Every night, nearly 60 percent of Americans are awake and staring at the ceiling when they should be in the arms of Morpheus. We are a nation of insomniacs, according to a string of studies, most recently a 2011 poll of 1,500 adults by the National Sleep Foundation. And when it comes to sleep deprivation, college students lead the way, with twice as many sleep problems as the general population, numerous studies report.
For weary students, trouble sleeping can cast a long shadow over the daylight hours, impairing judgment, sabotaging grades, making it unsafe to drive or ride a bike—even contributing to weight gain. Lack of sufficient sleep is a major risk factor in depression and suicide. But try to find students, even those who have no trouble sleeping once they get around to it, who routinely get the eight hours or more of sleep that physicians and sleep scientists say is essential for young people’s physical and mental well-being.
“Insomnia is a problem of our modern world,” says Terese Hammond, a School of Medicine assistant professor of medicine, pulmonary critical care, and sleep medicine. “Our lives have intruded so heavily on any kind of natural sleep pattern.” There’s a lot to learn about what may be causing the problem, whether it’s as big as a breathing abnormality or as small as the LCD light on a cell phone charger. Hammond is also director of the BU Medical Group Sleep Center, one of a chain of sleep health centers. At the center, she and her staff aren’t just treating those problems. They also counsel patients and hold student workshops on how to sleep. It’s called sleep hygiene, a recipe for rest in a frenetic, wired world. And it’s not all intuitive.
As Hammond laments with a sigh, proper sleep is becoming a lost art. Week after week students stream into her office with an identical complaint: “I can’t sleep.”
“I will never turn a patient away,” she says in her calming, down-to-earth manner. Particularly for students, finding the cool, quiet, pitch-dark, distraction-free room that’s optimal for deep sleep is almost impossible. “Life now goes all hours,” notes Hammond, who determinedly keeps her toddler daughter on a punctual sleep schedule. The fact that the Internet never sleeps isn’t helping things. “Insomniacs can be online at 3 a.m. talking to each other, and that perpetuates the problem,” she says. The National Sleep Foundation poll mentioned above found that 95 percent of subjects watch television or use a computer, video games, or cell phones in bed, and 6 in 10 surveyed said they use their laptops or computers at least a few nights a week within the hour before bed. In her initial consultations, Hammond gets a sense of the extent to which her patients are sleeping—or not sleeping—with the enemy. And when it comes to sleep, that’s what these gadgets are.
Evolutionarily honed long before the existence of artificial light, the sleep-wake cycle reflects our body’s primal response to light and dark, day and night, Hammond explains. The brain’s hypothalamus serves as a control tower, signaling other parts of the brain that regulate body temperature and hormones, one of which is melatonin, produced by the tiny pineal gland. After dark, melatonin levels rise sharply, hence the nickname “the Dracula of hormones.” Sleep actually “starts in the middle of the day,” she says. “Once you get through midday, that pressure starts to build.” Light inhibits the production of melatonin, whose daytime levels are barely detectible.
Even a 40-watt light bulb can decrease melatonin levels, she says. Of all stimuli, light has the greatest influence on sleep by keeping the brain’s visual cortex activated. Although no one wants to hear it, she advises against reading in bed. Read in the living room, or in your dorm’s common room, until you get tired, she suggests.
In addition to something as easily remedied as light intrusion, the causes, or as Hammond puts it, “flavors,” of insomnia include sleep disruption from a stressful event such as the death of a loved one, clinical depression, or chronic pain. But most young insomniacs have sleep patterns that went out of whack early in life, propelling them into a cycle of expectation of failure, until simply trying to fall asleep is stressful.
“Most of the recommendations you get from valid websites” such as Sleep and You are pretty standard, says Hammond.
“We certainly know that caffeine impacts sleep, and we know that amphetamines, chocolate, and light affect sleep. It’s pretty well validated that alcohol can help you fall asleep, but later it causes sleep fragmentation, and over the long term excessive drinking can affect REM sleep, when 80 percent of dreaming occurs.” So, she warns: no nightcaps.
No one needs convincing that sleep deprivation is bad, but students may not be aware of just how dangerous skimping on those seven to nine hours can be. At a Got Sleep? workshop sponsored by BU’s Educational Resource Center last fall, Hasmeena Kathuria, a MED assistant professor of medicine, warned that on four hours of sleep, the effects of one beer approximate that of a six-pack, that almost two thirds of car accidents are related to sleep deprivation, and that the peak age for falling asleep behind the wheel is 20.
And pulling an all-nighter is physiologically as ill advised as shooting oneself in the foot. Kathuria explained that staying up all night before an exam is “like taking an exam legally drunk.” One study at the Stanford University Center for Human Sleep Research found that students who pulled all-nighters had lower GPAs, but that academic performance improved with more sleep time.
Poor performance is just one concern. Over the long term, sleep deprivation causes a spike in a hormone associated with carbohydrate cravings. “That’s why you see the long line for caramel lattes at Starbucks at four every afternoon,” said Michelle George, wellness coordinator at BU’s Student Health Services, who spoke at the Got Sleep workshop. And when students stay up late they’re likely to crave fried foods in the morning, Kathuria said. A chronic sleep deficit can lead to greater insulin resistance and diabetes, even cardiovascular disease and stroke, she warned.
According to experts, most people without insomnia go to bed and wake up at about the same time every day, underscoring the importance of keeping to a sleep schedule. “The people who sleep best,” Hammond says, “are the farmers who go to bed when it gets dark and wake up with the roosters.”
Insomnia and interrupted sleep are best treated behaviorally, says Hammond, who often refers otherwise healthy patients to cognitive therapists. Sometimes the problem will disappear after a person cuts back on caffeine and alcohol and creates a space only for what she calls “sleeping and intimacy. And that’s it.” The Sleep Foundation’s recommendations for a healthy sleep regimen include: set and stick to a sleep schedule; expose yourself to bright light in the morning and avoid it at night; exercise regularly but avoid vigorous exercise close to bedtime; create a relaxing bedtime routine; keep a “worry book” next to your bed so you can write concerns down instead of lying awake obsessing about them; and treat bed as a sanctuary. And unless you work nights, sleep doctors advise against naps, but if you need to collapse for an hour or so, do it before 3 p.m.
For sleep problems with underlying pathologies, the sleep center, which opened last year on Commonwealth Ave near West Campus, includes a four-bed unit to monitor patients overnight. They sleep in what looks like a motel room with several electrical outlets, needed for the monitoring equipment. The equipment allows doctors to diagnose and treat a range of disorders, including apnea—a condition where people briefly stop breathing in their sleep—as well as chronic snoring, sleepwalking, and narcolepsy, a rare disorder that causes people to fall asleep for brief periods all through the day. Those diagnosed with apnea are given a nighttime breathing assistance contraption called CPAP (continuous positive airway pressure).
Whether they undergo overnight monitoring or not, all patients at the center are asked to fill out a questionnaire about their general habits (exercise, alcohol and/or tobacco consumption) and more specifically, their sleep habits, including bedtime, waking time, napping habits, and sleep medications. Patients also answer questions about anxiety, worrying, snoring, and teeth grinding. And sometimes when patients are asked to keep a diary, doctors find that people are sleeping more than they think they are. “For some people it’s a perception,” says Hammond.
What about sleeping pills? They are “poisons with a few good side effects,” Hammond says. In fact, the most popular prescription sleeping pills, Ambien and Lunesta, actually block REM sleep and inhibit memory, says Subimal Datta, a MED professor of psychiatry. Datta is coauthor of a recent study funded by the National Institutes of Health, published in the November 23 Journal of Neuroscience, identifying a new “signaling enzyme” that regulates the sleep-wake cycle, a development that could lead to more effective sleep aid medications. The finding is promising because with the drugs commonly used, “you get rest, but one of the most important parts of sleep is suppressed,” says Datta, emphasizing the importance of REM sleep. Although they work in different ways, Ambien and Lunesta affect the neurotransmitter GABA (gamma-aminobutyric acid), which plays a role in inhibiting the central nervous system and in muscle tone. While these drugs act outside the nerve cell to influence the cell-to-cell signaling system, a new generation of sleeping pills would act inside the cell, requiring much less drug, says Datta, who is studying the regulation of REM sleep in rats. Lunesta and Ambien, he says, “are little better than diazepam, or valium,” and drugs developed from the new enzyme don’t appear to cause memory problems.
Hammond herself is no stranger to sleep deprivation—after all, she was once a medical student. “I was the first person to stay up until 2 a.m. on a project,” she says. “I still have my nighttime responsibilities, but I get back to my sleep schedule.” Her expectation is that she’ll fall asleep quickly and easily. “I’m really grateful for that,” she says.