Catherine Darley, ND, is the director of The Institute of Naturopathic Sleep Medicine in Seattle. She specializes in the treatment of sleep disorders, especially insomnia and circadian-rhythm sleep-wake conditions. Dr. Darley views sleep health as a social-justice issue, and particularly enjoys working with sleep-disadvantaged populations like shift workers and teens. She regularly writes for lay and professional publications, speaks on a wide range of sleep topics, and consults with first-responder agencies.
According to the American Sleep Association, nearly 70 million Americans have a sleep disorder. Insomnia is the most common sleep condition, with 30 percent of adults experiencing short-term insomnia and 10 percent reporting longer-term issues.
Sleep disorders are not only pervasive, but also troubling. Lack of sleep leaves people exhausted, unfocused and moody. It affects relationships and performance at school and work. Sleep disorders increase the risk of accidents, mental health disorders, and medical conditions such as obesity, diabetes, and heart disease.
Helping patients overcome sleep difficulties is no easy task. That’s why we’re sharing expert advice from sleep specialist Catherine Darley, ND. In this interview with Element Senior Writer Sarah Cook, ND, Dr. Darley offers practical guidance for clinicians based on her extensive work in natural approaches to sleep health.
SARAH COOK: What’s the current scope of sleep problems in America?
CATHERINE DARLEY: Even in usual times, as many as one-third of Americans experience occasional sleep problems. Over the last year, we’ve seen a spike in sleep disorders. Most of the evidence is anecdotal, but a report from June 2020 showed markedly increased rates of insomnia.
There are a lot of reasons why sleep problems might be increasing. When people feel worried or unsafe, they can’t sleep. That starts a vicious cycle in which the lack of sleep intensifies worry and causes ongoing sleep disruptions.
Other situational factors that may be worsening people’s sleep include irregular schedules, sporadic eating patterns, increased alcohol consumption, social isolation, checking the news before bed, and rampant worry.
COOK: What are the stages of healthy sleep?
DARLEY: Sleep progresses through a series of stages, each of which is marked by different brain-wave patterns. The category non-rapid eye movement (NREM) goes from stage 1 to stage 3. Rapid eye movement (REM) or active sleep is the other category.
NREM stage 1 sleep is the transition period as we fall asleep, and lasts only about five to 10 minutes. NREM stage 2 is when the brain starts to produce bursts of rhythmic brain-wave activity called sleep spindles. These are thought to play a role in memory consolidation and learning. People spend about 50 percent of their total sleep time in stage 2.
NREM stage 3 is deep sleep. Brain waves are high amplitude and very slow. If your alarm goes off while you’re in deep sleep, you feel groggy and have a hard time waking up. Stage 3 is also when 75 percent of growth hormone is secreted. With advancing age, people tend to have reduced deep sleep, reduced growth hormone secretion, and a sensation of light sleep.
REM sleep is when the brain becomes active, but the muscles become relaxed and immobilized. This is when dreams occur. We ideally spend about 25 percent of our night in REM sleep.
COOK: What are the most common sleep disorders?
DARLEY: What a lot of people don’t realize is that there are six categories of sleep disorders and 59 sleep disorders in total.
Insomnia, which is the most common sleep disorder, involves the inability to fall asleep or stay asleep. Insomnia can affect people transiently for a few nights at a time, intermittently, or persistently on a regular basis.
Other sleep disorders include sleep apnea, restless-leg syndrome, and narcolepsy. Parasomnias are a class of sleep disorders that involve abnormal behaviors during sleep, like sleepwalking or nightmares. Children can also have sleep disorders such as obstructive sleep apnea or restless-leg syndrome, so be sure to screen for that.
Even in the absence of a diagnosable sleep disorder, many people don’t get enough sleep for their health. Most adults require at least seven hours of sleep per night, and teens require eight to 10 hours. Anyone who gets less than that on a regular basis can become sleep deprived and diagnosed with insufficient-sleep syndrome. We think that’s close tohalf of the population.
For some people, insufficient sleep is unavoidable. They may need to work two jobs to make ends meet, or stay awake to care for a family member. For other people, sleep deprivation is a choice. They’re prioritizing other activities and not giving themselves enough time to sleep.
Being able to differentiate among the many sleep disorders is essential for recommending appropriate treatment. We can’t get resolution without knowing the cause. If you’re a practitioner and don’t feel qualified to differentiate among the sleep disorders, you can refer to a specialist.
COOK: In addition to diagnosable sleep disorders, what additional conditions should be considered when a patient has sleep problems?
DARLEY: I always take a naturopathic approach to look for the root cause. There can be conditions that coexist with or aggravate sleep issues. Anxiety is a good example. Stress is also commonly associated with sleep troubles, so I look at adrenal health.
Food sensitivities and histamine intolerance can be other factors that interfere with sleep. Anecdotally from my practice, I can say that histamine intolerance may be contributing to sleep difficulties when there are also elements of heat and restlessness.
COOK: How do sleep issues affect mental health, and vice versa?
DARLEY: I don’t think it will come as any surprise that there’s a bidirectional link between sleep problems and mental health issues like anxiety and depression.
And it’s not only insomnia that is a problem. Obstructive sleep apnea can also contribute to depression. People with attention deficit and hyperactivity disorder (ADHD) have higher rates of obstructive sleep apnea and restless-leg syndrome. Narcolepsy is connected with depression.
Insomnia is considered an independent risk factor for suicide across all ages. Nightmares are specifically linked with suicides, so it’s important to screen for suicide risk in any patient who’s reporting nightmares.
COOK: Is it unhealthy to stay up late?
DARLEY: Some people have what’s called delayed sleep phase syndrome. Their circadian rhythm is shifted later than the norm, so it feels natural for them to fall asleep between 1 a.m. and 5 a.m. The problem occurs when they try to force themselves to go to bed early, knowing they need to wake up in the morning for work or school.
When they try to go to bed at a more typical time, like 10 p.m., they can’t fall asleep. They experience it as insomnia, when in fact they’re just going to bed earlier than when their body is physiologically sleepy. We think about 10 percent of people who are labeled as having chronic insomnia actually have delayed sleep phase syndrome.
The way to tell the difference between insomnia and delayed sleep phase syndrome is that a person with delayed sleep phase syndrome sleeps just fine if they go to bed late. When they fall asleep, they sleep well. They only have trouble sleeping when they go to bed early.
You asked if it’s unhealthy to stay up late. Not necessarily. Delayed sleep phase syndrome isn’t inherently problematic. The problem occurs when people aren’t able to sleep according to their natural rhythm because of schedules and commitments. This is especially a problem for teenagers with early school start times. There’s a negative bias against staying up late, and people are shamed. The reality is that a range of sleep rhythms can be healthy.
If you look at humans on any scale, they’re often on a bell curve. You have people on the short end and the long end. For example, there’s an interesting study that looked at sleep in a small pre-industrial village. They monitored all of the adults for a month. There were only 17 minutes when the entire village was asleep. We think that having different sleep rhythms serves as an evolutionary safety mechanism for the group.
COOK: What behavioral changes do you recommend for better sleep?
DARLEY: The place to start is by strengthening the circadian rhythm. I do this with natural exposure to sunlight: 20 minutes in the morning and 10-minute bursts every couple of hours throughout the day. Then we dim the lights in the evening. Think about the type of lighting people were exposed to 250 years ago. They worked outside all day in the sunlight and had only candlelight in the home at night.
Although it’s impractical for people to live by candlelight every night, I do recommend they spend two hours before bed in dim light. Many experts recommend only one hour of dim light before bed, but ideally, we should have two.
Melatonin will gradually rise during this time, but it’s depressed if someone is looking at light coming off screens. If people need to use electronics at night, I recommend they use blue light–blocking glasses that wrap around the eye area to block light from all angles.
Even though patients have heard the recommendation to turn off screens and dim the lights at night, few of them actually do it. You’ll be surprised to see how well it works—often in as little as two days.
Another way to make the circadian rhythm more robust is to stick with consistent habits throughout the day. Eat, be active, and schedule social interactions at the same time every day. If a person lives alone, have them schedule a phone call or online chat with a friend at the same time every day. This routine helps train the body to respond to a rhythm.
In addition to supporting a healthy circadian rhythm, I look at optimizing the bedroom for sleep. If people need to work in their bedroom during the day, cover the desk with a decorative tablecloth at night or separate that area of the room with a divider. Find a way to make the bedroom a sacred place for sleep. If a child does homework in the bedroom, it’s better to do it on a pillow or beanbag on the floor than on the bed.
Lastly, I encourage my patients to cognitively wind down at night. When people feel stressed, they tend to jump into bed without calming down first. It’s better to relax before climbing into bed. Different people need different amounts of time to transition, but I recommend engaging in an activity that’s relaxing and not task-oriented before bedtime.
COOK: Is there a foundational protocol of supplements you’ve found to be most reliable to support sleep in adults?
DARLEY: There isn’t one, single protocol, because we need to choose supplements based on the clinical picture. But there are four supplements I consider first: glycine, l-theanine, phosphatidylserine, and melatonin.
I start with one supplement at a time, and only change that or add other supplements if we don’t get satisfactory results. Let’s look at why I would choose one supplement over another.
Glycine is a calming amino acid that also helps depress a person’s core body temperature. As the body temperature drops, the person feels sleepier and sleeps more deeply. That’s good for people who have a sense of light sleep or struggle with sleep as they get older.
L-theanine is what I recommend when occasional anxiety accompanies sleep concerns. L-theanine is also useful for children, especially boys who struggle with both healthy attention and sleep.
Phosphatidylserine is the supplement I choose when we want to support healthy sleep in somebody who has stress during the day. It supports the healthy release of cortisol on the natural circadian rhythm.
Then there’s melatonin, which is very commonly used. But it’s not the first supplement I recommend. There are three different ways to use melatonin.
For people who struggle to fall asleep, melatonin can be taken about 30 minutes before bedtime. The amount to take depends on the person, but there’s no evidence that amounts any higher than 5 mg provide additional benefit.
For people who wake up in the night and struggle to fall asleep, melatonin can be taken before bedtime in a time-release form.
The third way to use melatonin is for people who tend to go to bed late and need to reset their circadian rhythm to fall asleep at an earlier time. In this situation, melatonin can be taken in a very small amount (0.3 to 0.5 mg) five to six hours before bedtime. In combination with morning exposure to light, this will gradually shift the body clock earlier. But the timing of taking the melatonin needs to be precise and systematic. If a practitioner is going to recommend this to patients, I suggest they fully consider the correct preparation and timing.
COOK: How do your supplement recommendations differ for children?
DARLEY: I recommend similar supplements, but lower intakes. I also advise caution with melatonin.
There’s not much research on the use of melatonin in children, but animal studies suggest there may be some concern because of the influence of melatonin on reproductive hormones and development. If I do recommend melatonin for children or teens, I use it only for two to three weeks while implementing light exposure and other behavioral changes to support a healthy sleep pattern.
The behavioral piece is extremely important for children. They need to have a consistent home routine and predictable bedtimes. There needs to be a sequence of events that always precedes bedtime so their bodies become programmed for sleep.
COOK: One of your specialties is family sleep plans. What are those?
DARLEY: When a child is sleeping poorly, it affects the entire family. Parents become deprived of sleep and become anxious or angry. They can’t constructively support the child with consistent expectations and routines. That’s why I create a family sleep plan that loops in the parents and the children.
First, we have to honor the fact that people of different ages have different biorhythms. Small children might wake up at 5 a.m., whereas a teenaged sibling might stay awake until midnight. Kids of all ages need parenting, so it becomes quite a balancing act.
One parent may need to wake up early with the smaller child, and the other parent stays up late with the older child. We also need to factor in time for couples to be intimate or to have time to themselves. My goal with a family sleep plan is to strike a balance that meets everybody’s needs.
COOK: Do you have any final words of advice?
DARLEY: Sleep problems are so prevalent and can have such an effect on other areas of health, that we all need to include questions about sleep as part of any patient intake.
We also need to address sleep in every treatment plan, even if it’s not a primary complaint. Whether a person is looking for blood-sugar support or mood support or pain management, we always need to address sleep. If you already ask about diet and exercise, sleep needs to be added as the third leg of the foundation of health.
Sleep Needs By Age
Age/Hours of sleep needed per 24 hours
4-12 months - 12-16 hours (including naps)
1-2 years - 11-14 hours (including naps)
3-5 years - 10-13 hours (including naps)
6-12 years - 9-12 hours
13-18 years - 8-10 hours
Older than 18 - 7-9 hours
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