Are we winning the War on Sleeplessness?

Or, as the authors of this paper put it, are we seeing the “first signs of success in the fight against sleep deficiency?”

Abstract:

STUDY OBJECTIVES:

The high prevalence of chronic insufficient sleep in the population has been a concern due to the associated health and safety risks. We evaluated secular trends in sleep duration over the most recent 14-year period.

METHODS:

The American Time Use Survey, representative of US residents ≥15 years, was used to investigate trends in self-reported sleep duration and waking activities for the period 2003-2016 (N = 181335 respondents).

RESULTS:

Sleep duration increased across survey years both on weekdays (+1.40 min/year) and weekends (+0.83 min/year, both p < .0001, adjusted models). This trend was observed in students, employed respondents, and retirees, but not in those unemployed or not in the labor force. On workdays, the prevalence of short (≤7 hr), average (>7-9 hr), and long (>9 hr) sleep changed by -0.44% per year (p < .0001), -0.03% per year (p = .5515), and +0.48% per year (p < .0001), respectively. The change in sleep duration was predominantly explained by respondents retiring earlier in the evening. The percentage of respondents who watched TV or read before bed-two prominent waking activities competing with sleep-decreased over the same time period, suggesting that portions of the population are increasingly willing to trade time in leisure activities for more sleep. The results also suggest that increasing online opportunities to work, learn, bank, shop, and perform administrative tasks from home freed up time that likely contributed to increased sleep duration.

CONCLUSIONS:

The findings indicate first successes in the fight against sleep deficiency. Public health consequences of the observed increase in the prevalence of long sleep remain unclear and warrant further investigation

Here is the American Time Use Survey which the authors used for their study.

Sleep disturbances in girls associated with more difficulties staying awake in and out of school

From Pedro de Bruyckere’s blog:

Sleep disturbances in girls associated with more difficulties staying awake in and out of school

We’ve known for some time now that we all sleep less than a decade ago and that our children often nowadays don’t sleep enough. This new study describes that there are maybedifferences related to gender. I wasn’t able to read the study because it’s something that was presented at a conference last week. From the […]

via Sleep disturbances in girls associated with more difficulties staying awake in and out of school — From experience to meaning…

Preliminary results of a recent study show that teen girls reported a higher degree of interference of daytime sleepiness on multiple aspects of their school and personal activities than boys.

The study examined whether teen boys and girls report similar negative impact of sleep disturbances on their daytime functioning.

“What was most surprising is the fact that teenage girls reported a higher degree of interference of daytime sleepiness than teenage boys on multiple aspects of their school and personal activities,” said co-author Pascale Gaudreault, who is completing her doctoral degree in clinical neuropsychology under the supervision of principal investigator Dr. Geneviève Forest at the Université du Québec en Outaouais in Gatineau, Québec, Canada. “For example, teenage girls have reported missing school significantly more often than teenage boys due to tiredness, as well as reported having lower motivation in school due to a poor sleep quality.”

Circadian rhythms Nobel Prize for Medicine or Physiology 2017

When I was young, the Oscars had an air of naffness, and the likes of the Golden Globes or Emmys even more so. One of the many many ways internet culture has failed to live up to its utopian hype   is the glorification of these sort of jamborees into moments of Great Cultural Significance, endlessly teased over by scolding columnists determined to weed out wrong think even about a glorified trade awards ceremony.

The Nobel Prizes haven’t quite reached the same point – indeed, as I wrote here before, their cultural impact may be somewhat diminished – but nevertheless, they are also subject to a strained search for important messages. The Nobel Prize in Physiology or Medicine 2017 was awarded jointly to Jeffrey C. Hall, Michael Rosbash and Michael W. Young “for their discoveries of molecular mechanisms controlling the circadian rhythm”

The video illustrates nicely what Circadian Rhythms are. 

 

Here is Robash’s lecture (with 5250 YouTube views) which is a good place to start a consideration of circadian rhythms:

And here is Young’s, which ties it all back to human circadian rhythms (just over 4000 views):

Here is Hall’s Nobel lecture, I note he is wearing a Brawndo hat from the film “Idiocracy”. I also note this video has just over 6000 views on YouTube (the Brawndo ad linked to above has over 3 million) Then again, it is a little hard going – Hall is not as funny as he thinks he is… and while there is some interest in his anecdotal style of various prior Drosophilia researchers it is not that effective an entry into this world (so while it is the first lecture given and includes the overall introduction, I have left it to last):

Slides of Robash’s and Young’s lectures are available on the Nobel site. Rather endearingly, they are basic PowerPoint slides replete with credits for everyone in the lab.

So there you go. 3 Nobel lectures on a subject of direct relevance to all our lives have a grand total of less than 15000 views on YouTube. I could easily find some ephemeral/trashy/obscene video with several multiples, but what is the point?

In the New Yorker, Jerome Groopman identified the “real message” of the prize as a rebuke to those who ignore or underfund basic science (in fairness his piece is also a decent introduction to this research).  While there may be some merit to this, it strikes me as more likely that the Academy recognised scientific work of genuine merit and enduring relevance.

And Groopman’s piece was one of the only ones I could find online that discussed the science and the issues related in some context (even though it was one I found slightly suspect) – most of the others essentially recycled the press releases from the Nobel Foundation and the US National Science Foundation

In my post “Why isn’t William C Campbell more famous in Ireland?” I discussed an excellent piece by Declan Fahy on “the fragile culture of Irish science journalism”. One wonders if this fragility is perhaps not only an Irish phenomenon.

.

 

Circadian Rhythms video from Oxford Nuffield Sleep & Circadian Neuroscience Institute

From here

In Space, No One Can Hear You Snore

Amazon Alexa informed me, as one of its “crazy facts” available on request, that astronauts do not snore because in zero gravity their airways do not collapse.

Sounds good, and plausible, but is it true? I decided to fact check Crazy Fact on this. And obviously one factchecks Alexa via Google.

First port of call was this 2008 piece, which informed me that :

Research on two space flights found some interesting sleep statistics. A 2001 study [1] conducted found that five astronauts actually stopped snoring completely while in space. As well, some who had suffered episodes of stopping breathing, called sleep apnea, had none when they were in space.

This was a breakthrough. They had proveN that gravity was indeed necessary to constrict the airflow, aggravate the throat and cause the vibrations along the soft palate and uvula. No gravity made it easier to breathe. Oddly they also learned that astronauts sleep fewer hours and use sleeps medications to assist them in sleeping.

An earlier study was done in 1998 aboard the shuttle Columbia to see how astronauts sleep in the artificial environment of a space shuttle. The result surprised many scientists and sleep specialists when microphones picked up snores from the crew. They were surprised because the feeling was that astronauts likely breathed less.

This led me to David Dinges who has the cool title “chief of the division of Sleep and Chronobiology and director of the Unit for Experimental Psychiatry in the Perelman School of Medicine at the University of Pennsylvania” and this 2001 editorial from the American Journal of Respiratory and Critical Care Medicine:

An excellent example of the latter outcome
is the investigation by Elliott and colleagues in this issue
of the American Journal of Respiratory and Critical Care Medicine
(pp. 478–485) (1). They recorded respiration and sleep
physiology in healthy astronauts during two National Aeronautics
and Space Administration (NASA) space shuttle flights
and compared these recordings to those made when subjects
were Earth-bound before and after flight. They found that microgravity
was associated with marked reductions in sleep-disordered
breathing, in time spent snoring, in arousals during
sleep, in respiratory rate during presleep waking, and in heart
rate during both presleep waking and slow wave sleep. The results
highlight not only the relative importance of gravity in
ventilatory mechanics during sleep, but also reveal that within
physically fit subjects there is a covariation between upper airway
resistance, snoring, and the likelihood of respiratoryrelated
arousals during sleep. It suggests Earth’s gravity has a
key role both in upper airway resistance and obstruction, and
in the relationship of these factors to arousals during sleep

So next to the paper “Microgravity Reduces Sleep Disorder Breathing in Humans” by Elliot and colleagues in that journal. Abstract:

To understand the factors that alter sleep quality in space, we
studied the effect of spaceflight on sleep-disordered breathing.
We analyzed 77 8-h, full polysomnographic recordings (PSGs)
from five healthy subjects before spaceflight, on four occasions
per subject during either a 16- or 9-d space shuttle mission and
shortly after return to earth. Microgravity was associated with a
55% reduction in the apnea–hypopnea index (AHI), which decreased
from a preflight value of 8.3 1.6 to 3.4 0.8 events/h
inflight. This reduction in AHI was accompanied by a virtual elimination
of snoring, which fell from 16.5 3.0% of total sleep time
preflight to 0.7 0.5% inflight. Electroencephalogram (EEG)
arousals also decreased in microgravity (by 19%), and this decrease
was almost entirely a consequence of the reduction in respiratory-related
arousals, which fell from 5.5 1.2 arousals/h
preflight to 1.8 0.6 inflight. Postflight there was a return to near
or slightly above preflight levels in these variables. We conclude
that sleep quality during spaceflight is not degraded by sleep-disordered
breathing. This is the first direct demonstration that gravity
plays a dominant role in the generation of apneas, hypopneas,
and snoring in healthy subjects.

Later:

All five subjects in this study showed some degree of snoring
from mild to moderate during preflight PSGs. Time spent
snoring ranged from 2.8 to 32.6% of the total sleep time. In
microgravity, snoring was almost completely eliminated in all
subjects. Importantly, the change in snoring habits of this
group correlated well with the changes in the number of respiratory
events per sleep period both on the ground and in space
(Figure 3). The correlation between snoring and AHI suggests
that the hypopneas were likely obstructive as opposed to central
in nature.

So truly, in space no one can hear you snore.

“#Sleeping, as we all know, is the most secret of our acts.”- #Borges and #sleep in #literature

I have blogged both here and on my other blog quite a few quotes from novels and other literature on sleep. I have found these passages capture a sort of phenomenology of sleep as effectively as any clinical text. In this post I use a quote from Jorge Luis Borges as the starting point for a more general, although ultimately quite personal, discussion of literature and sleep and other altered states of consciousness.

Séamus Sweeney

Sleeping, as we all know, is the most secret of our acts. We devote a third of our lives to it, and yet do not understand it. For some, it is no more than an eclipse of wakefulness, for others, a more complex state spanning at one and the same time past, present, and future,; for still others, an uninterrupted series of dreams. To say that Mrs Jáuregui spent ten years in a quiet chaos is perhaps mistaken; each moment of those ten years may have been a pure present, without a before or after. There is no reason to marvel at such a present, which we count by days and nights and by the hundreds of leaves of many calendars and by anxieties and events; it is what we go through each morning before waking up and every night before falling asleep. Twice each day, we are the elder…

View original post 325 more words

“The Wild West of Health” care: mental health Apps, evidence, and clinical credibility

We read and hear much about the promise of mobile health. Crucial in the acceptance of mobile health by the clinical community is clinical credibility. And now, clinical credibility is synonymous with evidence, and just “evidence” but reliable, solid evidence. I’ve blogged before about studies of the quality of mental health smartphone apps. I missed this piece from Nature which, slightly predictably, is titled “Mental Health: There’s an app for that.” (isn’t “there’s an App for that a little 2011-ish though?) It begins by surveying the immense range of mental health-focused apps out there:

 

Type ‘depression’ into the Apple App Store and a list of at least a hundred programs will pop up on the screen. There are apps that diagnose depression (Depression Test), track moods (Optimism) and help people to “think more positive” (Affirmations!). There’s Depression Cure Hypnosis (“The #1 Depression Cure Hypnosis App in the App Store”), Gratitude Journal (“the easiest and most effective way to rewire your brain in just five minutes a day”), and dozens more. And that’s just for depression. There are apps pitched at people struggling with anxiety, schizophrenia, post-traumatic stress disorder (PTSD), eating disorders and addiction.

The article also has a snazzy  infographic illustrating both the lack of mental health services and the size of the market:

naturegraph

The meat of the article, however, focuses on the lack of evidence and evaluation of these apps. There is a cultural narrative which states that Technology = Good and Efficient, Healthcare = Bad and Broken and which can give the invocation of Tech the status of a godterm, pre-empting critical thought. The Nature piece, however, starkly illustrates the evidence gap:

But the technology is moving a lot faster than the science. Although there is some evidence that empirically based, well-designed mental-health apps can improve outcomes for patients, the vast majority remain unstudied. They may or may not be effective, and some may even be harmful. Scientists and health officials are now beginning to investigate their potential benefits and pitfalls more thoroughly, but there is still a lot left to learn and little guidance for consumers.

“If you type in ‘depression’, its hard to know if the apps that you get back are high quality, if they work, if they’re even safe to use,” says John Torous, a psychiatrist at Harvard Medical School in Boston, Massachusetts, who chairs the American Psychiatric Association’s Smartphone App Evaluation Task Force. “Right now it almost feels like the Wild West of health care.”

There isn’t an absolute lack of evidence, but there are issues with  much of the evidence that is out there:

Much of the research has been limited to pilot studies, and randomized trials tend to be small and unreplicated. Many studies have been conducted by the apps’ own developers, rather than by independent researchers. Placebo-controlled trials are rare, raising the possibility that a ‘digital placebo effect’ may explain some of the positive outcomes that researchers have documented, says Torous. “We know that people have very strong relationships with their smartphones,” and receiving messages and advice through a familiar, personal device may be enough to make some people feel better, he explains.

And even saying that (and, in passing, I would note that in branch of medical practice, a placebo effect is something to be harnessed, not denigrated – but in evaluation and study, rigorously minimising it is crucial) there is a considerable lack of evidence:

But the bare fact is that most apps haven’t been tested at all. A 2013 review8 identified more than 1,500 depression-related apps in commercial app stores but just 32 published research papers on the subject. In another study published that year9, Australian researchers applied even more stringent criteria, searching the scientific literature for papers that assessed how commercially available apps affected mental-health symptoms or disorders. They found eight papers on five different apps.

The same year, the NHS launched a library of “safe and trusted” health apps that included 14 devoted to treating depression or anxiety. But when two researchers took a close look at these apps last year, they found that only 4 of the 14 provided any evidence to support their claims10. Simon Leigh, a health economist at Lifecode Solutions in Liverpool, UK, who conducted the analysis, says he wasn’t shocked by the finding because efficacy research is costly and may mean that app developers have less to spend on marketing their products.

Like any healthcare intervention, an App can have adverse effects:

When a team of Australian researchers reviewed 82 commercially available smartphone apps for people with bipolar disorder12, they found that some presented information that was “critically wrong”. One, called iBipolar, advised people in the middle of a manic episode to drink hard liquor to help them to sleep, and another, called What is Biopolar Disorder, suggested that bipolar disorder could be contagious. Neither app seems to be available any more.

And even more fundamentally, in some situations the App concept itself and the close relationship with gamification can backfire:

Even well-intentioned apps can produce unpredictable outcomes. Take Promillekoll, a smartphone app created by Sweden’s government-owned liquor retailer, designed to help curb risky drinking. While out at a pub or a party, users enter each drink they consume and the app spits out an approximate blood-alcohol concentration.

When Swedish researchers tested the app on college students, they found that men who were randomly assigned to use the app ended up drinking more frequently than before, although their total alcohol consumption did not increase. “We can only speculate that app users may have felt more confident that they could rely on the app to reduce negative effects of drinking and therefore felt able to drink more often,” the researchers wrote in their 2014 paper13.

It’s also possible, the scientists say, that the app spurred male students to turn drinking into a game. “I think that these apps are kind of playthings,” says Anne Berman, a clinical psychologist at the Karolinska Institute in Stockholm and one of the study’s authors. There are other risks too. In early trials of ClinTouch, researchers found that the symptom-monitoring app actually exacerbated symptoms for a small number of patients with psychotic disorders, says John Ainsworth at the University of Manchester, who helped to develop the app. “We need to very carefully manage the initial phases of somebody using this kind of technology and make sure they’re well monitored,” he says.

I am very glad to read that one of the mHealth apps which is a model of evidence based practice is one that I have both used and recommended myself – Sleepio:

sleepio-logo

One digital health company that has earned praise from experts is Big Health, co-founded by Colin Espie, a sleep scientist at the University of Oxford, UK, and entrepreneur Peter Hames. The London-based company’s first product is Sleepio, a digital treatment for insomnia that can be accessed online or as a smartphone app. The app teaches users a variety of evidence-based strategies for tackling insomnia, including techniques for managing anxious and intrusive thoughts, boosting relaxation, and establishing a sleep-friendly environment and routine.

Before putting Sleepio to the test, Espie insisted on creating a placebo version of the app, which had the same look and feel as the real app, but led users through a set of sham visualization exercises with no known clinical benefits. In a randomized trial, published in 2012, Espie and his colleagues found that insomniacs using Sleepio reported greater gains in sleep efficiency — the percentage of time someone is asleep, out of the total time he or she spends in bed — and slightly larger improvements in daytime functioning than those using the placebo app15. In a follow-up 2014 paper16, they reported that Sleepio also reduced the racing, intrusive thoughts that can often interfere with sleep.

The Sleepio team is currently recruiting participants for a large, international trial and has provided vouchers for the app to several groups of independent researchers so that patients who enrol in their studies can access Sleepio for free.

sleepioprog

This is extremely heartening – and as stated above, clinical credibility is key in the success of any eHealth / mHealth approach. And what does clinical credibility really mean? That something works, and works well.