Mind Dive
The Menninger Clinic’s Mind Dive podcast is a twice-monthly exploration of mental health topics from the professional’s perspective, including the dilemmas clinicians face in their practice. Hosts Dr. Bob Boland and Dr. Kerry Horrell dive into the complexities of mental health care including the latest research and other topical developments through lively discourse with distinguished colleagues from near and far.
Mind Dive
Episode 64: Sleep & Mental Health with Dr. Myrtle Jeroudi
Sleep takes up nearly a third of a patient’s life, yet its importance to mental health outcomes has been drastically understated in therapeutic conversations. Dr. Myrtle Jeroudi, a neurologist at The Menninger Clinic, weighs in on how deeply intertwined sleep disruption is to mental health disorders and why asking the right questions regarding sleep is a crucial step in clinical assessments. A patient’s disrupted sleep habits often signal deeper disturbances and, if left untreated, can lead to worsening symptoms. Early sleep intervention in treatment can lead to better sleep hygiene and habits, potentially eliminating the need for medication-based intervention. As more and more individuals seeking mental health care report sleep issues nationwide, Dr. Jeroudi stresses the need for clinicians to perform robust sleep assessments for better therapeutic outcomes and improved long-term health.
“When you don't sleep well, your mood is going to be impacted, but the way we've understood this relationship has changed to be bi-directional, where one affects the other,” notes Dr. Jeroudi. “So, if you have depression or anxiety, you're not getting good sleep. And when you have those bad nights of sleep or poor quality of sleep, it's going to impact how severe your mood disorder is too.”
Dr. Myrtle Jeroudi, MD, is a staff neurologist with the Menninger Clinic's Sleep Medicine Service and is an assistant professor in the Menninger Department of Psychiatry & Behavioral Sciences at Baylor College of Medicine. She is board certified in neurology, clinical neurophysiology and sleep medicine. Her research has been published in peer-reviewed journals that include the Journal of Neurotrauma and Epilepsia and Seizure: European Journal of Epilepsy. Dr. Jeroudi earned her bachelor’s degrees in biology and medicine and society from Washington University in St. Louis and her medical degree from UT Southwestern Medical School.
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Dr. Bob Boland:
So today we're lucky again to have another person that we have locally here right at Menninger. This is Dr. Myrtle Jeroudi. She's a staff neurologist with the clinic sleep medicine service. She's an assistant professor at the Menninger Department of Psychiatry and Behavioral Health Sciences at the Baylor College of Medicine board, certified in neurology, clinical neurophysiology and sleep medicine. She has research that's been published in peer-reviewed journals, including Journal of Neurotrauma and Epilepsia and Seizure: the European Journal of Epilepsy.
Dr. Bob Boland:
She earned her bachelor's degree in biology and medicine and society from Washington University in St Louis and her medical degree is from the UT Southwestern Medical School. She completed an internal medicine internship and neurology fellowship at UT Southwestern Medical School. She completed an internal medicine internship and neurology fellowship at UT Southwestern and fellowships in clinical neurophysiology and sleep medicine at the Baylor College of Medicine. That's a lot, Dr. Jeroudi, welcome, thank you, I will say I was I, of course we've met you.
Dr. Bob Boland:
You're on Compass with my patients all the time.
Dr. Kerry Horrell:
And so, I did that thing I do as a psychologist. But I was like, of course, we've met you, you're on Compass with my patients all the time. And so, I did that thing I do as a psychologist. I was like, obviously, Dr. Jeroudi is a psychiatrist. I was like, doctors around here are psychiatrists. And as we were preparing for the podcast, I was like Dr. Jeroudi is not, right?
Dr. Bob Boland:
I got that right, you're a neurologist, which?
Dr. Kerry Horrell:
is the simplest way to say it. I was reading through all of your bio and was like oh my gosh, badass, that's super cool.
Dr. Myrtle Jeroudi:
I think I'm the only neurologist here.
Dr. Bob Boland:
I think you're the only neurologist here and yeah, I mean, there's a lot of different pathways to sleep and specialties in sleep and we're very lucky to have a different perspective.
Dr. Kerry Horrell:
Again, I will say just to brag on you for a little bit, because I think in getting to know you a bit, I don't think you're going to brag on yourself very much. I'm going to do it really quick at the top of the episode. My patients love you. They're always like Dr. Jeroudi has made such a difference in my treatment. I feel like again, like we are so lucky to have you, and so thank you for coming on and for talking to us about this Again.
Dr. Bob Boland: 26
I've been trying to get you for a while.
Dr. Kerry Horrell: 28
This is a hugely important topic, so yeah, that means a lot to me, yeah, why don't we start off?
Dr. Bob Boland:
I mean, just tell us a little about your career. You know how you got interested in sleep medicine.
Dr. Myrtle Jeroudi:
So, at WashU I studied medicine and society and that's actually an anthropology degree, and I came to medicine a little bit different than some people, because I liked medicine and the way that you. To me it was a way of answering questions like who are we, what, what things mean to us, how do we interact with our environment around us? To me that's what drew me to medicine sort of the anthropological aspect of it, and I knew I wanted to do sleep medicine pretty early, maybe even before I knew that I wanted to do neurology. Because those are two areas neurology and sleep medicine where the conditions that people have in those areas really impact their how they interact with their world, their worldview, how they see themselves and what their life means to them.
Dr. Myrtle Jeroudi:
And I like taking a sleep history from people because it's amazing how much you learn about somebody just from asking them about their sleep. You learn what things are important to them, what their hobbies are like, who their bed partners are, their relationship, loved ones, stress. So, just asking somebody truly about how they sleep, you'd be amazed how much you learn about things that you would otherwise never even think of asking them. Sleep medicine, what I like about that about it is that it's biological, it's physiological, it's also sociologic, it's very cultural, anthropological. So, all of those things I love about sleep medicine and for sleep disorders, sleep is. We spend a third of our lives in sleep.
Dr. Bob Boland:
Well, maybe you do!
Dr. Kerry Horrell:
I was actually. I was about to ask that. As you were saying that cause, I thought to myself like of course it's important. We spend so much of our lives asleep. And then I was like, how much of our lives do we spend asleep? A third sounds right, like, yeah, that it's wild. We're asleep for a lot of our lives.
Dr. Myrtle Jeroudi:
Yes, but it's this like temporary encephalopathic state. So, when people wake up, they don't realize how much it is impacting their physical and mental wellbeing and also people don't always realize this is something you can talk to a doctor about. So, when I first started before, I did the sleep fellowship, I would ask people, how did you sleep? And it's almost like it's impolite to bring it up to say like I didn't sleep well, or I don't sleep well or I'm still tired in the day. People are always we'll just respond I slept fine. Or maybe they think that's not something that like it's wasting their doctor's time to bring up those specific concerns.
Dr. Myrtle Jeroudi:
So, we spend so much of our time in sleep but if there's so many impacts on how it can affect your daytime that it really is such an important thing, and I think it's can sometimes be minimized or not really well understood. And you mentioned that you can sleep from so many different disciplines. That's another thing I love about it. You can come from a handful of different backgrounds, all coming together to look to contribute to this sort of new field of medicine.
Dr. Myrtle Jeroudi:
I mean it's a baby compared to other fields of medicine, and you don't have to be stuck to like the old ways or the algorithmic ways. You can still be creative in figuring things out, which not a lot of fields of medicine still have.
Dr. Bob Boland:
that I think, even though you sort of minimized it as like something people may not want to talk about, all the same, I've seen some lists that suggest it's certainly on the top five complaints that patients come in with as far as reasons to come in, along with headache and a few other things that might bring you in to your general doctor. Usually, insomnia is probably very high on that list of reasons why people might see a doctor, and I would bet a lot of people listening probably have no idea about how little training the average doctor gets in sleep. I'm trying to think back to my med school and if I got any at all, I don't remember it. It's probably the usual thing where you learn about, you know, normal sleep, like the different stages of sleep.
Dr. Bob Boland:
And that's probably about as much as we learned. And even in my psychiatry residency, where it's kind of seems relevant to sleep, , we had maybe one lecture or something on sleep at one point certainly not something that we ever became particularly competent at treating, and yet patients come to us all the time with those complaints well, it wasn't even required that you do special fellowships until like the mid-2000s. So I mean to declare yourself an expert wow, yeah, mid-2000s that's not long at all ago.
Dr. Myrtle Jeroudi:
And when I say it's a baby of a field, it's a baby of the field because we didn't even know that it was, didn’t even know that when you go to sleep, it's not just like your brain shuts off until pretty late. Rem sleep was discovered in the fifties. It was discovered the same year that DNA was discovered. And I know the Smithsonian magazine compared that to us learning more about the moon than we did our own depths of our oceans.
Dr. Myrtle Jeroudi:
There's a little bit of mismatch with us. I mean, we still don't exactly know the full function or meaning behind REM sleep was discovered in the fifties. Sleep medicine didn't really accelerate into the invention of CPAP because at that point you could charge somebody something for it so sleep medicine didn't really become a thing until that was 86, something like that.
Dr. Kerry Horrell:
If you know, if we think about some of the I don't know, like probably some of the first or more clear connections, like is there an overlap between things like heart disease, diabetes, some of the major health concerns that bring people in and sleep? Have we found some links to those?
Dr. Myrtle Jeroudi:
It should be.
Dr. Myrtle Jeroudi:
I mean you know a lot of the referrals to sleep are from other doctors because of health conditions that people discover, but at that point sometimes it's too late. We do know that they're that untreated sleep apnea, for example, is a really strong cardiovascular and stroke risk factor. You can pretty much think of any health condition and draw a line to sleep. We know now that it's a risk factor for the development of Alzheimer's dementia. We know it has strong impacts to prognosis of treatment of mood disorders, insulin regulation at night, leptin and ghrelin regulation, pretty much anything that has some sort of physical basis is going to be impacted by sleep.
Dr. Myrtle Jeroudi:
Yeah, and so if you are seeing your cardiologist because you have atrial fibrillation, you should have had some evaluation of your sleep, for example. So, it's pretty scary.
Dr. Bob Boland:
So once again, I don't know if we're all giving enough attention to that in our usual evaluation of patients.
Dr. Kerry Horrell:
Well, it's reminding me, you know, one of our very first episodes, like one of the first three we did. We did talk with Dr Michelle Patrick Quinn on wearable technology, and we were talking about that. Even when people come into the highest level of psychiatric care, one of the first things we're doing is we're disrupting their sleep with 15-minute checks and how that that's so. It's understandable for safety, but it's really goes against the face of the research we know about psychiatric care and the relationship between mental health and sleep. And I wonder since, of course, this is what our podcast tends to focus on If you can say a little bit more about what we have learned about sleep, quality of sleep, these things, and mental health, and how much it impacts the world of psychiatric disorders.
Dr. Myrtle Jeroudi:
So, they're definitely related, and I think it doesn't take a scientist to say that, like, when you don't sleep well, your mood is going to be impacted. But the way we've understood this relationship is that it's bi-directional one affects the other. So, if you have something like depression or anxiety, you're not getting good sleep. But when you have those bad nights of sleep or poor quality of sleep, it's going to impact the prognosis or how severe your mood disorder is too. , we know that even for the things that kind of sound like they wouldn't be mental health related, like sleep apnea, we know that when you have disrupted nighttime sleep quality, , your cognition is going to be impaired. So even the progress you can make with things like trauma therapy for your PTSD, if you have an untreated sleep disorder, you can only make so much progress. You're not getting the REM sleep to consolidate information or to be able to progress with those therapies. So, we know if you want the overall prognosis.
Dr. Myrtle Jeroudi:
you have to treat these things Now. In the past there was a little bit of emphasis on us knowing that there's a relationship. Maybe if you just treat the mood disorder the sleep will get better. But we know now that that's not really true, that you have to give the sleep problem its name and address it as its own distinct entity. So even in research this was a problem for many years where, you know, sleep was just sort of a secondary outcome and it wasn't even defined. It wasn't saying this person has comorbid insomnia. It's saying sleep problem. And when you don't call it what it is, then it becomes this vague secondary symptom that's not really part of anything specific, that you just sort of wait for it to get better. But even in the Menninger study with Michelle that Michelle Patrick was a part of, we know that at Menninger 90% of people have a sleep problem.
Dr. Myrtle Jeroudi:
But even when everything else gets better, a lot of people leave mental health settings, you know, prior to specific interventions with those same sleep problems and that impacts their quality of life and prognosis and risk of relapse and trauma therapy and all those other things that you might not think of as being sleep related.
Dr. Myrtle Jeroudi:
But we know that because things are so there is such a strong bidirectional relationship that they are. So, the other thing about its impact on mental health is that mental health isn't really an area where we think of preventative medicine. I mean, what does that even look like? But when you're thinking about sleep, a lot of people's sleep symptoms proceed their relapse, to your depressive episode, and if you can identify that the person is not sleeping well, you can actually intervene before their mood gets worse. And so, I mean, even as a neurologist, there's not a lot of like preventative medicine that you do. But if you see sleep as something that's like preventative medicine, it's homeopathic. There's not a lot of side effects to treating somebody's sleep and it can be like adding another medication a lot of times with how much it can actually cause improvement for the other things that you're trying to treat.
Dr. Bob Boland:
I don't think that's as commonly known. I think everyone sort of like in the mental health field knows that people who are depressed don't sleep well. I mean, that's such a common symptom. I don't think it's as well known that, like that, there may be some preventive aspect that if you address sleep early then it might actually decrease your risk of depression.
Dr. Kerry Horrell:
Well, and also it feels like other things around, especially depression and anxiety, where the idea is, well, if we treat the depression and anxiety, this will go away too. When it's like nope, this actually ends up being its own issue. We got to treat it as well. And again, I think that that's a big problem that I imagine occurred, which is like oh well, once we get the depression under wraps, their appetite, their sleep, everything will just kind of come back online.
Dr. Bob Boland:
That's the way it was taught for many years, yeah, yeah. And if you tried to treat their sleep, you were told that you're sort of like just you're just getting symptomatic treatment. You're not addressing the core problem.
Dr. Kerry Horrell:
How do you address anything related to depression If?
Dr. Bob Boland:
you're not sleeping. Well, it's hard.
Dr. Myrtle Jeroudi:
And I think there's a little bit of misconception on how to best do that too Sometimes, because it's amazing how many people hear what the gold standard treatment for insomnia is from me after being in mental health care for over two decades and I'm and somehow I'm still the first person telling them that there's limitations to the use of medications. This is something you know. This Ambien is not going to take away the stress trigger or that is causing your sleep problems.
Dr. Bob Boland:
Why don't we get into that a little bit more depth in a sec? But can you say, like you know when? So, when people come to you with sleep problems, what kind of sleep problems are you seeing Like what's most common?
Dr. Myrtle Jeroudi:
Insomnia is super common. I think that the general population prevalence is 30% and people with chronic insomnia is 10%, and that's just general population prevalence. Sleep apnea is also super common, and our understanding of prevalence varies, I guess, depending on which study you look at, but it’s at least 10%. And when you're looking at mental health, if you're in a, in a clinic being seen for depression, your risk is probably closer to 30%. If you're a trauma patient, probably closer to 70% risk for obstructive sleep apnea. So that's another super common one.
Dr. Myrtle Jeroudi:
And sleep related movement disorders are also common in our population. Because restless leg syndrome is super common, has super high genetic predisposition, but the things that are known to well, known to exacerbate it, are antidepressants and antipsychotics, and so we see a lot of restless leg syndrome and the nuance of. You know that's not a hard diagnosis to make, and even treating it is not that difficult, but it seems like it's under diagnosed and undertreated as something sort of like easy to do to identify and manage Hypersomnia disorders. Maybe not, maybe sleeping too much, especially in patients with depression, hypersomnia can be a little bit more common. But actual sleep disorders causing sleepiness like narcolepsy and idiopathic hypersomnia are not super common.
Dr. Bob Boland:
Yeah, I mean let's take insomnia, since that is probably the most common right and the one that patients are so troubled by. First of all, I mean you know how often is it due to something, because you're talking about primary insomnia. How often is it due to something else? Like we can find some other cause that's treatable that would help the insomnia.
Dr. Kerry Horrell:
Also maybe, maybe before that too, because I think I don't know.
Dr. Bob Boland:
No, I really want to know the answer to that. I know but what?
Dr. Kerry Horrell:
What is insomnia? I think we use that term a lot. But like what? What qualifies for insomnia? And then, and then, bob's question.
Dr. Myrtle Jeroudi: 100
And that, and that also goes to the question of when do you see a doctor, because insomnia, as I mentioned, is quite prevalent.
Dr. Myrtle Jeroudi:
So, insomnia is difficulty falling or staying asleep or some subjective complaint about the quality of your nighttime sleep. And insomnia, by definition, should be in the absence of other causes, including other sleep disorders. So, if you've got obstructive sleep apnea, you can still have insomnia on top of that. But to understand insomnia you sort of look for those things to, chronic insomnia is based on the duration. If it's been going on for two to three times a week for six months, then you've got a diagnosis of chronic insomnia.
Dr. Myrtle Jeroudi:
And a lot of patients will ask me questions about, like total sleep time or, you know, my insomnia is this bad because I only sleep this much? That's not quite true. Insomnia is so subjective in its nature that really, we don't define it based on like okay, you slept six hours, so that's insomnia. It's more based on like I don't care, you know, however much you slept didn't feel good to you and caused a lot of stress and daytime disruption, fatigue, attention, concentration, impaired social, professional interactions, things like that. So insomnia has such a high subjective component to it, which is why things like a sleep study, have you know, just for insomnia, would be of limited use. So, a lot of people will say I want to do my sleep study because I want to see that I don't get REM sleep. I wouldn't really base an insomnia diagnosis Like you telling me that you sleep terribly is simply enough. Like I know at that point that even if you got five or 30% REM sleep in your sleep study, you have insomnia.
Dr. Myrtle Jeroudi:
The reason why sleep studies can help is because of the question of how often is it really due to something else. For somebody who's been enduring insomnia for a long time, this can have such an impact on quality of life. Really, I think it's to the point where that might be even all the person is thinking about, like how much do I sleep and my difficulties with sleep. Sometimes you would do a sleep study really just to look for other causes or etiologies of that person's symptoms. Is it really sleep apnea which can cause trouble falling and staying asleep? Is it limb movement disorder? So a sleep study is really good at looking for breathing and limb movement things.
Dr. Myrtle Jeroudi:
You can certainly look at other aspects and other sleep disorders, but those are the two major things that you look for on a sleep study. Now, can you have insomnia and something else? We know more now that even our obstructive sleep apnea patients with insomnia. It's another one of those things where just because you're treating the sleep apnea doesn't mean your insomnia is going to go away. And that's actually a lot of the patients we end up seeing at Menagerie, because lots of people can diagnose OSA and give you CPAP but, to follow up on your insomnia symptoms.
Dr. Myrtle Jeroudi:
It takes a little bit of nuanced patient's time that not everybody has to spend with the patient, and we know that 30% of people with obstructive sleep apnea have comorbid insomnia. This entity, COMISA, comorbid insomnia and sleep apnea and even though we don't know the best order to treat things, we know that they should be treated as distinct entities. The other side of the it's easy to give a CPAP and hope everything gets better is the excessive sleepiness patients, because we also know that 30% of OSA patients, even if they have a CPAP, are still going to have residual excessive daytime sleepiness. That does require follow-up to ask the questions Are you still sleepy, even though your CPAP shows that you're at a hundred percent compliance with no sleep apnea events? For patients who have residual excessive daytime sleepiness, there are interventions including pharmacological interventions for that too interventions including pharmacological interventions for that too.
Dr. Myrtle Jeroudi:
So, sleep is easy, but also it can be hard, yeah, those things, because a lot of people in my experience, people rarely have just one thing. They often do have more than one thing. And insomnia is notoriously challenging because the easiest thing is to give somebody a pill. I mean, it's, it's. I guess in med school we used to call it the doorknob question. Oh, by the way, I'm not sleeping.
Dr. Bob Boland:
And then you've got about two seconds to come up with a treatment, right? But just first of all I mean, since we're still definitional to Carrie's point, I'm just curious like do you, how do you, do you have a definition of, like what's enough sleep?
Dr. Myrtle Jeroudi:
So there are guidelines.
Dr. Bob Boland:
I'm bracing myself. Are you bracing yourself?
Dr. Myrtle Jeroudi:
Yeah, like from the CDC WHO like how much a person should sleep, and there's it. There are like norms for age and the norms are pretty broad. I mean, most adults are getting eight hours of sleep.
Dr. Bob Boland: 23:42
Really. And older people might actually need less sleep. Is that true? Wait, wait, wait, do we? I'm older, do we need less sleep, or do we just get it?
Dr. Kerry Horrell:
Both.
Dr. Bob Boland:
Oh, okay.
Dr. Kerry Horrell:
You just get it, and then you're doing fine.
Dr. Bob Boland:
Then we decide, we need it, but the norms.
Dr. Myrtle Jeroudi:
There are less, but from what I understand from the history of sleep medicine is those norms came from a survey mail to a bunch of people. So, when you say, like, how much sleep do you need, I don't know that that's how we answered the question. I think the question we've answered is how much do people without problems sleep?
Dr. Bob Boland:
I'm going to ask because occasionally I do see patients who say like I don't sleep well or I don't get enough sleep, and then I ask them you know, I go through kind of their sleep schedule with them and it's like about eight to 10 hours or something. I'm like, well, how much do you want to get? I mean, it seems like that seems right to me. So, I think we all have subjective senses of what normal sleep is yes, and I think we're also terrible at actually being accurate.
Dr. Myrtle Jeroudi:
That's the other part right, right, exactly, which is why I'm surprised.
Dr. Bob Boland:
You said that it's enough for you just to ask them to decide if they have insomnia.
Dr. Myrtle Jeroudi:
Because it doesn't matter so much about the total sleep time If you know it's. It's important in my history to understand like what is this person gauging is how much they sleep.
Dr. Myrtle Jeroudi:
But if they say I sleep seven and a half hours and I feel terrible. I feel like I can't sleep. I feel like I'm waking up in the middle of the night. When I wake up, I'm not refreshed. That's different than somebody, even sleeping less, who says I have literally no complaints. Because what? Because that means that that person, whatever they're sleeping, they're doing fine and with insomnia, we do know that. There, you know, some people will have this sleep state misperception where they think they're sleeping two hours and they're sleeping more like seven. But if you feel like you're sleeping two hours, I guess what I'm saying is it doesn't matter if you're actually sleeping six, and for me to like prove that on a sleep study and wave it in your face is not helpful, I will say I do think.
Dr. Kerry Horrell:
I do think that happens on our units, which is patients will say I feel like I'm not sleeping at all, I'm hardly sleeping, and then, like the people who are doing those rounds will be like buddy, we, we checked on you all night, like you were asleep, yeah, you were asleep for a while, but it's like it doesn't feel.
Dr. Kerry Horrell:
It doesn't feel like you're getting restful sleep and you're feeling a lot of daytime sleepiness, and so I guess, because you're alluding to this so much and perhaps you've even said this it's really complicated, like it doesn't sound easy to me at all because of how many factors can go into it. So, when you're meeting with a patient and they're like, okay, this is a huge part of my treatment, and it is like you're looking at what's their sleep, you know who are their sleep partners, what does their life look like? What are things like me impacting it that I have to do with their lifestyle? What meds are they on? You know all these things like how do we get from like here's this problem, to developing a treatment plan?
Dr. Kerry Horrell:
It sounds like sleep studies can be a part of that, which I have to say let me end there, cause that's one question, but I have thoughts on that. I've never done a sleep study, but it sounds like if you, if you put me in a lab and said, okay, Kerry, go to sleep, oh my God, I would not sleep, I would struggle. I feel like I'd probably look, absolutely it's like taking a test.
Dr. Kerry Horrell:
Oh my gosh, they'd be like all right, we're just going to see how you normally sleep, and I'm like in this lab where I don't normally sleep. So, anyways, I go back to.
Dr. Myrtle Jeroudi:
So, the sleep history is pretty detailed, especially for somebody with insomnia, because there's such socio-behavioral impacts that cause insomnia.
Dr. Myrtle Jeroudi:
But a sleep history, I mean to the way I dumb it down in my brain, to the people who are too sleepy, the people who don't sleep well and the people who are not sleeping enough, and that kind of makes it easy for me in my brain to like category cat, categorize patients into kind of these big umbrellas. And, you know, there's not our, our sleep diagnostic manual is not even that thick. I mean, there's only so many things that we've given credence to. There's probably more nuance than that, but there's only so many sleep disorders and usually they'll fall into those three categories.
Dr. Myrtle Jeroudi:
And so, for the people who aren't people, so sometimes the insomnia people and the other sleep disorder people can like look the same, because those are people who aren't sleeping well or not sleeping enough that a sleep study can help determine if it's a breathing problem, a movement problem or, , an insomnia problem. And I don't know which category you want to put insomnia, maybe mental health would be a place for it. But, for the breathing problems, we have lots of treatments. They're not always easy to use but we know, if you have a sleep doctor, your chance of actually acclimating to PAP therapy or finding an alternative that suits you as much better.
Dr. Myrtle Jeroudi:
The movement disorders, there's still some mystery, but we have a lot of you know guidelines on how to treat these. Restless leg syndrome that the guidelines were updated recently. We have lots of ways we can treat that, including iron evaluations and medications. And for insomnia I mentioned before. It's amazing to me that I'm the first person to bring up the gold standard treatment for insomnia, which is cognitive behavioral therapy for insomnia.
Dr. Myrtle Jeroudi:
So lots of people with the doorknob question get you know their Ambien, they get a medication subjective and related to you know other things that you have going on in your life, that medications are sedatives and they can make you sleepy, but so is missing, you know, the last five nights of sleep. So, if, like, not sleeping for five nights in a row is not going to make you sleepy, sometimes a drug isn’t going to be enough either. Like there's only there's only so much that being sedated can do for somebody with insomnia, because being sedated does not always mean that you will be asleep. , there's a role for medications, you know, in a patient that might be admitted to Meninger and it's a new environment and they just need something to help them sleep. Perfect use. But if you have chronic insomnia, you should at least have access to the first line treatment, which is cognitive behavioral therapy for insomnia, and it's fine to do that with or without medications, but to at least have access to this first line treatment.
Dr. Myrtle Jeroudi:
The problem with CBT insomnia cognitive behavioral therapy for insomnia is it's a limited resource. There's less than 200 people in the country that do this. Some people say they do, but there's really less than yeah, very limited. So, you've got geographic barriers Telehealth has addressed that some and then you've got financial barriers. It's not something that's like a well-covered, you know ambience. Like what? $5 CBT insomnia.
Dr. Bob Boland:
And I think that's part of the. I mean I may be over-journalizing, but in the past it's been sometimes difficult to convince patients to even give it a try, because therapy sounds like work, I mean, and it is, it's a fair amount of you know, it's like learning something new. So, when you put that up against just taking a pill, it's sometimes it's hard, and so I'll often kind of hear well, why don't you give me the pill first, let's see if that works.
Dr. Bob Boland:
And then you know, if not, then maybe I'll come back and talk about that, which I know is probably the wrong direction to go, and I'm and I'm biased, because I usually see people after they've tried their five pills. So, when I bring it up.
Dr. Bob Boland:
usually people are like I will try anything, and so that's usually a different discussion, but I've never been on that side of it and I'm thinking and certainly what I hear from my primary care friends is even more so because other ones are just getting the doorknob conversations any more than we are, and you know, and the idea is that you know, telling them they need to do something hard is going to take time when they know there's a pill, like there's advertisements for it all the time.
Dr. Myrtle Jeroudi:
Yes, yeah, it's kind of hard to kind of compete with that sometimes, but the American Academy of Sleep Medicine supports every single medication with only weak levels of evidence, and CBT insomnia is supported by strong levels of evidence and sometimes I tell patients that, like you know, they're because some people will internalize this like Ambien didn't work for me, or I'll say a sleep drug didn't work for me, so therefore nothing will work for me. And that is one of the factors that perpetuates insomnia that feeling that nothing, nothing will work. You are physically different; you are never going to sleep. These are the things that people think that make it instead of like one bad night, where it's like several bad nights, and so that can sometimes play into cognitive distortions.
Dr. Bob Boland:
My worry is, Dr Chu, is not merely that it won't work, but that it might make things worse. And I don't know, is that your sense? I mean what were the downsides of?
Dr. Kerry Horrell:
taking like Ambien.
Dr. Bob Boland:
Besides, ineffectiveness, it, the daytime impacts on cognition can be important. Yeah, or sleep and sleep medicines in general.
Dr. Myrtle Jeroudi:
Because, right, because we don't want different to pick on one. Ambien, truthfully, they are the only one that's FDA approved for large use.
Dr. Myrtle Jeroudi:
So anyways, the downside of medications is that most people are going to build tolerance and that's another reason why you know, after people use these for a couple of weeks, they might feel like they stop working or they're not working the same way they used to. They can impact your sleep architecture, which is not always a good thing. I mean you want to get good quality of sleep, and they can cause residual daytime symptoms, not just sleepiness but also impaired cognition, and certain ones of those can be dangerous because of complex nighttime behaviors that you do not want to endure. So, side effects is another downside to endure.
Dr. Myrtle Jeroudi:
So, side effects is another, another downside to those, the way that they, you know, are not hurtful per se, but the other way that they can perpetuate insomnia is, as I mentioned, just that feeling that you need them to sleep. And then, as soon as you stop taking your medication, you have a physical phenomenon called withdrawal insomnia, and then that tells your brain wait, you, I was right, I did need those to sleep, when really it that what you're experiencing is more of a withdrawal symptom, not the actual dependence on the medication itself.
Dr. Kerry Horrell:
It's like when someone stops taking a more like acute anxiety drug and then they have rebound anxiety and they're like, see, I needed it. It's like, no, this is just a rebound symptom.
Dr. Myrtle Jeroudi:
And because insomnia in particular is so subjective in its nature, those things make a big difference. You mentioned before, like on a sleep study, you're not going to sleep, that's you know. We see that a lot. You know first night phenomenon, when people don't sleep that well, we like to see four hours of sleep. A lot of times we do get that and that sounds doable.
Dr. Bob Boland:
Have you seen our sleep lab?
Dr. Kerry Horrell:
No, I should.
Dr. Bob Boland:
It's pretty comfy.
Dr. Kerry Horrell:
I was like I have. I especially haven't seen the new one, because I think I maybe saw it when it was in, like one of our older buildings, but in the new outpatient building I know.
Dr. Bob Boland:
I should come over Full disclosure. I stayed overnight during the snowstorm.
Dr. Myrtle Jeroudi:
Did you?
Dr. Bob Boland:
I was trying to break in there because it looks like a really comfortable place, I almost brought my whole family. Yeah, exactly, I was worried that the heat wouldn't be on in the outpatient building. Yeah, and we have TV. I mean it's a nice hotel setting. It looks like a nice hotel, it's en suite.
Dr. Myrtle Jeroudi:
Each room has its own bathroom. Our techs are amazing too.
Dr. Bob Boland:
Actually, even the most anxious patients who thought there was no way they could do a sleep study as soon as they were in the hands of our technicians did awesome so a lot of it has to do with where the sleep lab is, I think, and who's running it, and it's not too intrusive, I think you have to put electrodes on, I guess.
Dr. Myrtle Jeroudi:
But yeah, it's lots of wires, but most people sleep enough there. There's rarely been a case where somebody, where I, didn't get the information I needed and actually some people with insomnia sleep better in foreign environments because it's not their stress place that their own bed has become, so they sleep just fine in our lab.
Dr. Bob Boland:
And since you already mentioned some of the best treatment, do you want to say a little bit more about it? What does it entail Like, how hard is it to do? CBT for insomnia.
Dr. Myrtle Jeroudi:
I don't do the CBT insomnia. Our colleague Mary Rose does the insomnia. I don't do the CBT insomnia, our colleague Mary Rose, but it's generally, a set number of sessions and you have a specific goal that you accomplish with each session. The idea, the overall idea, is that for people with insomnia, you know you might have this predisposition, genetic risk, something might have happened that set it off, but the thing that makes it chronic insomnia is these perpetuating factors. A lot of these are cognitive distortions that you have about your sleep. A lot of it can be related to your bed just literally being a stressful place. You went to bed; you couldn't sleep there. You started worrying about your marriage or your kids, and then when you go to bed the next night, you're kind of habituated. Where this is my stressful place, it's like Pavlov's dog, like the food wasn't there. The bell rings, you're still salivating.
Dr. Myrtle Jeroudi:
Your bed is a place where you're now conditioned to experience this stress which makes it harder to sleep. Ultimately, people will put stress on themselves. I have to sleep. Once you're having to tell yourself to sleep, I think at that point you're you know this is insomnia, because most people's sleep is not like a. You force yourself to do it. It's something that you effortlessly transition into, and then you know the next day you might do compensatory activities to make up for that. Drinking more caffeine, laying down in bed and spending more time awake in bed these are all things that people do. I feel like it's almost human nature, if you have insomnia, to do these things. But understanding that these are counterproductive and maladaptive, addressing those things and reframing them and understanding to more constructive things is the concept behind cognitive behavioral therapy for insomnia, and it's nice that it should be a restricted number of sessions.
Dr. Myrtle Jeroudi:
So, like CBT, insomnia is not something that you're going to be doing for the rest of your life. You might be doing it for like a couple months or, you know, 10 sessions or whatever it might be, but it's not like you're stuck with this forever.
Dr. Bob Boland:
And, of course, you know you talked about the access problems, but I don't know. Is there an app or something? Can I get this on my phone?
Dr. Myrtle Jeroudi:
There are apps and digital CBT insomnia. Any thoughts about those? I think in person it is still better because I think the apps have a use for maybe a lot of people, but what about the people who hit roadblocks? I think an app is not able to address your concerns about getting out of bed in the middle of the night, like the app might tell you to do that, but having an actual person walk through what that would look like is I think only a person could do that. We don't. I don't know that. We have a lot of data comparing just the apps to. I think in-person is better, but we do have data comparing also in-person and telehealth. Yeah, Baylor in 2020 did those studies and they're it's equivalent. So, you can access CBT insomnia through telehealth and get the same, if not better results Wow.
Dr. Kerry Horrell:
And I think the I mean the word that I tend to hear that goes around along with this is sleep hygiene, having good sleep hygiene, and yeah, it doesn't feel patient about that.
Dr. Bob Boland:
Initially. They roll their eyes because it's things like you know make sure it's a dark room.
Dr. Kerry Horrell:
Well, try, try doing that with college students like shout out to my Compass patients listening and like I feel like you're in a dorm room and you're like don't lay in your bed if you're not sleeping.
Dr. Bob Boland:
And make sure it's quiet.
Dr. Kerry Horrell:
Yeah, and like get off your phone, you know, an hour before sleep. They're like I'm not going to do that, but it does seem like you know, like there are practices. Even if you don't have insomnia or, for example, I'm pregnant at the moment, my sleep is worse, like way worse. So, even though I don't think I have insomnia, I've been having to do things that are more practice than I would normally have to do because of the season of life that I'm in, and so I feel like there are good sleep hygiene practices. We should all be practicing at some level, right, yeah?
Dr. Bob Boland:
Are there ones that people don't normally know, like people know, like don't drink coffee before you go to bed, or yes you know, or keep the room dark.
Dr. Myrtle Jeroudi:
I suppose people know that, but yeah, a lot of them are intuitive and maybe that's why people feel like I've already done those things and I still not sleeping well.
Dr. Myrtle Jeroudi:
but I think that this, the ones that are not intuitive, would be ones related to bed restriction, the recommendation that if you're laying there for more than 20 minutes, you cannot just stay there in the bed, that you really should get out of the bed, do something else and return to the bed when you're sleepy. Now is that helpful for everyone? Yeah, it's a healthy sleep tip that's helpful for everyone, but sometimes there does require a degree of individualization. What if the person says there's nothing I could do in the middle of the night if I got up out of bed and there some somebody like a sleep psychologist, doing CBT, for example, instead of just sleep hygiene, could say make a, make a. Why don't you make a list of things that you would rather do than lay down in bed stressing?
Dr. Myrtle Jeroudi:
yeah, and I imagine they can't be things that wake you up too much, right, and probably shouldn't exercise yes, yeah, and then make a in on list see if any of those things are arousing, so like it can be a book that you read but not like the most interesting book in the world that you do instead, and some textbooks that can work, yeah, and then some people say I tried this for a night and it didn't work, having somebody tell you have to try it for a little bit longer.
Dr. Myrtle Jeroudi:
Sometimes you even like things that sound intuitive. You know it can be counterintuitive.
Dr. Bob Boland:
Well, I'm not saying it's me, but I can imagine that there are some people like me who, in the middle of the night, probably do the worst possible thing.
Dr. Myrtle Jeroudi:
TV, computer?
Dr. Bob Boland:
Or just or just turn on my phone. I imagine that's not a good thing to do.
Dr. Myrtle Jeroudi:
Yes!
Dr. Kerry Horrell:
Dr. Jeroudi is like literally yes!
Dr. Myrtle Jeroudi:
The way I see it is like if you know if it's your crutch and you fall back to sleep and tomorrow is fine. Who am I to judge? But if you're coming to me with sleep problems, then it's sort of my job to at least like point out that the screens themselves, like the light itself, is suppressing your melatonin, making it hard for you to sleep. So, there's biological, and then also like, being mentally alert is not productive to sleep.
Dr. Bob Boland:
Plus, I'm probably reading an email about something I didn't do that I was supposed to do, and then you worry about it, yeah, and then it's like all kinds of reasons, right, and then you're stressing about that in bed.
Dr. Myrtle Jeroudi:
And then, yeah, you're, you're making it so that it's harder for you to be calm and restful you've got to do something different, like scroll through TikTok not that I would ever do that that's too entertaining.
Dr. Bob Boland:
That can go on for hours. I'm teasing.
Dr. Kerry Horrell:
I'm teasing, that's not good sleep practice.
Dr. Bob Boland:
I just don't think there's probably I try to.
Dr. Myrtle Jeroudi:
I try hard to avoid my phone yeah, but if you're someone who watches tv to fall asleep and you have zero problems. You're probably not talking to me, so I guess I wouldn't tell you to do otherwise, but if you're seeing me, then, , who knows how long that behavior has been brewing sleep problems, and it's like if you have an actual medical problem, then, , then the recommendations are going to be different than for somebody who doesn't.
Dr. Bob Boland:
I know we've gone on a bit, but I have to ask about melatonin, since that's probably one of the more popular sleep aids that people use and we probably have no idea how many, because yeah, okay, so just a thumbs up, thumbs down are just too complicated to say.
Dr. Myrtle Jeroudi:
It's like a mid-thumb. A thumbs up, thumbs down are just too complicated. I know a lot of a lot of sleep doctors are more cautious about it than I am, because the safety and efficacy is there. I mean, it's not the most dangerous thing in the world. The only danger is that the journal of clinical sleep medicine pulled 30 jars from a shelf, and you don't know what you're getting all the time so it could have serotonin.
Dr. Myrtle Jeroudi:
You know tryptophan. It couldn’t know what you're getting all the time, so it could have serotonin. You know tryptophan. It could have 400% what you think you're getting.
Dr. Bob Boland:
Right, these aren't FDA regulated.
Dr. Myrtle Jeroudi:
There's not really studies on kids, and you know, except for kids with, for example, neurodevelopmental disorders and I know that it was a public health concern people giving this to kids, it'd be only to me. Another downside, you know, besides interaction with medications and not knowing what you're getting, is that, say, you did have a disorder that needed specific treatment, and melatonin delayed your access to care.
Dr. Kerry Horrell:
That might be something of concern. As we wrap up, I wonder if you have any advice for our audience. These are, again, primarily people who work in the mental health field. But yeah, just thoughts about when to refer to sleep medicine, any tips about things to be on the lookout for. I mean, imagine some of it's just ask about this. But yeah, what might you say to our clinicians?
Dr. Myrtle Jeroudi:
Everybody, because we know from the Menagerie study, it's 90% at least. So, I feel like everybody probably could benefit from some sort of sleep evaluation, whether that means screening and you're in the office for things like snoring, kicking. Do you feel rested when you wake up? You know simple questions like that, but because there is such an impact on mental health, I feel like even if you sent somebody to a sleep doctor and they found no problems at all, that's better than not having referred, so I feel.
Dr. Myrtle Jeroudi:
I feel like there's a very a lot of people that sleep medicine helps.
Dr. Bob Boland:
And I imagine, at least for the clinicians with listening, who are a lot. They just need to spend more time talking to patients about sleep, would you?
Dr. Myrtle Jeroudi:
Agree but because of the nuance, I think, like if, even if you didn't just send the sleep medicine, that's probably fine just some of you. Yeah, because yeah, I mean there's a lot to it, so this has been fascinating.
Dr. Bob Boland:
It goes to show just how interesting a subject it is, because we've gone on some. This is probably one of our longer podcasts and there's so many other questions I could ask.
Dr. Kerry Horrell:
I know same I have like I have lots of things I could ask.
Dr. Bob Boland:
Perhaps we can get you another time to talk more, but I sure appreciate you coming on now. So once again we've been listening to Dr. Myrtle Jeroudi and once again, I'm your host. I'm Bob Boland.
Dr. Kerry Horrell:
I'm Dr Kerry Horrell.
Dr. Bob Boland:
And thanks for diving in.
Dr. Kerry Horrell:
Thanks for diving in.