An Interview with Psychiatrist David Neubauer
Dr. David Neubauer is Associate Professor of Psychiatry and Behavioral Sciences at Johns Hopkins University and an expert in sleep medicine.
Jennifer Ghahari: Thanks for joining us today. I'm Dr. Jennifer Ghahari, Administrative Director at Seattle Anxiety Specialists. I'd like to welcome with us Psychiatrist David Neubauer. Dr. Neubauer is Associate Professor of Psychiatry and Behavioral Sciences at Johns Hopkins University. He's an expert in the field of sleep medicine and has written several articles on the topic, including: “Understanding Sleeplessness: Perspectives on Insomnia” and “Pharmacologic Approaches for the Treatment of Chronic Insomnia.” Before we get started, can you please let us know a little bit more about yourself and what made you interested in studying insomnia?
David Neubauer: Sure. I guess going back to my brief history, I just always was interested in the brain and the mind as a teenager, even. And I used to cut out articles out of the magazines about all sorts of brain-related activities. And so, I came upon articles about sleep, and this was a long, long time ago. And so, I remember cutting these articles out of these young sleep researchers who decades later, I actually got to know later on. In any case, I guess my interest in sleep was sort of latent for a while. I went to college, got interested in lots of different things, anthropology in particular. So, I got a master's degree in anthropology down in Florida. Decided that I would work towards a PhD so I came up to the northwest. So, I went to Vancouver. I studied at University of British Columbia for a year.
And then despite the fact that it was heavenly and I was really interested in what I was doing, I sort of switched gears at that point and decided that I would go to medical school. And so, I learned a lot there. And when I was doing my psychiatry rotation, that just fit well with me considering my social science background. So, I did a psychiatry residency, and that was where my interest in sleep really blossomed more because there was interesting research going on about sleep architecture and how it related with mood disorders.
And so, that really captured my interest at that time. And I broadened that to a bigger interest in the mechanisms and regulation of sleep, and then onto the whole spectrum of sleep disorders and really finally into a sleep health for everybody. So, I'm become an evangelist for sleep in a lot of different settings, academic, writing, lecturing, but a lot of other activities, for instance through the National Sleep Foundation of which I'm on the Board of Directors. So, we do a lot of the public-oriented activities.
Jennifer Ghahari: Fantastic. Thank you. So, I presume that that most people, at some point in their life, have had difficulty sleeping. And what actually defines having insomnia as opposed to just having difficulty sleeping or trouble sleeping throughout one or two nights?
David Neubauer: Well, you're exactly right. Everybody has trouble sleeping at some point. Fortunately, our sleep-wake cycle is very robust and works well for us. But sleep is sort of the final common pathway to all sorts of different types of disturbances. So, we're all vulnerable to a bad night here and there. When it goes on for a longer period of time, we may meet the criteria reaching a certain threshold to be diagnosed with an insomnia disorder. There are several different categorizations of sleep disorders. The two current main ones are in the DSM-5. There's also one in the sleep community which is the International Classification of Sleep Disorders, and that's the third edition of that. Unfortunately, the diagnostic criteria for insomnia disorder are very similar for both of those. So first, you have to have the sleep problem, and that needs to be the complaint of difficulty falling asleep, staying asleep, waking up too early.
But, in addition to that, there has to be some daytime consequences or impairment that might be associated with that. And so, that could be fatigue, irritability, complaints of cognitive difficulties, impairments in productivity, whether it's work or school or family life. For a lot of people, it just evolves into a worry about sleep, itself, that lingers throughout the daytime. So that may be part of it. So, you have the nighttime complaint, daytime consequences. Then, you have to have a good opportunity for sleep. So, it's not insomnia not getting enough sleep because you're staying up too late and getting up too early. Or if you're sleeping in an environment that is very unfriendly for sleep. So, you have to have adequate opportunity and circumstances. Then, you have to have frequency in terms of the criteria because they always do that.
So it has to be at least three nights a week. And the duration is this going on for at least three months. Now, the patients that we see, more likely three years or three decades in some cases, but, so it has to be a persistent problem. And it shouldn't obviously be due to some other disorder. For instance, sleep apnea may cause disruptions in sleep or some other medical conditions or a pain disorder or use of a substance or medication that might be causing it. Now, you might have co-morbid conditions. You might have insomnia disorder along with sleep apnea. But it shouldn't be obviously due to that.
All of that put together pretty much defines insomnia disorder. So that's what's setting it apart from the bad night here and there that any of us might feel when we have bad news or even excitement.
Jennifer Ghahari: You had mentioned a pain disorder. And I recently read some research which regarded the link between poor sleep and the inflammatory response, inflammatory response chronic pain and depression. And can you explain what is exactly happening in that regard about that link and how someone with those symptoms could possibly break the cycle?
David Neubauer: So, I'm not sure that we fully understand the relationships, but we know that the poor sleep often is associated with increased inflammatory markers that go along with a lot of other conditions. So, particularly with chronic pain, there's a very strong relationship with sleep. And it's rather interesting. Even for people who don't have pain conditions, if they are deprived of sleep, in experimental circumstance, their pain is worse the following day. So, there are particular standard measures of pain, you know how long somebody can be subjected to a certain amount of heat or how long they can have their hand in a bucket of ice water. And the people who are sleep-deprived, and again, this is any of us, have a greater pain response.
So imagine those people who have a pain disorder that interrupts their sleep, well, their pain experience can be even greater the next day. So, it can be really a downward spiral for their misery throughout the daytime and nighttime as well. And you mentioned depression. So huge amount of co-morbidity, it's very much a two-way street. People who are depressed very likely are going to have some disturbance in their sleep. And people with chronic insomnia have a greater risk than for developing a depressive disorder, actually anxiety disorders as well.
Jennifer Ghahari: A lot of our clients come to us with co-morbid insomnia and depression. So, we do see that a lot.
David Neubauer: I'm not at all surprised.
Jennifer Ghahari: Unfortunately.
As your research touts, there are some pharmacologic approaches to treating insomnia. And generally, how effective are prescriptive medications against insomnia? And are they usually good for short-term or long-term use?
David Neubauer: So the answer is all of the above. So, all of the medications, at least those that are approved by the FDA for treating insomnia of which there are quite a lot. There are: benzodiazepine receptor agonist hypnotics, there is a melatonin agonist, there is a histamine receptor antagonist, there are two orexin receptor antagonists, all specifically approved for treating insomnia. They have different characteristics, different pharmacology, different pharmacodynamics and pharmacokinetics, meaning, that you can customize what might work for somebody best and not somebody else. Some are good to help people fall asleep. Some are good to help them stay asleep after that. All have gone through a huge amount of testing. And so, under those circumstances compared with placebo medications, they're statistically better. And people report better results with them. Out in the real world, things vary quite a bit because people have different lives, different co-morbidity, other medications that they might be taking.
And so, any of these medications may be beneficial. Some of them are approved for short-term use and several of them really don't have any limitation on the duration of use. So, it's very customized. I think a lot of people coming in with severe insomnia may benefit from a medication for a short period of time, maybe transitioned to intermittent use under a period of time where there may be increased stress and maybe that can cut short the progression of insomnia so it's not going to get worse and worse. And there are some people who use these medications long term and for those people that may be appropriate, especially when they're being well-monitored, I mean, they certainly should be if they're getting continued prescriptions for a sleep promoting medication.
But as I say, it varies quite a lot. Fortunately, we have a wide variety of medications. I do want to say though, that we never turned to a sleep medication first. We always do it in a much broader context and want to make sure that people are following good sleep habits as a foundation of treatment. And of course, there's cognitive behavioral therapy as well, which is well supported for treating insomnia disorder. So, I don't want to suggest that this is the treatment for insomnia. But it can play an important role for some people.
Jennifer Ghahari: Nice. In terms of other treatments, you mentioned cognitive behavioral therapy, are there other maybe natural ways that people can use to try to combat insomnia, other ways that can help restore sleep?
David Neubauer: Absolutely. So, I'd like to emphasize the importance of the infrastructure that supports our sleep. I'm all for roads and bridges and ferries and all those other social supports that we need to function well about the society. But for our sleep-wake cycle, it's important to pay attention to the fundamentals to those processes that regulate sleep. We have a circadian system that under normal circumstances, is very effective in promoting sleep at nighttime and wakefulness during the daytime. It interacts with a homeostatic process. So, these two working together help us out. But we need to do our part as well. And so, people with insomnia disorder, this is really important, but really for the entire population and people who want to maximize the benefits of good sleep, should be following pretty basic rules.
So, the first one is going to bed, which is important because people tend not to. People stay up too late doing whatever, doing things on their phone or watching TV or other computer things. We can usually, we would be able to fall asleep a lot earlier than the time that we actually get into bed and turn out the lights with the intention of falling asleep. So, you got to go to bed and should be leaving sufficient time to get enough sleep. We should be active in the daytime outside if possible. Sunlight is a good thing to help with the robustness of our circadian system, exercise, other physical activity. But we should wind down in the evening. Part of the reason is that we should just have a relaxing routine to transition into sleep rather than scurrying about and turning out the light and instantly expected that they'll be able to fall asleep. But also, because we want our natural processes to work for us.
So melatonin is one example. So, melatonin plays a really important role in facilitating our ability to fall asleep. So normally, we produce melatonin from my pineal gland and our level is very low throughout the daytime, but it gradually rises in the evening for a period of two hours or so as our bedtime approaches. And then it plateaus during the night and then comes down by the next morning. And it's a cycle that repeats itself night after night after night. Well, in the evening, if we have a lot of light from our room lights, from our phones close to our eyes, or all of other sources, we're actually suppressing our melatonin. And therefore, we are depriving ourselves of that natural process, again, which facilitates our ability to fall asleep. What melatonin does is: when it's rising, it interacts with particular receptors in our suprachiasmatic nucleus. And those are the ones that really help us out in the evening.
So we typically are the most awake and alert in the early evening than any time throughout the whole 24-hour cycle which makes sense because otherwise, if we didn't have our circadian clock doing that, from the time we get up in the morning, we would be progressively sleepy right up until the time we fall asleep and then sleep and reverse that, and then do the same thing every day. But, it's not the case. We are able to be alert and functioning for 16 hours or so during the daytime and evening, and then sleep eight hours or so during the nighttime. But part of the reason that we're able to keep going through the evening is because our circadian system is promoting maximum arousal at that time. Now, the exact time depends on the individual and it might be 7:00 or 8:00 in the evening. But when melatonin is rising, it's interacting with those receptors and decreasing that arousal signal, leaving that background sleepiness from the homeostatic processes that's been building up from the time we woke up in the morning.
And so, that's why I emphasize that melatonin really has a permissive role. It facilitates sleep onset. It really doesn't it stops sedating in and of itself. It just allows sleep to occur. And so, I tell people if they're interested in using melatonin I say, "Try your own melatonin." Avoid lots of light in the evening, particularly the blue end of the spectrum. But even then, the apps and filters and glasses that people wear to block out the blue spectrum, that's really pretty limited. And I think, relatively dim light and going to bed relatively early, is the way to go to help maximize the ability to sleep.
Jennifer Ghahari: You had mentioned eight hours is what people should receive in order to get a good night's sleep. Is that the standard that everybody should get, because I think everybody has heard that growing up throughout their lives, is that really the standard or is that been debunked or is everybody individual?
David Neubauer: Well, there is a lot of individual variation, but most people who are on the lower end of that variation who are saying, "Oh, I'm fine getting five to six hours of sleep," really aren't. And, that “eight” hours is a good number. If you're not getting that much every night, shouldn't be too anxious about it. And it really depends on how you're feeling during the daytime as well. The guidelines from organizations like the National Sleep Foundation, also from the American Academy of Sleep Medicine, for adults are recommending seven to nine hours of sleep. And that's based upon review of just huge amount of research. So, we really don't want to cut ourselves short on sleep because there are so many health benefits of sleeping. People tend to think, "Well, I'll sleep later. I'll sleep when I die." Whatever.
Jennifer Ghahari: We'll “catch up later.”
David Neubauer: You want to age well and decrease your risk for chronic diseases that may go along with sleep deprivation. And you may be aware that there have been a lot of health headlines in recent years about discoveries of the role of sleep in helping to minimize the risk for Alzheimer's disease. So, it turns out that while the brain doesn't have a lymphatic system like the rest of the body, which helps to move fluids and sort of recycle fluids in the body, that's not in the brain. But there is something that's been called the glymphatic system. And so, while we are asleep, our cerebral spinal fluid is able to wash away the toxic byproducts of reactions in our brain. And brain is one of the most active organisms in the body, probably the most, and all of those neurotransmitters being recycled and other neurochemical reactions that are occurring, have byproducts that need to be washed away. That's happening best during sleep.
And there are both laboratory studies, as well as epidemiologic studies supporting this conclusion that sleep has an important role in helping to wash away things like beta amyloid and the tau proteins that are associated with Alzheimer's disease. So, it may not be the answer. It may not be the most important factor, but it is a factor. And for that reason, we shouldn't be trying to minimize our sleep so we can be doing other things because all the other things we want to do in our life are going to be better with a well-rested brain and body.
Jennifer Ghahari: Right. Have you found that people are reporting worsening sleep patterns since the pandemic began? Or is this one area that COVID-19 actually has not had much impact?
David Neubauer: Well, if you think about how people's lives have been affected by the pandemic, it's easy to think about how sleep is affected. But there are so many life trajectories that people have experienced as a result. So, on the one hand, you have those people who are the first responders on the front lines working in hospitals, working in ICUs, incredibly stressed, not just because of the patients that they're dealing with, but also with the hours that they have. So, those individuals clearly have a tremendous amount of stress and anxiety and sleep is worse for them.
On the other hand, I talked to people who tell me that the pandemic has been a blessing for them because they're getting more sleep if they are working remotely. They don't have that hour-commute in frustrating traffic. People working from home tell me that not only are they able to get more asleep, but they're able to get outside more, they can take a break, they can walk outside, they can exercise and more flexible with their schedules sometimes. And so, I'm just as likely to hear from people that they're sleeping better than as opposed to those people who are right in the middle of much more stress associated with the pandemic. So, there are so many different stories that people have and so many different ways that their at sleep has reacted.
Jennifer Ghahari: In my own experience, because I think we all have a story to tell, I found that even minor hypoglycemia at night can lead to a type of anxious feeling and the subsequent inability to sleep. And this is usually mitigated by doing something as simple as eating our granola bar, which I found out the hard way, but I found it. So that was good. So, I'm curious how common is this phenomenon of hypoglycemia at night leading to insomnia or lack of sleep? And is there a better way to mitigate this and lessen the problem from happening?
David Neubauer: Yeah. So, I'm not sure that I have the answer for you in terms of what pattern of sleeping and eating is going to work best for you. It does make sense of hypoglycemia can elicit a sympathetic response that's very alerting and could easily wake you up. And so, it's nice that you've found a solution for that. So clearly, that makes sense. And some people with diabetes, if their insulin levels and dosages are not prescribed optimally, may dip down and have very severe hypoglycemia during the night and rather dramatic awakenings associated with that. So, it is a phenomenon.
One thing that I do advocate for people is maximizing the robustness of their circadian clock. And so clearly the behaviors that we've talked about getting outside and being active and winding down early in the evening, all of that's really good. It turns out that it's further enhanced by the timing of eating. So, there's a lot of literature out now about time-restricted eating, usually meaning big breakfast, smaller lunch, smaller supper, and then stopping eating. So, you have just a zone of eating and then fasting during the rest of the evening and until the next morning. And, that's very potent in helping to reinforce our circadian system. And probably, although there's not much literature to support it yet, probably has a very positive effect on sleep as well. It does appear that not eating for a few hours prior to going to bed is a good thing that has a positive effect on sleep. And there's recent literature showing that there are metabolic reasons to avoid eating close to bedtime as well.
Traditionally, the sleep hygiene lists for all say, "Well, have a bedtime snack and maybe you'll fall asleep better." And so, I've taken that off my list because we have a more negative metabolic response as the evening goes on especially around the time that melatonin is starting to come up. And so, we know that people who have a particular meal in the morning, say 8:00 in the morning, if they have that identical food at 8:00 PM, they're going to respond differently and have a larger glucose response and a larger insulin response, which is what happens when people have pre-diabetes. So, we all get a little pre-diabetic in the evening and so it's good to avoid eating mid to late evening. So, cutting off meals early in the evening and not eating anything after that is probably optimal for our circadian system and probably for sleep as well. I don't know what that means for your cycle, but I think it's good advice for a lot of people.
Jennifer Ghahari: Yeah. Thank you. So as a prominent psychiatrist specializing in sleep medicine, do you have any other advice or recommendations that you'd like to share with our listeners?
David Neubauer: Well, I'll just go back to the concept of the infrastructure. Your own body has regulatory mechanisms that control the sleep-wake cycle. And as humans in our society, we tend to mess with all of that. We're up and doing things at all different hours. And we have lights, electric lights, and we have all these other electronics that can interfere with our sleep-wake cycle. We live in a 24-hour society and can go online, or even go out to stores, some, at all hours as well. So just trying to go back to our natural rhythms, it's really what I preach.
Jennifer Ghahari: Perfect. Thank you, Dr. David Neubauer of Johns Hopkins. Thank you again for reaching out and helping us with the project, and hope to speak with you again in the future.
David Neubauer: That'd be great. This has been a pleasure.
Jennifer Ghahari: Thank you.
Please note: The views expressed by the interviewee are for educational and informational purposes only, are not meant to diagnose or treat any condition, and do not necessarily reflect the views of Seattle Anxiety Specialists, PLLC.
Editor: Jennifer (Ghahari) Smith, Ph.D.