Getting better sleep in difficult times

With all this COVID-19 outbreak I’m seeing many friends saying they are struggling with getting good sleep.

I have dealt with chronic insomnia my whole life and collected a variety of lessons with a lifetime of try and error, so I thought about documenting what did and what didn’t work.

Before going there, I want to make a disclaimer: I’m not a doctor. Don’t believe me. Talk to your doctor and if their opinion is different than mine, believe them, not me.

Alright, here we go:

It turns out, sleep is not as easy and automatic for many of us. Several times in my life I would often go 4 days in a row unable to sleep a single hour, no matter how hard I tried. I can tell you I would rather have chosen a variety of other illnesses, because this is torture: When you don’t sleep well, everything becomes harder. Thinking is harder, handling your life is harder, problems feel bigger… Which is exactly what you don’t want people to face in times like this. So I went to a variety of doctors in different domain areas, different countries and tried a variety of approaches. Here is a summary of what I learned:

What didn’t work:

  • Sleep studies:

Look, far from me to question science, science is awesome and it works, but I will tell you what my experience was with this particular approach. I went to three different doctors and did 3 different sleep studies, all within the interval of a month. Each study ended up with a completely different result, they directly contradicted each other and often reported the opposite of what actually happened. I remember coming back to the doctor with the device I had to plug all over my head and chest for 3 nights in a row collecting a bunch of data. The doctor looked at the data and said: Great news! It looks like you slept pretty well in these three days!

Turns out I did not, at all. I was in a particular bad mood exactly because I had 3 awful nights. In one of them I literally got up at 3am and stayed awake until the morning with the device attached to me the whole time and the data recorded didn’t report anything, it said I just slept thru. Seriously… My wife wears an Apple watch to monitor her sleep and I can tell you the results are not much different. Completely inconsistent.

One of the sleep studies reported sleep apnea, the other reported that I don’t have it, and so on. Basically an useless effort I couldn’t draw any conclusions from.

The lesson here was pretty simple: A machine here won’t give you a lot of data, you have to spend time learning about yourself, your routines, your diet, observe what affects your sleep, take notes, do blood exams. Research, research, research. Which brings me to the second thing that didn’t really add a lot of value:

  • Doctors:

I lost account of how many doctors I visited. Sleep specialists, GPs, neurologists. Maybe it is my bias or maybe it’s a thing about American doctors but there was such a lack of curiosity to investigate this problem further that put me off. I remember going to a neurologist, after trying several doctors and she basically didn’t bother suggesting a single exam. She looked at my records, saw some notes from one of those sleep studies above and concluded: Oh, see, you have sleep apnea, that’s it. She finished her consultation within about 15 minutes. Didn’t ask any questions, didn’t bother doing any further investigation.

It became clear to me that if I wanted to learn what was going on, I would have to spend an amount of investigation time that these doctors weren’t willing to spend. I also worry about the kind of recommendations they made along the way, which brings me to the next point of what didn’t work:

  • Medications:

This again might be my bias, or it might be about how doctors in America operate, but dear God, the way medications are prescribed around here is scary.

It turns out that folks don’t really know what will or won’t work, and they have very little information about the root causes of your insomnia, so what they will do is experiment on you. Try this medication, see what happens for a while, oh didn’t work so try this one, and so on.

You would say that’s ok, and I would agree, until you start looking at what they are prescribing. My sleep specialist, someone widely respected in this field, prescribed me a medication and I decided to validate it with my GP. She was shocked. The medication was actually intended for people with epilepsy, to control seizures, and she had never heard of anybody taking that for sleep. He apparently ran out of things to try so he decided to try this… on me.

There are a few things to keep in mind here: First, not all types of insomnia are the same. If it’s something temporary, you have more options. If it’s something chronic like in my case, your options are restricted. That is the case because you can’t take something that could cause dependency, or lose the effects over time. This leaves you with only a few FDA approved choices: Check this: https://aasm.org/fda-new-warning-insomnia-medications/ and this: https://www.webmd.com/sleep-disorders/insomnia-medications Even if that wasn’t the case, it turns out that for some reason these medications don’t seem to work on me very much. Taking the maximum dosage of Ambien, for example, never did anything, I would just spent the whole night awake.

Even if you take medications like Doxepine, which is arguably safe, shouldn’t cause dependency and should help you sleep, I can tell you that it will affect your state of mind during daytime. I couldn’t find a combination that would put me to sleep and at the same time make me feel alert when I needed it, or not cause me side effects like terrible migraine, which one neurologist, without doing any exam, suggested it happened because when I finally slept, my body lacked oxygen due to apnea (I have plenty of evidence that this isn’t the case now). So you end up with this paradox: Face your insomnia and struggle to be yourself during the day or take a medication for it and still struggle to be yourself during the day. Not great choices.

Having said that, if you have one-off cases where you really need some help, I would think these might help you. I noticed in some friends that sometimes you just need to be able to break a bad cycle of multiple bad nights with a good one, and then you can handle from there on your own. Sometimes you need to be reasonably rested in order to be able to sleep well, ironically.

  • Melatonin:

Now this one drives me crazy. Everybody, every doctor I spoke with immediately told me to take Melatonin. Why that annoys me? Because if you’re going to prescribe a thing that your body should be producing by itself, you must have reasons to believe that the body isn’t building enough of it. Did anybody check? No. Then even if that was the case, you would want to know why your body isn’t building enough of it. Did anybody check that? Nope.

Even then, you could argue: Well, what’s wrong with it? It’s safe.

You would think so, right? Then why isn’t it sold over the counter in many countries? (Example: https://www.theguardian.com/money/2018/jan/03/illegal-sale-melatonin-ebay). Also, if it is sold freely here in the US, it means the regulations around the quality are also very weak. How do you know you are buying a good quality product? (data: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5263069/). Third, is it safe to take long term? “POSSIBLY”… (data: https://www.webmd.com/vitamins/ai/ingredientmono-940/melatonin). Fourth, most supplements you find here have dosages orders of magnitude higher than what your body should be producing. What does it do to your body over time? I don’t know, do you? Will your body learn that it needs to produce even less of it, making your insomnia worse over time? No idea. (some more data: https://www.medscape.com/viewarticle/906835)

But above all those reasons for my skepticism, the main reason is that I tried, and not only it did not work, after a couple of weeks I had a strong impression that my sleep got worse, not better, and I found reports online of others who felt the same. That was enough for me to give up on this.

So, what did work then:

Now that I crushed your hopes and dreams, let me start with the good news: When it comes to good quality sleep, I think I’m at my peak today. Significantly better than anything I experienced most of my life. I won’t say I’m done with insomnia, it’s still there, but way more manageable than before. To get there, I had to do a few things:

  • Blood tests and supplements:

I highly recommend you to do tests. Good thing is these days there’s a lot you can just go and test yourself, you can order tests online and figure many things on your own.

For example, I tested my melatonin levels and found they were mostly within acceptable range – hence why doctors telling me to take more of it made zero sense. They could have checked that themselves:

But I tested a bunch of other stuff. For example, Cortisol levels:

And that didn’t look great at all, did it? Again, no doctor suggested looking into that. This gave me some hints on where to focus on next.

I also found out my vitamin D levels were low and it turns out, a significant part of the population also has low vitamin D (data: https://www.cantonmercy.org/healthchat/42-percent-of-americans-are-vitamin-d-deficient/). And it turns out that lack of vitamin D can cause insomnia (data: https://www.insider.com/how-vitamin-d-affects-sleep-2019-2). Which is specially a problem if you live somewhere without a lot of sunlight. Taking supplements, especially later in the evening, made a significant difference for me.

  • Temperature:

I had doctors telling me to wear socks at night, or to take warm baths. These things only made it worse. What actually helped was the very opposite: Cold temperatures. Anything from 60 to 67 degrees (data: https://www.huffpost.com/entry/best-temperature-for-sleep_b_3705049). A very cold shower before going to bed also helps. I also started doing cryotherapy and I’m under the impression that this too helped.

If you are going to try heavy blankets (which you will find data suggesting that they are too helpful) you need to be careful with how much warmer it will feel. It will be hard to balance the additional weight and keeping the temperature low. A thing you can do is adding a device that cools the bed itself, like this: https://www.amazon.com/gp/product/B07GTBWQKZ/

With that, you can have the best of both worlds, although to me, having the colder temperature was the most significant aspect here.

  • Timing things:

It turns out, the body likes routine. Our circadian rhythm appreciates responds well if you set yourself to certain routines. Light exposure, meals, these things matter.

For starters, you do want a lot of light exposure during the day. All this stuff about blue light blocking glasses is only helpful at night only. Buying glasses that block blue light and wearing them during the day is not going to do anything to help. In fact, they are going to cause problems such as lack of melatonin (remember, fix the source problem, not the symptom). You should get a lot of light exposure and avoid sunglasses during the day. In fact, early in the morning you might get yourself some very bright light and use it right after you wake up. If you want to go crazy, maybe get some of these: https://www.amazon.com/PEGASI-Therapy-Feather-Light-Research-Backed-Blue-Green/dp/B07FYKNG3L/ref=sr_1_2

Then at evening you want to block those blue lights. No, just changing your phone to warmer color combination does nothing, it’s bullshit. In fact, it may even make things worse (data: https://www.businessinsider.com/night-mode-shift-warm-colors-worse-for-sleep-2019-12). You will need to either cut screen time or wear some pretty decent light blocking glasses (a lot of them claim to do it but won’t really work). Something like this: https://www.amazon.com/gp/product/B07CZ499J5/

You know it’s doing the work because you can’t distinguish colors with it. Everything is either white or red, and everything is pretty dark. Also dim your screens and lights.

Then manage your meals: Eat right when you wake up. That trains your body to get ready in the morning. You will find yourself waking up at the right time without an alarm, consistently. Also don’t eat too late. I try not to eat anything after 5pm (often I try not eating anything after 2pm but you don’t need to go that far).

A good book that talks a lot about these recommendations is The Circadian Code.

Again, not a single doctor walked me these things and how they affect my sleep… They would tell me to take Melatonin, not to understand why I might not be producing enough of it…

  • Teaching yourself to fall asleep:

This might be the most fundamental learning and the most beneficial thing I could recommend.

People don’t just flip a switch and fall asleep. Well, some of them do and we can all hate them but for a lot of us, falling asleep is a process. Think how you shut down your computer: You don’t just flip a switch, you ask it to shut down and it does a bunch of stuff in the background before it can really go from “on” to “off”. Our brain and body need to execute some tasks too. If you expect to just be able to lay down and fall asleep you might be missing some of these stages. The problem I have with medications, for example, is that they often work as shortcuts that don’t help you learn this process, but just avoid it all together instead. Even when these meds work, it doesn’t feel right. It always feels like you missed something and aren’t fully rested. Not much different than people who drink alcohol to sleep (which you shouldn’t).

The first insight I’ve got into this concept of learning to fall asleep was when I learned about Cognitive Behavioral Therapy for insomnia – CBT (some reading on that: https://www.sleepfoundation.org/articles/cognitive-behavioral-therapy-insomnia). This started to make me understand this gap I needed to work on. They have a variety of recommendations, for example only going to bed when you’re ready to sleep, don’t watch TV in the bedroom, if you can’t sleep after a while, get up and get out of the bedroom and so on.

To be honest, although the general thinking makes sense, the practices they recommended didn’t really do a lot (Doctors will argue this is by far the best thing you can to do fix insomnia, statistically, which makes sense. All I’m saying is it wasn’t nearly enough). They even have some pretty intense exercises, like you go to a lab, fall asleep and they wake you up immediately, then wait for you to fall asleep again and wake you up again, over and over all night, with the idea of training you into this process of falling asleep by repetition, which is pretty close to the kind of torture you hear about war prisoners having to endure. Not a pleasant experience at all (trust me, I tried that too). But the thinking behind of it made sort of sense to me: There was some kind of process that I was missing and I needed to practice that until I got better at it.

I noticed that the whole giving up after 20 minutes without being able to sleep and go do something else wasn’t helping either. I was getting up, getting frustrated for not having enough sleep, and then waiting until I felt like sleeping again which maybe for you could mean 15 minutes but to me it often means 24 hours. So effectively it meant spending one or two nights without sleeping. Also, after I developed a better processes here, I found out that often I can in fact end up getting back to sleep and having an amazingly deep sleep that only lasts 30 minutes but makes a huge difference in the rest of the day. Getting up, though, didn’t help. More to that further below.

Part of training to fall asleep involves meditation, a thing I’ve done for some good 20 years. Meditation is an exercise, it’s like building a muscle. It doesn’t work if you do it once a week, or only when you feel like you need it. It also doesn’t work if you try to do it laying on your bed trying to fall asleep. I recommend mindfulness meditation, daily, for as long as you can manage it. In the beginning you will find out you can’t do it for longer than 5 minutes. Over time, you will be able to do it for 10, 20, 30, one hour or more. Maybe one hour is too much, I’d say 20 minutes is good enough. Note that as your life gets crazier, you end up sacrificing that and not doing it some days. Ironically, those are the days when you need it the most, so you need consistency. People often recommend doing this in the morning after you wake up, that might be a good time.

Then the next thing is training the “fall asleep” process. This has been an interesting one and here’s how I went about it:

When you go to bed, lay down on your back. It doesn’t matter if that’s the position you sleep or not, just stay like that for a while. Then, focus on starting shutting down every thought (where meditation should have helped you if you have been doing it daily) and every muscle. I noticed I need to do this for at least 20 minutes. You know it’s working when you start feeling as if you took a sleeping pill: You start feeling drowsy. In fact, this also works when I wake up at 4am and can’t fall back asleep, I repeat the process.

But how do you know you are doing the right things that are getting you closer to a state of mind to fall asleep? It’s not like learning to ride a bicycle, where you either fall or you don’t, so the “signal” is obvious. Here, the signal isn’t obvious and, I believe, this is the key issue with people who suffer from insomnia: They don’t know how to train themselves because there’s no clear signal.

To help with that, I tried a variety of things. One that seemed particularly helpful was using Muse, which is essentially a biofeedback device: https://www.amazon.com/Muse-2-Brain-Sensing-Headband/dp/B07HL2S9JQ/

The problem with these kind of “just relax” recommendations is that they are vague. It’s not like “switch this thing off and then that thing”. If your brain doesn’t know how to get there, it’s kinda hard to figure it out on your own. What Muse does is giving you an audible feedback. You put the headset, wear some earbuds so you don’t wake up your partner and then you can hear what you are doing with your brain and body and whether it is working or not. I noticed with very few days of practice that something was different: After doing that for 20 minutes, falling asleep became easier, and my sleep felt significantly more restful. The difference was too much to be a coincidence. In fact, even if I found out I woke up at 4am and couldn’t get back to sleep, I would do it again. And often it worked.

More surprisingly, after a while, it felt as if I learned the “process” I needed to execute in my brain to get to that state, even without wearing it. Today I often go days without using it and it is fine. But I get back to it every now and then just to make sure I don’t lose that practice, just like I do with meditation.

What surprised me the most was quality vs quantity: Doing this often allowed me to feel absolutely rested even when I only managed to get some 3 or 4 hours of sleep at night, when in the past I could stay in bed for 10 hours and still get up exhausted.

You can also do it in the middle of the day for 20 minutes and feel a huge energy boost. It also had effects in lowering my cortisone levels mentioned above. I also found out other things correlated to higher cortisone, such as the kind of nutrition supplements I took during my workouts, so you have to watch that closely too.

In summary:

To summarize all of the above, this is basically what I’m suggesting:

  • If someone tells you to take something, whether it’s a supplement or medication, ask why. If it’s a supplement, ask how do they know you lack that, what exams can prove it, how do they know this is the thing that will fix your problem. If you hear something like “it’s common practice”, I would recommend talking to another doctor, and then another one, until someone applies real scientific method and runs exams to really find what’s going on.
  • Regulate your light exposure: Lots of bright light, including blue light, during the day, and no blue light at night.
  • Regulate your meals: Have breakfast as soon as you wake up. Don’t eat late. This isn’t just good for your sleep, there are a variety of other health benefits too
  • Probably take D vitamins. Many people lack them. I usually take 5000 IU at evenings. Note that 5000 IUs is quite a lot, I found that to work for me, but you should be careful with taking high dosages as this could cause other problems. Again, talk to your doctor. I also noticed taking magnesium regularly also seems to help
  • Meditation, daily
  • Train yourself to fall asleep. There’s a process. No medication will teach you that process. Using biofeedback can be hugely helpful to get you there.
  • On top of all of that, there are generally good advice you will find everywhere: Go easy on coffee, avoid alcohol, exercise, etc. All of these help too.

There you go. Hope that keeps you sleeping better in these times.