety. But again, evidence-based, digital therapeutic, highly recommended, and it's something that you can access as an app. So Daylight is something that provides CBT for anxiety on your phone, as and when you need it, you know, to help you when you need it in the situations in which it arises. And Sleepio is more of a course of treatment that you can access on your computer. That's all from me. I'll just stop the slideshow. But very happy to answer some questions if there are any. Thanks for listening.- [Dan Cudmore] Thanks Dimitri. My name's Dan Cudmore, I'm the UK engagement leader at Big Health. I'm just gonna ask Jenna and Sarah if they can pass through any questions on the Q&A, I'm sure we've been getting a few. We'll keep an eye out for that. But if anyone has got any questions that they haven't posted, please, please pop them in the Q&A now, and we'll put them to Dimitri. So anything kind of sleep or anxiety related, please pop them in the Q&A, and I'm sure Jen and Sarah can pass them through to us now. We've got one straight away, Dimitri, there's a few, So, "Do you have any advice for coping with sleep issues"when the soundproofing is not very good,"you might be able to hear your neighbours"or other stuff going on outside?"- So this is a really, really good question. And it's not one that has, I mean, it's a really practical question, isn't it? And I struggle with being a light sleeper, so I'm in a house with two small children, a five-year-old and a one-and-a-half-year old, and I've got my wife and I've got our family dog as well. And so we're all, you know, moving around in bed, we've all got, you know, sometimes people pop to the loo in the middle of the night. We live in an urban street, so we have people walking past the house. We have foxes making noises outside, owls sometimes, trains passing, planes sometimes. You know, things wake you up. Neighbours again, just another one of those things that happen. If they're really, really raucous, and if they're causing a lot of problems, then, you know, without wishing to be overly kind of obvious about it, then having a chat with them might be a good idea. And if need be looking to chat to someone at the council, if it's really that problematic. But if it's just general sort of general noise, and it's not really something that's that serious, but you're finding it difficult, then there's actually no harm in trying things like ear plugs. I don't have, you know, any kind of magic formula for it because this isn't an everyday problem. But I use a pair of ear plugs, that's a very squishy, foam, earplug. Works brilliantly for me and helps me sleep really well. You know, ideally it'd be great not to have 'em, but I find it helpful for me, I don't think it's a big deal. And if I don't have them, I still sleep okay. But the idea is that it just kinda takes the edge off a bit. Another thing that might be helpful if you're noticing that this is something that's impacting your ability to sleep, even with ear plugs, then you could put maybe some white noise on, just to kind of dampen the sound a bit. And there are lots of white noise apps out there that provide consistent white noise throughout the night. White noise is not a treatment for insomnia, bear in mind. There was a review done, I think last year, they published results. Looking at the literature, found that white noise wasn't a cure for insomnia. But we're not using it as a cure for insomnia here, we're using it as a means of dampening the noise level in an environment where noise is impacting on someone's ability to sleep. You know, so a couple of practical suggestions there. I'm not sure how helpful they are, but I hope it's of some help. It is a problem for lots of us living, if we live with other people, if we live around other people, which of course most of us do, then we're bound to be disturbed by them in some way, shape or form.- [Dan Cudmore] Thanks, Dimitri. Really a useful answer, some practical things there for sure. I can see this, one's got a few likes. So I'm gonna tackle that one next, a few people putting thumbs up, may be experiencing the same. So someone says that they're waking up every few hours, so maybe not getting there for seven to eight, nine hours. They might use hypnosis or something to get them off to sleep. But are there any tips for someone who's waking in the night throughout the night?- That's a great question. And so there's a couple of things to think about here. So the first one is that, remember we all wake up at night, all of us, multiple times during the night, we come up into wakefulness and we go back down into sleep. That is not a problem. In itself, you know, brief awakenings throughout the night are not a problem. When they start to impact on your ability to get a continuous night's sleep, so you're awake for say an hour at a time, or you're really struggling to get back to sleep, or you're becoming irritated or upset about being awake at night, which is understandable, or when they're the result of something else. So it could be that you wake as a result of feeling breathless. Or it could be that you wake as a result of discomfort in your limbs. Those last two things, physical symptomatology, that might be a sign of a sleep disorder, something like obstructive sleep apnea, in the first example, and the second example may be a periodic limb movement or restless leg syndrome or something like that. If that's the case, then those physical symptoms require further investigation, beginning with your GP but then with specialists afterwards. If you're waking frequently throughout the night, and you're finding it difficult getting back to sleep because you're just on edge or you're trying, one of the things to bear in mind is that the harder we try, the irony is the cruellest of ironies, it's just very, very cruel, but the harder we try to get to sleep, the more difficult it is to get to sleep. You know, physiologically we are hardwired to pick up on threat, to pick up on potential danger, and for our physiology to then change to deal with that danger, to mitigate that danger. It's called the Fight-or-flight response, the Acute Stress Response. If we, you know, dial it back to cave people times, you see the saber-toothed cat, you immediately, you know, don't feel sleepy anymore. Say it's happening at night, you're just back to go to sleep with your family, you hear a roar outside, immediately you stand up, you grab a spear, you run to the front of the cave and you're ready to fight off the predator. Now that's fine and good in that example, rather dramatic example, but if we think about how that impacts us during the night, when we're struggling to get back to sleep, the threat is no longer a saber-toothed cat, but the threat is what if I can't get back to sleep. Or maybe the threat is even more subtle. Maybe the threat is just,"I'm not sleeping and this is irritating me." You know, some people say to me,"But yeah, but I'm really relaxed when it happens." But the fact that you're aware of the fact that you're not sleeping is enough to just cause you a little level of being kind of slightly on edge. And that is enough to irritate you into wakefulness. So there are a couple of techniques which might be helpful for people. I think the most helpful thing to do is to suggest people go in and use Sleepio, which we've just spoken about earlier, because Sleepio has a range of different things that will be helpful for a range of different people. But there are some things that people might find helpful in the short-term. not in the short-term, but kinda putting it into practise tonight, and one of these is called paradoxical intention. So paradoxical intention is illustrated best by the example of my parents-in-law. So my parents-in-law come and sit on the sofa, watching telly. And very often when they're watching telly, one will slump forward and snore like this, and then one will have their back and snore like that. And they'll both be watching telly, or not watching telly. But when you ask them, you know, what's happened, they'll both say, you know,"We're watching telly." Or, "We're trying to watch telly." What they're doing is they're trying to stay awake to watch the television, whatever they were watching, but because they're sleepy, right, because their bodies are sleepy, and actually as you get older, your body clock becomes earlier, so you get to sleep a little bit earlier, there is truth to that stereotype, but as you try to pay attention to the TV and you're really tired, you end up just nodding off. Because you're not trying to chase sleep, you're trying to chase wakefulness, you're being alert and attentive or trying to be, and you're fighting this, you know, trying to stay awake, just trying to stay awake, just trying to stay awake. And so what happens is sleep overtakes you. You know, a very sad corollary of this is, you know, road traffic accidents, when people are sleepy, they try to stay awake to keep going, and because they're so tired, they're so sleepy, sleep overwhelms and they have an accident. So in this sense, the more we run towards sleep, the more unhelpful it is, the more we experience that anxiety, that anticipatory anxiety, performance anxiety, we call it in the jargon. And that triggers that sense of not being able to get to sleep. So the best thing to do, to try to get to sleep, is not to to try to get to sleep. So one of the things we recommend is what I mentioned earlier, which is getting out of bed and going and doing something relaxing. But before you get to that stage, one of the things you can try is something that will be called paradoxical intention. So paradoxical intention is what the Americans call a reverse psychology. You see another sitcoms, they talk about reverse psychology. But paradoxal intention is, maybe one example, might be lying there in bed and lying stock-still, not doing anything, closing your eyes, and instead of trying to get to sleep, trying to make yourself sleep, just try desperately to stay awake. I know that sounds a bit silly. This might sound very facile, but give it a go, lying there, don't move and just try and stay awake."I've just gotta stay awake for another couple of minutes,"I'm gonna try and stay awake."I'm just gonna try and stay awake."Stay awake, stay awake, stay awake." And just keep repeating yourself, stay awake, stay awake, stay awake, or whatever it happens to be. And that's quite a boring, repetitive, exhaustive process. If you're sleepy, it may well induce sleep. Another thing you can try maybe is a relaxation exercise, something like a mindful body scan. So if you're not come across a mindful body scan before then that's something you can look up online. There's plenty of examples of it out there, where we gradually sweep through the body with a mindfulness, noticing the sensations in the body. Again, it's a very relaxing activity, but it's one that's quite active. You're having to try to be aware of what's there in the body. And so you're actively trying to stay awake to do so. And if you're tired because you're actively trying to stay awake, very often it puts you to sleep. And that's not the intent of the practise, but it is a kind of helpful side effect, in this case. But there are other things too that people can do. But one of the things that Sleepio shows, you know, for those of you who are gonna go on and use Sleepio, is that if you get out of bed and go and do something relaxing, have your dressing gown ready, predict that this is gonna happen. If it happens every night, say to yourself,"Right, it's gonna definitely happen tonight, for sure."Let me put my dressing gown at the end of the bed"and have my slippers ready."I'll go down to the armchair in the sitting room,"I'll make sure there's a couple of pillows there,"I've got a blanket there, I'll make it a nest." That's what I call it to my patients, I always say, make a nest. You know, and grab yourself a nice, maybe it's a decaf tea or maybe it's a hot cocoa or whatever it is. Put it in a thermos ready, you know, get your favourite book, put it there, maybe have the remote control for the telly ready and waiting for you. So when you feel this, "Oh God, it's not happening again." Get out of bed, go to the nest and relax. Don't try to get asleep. Don't even think about sleep. Don't even get involved with the thought about sleep. Just sit there and relax. Watch telly, read a book, drink a cup of decaf tea or herbal tea is probably better. And in doing so, what you give yourself the opportunity to do is to relax, to let go of the anxiety, the stress, the irritation, the frustration around not being able to get to sleep. And then sleepiness may come back. And when it comes back and you start reading that second sentence in the chapter, again, you kinda go,"Oh, I have to start again." And you notice you're tired and your eyes are stinging, you close the book, you head back upstairs and you go back and lie down in bed and see what happens. And you just repeat that. That's what's called stimulus control. It's a very important part of CBT for insomnia. So there's a couple of ideas there. I hope that that's helpful.- [Dan Cudmore] Thank you Dimitri, really helpful. We're getting a lot of questions. So guys we'll get to as many as possible. There's a couple that are cropping up quite a lot. One I'm just gonna tackle very quickly. And the question is, "Is Sleepio only available"to NHS staff?" And the answer is no. If you're a Scotland resident, you can access Sleepio at no cost. All you have to do is enter, I believe, the first half of your postcode when you're going to sign up, and that should give you access. So Sleepio is available to the whole of Scotland and Daylight is too, as Dimitri's already mentioned. So Dimitri back to back to some questions for you. I think one that's cropping up a lot is shift workers. And I know we get this often. But is there any specific advice for shift workers around sleep and maybe some resources you could point them to?- So great question. And absolutely tip top important shift work. Worth bearing in mind that we've done a webinar on shift work already, and so there'll be lots of resources and things there too. So I want to signpost people to that on the National Wellbeing Hub. But in terms of shift work, one of the things to understand with shift work is that, it's a big topic, I really recommend watching the recorded webinar, if you can stomach watching me again. But one of the things to understand about shift work is that we're primed to sleep at night and we're not primed to move our sleep around. That's not what we do naturally. So we have this natural predisposition to do something in a particular way. When we start to move it around a bit, it can of course create problems with our sleep. And that's not a sign that anyone is in any way broken, and, or sort of weak or problematic. You know, that's a sign that they're working fine. It's just that the kind of artificial nature of sleep of shift work is getting in the way. So one of the things that we have to start with understanding is what the nature of the problem is. For some people, with shift work problems, it's about staying awake at night. And if you're a late type, if you're a later type, a night owl, as we call them, then the night shifts are probably easier for you than people who are morning times. In fact, we know that from the literature that late types, naturally late people, often do really well on night shifts versus people who are morning types or kind of intermediate types. Like I'm probably in early, intermediate type. And so when thinking about shifts, if you can choose shifts, difficult to do, but if you can't use shifts that are in line with your current type, that might be helpful. The second thing is to say that the worst thing that you can do with shifts is to try and sort of artificially prop up things like your wakefulness during the shift with things that will then affect you when you get back home. So lots of caffeine and Red Bull and all kinds of stuff, as a means of keeping you awake during the shift, is probably gonna be less helpful if done, particularly at the end of the shift, that if you do maybe a little bit before you go on shift in the evening, that might be helpful. But when you get back home, you want it to have been plenty of time, such that the effects of the caffeine can have been dealt with, metabolised really, have the molecule metabolised. But the other thing to bear in mind is that you can also use stimulants like light. So light is very potent, alerting mechanism. And having brief naps. You know, if you can get, difficult to do it in an NHS setting, there are some NHS settings that may allow for this, but by and large, it's not something that's been adopted, having brief naps, recovery naps during the course of a shift, maybe only 20 minutes, as it can be a very helpful way of maintaining alertness. Once you get home or once you're on your way home from a night shift, then reducing the effects of, the first thing you need to do is make sure that when you travel, you're travelling safely, that's the most important thing to say. The likelihood is that you'll be very sleep deprived by that stage because you've done it over numerous nights and driving home will be, you know, you want to do it slowly, carefully, safely. I won't go too much into that. But also making sure you minimise the effects of bright light in the morning on your going home. So bright light in driving home in the morning, bright light hitting you in the eye, that's not gonna be helpful because it has an alerting effect. So what we want to try and do is keep it dim, keep it dark. When you get inside and you get home, the best thing to do is take public transport, but you can get home, it's not really practical, but then keep the room dark, you know, a little bit of a wind-down, see if you can relax before getting into bed. Do your wind-down as you do normally. And then once you've got into bed, make sure that the curtains are completely closed, blackout blinds, so on and so forth, do-not-disturb signs and the door, maybe earplugs or white noise to try and drown out the sounds of the day and make sure that this is the night, make sure it's as much like the night as possible. It's really hard. It is really, really, really hard. There are no quick fixes, quick, easy fixes. But you know, these are kind of ideas that you can play with. And as I say, in the webinar we did on shift work, there may be more information there. Other things that can be helpful can be thinking about the way in which you partition sleep. So maybe you have a block of sleep to begin with, you allow for that circadian, middle-of-the-day effect where you won't be able to sleep, and then you have another nap before you go on your shift, which might be another way of dealing with it. So, you know, there are ways in ways. But part of what I think is really important to say is don't forget that when it's shift work it's not all about sleep, it's also about how you function within your family, the time you spend with your kids, with your loved ones and the time you get to socialise. All of these things change when you're on a shift work pattern. And so it's important to start bearing that sort of stuff in mind too,"What am I getting back from"in addition to when I'm getting my sleep?"- [Dan Cudmore] Thanks Dimitri. Really, really helpful advice. And yeah, absolutely, please do look at the National Wellbeing Hub for the previous shift work webinar. Hopefully that goes into a lot more depth than we've been able to today. So Dimitri, just conscious of time, so I'm gonna say one more and if we can do it within a couple of minutes, we'll give everyone a chance to grab a brew before they get to their next meeting or maybe catch some lunch. So, something that's come up quite a lot in the chat is melatonin.- Yeah.- [Dan Cudmore] And whether it's GPs maybe being reluctant to prescribe it, in some people's experience, or just asking generally, you know, whether melatonin supplements are worthwhile. I don't know if you could just talk very briefly about that, Dimitri.- Yeah, sure, absolutely. And I'll try and do it in two minutes. So melatonin is a naturally occurring hormone that's secreted by the pineal gland that's in the brain, back of the brain here. And it's something that is secreted in the absence of light. So when we have light hitting in the eye, it turns the secretion tap off and when it's dark, it starts to be secreted again. That pattern is governed by a circadian rhythm, okay. So that's important. The idea that melatonin as a supplement is necessary to fall asleep is something else. So that process happens for most of us. There's very few people with specific, often with things like neurodevelopmental disorders or various other things that are going on, it may not happen in exactly the right way, maybe for some older people, might happen exactly the way I just described, but by and large, it happens fine. And a supplement or a kind of an artificial synthesised version of melatonin is not actually necessary. It's not something that will have much of an effect on their ability to sleep. Melatonin only has a very mild hypnotic effect, it's not a sleeping pill in the same way as, you know, some of these other heavy sleeping pills are. And the likelihood is that what's best dealt with first is the behavioural and the cognitive stuff before looking at melatonin. So GPs are reluctant to prescribe it for various reasons, but principally, because it's not indicated for the treatment of insomnia in general adult care. So I hope that's kind of succinct enough. It has a role, of course your brains produce it already, but the stuff that you get in in a pill is a very different calibre. You know, you've got much more going on in your brain already than there is in any kind of pill.- [Dan Cudmore] Thanks Dimitri, very helpful. So with one minute remaining, I think all that's left for me to do is to say, thank you, Dimitri, for all of you insight. I can see lots of comments coming through in the chat, to say, thank you, very helpful. People might go and check out Sleepio or Daylight. So yeah, thanks very much, Dimitri.- Thanks everyone, thanks for having me. And yeah, sleep well. Wishing you well, wishing you a happy New Year. And do check out Sleepio and Daylight. We're so pleased that people have access to them now in Scotland. It's the Vanguard of the UK, really, because this is what's happening, it's happening in Scotland first, so it's fantastic. Make use of them. They're great programmes. And wishing you all the very best.- [Dan Cudmore] Brilliant, thanks, Dimitri. Thanks, everyone, take care.