I was asked at my last appraisal if I was sleep deprived.
When considering our health and fitness to practise, the Leicester Health Structured Reflective Template (SRT) suggests asking about sleep, along with other questions relating to managing stress and work-life balance.
As a mum of three, my youngest being 15 months old, I certainly was sleep deprived. Not unusual for any parent or for anyone working shift patterns. So, I admitted that I was sleep deprived, but was hopeful that this was just a brief phase in my life. With time, things would surely improve.
What I didn’t acknowledge to myself, let alone to anyone else, was that my children weren’t the only reason that I wasn’t sleeping well. On most nights, I was waking in a cold sweat, worrying about work; a dreadful pit in my stomach, fearful that I had missed something, forgotten to do something or not considered some rare diagnosis.
I started to sleep with a notebook by my bed so that I could write things down in the middle of the night as they woke me. My hope was that I might return to sleep more quickly knowing that I could action them in the morning. Sometimes this worked. Other nights, I would lie awake for hours worrying and berating myself for my perceived incompetence.
So not only was I getting insufficient sleep, but the sleep that I was getting was such poor quality. My anxiety and stress drove my lack of sleep and the lack of sleep drove my stress and anxiety. It was a vicious cycle. One I didn’t know how to break; until too late.
Sleep and its link to mental health
The link between sleep and mental and emotional wellbeing is widely known. Many of us are aware that reduced sleep can be an early warning sign for relapse in serious mental illness.
Newer research by Professor Russell Foster and his team in Oxford has shown that sleep disruption is common in those at risk of bipolar disease prior to diagnosis. And that mental illness and sleep actually share overlapping pathways. For example, a gene linked to schizophrenia when mutated also disrupts sleep. Following from this, they have shown that by inducing sleep in those at risk, paranoia is reduced and mood is more stable.
Sleep is therefore intrinsically linked to our mental wellbeing.
Why is sleep so important?
Sleep is restorative. Important neural connections are linked and strengthened.
Sleep helps us to process information, build memories, learn and uncover new solutions to complex problems. John Steinbeck, acknowledged this when he said:
“A problem difficult at night is resolved in the morning after the committee of sleep has worked on it.”
How much sleep do we actually need?
The general consensus is that we need around 8 hours of sleep a night. Teenagers need more – 9 hours is recommended for them to achieve full brain performance.
How much do we value sleep as a society?
Over the decades, we have been sleeping less and less – 8 hours in the 1950’s compared with an average of 6.5 hours in 2013.
Our lifestyles have changed enormously. We are constantly ‘plugged-in’. We rarely leave work at the office and are often digitally connected well into the night. Most of us will sleep with our phones by our bed.
We live a 24/7 culture where we expect things to get done now or at the click of a button.
There has also been an historical one upmanship around sleep, not helped by leaders like Margaret Thatcher who allegedly quoted that “Sleep is for wimps”, adding to the illusion that somehow less sleep equals increased productivity.
Donald Trump claims to have survived for decades on less than 4 hours sleep a night. His critics claim that this may explain some of his behaviour as he ‘displays all the scary symptoms of sleep deprivation’.
Arianna Huffington, founder of the Huffington post and author of “The Sleep Revolution”, comments on this one upmanship in her TED talk. She uses the example of suggesting a breakfast meeting for 8am. Her one upmanship responder would agree commenting that “Eight is a bit late, but I guess it’s fine because that’ll give me time to have gone to a spinning class and get in a few conference calls first!”
This bravado exists in medicine too. We will all be familiar with sleep deprivation from our junior doctor years, whether through gruelling hours or shift-work. Those that can’t cope with it have often been considered to be less resilient. And we all know that resilience is what we lack as doctors today….
The Sleep Revolution
Getting sleep has now become fashionable, defined by slogans such as “Sleep your way to success” or Sheryl Sandberg’s “Sometimes we need to sleep in to lean in!”
A whole industry of apps and wearable devices has sprung up.
Critics cynically observe that sleep has become a status symbol for the rich. They are the ones that can afford to sleep whilst their minions work for them. They don’t have the financial stresses of the poor that may be associated with poor sleep.
Leaving these debates aside, it is important that we do remain mindful that sleep is not a luxury. It is a necessity.
What are the consequences of sleep deprivation?
There has been much in the media lately highlighting the dangers in hospital doctors and car accidents.
According to Professor Russell Foster, there are figures from the States estimating that 100,000 RTA are due to lack of sleep. He also highlights the review of the failings in Chernobyl and the Space Shuttle Challenger disasters, which revealed that lack of sleep was partly to blame.
Bill Clinton, who used famously to get only five hours of sleep, allegedly once admitted,
“Every important mistake I’ve made in my life, I’ve made because I was too tired.”
As these examples demonstrate, the consequences of sleep deprivation are serious.
Particularly worrying consequences for us as clinicians are lack of empathy, poor memory, lack of creativity, increased impulsiveness, poor judgement and poor vigilance.
Other effects include weight gain. Professor Foster claims that there can be as much as a 50% increase in obesity if we regularly get <5 hours sleep. Our tired brains release the Ghrelin hormone, which makes us crave carbohydrates.
Feeling tired also causes us to feel more stressed. When this becomes sustained, it can cause raised glucose levels with subsequent increased incidence of Diabetes; increased Cardiovascular Disease through raised blood pressure and increase incidence of Cancer (seen in shift workers) due to suppressed immunity.
Many of us self medicate to overcome our tiredness. We drink caffeine or take other stimulants to wake us up. These can make us then too wired to sleep so we start to self-medicate further to sleep – alcohol, tranquillizers, opiates. This sedates us but does not give us a biological restorative sleep. We feel groggy the next day, take more caffeine and so another vicious cycle develops.
How can we get better sleep?
The key is to prepare well for sleep. Sleep experts suggest that you ideally prepare an hour before to allow yourself to decompress and unwind.
Some suggestions are to:
1. Use an evening alarm to remind your body that it is time to wind down.
2. Create the best sleeping conditions. The ideal sleep environment is cool (about 65 to 70 degrees), dark and quiet.
3. Take a hot bath. When you step out of the tub, your core body temperature immediately drops, which may help you settle in for a deeper sleep. Bath products and candles with a soothing scent all help.
4. Watch soothing television. Avoid gripping dramas later. I was in the middle of “Bosch” at the height of my burnout, a crime drama about a serial killer. This did nothing to calm my nerves!
5. Read something calming. Think of pleasant narratives as the literary equivalent of comfort food.
6. Set a digital sunset. Avoid screens, in particular e-mails and messages. I made the mistake of checking e-mails in my bed on so many occasions to detrimental effect. Most things can wait till the morning and are usually far better managed when fresh after a night’s sleep.
7. Avoid eating heavy meals late at night. Try to eat at least 2-3 hours before you sleep
8. Have a caffeine curfew. Caffeine has a half-life of 5-8 hours. So any caffeine that you have beyond late afternoon is likely to interfere with you sleep.
9. Reduce alcohol. We often use alcohol as a way to relax. Although alcohol may help us get to sleep (particularly if we have had too much caffeine late in the day), it does not promote good quality sleep. It can often leave us feeling groggy and irritable the next day so we are not able to give others our best self.
As we can see, the consequences of sleep deprivation are huge. And for many of us, poor sleep is a warning sign that something is not right. This was certainly the case for me.
Listening to our body is important. Technology allows us to be so connected with the outside world that often we lose connection with ourselves. As Professor Foster states,
“We need to take sleep seriously.”