Tag: Articles

Yoga Nidra for Sleep

Posted on June 26, 2025 by IntraBalance - Sleep Health

You may have heard the buzz around Non-Sleep Deep Rest (NSDR), popularized recently by neurobiology professor Andrew Huberman.

While he’s not a sleep specialist, there is evidence for NSDR which is rooted in an ancient yogic practice called Yoga Nidra, often described as “aware sleep.”

Yoga Nidra is a guided, supine practice that induces delta brainwave activity, seen in deep sleep (stage 3 sleep), while you stay awake.

It’s especially helpful for reducing stress and improving sleep quality, with evidence supporting its use in insomnia, PTSD, and anxiety.

That’s why, in our practice, we blend CBT-I (Cognitive Behavioral Therapy for Insomnia), ACT (Acceptance and Commitment Therapy), and Yoga Nidra. This combination allows us to address both the behavioral and emotional barriers to restful sleep.

CBT-I remains the gold standard for chronic insomnia and I do recommend it.

But in real-world practice, CBT-I alone isn’t always enough. For patients with high arousal, sleep-related anxiety, or trauma histories, it can feel too rigid or triggering, sometimes leading to dropout or poor adherence.

That’s why, in our practice, we blend CBT-I, ACT (Acceptance and Commitment Therapy), and Yoga Nidra. This combination allows us to address both the behavioral and emotional barriers to restful sleep.

This week, I’m joined by Lauren Ziegler, sleep coach and yoga therapist teacher to discuss how yoga nidra works for insomnia. Click here or watch the video below.

What the Evidence Says

RCTs show Yoga Nidra improves both subjective and objective sleep parameters, including sleep latency, total sleep time, and sleep efficiency.

It helps reduce psychological and physiological arousal, two of the biggest perpetuating factors in chronic insomnia.

Early findings also suggest benefits in post-sleep refreshment, cognitive clarity, and emotional regulation…key for daytime functioning.

Who benefits?

Patients with insomnia, especially with high cognitive or physiological arousal
People who have “failed” meditation
Those tapering off sleep aids and looking for alternatives
Those who struggle with implementing CBT-i

One of the clients in our sleep program was initially skeptical, but found Yoga Nidra so effective it helped him sleep more deeply, feel calmer, and even reduce his use of sleeping pills.

How to Introduce It in Clinical Practice

You don’t need to be a yoga teacher to recommend it. Just frame it as a guided rest practice that’s low-effort, low-risk, and deeply restorative.

“You don’t have to clear your mind, just lie down and listen.”
“Even five minutes can help.”
“This isn’t about trying to sleep. It’s about letting the nervous system soften.”

Next Steps

Yoga Nidra is simple, accessible, and research-backed. For many of our patients, it’s the first time they experience what deep rest actually feels like.

Watch the YouTube conversation with Lauren to learn more.

Did you learn something today? Click here to find out how Learner+ can help you meet your evolving educational goals.

References:

1. Alghosi M, Sharifi M, Namavari S, Rajamand N, Bamorovat F, Norouzi N, Alimoradi M, Konrad A. The effect of chronic yoga interventions on sleep quality in people with sleep disorders: a scoping review. Front Neurol. 2025 Apr 29;16:1566445. doi: 10.3389/fneur.2025.1566445. PMID: 40365457; PMCID: PMC12071090.

2. Datta K, Bhutambare A, V L M, Narawa Y, Srinath R, Kanitkar M. Improved sleep, cognitive processing and enhanced learning and memory task accuracy with Yoga nidra practice in novices. PLoS One. 2023 Dec 13;18(12):e0294678. doi: 10.1371/journal.pone.0294678. PMID: 38091317; PMCID: PMC10718434.

3. Sharpe E, Butler MP, Clark-Stone J, Soltanzadeh R, Jindal R, Hanes D, Bradley R. A closer look at yoga nidra- early randomized sleep lab investigations. J Psychosom Res. 2023 Mar;166:111169. doi: 10.1016/j.jpsychores.2023.111169. Epub 2023 Jan 29. PMID: 36731199; PMCID: PMC9973252.

4. Sharpe E, Tibbitts D, Wolfe B, Senders A, Bradley R. Qualitative Impressions of a Yoga Nidra Practice for Insomnia: An Exploratory Mixed-Methods Design. J Altern Complement Med. 2021 Oct;27(10):884-892. doi: 10.1089/acm.2021.0125. Epub 2021 Jul 15. PMID: 34265219; PMCID: PMC10772320.

Does cannabis help sleep?

Posted on June 12, 2025 by IntraBalance - Sleep Health

Exploring Cannabis in Medicine: Insights with an Internal Medicine Doctor

Cannabis for medical issues wasn’t on the radar when I was in med school. Now it’s everywhere…the local coffee shop offers CBD shots for your morning espresso and medical cannabis has become mainstream.

Even my dog gets CBD treats PRN anxiety.

You may be getting more and more questions about cannabis in clinic…but most of us were never taught about medicinal cannabis in training.

This week I sat down with Dr. Janice Makela MD, an internal medicine and palliative care doc with training in cannabis-based care, to unpack the practical, clinical side of cannabis.

In our conversation, Dr. Makela shares what every clinician should know before saying yes or no to cannabis as part of a treatment plan.

The endocannabinoid system (ECS) helps regulate pain, sleep, metabolism, and immune response. Dr. Makela points out that we learned about the renin-angiotensin system in med school, but there’s no training on the ECS.

She makes the case that understanding the ECS is foundational, not fringe, especially if we want to evaluate cannabis objectively in modern practice.

Clinical Pearls

Chronic Pain

Cannabis can modulate pain pathways through CB1 receptors. Some patients reduce their opioid burden with its use, but it’s not one-size-fits-all.

PTSD

For some, cannabis reduces nightmare frequency and intensity. However, there isn’t enough data to recommend treating patients with it.

Dementia

Low doses may reduce agitation in geriatric populations. Dr. Makela shared some clinical pearls on dosing.

Cannabis is not benign, but it’s also not going away.

Risks and Red Flags

While anxiety and insomnia are two of the most common reasons patients turn to cannabis, the response is highly formulation- and person-dependent.

It can both help and harm. Be careful in people with underlying trauma, addiction histories, or schizophrenia-spectrum vulnerabilities.

What About Sleep?

While people feel like they sleep better, the data tells a murkier story, with increased light sleep, reduced REM, and potential disruption of architecture over time, depending on the formulation.

Patients with chronic non-cancer pain are most likely to experience benefit from cannabinoids for sleep disturbances.

Where Do We Go From Here?

Dr. Makela believes cannabis in medicine could eventually take a place like digitalis or morphine: powerful when used wisely, dangerous when not.

That’s why education matters to help clinicians think critically, communicate clearly, and meet patients where they are.

I don’t recommend medical cannabis in my practice because I don’t have adequate training in how to prescribe it appropriately. However, I’m open to having conversations with patients about it and pointing them in the right direction when they need more information.

If you’ve been curious about how to bring cannabis into the conversation with patients, or when to leave it out entirely, this interview is worth your time.

Take a listen and let me know what stood out to you.

Did you learn something today? Click here to find out how Learner+ can help you meet your evolving educational goals.

References:
AminiLari M, Wang L, Neumark S, Adli T, Couban RJ, Giangregorio A, Carney CE, Busse JW. Medical cannabis and cannabinoids for impaired sleep: a systematic review and meta-analysis of randomized clinical trials. Sleep. 2022 Feb 14;45(2):zsab234. doi: 10.1093/sleep/zsab234. PMID: 34546363.

Bhagavan C, Kung S, Doppen M, John M, Vakalalabure I, Oldfield K, Braithwaite I, Newton-Howes G. Cannabinoids in the Treatment of Insomnia Disorder: A Systematic Review and Meta-Analysis. CNS Drugs. 2020 Dec;34(12):1217-1228. doi: 10.1007/s40263-020-00773-x. Epub 2020 Nov 26. PMID: 33244728.

Morin CM, Buysse DJ. Management of Insomnia. N Engl J Med. 2024 Jul 18;391(3):247-258. doi: 10.1056/NEJMcp2305655. PMID: 39018534.

Sznitman SR, Meiri D, Amit BH, Rosenberg D, Greene T. Posttraumatic stress disorder, sleep and medical cannabis treatment: A daily diary study. J Anxiety Disord. 2022 Dec;92:102632. doi: 10.1016/j.janxdis.2022.102632. Epub 2022 Sep 16. PMID: 36182689.

Velzeboer R, Malas A, Boerkoel P, Cullen K, Hawkins M, Roesler J, Lai WW. Cannabis dosing and administration for sleep: a systematic review. Sleep. 2022 Nov 9;45(11):zsac218. doi: 10.1093/sleep/zsac218. Erratum in: Sleep. 2023 Mar 9;46(3):zsad008. doi: 10.1093/sleep/zsad008. PMID: 36107800.

Sleep Strategies for Shift Workers: Clinical Insights for Healthcare Providers

Posted on May 19, 2025 by IntraBalance - Sleep Health

I was in elementary school when the Exxon Valdez oil spill made headlines. The images of oil-drenched wildlife and thick, syrupy water are etched in my memory. We even discussed it in class.

What I didn’t learn at the time, though, is that the worst oil spill in U.S. history was also a sleep-related disaster.
The person responsible had reportedly been awake for 22 hours before the incident. At that point, the brain functions as if you’ve been drinking alcohol…equivalent to a blood alcohol level of 0.08%.

In other words, sleep deprivation isn’t just a health issue, it’s a public safety problem, especially for those working shifts.

Shift Work and Sleep Deprivation: A Growing Public Health Concern

If you’re a doctor, nurse, or healthcare provider who works shifts or manages patients who do, you understand the toll shift work can take on sleep and overall health. But the impact goes beyond just feeling tired.

The consequences of chronic sleep deprivation in shift workers, whether in healthcare or other industries, can lead to burnout, poor decision-making, and serious safety risks.

This week, I’m joined by Dr. Alison Kole MD, a pulmonary, critical care, and sleep medicine physician who understands the brutal reality of shift work from experience.

After burning out working ICU shifts during the COVID-19 pandemic, Dr. Kole pivoted and is now the host of the Sleep Is My Waking Passion Podcast. In this masterclass, Dr. Kole shares her experience and evidence-based strategies to help shift workers manage their sleep better.

Watch Dr. Kole’s Masterclass on Shift Work and Sleep

Here’s what you’ll learn in this shift work sleep masterclass:

What qualifies as shift work and why it’s not just night shifts
The real-world impact of sleep deprivation on decision-making and public safety
Evidence-based sleep strategies for managing sleep during shifts, including the role of anchor sleep, naps, and sleep banking
How to strategically use caffeine and follow the jet lag diet to improve alertness and recovery
Practical advice for healthcare professionals to avoid burnout and sleep deprivation-related accidents

Start Building Your Clinical Sleep Medicine Knowledge with My Free Course

If you’re a healthcare professional working with patients, it’s crucial to have a strong foundation in clinical sleep medicine.

That’s why I’ve created a free sleep mini-course focused on the foundations of clinical sleep medicine. This course is specifically for doctors and healthcare providers who want to understand the science of sleep and gain practical tools for treating sleep issues in their patients.

Click here to get immediate access to the free course

Why Sleep is Crucial for Doctors and Healthcare Providers

As a doctor or healthcare provider, your ability to provide excellent care depends on how well-rested you are. Shift work sleep issues are more than just inconvenient—they can seriously impact your performance and decision-making. Sleep deprivation can lead to mistakes that affect patient care and safety.

By learning the fundamentals of clinical sleep medicine, you can not only improve your own understanding of sleep but also provide better care for your patients, especially those working irregular hours.

Bottom Line: Sleep is Essential for Shift Workers

Sleep isn’t a luxury for shift workers. It’s a health necessity…and it’s something you can learn to treat more effectively with the right clinical sleep strategies.

Did you learn something today? Click here to find out how Learner+ can help you meet your evolving educational goals. https://champions.learner.plus/?champion=Dr%20Nishi%20Bhopal

Can the Oura Ring Improve Sleep Insights for Your Patients?

Posted on May 14, 2025 by IntraBalance - Sleep Health

As a sleep physician and psychiatrist, I’ve found the Oura Ring to be a surprisingly useful tool, both personally and clinically.

I’ve worn my Oura Ring for years and regularly use it to track sleep trends in relation to lifestyle factors like late-night screen time, stress, and diet. While I’ve always known I sleep better after a nature hike or worse after a late dinner, having objective sleep data makes these patterns undeniable.

It turns out my HRV tanks after evening laptop use or meals close to bedtime—exactly what I counsel patients about. Tools like this can be a valuable addition to our clinical sleep toolkit…when used wisely.

How Clinicians Can Use the Oura Ring in Practice

Here are 3 practical ways doctors can integrate the Oura Ring into clinical conversations about sleep health:

1. Monitor HR and HRV as Stress Biomarkers

The Oura Ring performs well in capturing nocturnal heart rate and HRV (heart rate variability). Several validation studies have shown a high correlation with ECG overnight HRV readings [1–3].

‣ Use Case: For patients dealing with burnout or ANS dysregulation, these metrics offer a non-invasive way to measure recovery, especially in response to interventions like mindfulness or behavioral and lifestyle changes.

2. Track Sleep, But Focus on Trends, Not Sleep Stages or Single Nights

While the Oura Ring does a decent job estimating total sleep time, its sleep staging accuracy doesn’t match polysomnography (PSG) [4].

‣ Tip: Encourage patients to look at sleep trends over time rather than individual nights or specific stages. Emphasize that we’re not diagnosing, we’re pattern-tracking.

3. Support Lifestyle Interventions with Wearable Feedback

A recent 12-month study showed that pairing the Oura Ring with guided health coaching improved sleep, activity, and metabolic health markers [5].

I’ve seen this play out in real life. When patients visualize how meditation or limiting alcohol affects their HRV and sleep quality, they’re more likely to stick with healthy behaviors.

How Patients Can Share Oura Ring Sleep Data with You

Patients can now easily export their sleep data using the “Shareable Sleep Reports” feature. Just go to the top-left menu, > “Shareable Reports” > “Sleep Reports” > Choose your time frame > Download the PDF.

3 Common Pitfalls of Sleep Wearables

While wearables can be helpful, they come with limitations. Here’s what to watch for:

1. Orthosomnia or obsessive behaviors:
Some patients develop sleep-related anxiety or obsessive behaviors around sleep and activity tracking, fixating on their scores instead of tuning into their body.

In those cases, I recommend taking a break for a few weeks or months, and shifting attention to how they feel.

2. Over-Reliance on Metrics:
Data is not the whole picture. Patients may feel fine but score “poorly”, or vice versa. Teach them to listen to their body first.

3. Skipping Medical Evaluations:
A good score doesn’t rule out sleep apnea, mood disorders, or circadian rhythm issues. Wearables complement, not replace, your clinical judgment.

3 Sleep Coaching Tips for Doctors Using Oura Ring Data

Track Trends, Not Single Nights
Two weeks of data gives a clearer picture than a single off-night.

Use Data to Build Insight
Let patients discover how lifestyle impacts sleep…especially caffeine, alcohol, and late screen use.

Watch for Tracking Burnout
If the ring is causing more stress than clarity, press pause. Help patients reconnect with body cues, lifestyle changes, mindfulness, and what I like to call Vitamin J (Joy).

Final Word: The Oura Ring Is Like a Stethoscope for Sleep

The Oura Ring is not a diagnostic device, but it’s a powerful adjunct when paired with clinical insight. Think of it as a modern stethoscope for sleep and recovery…helpful for gathering clues, but not the whole story.

Want More Clinical Sleep Tips for Healthcare Professionals?

Check out our Sleep Medicine Pearls Course for Clinicians

Did you learn something today? Click here to find out how Learner+ can help you meet your evolving educational goals. https://champions.learner.plus/?champion=Dr%20Nishi%20Bhopal

References:

1. Kinnunen H, Rantanen A, Kenttä T, Koskimäki H. Feasible assessment of recovery and cardiovascular health: accuracy of nocturnal HR and HRV assessed via ring PPG in comparison to medical grade ECG. Physiol Meas. 2020 May 7;41(4):04NT01. doi: 10.1088/1361-6579/ab840a. PMID: 32217820.

2. Cao R, Azimi I, Sarhaddi F, Niela-Vilen H, Axelin A, Liljeberg P, Rahmani AM. Accuracy Assessment of Oura Ring Nocturnal Heart Rate and Heart Rate Variability in Comparison With Electrocardiography in Time and Frequency Domains: Comprehensive Analysis. J Med Internet Res. 2022 Jan 18;24(1):e27487. doi: 10.2196/27487. PMID: 35040799; PMCID: PMC8808342.

3. Herberger S, Aurnhammer C, Bauerfeind S, Bothe T, Penzel T, Fietze I. Performance of wearable finger ring trackers for diagnostic sleep measurement in the clinical context. Sci Rep. 2025 Mar 19;15(1):9461. doi: 10.1038/s41598-025-93774-z. PMID: 40108409; PMCID: PMC11923143.

4. Robbins R, Weaver MD, Sullivan JP, Quan SF, Gilmore K, Shaw S, Benz A, Qadri S, Barger LK, Czeisler CA, Duffy JF. Accuracy of Three Commercial Wearable Devices for Sleep Tracking in Healthy Adults. Sensors (Basel). 2024 Oct 10;24(20):6532. doi: 10.3390/s24206532. PMID: 39460013; PMCID: PMC11511193.

5. Browne JD, Boland DM, Baum JT, Ikemiya K, Harris Q, Phillips M, Neufeld EV, Gomez D, Goldman P, Dolezal BA. Lifestyle Modification Using a Wearable Biometric Ring and Guided Feedback Improve Sleep and Exercise Behaviors: A 12-Month Randomized, Placebo-Controlled Study. Front Physiol. 2021 Nov 25;12:777874. doi: 10.3389/fphys.2021.777874. PMID: 34899398; PMCID: PMC8656237.

Pink, Brown, and White Noise for Sleep

Posted on April 21, 2025 by IntraBalance - Sleep Health

As always, it's essential to make personalized recommendations and to “look under the hood” to see what else might be going on with your patient’s sleep.

This question came up twice this week – once in my insomnia group program, and again in a patient visit:

“Does white noise help with sleep?”

During sleep, the auditory system remains active and the brain continues to process environmental sounds.

When I was living in downtown Chicago, there was constant background noise, which can disrupt sleep.

Nowadays there are tons of apps, YouTube videos, noise machines, and other devices providing auditory stimulation (like white, pink, and brown noise, binaural tones, etc.)
to block noise and promote sleep.

First of all, what are white, pink, and brown noise?

White noise is often used to mask sounds in the environment. Examples include radio static or a whirring fan.

Pink noise is thought to be more pleasant than white noise. Examples include steady rainfall or gentle ocean waves.

Brown noise involves lower frequencies than white or pink noise. Examples include thunder or crashing waves.

Do they help with sleep?

White noise is quite popular – in fact, I have a white noise machine on right now while I’m working. However studies on sleep show mixed results.

Less than a third of research on white noise demonstrates positive effects on sleep quality. (1)

Some studies even suggest white noise could potentially have negative effects on brain function and cognition, more evidence is needed.

Pink noise has been suggested as a potentially more effective alternative to white noise, though research is still limited.
It may improve sleep quality for some individuals, but, like white noise, the rigor of studies on pink noise remains weak.
Brown noise has also gained attention as a sleep aid. While it’s less studied than white and pink noise, some people report that the deeper tones of brown noise help them sleep more soundly.

As with the other types, more research is needed to conclusively determine its effectiveness.

It’s also possible that listening to the same thing each night can trigger a conditioned response, where people associate the noise with falling asleep.

Interestingly, hospital settings have begun experimenting with audio interventions to improve sleep for patients.

When I was in residency, they used to play classical music on the general medical floor and I found it calming as a sleep-deprived resident. But it was only played during the day.
Given the noise-sensitive environments in many hospitals, noise reduction strategies paired with audio interventions may help improve sleep quality in these settings.

Is it safe?

There’s no strong evidence to suggest that audio interventions like white, pink, or brown noise are harmful when used short-term.

In fact, they may be a good option for patients struggling to sleep in noisy environments.
A small study done in NYC found that white noise significantly improved sleep latency and reduced wake after sleep onset (WASO) in people exposed to high levels of environmental noise. (2)

However, like a Pavlovian response, people may inadvertently condition themselves to rely on the sounds, potentially making it difficult for them to sleep without them.

There are also potential concerns about not allowing the auditory system to switch off, rest, and repair overnight.

Continuous exposure to high levels of white noise could potentially lead to hearing damage. White noise machines can sometimes hit unsafe noise levels, especially if they’re turned up too loud. (3)

Another study indicated that prolonged exposure to white noise can induce maladaptive changes in the brain, potentially impacting neurological health and cognition. (4)

Back to sleep, some studies suggest that continuous noise may actually disrupt sleep. (1)

Bottom line

The evidence is still inconclusive, but this area of sleep science is evolving.

If patients ask you about this, here are considerations:

Mixed Effectiveness: Research on white, pink, and brown noise for sleep shows mixed results, with some studies reporting benefits and others showing limited or no effect.
Conditioned Response: Regular use of noise for sleep may create a dependency, making it harder to sleep without it.
Safety Concerns: Long-term exposure to high volumes of background noise may cause hearing damage.

How I guide my patients: I wouldn’t recommend using white, pink, or brown noise continuously.

However, if it helps them wind down and fall asleep, using it for a set time at night could be helpful. And of course, be mindful of the volume and risks of hearing loss.

As always, it’s essential to make personalized recommendations and to “look under the hood” to see what else might be going on with your patient’s sleep.

References

(1) Riedy SM, Smith MG, Rocha S, Basner M. Noise as a sleep aid: A systematic review. Sleep Med Rev. 2021 Feb;55:101385. doi: 10.1016/j.smrv.2020.101385. Epub 2020 Sep 9. PMID: 33007706.

(2) Ebben MR, Yan P, Krieger AC. The effects of white noise on sleep and duration in individuals living in a high noise environment in New York City. Sleep Med. 2021 Jul;83:256-259. doi: 10.1016/j.sleep.2021.03.031. Epub 2021 Apr 6. PMID: 34049045.

(3) De Jong RW, Davis GS, Chelf CJ, Marinelli JP, Erbele ID, Bowe SN. Continuous white noise exposure during sleep and childhood development: A scoping review. Sleep Med. 2024 Jul;119:88-94. doi: 10.1016/j.sleep.2024.04.006. Epub 2024 Apr 16. PMID: 38663282.

(4) Attarha M, Bigelow J, Merzenich MM. Unintended Consequences of White Noise Therapy for Tinnitus-Otolaryngology’s Cobra Effect: A Review. JAMA Otolaryngol Head Neck Surg. 2018 Oct 1;144(10):938-943. doi: 10.1001/jamaoto.2018.1856. PMID: 30178067.

The RISE-UP protocol

Posted on January 21, 2025 by IntraBalance - Sleep Health

Over the Christmas break, I found this gem of a book at my mum’s house: The Book of Negroes by Lawrence Hill.

It won a ton of awards including the CBC Radio’s Canada Reads competition and the Commonwealth Prize for Best Book.

It came out in 2007 but somehow I hadn’t read it until now. It’s a story about a virtually unknown chapter of history…and so compelling. There are also loads of quotes about sleep. Highly recommended.

Now, I found myself staying up to read way past my bedtime for a few nights…leading to heavy sleep inertia in the morning.

Sleep inertia is the groggy, disoriented feeling people may experience after waking up, making it hard to feel alert and get going.

Whenever patients struggle with sleep inertia, I recommend they try the RISE-UP protocol.

The RISE-UP protocol is a behavioral intervention designed to reduce the duration and severity of sleep inertia, especially in people with insomnia and bipolar disorder (1).

Here’s what it stands for:

R = Refrain from snoozing: Avoid the use of the snooze button to prevent fragmented sleep
I = Increase activity: Engage in physical activity within an hour of waking to boost alertness
S = Shower or splash your face and hands with cold water
E = Expose yourself to sunlight: Get morning bright light with sunshine or a light therapy device
U = Upbeat music: listen to upbeat music, a podcast or audiobook while moving around
P = Phone a friend: any kind of social contact counts, even a chat with your housemate

I share this protocol with patients all the time, as so many of them struggle with sleep inertia and irregular wake up times.

You don’t have to do all the things in the protocol, but pick a few to try out…and, if you struggle with sleep inertia yourself, let me know how it goes.

Did you learn something today? Click here to find out how Learner+ can help you meet your evolving educational goals.

References
Kaplan KA, Talavera DC, Harvey AG. Rise and shine: A treatment experiment testing a morning routine to decrease subjective sleep inertia in insomnia and bipolar disorder. Behav Res Ther. 2018 Dec;111:106-112. doi: 10.1016/j.brat.2018.10.009. Epub 2018 Oct 27. PMID: 30399503.

How to use melatonin ER

Posted on December 20, 2024 by IntraBalance - Sleep Health

I was recently on a podcast hosted by a physician who asked me, “Is melatonin ER (extended release) a thing? I asked in a physician Facebook group and some docs said there’s no use for it.”

I was surprised…yet not surprised.

There are so many misconceptions in the medical community about melatonin and how to use it.

That’s because most of us docs don’t learn how to prescribe it effectively.

Plus, here in the States, it’s OTC (over the counter), so loads of patients take melatonin like a daily multivitamin without really understanding how it works.

It’s now the 4th most popular natural product taken by adults and the 2nd most popular product taken by children in the US.

Melatonin is a hormone produced by the pineal gland in response to darkness.

It’s also known as “the hormone of darkness” and is involved in regulating the sleep-wake cycle.

It exerts its effects through high-affinity G-protein coupled receptors, MT1 and MT2, which are distributed in various brain regions involved in sleep regulation.

Additionally, melatonin can advance the circadian timing of sleep (i.e. help people shift their body clock to fall asleep and wake up earlier).

In fact, we use melatonin strategically in my practice mostly as a body clock regulator to modulate the circadian rhythm, rather than as a sleep aid.

While it’s not indicated for chronic insomnia, melatonin is recommended for sleep issues including but not limited to:

Circadian rhythm sleep disorders, like delayed sleep phase syndrome, jet lag, etc.
Children with neurological conditions like autism and ADHD
REM sleep behavior disorder

Now, what about melatonin ER (extended release)?

There’s a form of melatonin supplements called Circadin.

Circadian is a 2mg extended release melatonin formulation designed to mimic the endogenous pattern of melatonin production.

It’s primarily indicated for the treatment of primary insomnia characterized by poor sleep quality in patients aged 55 years and older.

Now, I said earlier that melatonin is not typically used for chronic insomnia.

However, endogenous melatonin secretion decreases with age, thus melatonin may be helpful in patients over 55.

Circadin is available by prescription in the UK and Australia.

If you’re in the US, you may be surprised to know that in many regions around the world, melatonin is considered a medication and is not available OTC.

In my practice, we do sometimes use extended release melatonin 2mg in our patients over the age of 55 to support sleep, taken 1-2 hours before bed.

So, my answer on the podcast was, “Yes, melatonin ER is a thing.”

But with melatonin, you have to know how to use it effectively…which includes understanding the indications, timing, dosing strategies, quality considerations, and when to stop it.

If you’re ready to use melatonin effectively in your clinical practice, register for the Melatonin Best Practices Masterclass. https://members.intrabalance.com/melatonin-masterclass

It’s a self-guided program where you’ll leave with the knowledge and tools to use melatonin strategically in your practice and enhance patient outcomes.

Sign up here. https://members.intrabalance.com/melatonin-masterclass

References:
Chua HM, Hauet Richer N, Swedrowska M, Ingham S, Tomlin S, Forbes B. Dissolution of Intact, Divided and Crushed Circadin Tablets: Prolonged vs. Immediate Release of Melatonin. Pharmaceutics. 2016 Jan 7;8(1):2. doi: 10.3390/pharmaceutics8010002. PMID: 26751472; PMCID: PMC4810078.

Lemoine P, Zisapel N. Prolonged-release formulation of melatonin (Circadin) for the treatment of insomnia. Expert Opin Pharmacother. 2012 Apr;13(6):895-905. doi: 10.1517/14656566.2012.667076. Epub 2012 Mar 19. PMID: 22429105.

Verma AK, Khan MI, Ashfaq F, Rizvi SI. Crosstalk Between Aging, Circadian Rhythm, and Melatonin. Rejuvenation Res. 2023 Dec;26(6):229-241. doi: 10.1089/rej.2023.0047. Epub 2023 Dec 4. PMID: 37847148.

Mommy Wine Culture and Sleep

Posted on December 13, 2024 by IntraBalance - Sleep Health

My local TJ Maxx is filled with Christmasy “word art” – for example, coffee mugs with phrases like “This is probably wine”, or throw pillows embroidered with “Mommy Needs Merlot.”

It might seem playful, but it subtly reinforces the normalization of using alcohol to cope with stress.

This is known as “mommy wine culture”…and many of your patients may unknowingly be caught in it.

As clinicians, we’re no strangers to the cultural normalization of alcohol as a stress-reliever, including for parents navigating the demands of family life.

However, it’s quite problematic on many levels.

“Mommy wine culture” normalizes unhealthy coping mechanisms and can make it harder for people to recognize the broader impact alcohol has on their mental and physical health – including issues with disrupted sleep, increased anxiety and depression, and a higher risk of dependency.

For patients struggling with chronic stress or burnout, this can perpetuate cycles of exhaustion, poor quality sleep, and poor self-care.

People sometimes ask me if alcohol is really all that bad for sleep, because they feel like it helps them relax and fall asleep more quickly.

While alcohol is sedating, its physiological effects on sleep are far from benign.

Addressing alcohol use is a crucial step in optimizing sleep health for your patients.

3 Things to Know about Alcohol and Sleep

Initial Sedation but Poor Sleep Quality:

Alcohol reduces sleep latency (time to fall asleep), which may seem beneficial at first, but it suppresses REM sleep.
Patients may report feeling unrefreshed even after a full night’s rest.

Disrupted Sleep Architecture:

Alcohol increases slow-wave sleep early in the night but causes a rebound in lighter sleep and awakenings in the second half.
This fragmentation worsens with higher doses.

Exacerbation of Sleep Disorders:

Alcohol can worsen conditions such as insomnia, sleep apnea, and restless leg syndrome, creating a vicious cycle.

3 Tips for Addressing Alcohol, Sleep and “Mommy Wine Culture”

Ask Targeted Questions:

Move beyond general alcohol use inquiries to explore timing, quantity, and the perceived relationship between alcohol and sleep. Examples: “How often do you use alcohol to wind down at night?” and “How does it impact your sleep quality and daytime energy?”

Educate with Empathy: Many people are unaware of the link between alcohol and sleep disruption. Share how even small amounts of alcohol affect sleep stages and quality.

Suggest Substitutes: Recommend alternative evening routines, such as non-alcoholic cocktails (hint – ask ChatGPT for a virgin mojito recipe), herbal teas, or activities without alcohol, to transition away from alcohol use and have other things to look forward to.

Next steps: Encourage people to experiment with reducing or eliminating alcohol for a trial period (i.e. 30 days) and track changes in their sleep using wearables or sleep diaries.
Wishing you a safe and healthy holiday season!

3 Ways Yoga Can Improve Mental Health

Posted on March 31, 2021 by IntraBalance - Yoga

This year’s World Mental Health Day, recognized on October 10, comes at a time when depression rates are tripling and there’s a looming mental health crisis on the horizon. We’ve all been affected by the COVID-19 pandemic in one way or another, and many of us are feeling stressed and overwhelmed.

While the emotional toll of the pandemic is causing an increased demand for mental health services, limited access to treatment is a huge problem.

It’s high time that the mental health conversation goes mainstream and we find effective solutions that don’t rely solely on access to healthcare services.

Conventional psychiatric treatments like medications and talk therapy typically address symptoms only from the “head up”. However, research shows that a full body approach that incorporates exercise, nutrition, and mind-body practices like yoga into treatment is most effective.

As a practicing psychiatrist and sleep specialist, yoga has become an integral tool in my toolkit.

Now, when I say “yoga”, it may conjure up images of twisting your body into pretzel-like poses while outfitted in figure-hugging lycra. However, yoga is more than just a physical exercise.

The word yoga comes from Sanskrit and literally means “yoke” or “union”. It’s a complete system that includes physical postures (asanas), breathing practices, and meditation.

Ironically, it’s when I was training to become a psychiatrist that my feelings of burn-out hit the roof. I was exhausted, disillusioned, and looking for a solution. At that point, I was introduced to kriya yoga, which is a type of breathing-based yoga practice, and I noticed a difference almost immediately.

Although the external situations hadn’t changed, with my consistent yoga practice, things just felt easier.

The great thing about yoga is that it’s effective for reducing stress and is accessible to everyone. This is something we all need during this unprecedented time.

Here are 3 ways yoga can help with mental health

1. Yoga can alleviate depression in people who haven’t responded to antidepressants.

A study on breathing-based yoga done through the University of Pennsylvania showed reductions in depression and anxiety scores after only 8 weeks of practice in people with major depressive disorder (MDD) who continued to feel depressed on antidepressant medications (1).

2. Yoga improves physiological markers of stress like heart rate variability (HRV) and blood pressure.

Heart rate variability (HRV) is an indicator of how well your body handles stress. A high HRV usually indicates better health, better physical fitness, and an increased ability to handle stress. Yoga helps to increase HRV and is an effective way to reduce negative emotions and reduce stress in people living under high stress situations — which is most of us at this moment in time(2)!

A study of college students showed that practicing meditation for 3 months reduced blood pressure, psychological distress, anxiety, depression, anger/hostility, and improved their ability to cope with stress(3).

3. Practicing yoga from the safety of your home is effective, and you can still reap the benefits you’d get from going to a yoga studio!

Participants in a tele-yoga program offered during the pandemic in April 2020 reported improved energy, increased mental relaxation and calmness, feeling more refreshed, and concentrating better after just 4 weeks of practicing yoga at home through guided videos⁴. The best part is that you can do this in your pj’s, no Lululemon yoga pants required.

These mind-body tools are effective, safe, and available to everyone regardless of age, health status, and access to healthcare services.

Not sure where to begin? Here’s a free resource to get you started, whether you want to try a guided meditation or a simple, 5-minute physical yoga practice. Click here to get started.

References:
1. Sharma A, Barrett MS, Cucchiara AJ, Gooneratne NS, Thase ME. A Breathing-Based Meditation Intervention for Patients With Major Depressive Disorder Following Inadequate Response to Antidepressants: A Randomized Pilot Study. J Clin Psychiatry. 2017 Jan;78(1):e59-e63.

2. Zou L, Sasaki JE, Wei GX, et al. Effects of Mind⁻Body Exercises (Tai Chi/Yoga) on Heart Rate Variability Parameters and Perceived Stress: A Systematic Review with Meta-Analysis of Randomized Controlled Trials. J Clin Med. 2018;7(11):404. Published 2018 Oct 31.

3. Sanford I. Nidich, Maxwell V. Rainforth, David A.F. Haaga, John Hagelin, John W. Salerno, Fred Travis, Melissa Tanner, Carolyn Gaylord-King, Sarina Grosswald, Robert H. Schneider, A Randomized Controlled Trial on Effects of the Transcendental Meditation Program on Blood Pressure, Psychological Distress, and Coping in Young Adults, American Journal of Hypertension, Volume 22, Issue 12, December 2009, Pages 1326–1331

4. Jasti N, Bhargav H, George S, Varambally S, Gangadhar BN. Tele-yoga for stress management: Need of the hour during the COVID-19 pandemic and beyond? [published online ahead of print, 2020 Aug 2]. Asian J Psychiatr. 2020;54:102334.

5 Easy Breathing Exercises to Try Today (VIDEO)

Posted on September 5, 2020 by IntraBalance - Breathing

Breathing is a really interesting physiological process. Unlike other bodily functions like digestion, breathing may be involuntary (happens automatically without us thinking about it), or voluntary (happens consciously under our control). The way we breathe has a direct impact on the way we feel.

Have you ever noticed what your breathing is like under different circumstances?

You may have noticed that when you’re stressed out, your breathing is more rapid, that your breaths are more shallow and come from the upper chest. This is how we breathe when our body senses danger.

What about when you’re relaxed, what’s your breathing like then? You may have noticed that in a relaxed state, your breathing is slower, deeper, and comes from the belly. This is how we breathe when we’re comfortable and at ease.

How might you feel if you were breathing like that all the time?

There are a multitude of benefits to practicing breathing exercises, like:

Balancing the sympathetic nervous system (fight or flight) and stimulate the parasympathetic (rest & digest) nervous system
Stimulating the vagus nerve to reduce feelings of anxiety and depression
Promoting a healthy cardiovascular system by reducing the heart rate and blood pressure
Improving immune function and lung function
Reducing insomnia

Here are 5 easy breathing practices to try

1. Start by noticing your breath

Check in with yourself a few times a day, like before you start work, when you sit for a meal, or before you get on a meeting. Take a few seconds to notice your breath. You don’t need to change anything, just notice it. Over time, the act of paying attention to your breath will become automatic and will help you feel more present and mindful.

2. Focus on the exhalation

Oftentimes, when doing breathing exercises, people focus too much on the inhalation and this can actually cause more anxiety. Shifting your focus to a long, slow and complete exhalation will help with relaxation.

3. Box breathing

This is so effective that Navy SEALS are trained to use this technique to help with focus in high pressure situations. How to do this: inhale for a count of 4, hold for a count of 4, exhale for a count of 4, and hold for a count of 4. Do this 4 times.

4. 4-7-8 Breathing

This is another great technique that is very effective at promoting relaxation. Inhale for a count of 4, hold for a count of 7, and exhale for a count of 8. Do this 4 times.

5. Alternate nostril breathing

You may have done this in a yoga class. This is a very effective practice that has tons of research behind it and provides so many benefits for physical and emotional health. There is a specific method to it, so I recommend learning it from a trained yoga teacher or through an instructional video like this one.

Breathing practices are not just for when we’re feeling stressed. Daily practice of breathing exercises can improve your health and performance in your personal and professional life. It’s a free, renewable resource without side effects! Try a few minutes of these breathing exercises every day for the next week and see how it affects your experience of the day.