pigeon 3.13.18 - 3 14 18, 9.36 am page 1 of 27 transcript...

Pigeon 3.13.18 - 3 14 18, 9.36 AM

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Rob Bossarte: Welcome to [Oomf 00:00:06]. Oomf is an informal discussion with entry-control researchers to help our listeners think about injury prevention in a brand-new way. I'm Rob Bossarte, Director of the West Virginia Injury Control Research Center, and I'm joined today by Cara Stokes, epidemiology PhD student, Dr. Dan Shook, Director of the Greater Morgantown WVU Safe Communities Coalition, and our special guest on our inaugural edition, Dr. Wil Pigeon from the VISN 2 Center of Excellence for Suicide Prevention in beautiful Canandaigua, New York. Welcome, Wil.

Wil Pigeon: Thank you. Great to be here.

Rob Bossarte: Before we begin, we'd like to invite you to tell us a little bit about yourself and then we'll talk a little bit about your research and then we have some questions for you.

Wil Pigeon: Very good. I've been doing sleep research for about 15 years, and about 10 years ago began to be interested in ways that sleep is associated with all manner of health conditions, health problems, and then potentially its reverse, but helping others recover ... Oh my God, are we live? How's it going so far? [crosstalk 00:01:18] great?

Rob Bossarte: I like that.

Dan Shook: Well okay, he's into it.

Rob Bossarte: Yeah, yeah, that's good.

Wil Pigeon: That's great.

Cara Stokes: We are great. [crosstalk 00:01:25]

Dan Shook: We're broadcasting in about a three-block area here.

Rob Bossarte: We were actually going to get to that later. What I would like to know or have people know about you is just something about yourself. I mean how did you end up doing research, and sleep research, and what do you do? I know, for example, you live on a farm.

Wil Pigeon: I do live on a farm, Rob.

Rob Bossarte: You have sheep.

Wil Pigeon: I have sheep.

Rob Bossarte: And little baby lambs, with the last time that I saw you, which was a couple weeks ago, a sheep had twin lambs?

Wil Pigeon: That's right. We were having dinner and my wife was texting me. I had to excuse

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myself because she was panicking and wondering if she needed to do anything and the answer was no, and-

Rob Bossarte: One of the lambs was being neglected.

Wil Pigeon: One of the lambs was being neglected.

Cara Stokes: Are they considered twins, or do they normally only have one, or is this a weird thing where they had two?

Wil Pigeon: They often have twins, yeah.

Rob Bossarte: Really?

Wil Pigeon: Yeah.

Rob Bossarte: Are they both okay?

Wil Pigeon: Both okay, so we had twin little baby black boy lambs and last night we had a twin white baby girl lamb. We have black sheep, white sheep-


Wil Pigeon: Which is very cool.

Rob Bossarte: They're not all just one color when they come out? There are different color sheep?

Wil Pigeon: There are, depending on what color the parents were, somewhere in the lineage.

Rob Bossarte: See what I learned today? How do you go from being a farmer-

Wil Pigeon: Exactly-

Rob Bossarte: To a sleep researcher?

Wil Pigeon: Let me tell you. I grew up as a farmer. My dad is a third-generation dairy farmer and I did not make it to the fourth generation. I have the farming in my blood and that's from, I was in northern Vermont for my entire childhood. I'm the third Wilfred also, which is very-

Cara Stokes: Ah, my husband's a third-

Rob Bossarte: In a row?

Wil Pigeon: Yeah, third Wilfred in a row.

Cara Stokes: Bill's a third.


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Wil Pigeon: I told my wife when I met her that there wouldn't be a fourth. Rob, I was in grad

school and I needed a job. I was writing a paper in the med school library and there was a handwritten job posting. "Wanted, sleep technician, work overnight, three 12-hour shifts," and I thought, "Perfect, I can work on my papers while I'm working at night."

I ended up working in a sleep lab as a sleep technician while I was a grad school student. The first night I was there, I was observing EEG activity over the monitor. I was seeing eye movements and brain-wave activity, and at about two o'clock in the morning, I saw running live across the screen, eye channels, the eye-movement channels going crazy. It was rapid-eye movement. This person had entered REM sleep, and I could see that the eyes were moving because they were being recorded, and it was on the monitor, and I was seeing REM sleep.

What was amazing to me was there's a person 20 feet away from me in a bedroom who has just gone from non-REM sleep which, into a third-state of conscious existence, which is REM sleep. I was watching the physical, the digital manifestation of that go across the screen at the same time-

Rob Bossarte: I was going to ask-

Wil Pigeon: I fell in love with sleep, right there.

Rob Bossarte: I would too-

Cara Stokes: That was it-

Rob Bossarte: The way you put it. [crosstalk 00:04:38] exciting.

Wil Pigeon: It was so cool.

Rob Bossarte: What is REM sleep? I've heard of REM sleep [crosstalk 00:04:42].

Wil Pigeon: First, great name for a band, right?

Rob Bossarte: Right.

Wil Pigeon: REM was awesome.

Rob Bossarte: Still is.

Wil Pigeon: REM sleep stands for rapid eye movement, which is discerned from non-REM sleep by the fact that it's REM and not non-REM. There's some brilliant labeling in sleep. There are four stages of sleep and they're labeled one, two, three, and four.

Rob Bossarte: Smart.


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Wil Pigeon: Very good. Can't mix that up.

Rob Bossarte: No.

Wil Pigeon: Then [crosstalk 00:05:13] REM sleep is another stage. Interestingly, the first EEG-

Rob Bossarte: Do you always go through all four stages before you get to REM, so you'd have to-

Wil Pigeon: Typically, yeah, typically [crosstalk 00:05:24] yeah. You cycle through, three or four

times a night. Take for a normal person before they reach REM sleep, 80 to 100 minutes into the night. Then we'll cycle through most of the stages every hour and a half or so, so there's an ultradian rhythm to the stages of sleep.

Rob Bossarte: A what?

Wil Pigeon: The stages of sleep. Ultradian, so circadian, circadian 24 hours, and this other cool term that I also learned when I was first studying sleep, ultradian, which means something other than circadian. Instead of within 24 hours-

Rob Bossarte: Shorter?

Wil Pigeon: It's shorter, yeah.

Rob Bossarte: Do you need all four stages of sleep and the REM sleep to feel rested in the morning? Is that why getting up several times a night, you feel like you're completely shot in the morning?

Wil Pigeon: Yeah, so there are a number of reasons you can feel completely shot in the morning. I understand that you guys go out at night sometimes and stay out late and imbibe in-

Rob Bossarte: Not me, [inaudible 00:06:18]-

Wil Pigeon: Beverages. That could be the reason, but if it's related to sleep, some other reasons could be that yeah, you're not getting the good stuff. There are two kinds of good stuff where there's back to sleep. There's deep sleep, which people use euphemistically, and that's the stages three and four of sleep. It is also named slow-wave sleep. Here we wanted to get things confusing. For the same exact [crosstalk 00:06:49], that's good, okay, good.

Cara Stokes: I'm taking notes.

Wil Pigeon: Stage three sleep-

Cara Stokes: I'm literally a student, taking notes-


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Rob Bossarte: Yeah good, all right-

Wil Pigeon: This is on the boards. Stage three sleep equals slow-wave sleep, equals deep sleep.

Rob Bossarte: Is that when you feel rested?

Wil Pigeon: Yeah, if you get enough of that and you have to get enough of the REM sleep.

Rob Bossarte: I'm guessing that all sorts of things get in the way of this. Going out and having adult beverages, staying up too late, certain medications, watching-

Wil Pigeon: Age-

Rob Bossarte: Age-

Wil Pigeon: Kids-

Rob Bossarte: Kids-

Wil Pigeon: Pets-

Cara Stokes: Pets-

Wil Pigeon: Having an overactive mind [crosstalk 00:07:22]-

Dan Shook: Rachel Maddow-

Wil Pigeon: Going to the bathroom 18 times during the night, right? When sleep is interrupted, it's a problem for a number of reasons. Sleep is interrupted, but the other reason is for some reason, our brain is built that in order to get to the good stuff, you have to go through the mediocre sleep. If you are awoken out of stage three sleep, out of deep sleep or out of REM sleep, you wake up, you don't go back to where you started. You don't go back to ... You go back to stage one.

Rob Bossarte: You've got to start all over.

Wil Pigeon: Then two, and then you might not get there again for another half an hour or an hour, and if you're woken up repeatedly throughout the night, you hardly ever get to the good stuff. You could sleep for eight hours, and not have enough REM or slow-wave sleep to feel good.

Dan Shook: Welcome to my life. Being a sleep novice, sleep has gotten to be a big issue in my life, and when I don't sleep well during the night I try to get a nap in, and I've noticed over the course of my life if I have a nap that's a certain period of time, I wake up and I feel horrible, I feel sick to my stomach, and I just don't feel well.

What I try to do, is I try to do those 90-minute naps. Try to do this little sleep cycle


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phase that you're talking about, about an hour, an hour and a half. Am I crazy for trying to do that, if I try to take a nap for hour and a half, will I hit those different phases of sleep during my nap to make me feel better when I wake up?

Wil Pigeon: You are a little crazy to do that.

Dan Shook: Thank you.

Wil Pigeon: I'll tell you a couple reasons. First, the reason you're not crazy, you're trying to recover some sleep somehow. To the extent that you're able to do that, that's to the positive, obviously. It's very difficult to get deeper sleep during daylight hours. Our brain is built to sleep more deeply at night.

People who, shift workers are really screwed. If they can possibly get eight hours of sleep during the day, we've been able to show that even if they get eight hours, they don't get as much of the deep stuff, unless they're on that schedule for a long time. You're not going to get as much of the deep stuff. It's also more difficult to get to the REM sleep in an hour and a half during the day than it is at night. You may or may not get it, and we'd have to record you to see.

The other thing that happens, of course, is if you sleep in the afternoon, you're decreasing the likelihood that you're going to fall asleep at the time you want to sleep that night because you've used up some of the sleep juice, right?

Dan Shook: Why are you looking at me?

Rob Bossarte: I'm actually thinking-

Dan Shook: That's true-

Rob Bossarte: I may actually inadvertently be causing you greater sleep problems at night if you're trying to catch up during the day.

Dan Shook: Yeah, I struggle with that.

Wil Pigeon: I don't know if you've experienced this. Some people say if their nap is too long, they feel worse than if they have short nap. Is that what you were saying?

Dan Shook: Oh that's me, yeah.

Wil Pigeon: Yeah, yeah, and so and some people say actually if you go more than half an hour, they start to feel like that. You wake up a little groggier, and that happens so consistently that people call that sleep inertia. Like oh God, you wake up on the couch and you just don't feel like moving, even though you've just had a nice nap.

If one must nap, the recommendation is 20 or 30 minutes [crosstalk 00:10:37], a little quick 20 or 30-minute nap, just a little quick one. [crosstalk 00:10:39]


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Rob Bossarte: If I'm going to nap and I'm all [crosstalk 00:10:39] curled up on the couch, I'm not

getting off that thing.

Wil Pigeon: For how long? For how long?

Rob Bossarte: I don't know, until I'm forced to go eat or-

Wil Pigeon: Or it's tomorrow?

Rob Bossarte: Or it's, right. Tomorrow shows up and it's time to get up and do it again, right.

Dan Shook: You know, again, sleep is such, I mean it's on my mind all the time now because I'm having a real issue with it and because I struggle with it. I go to bed at 8:00, wake up at midnight and 1:00, but this past weekend when we had the time change, I put an article on our web page that talked about the increase of injuries on the Monday after Daylight Savings Time, and I mean maybe this question isn't really related to that, but there is such a thing as a sleep deficit, and if there is, can you ever-

Cara Stokes: Recover from that? Yeah.

Dan Shook: Yeah, yeah.

Wil Pigeon: Wow, two great questions. Is there a sleep deficit? Well of course, right? If I don't sleep well for one night, I don't do as well as I could the next day, as if I had slept a full night. If that goes on for three or four or five nights in a row, that begins to accumulate, and indeed the term, "Sleep debt," has been used fairly broadly to capture this very thing, that people have not enough sleep repeatedly, and they essentially develop a sleep debt.

The second question was, "Well can you pay it back?" Can I, if I only sleep four hours tonight, can I make up, and I need eight, can I get an extra four hours? The answer is yes, to some extent, but how often as adults do we sleep for 12 hours? It's really hard to do.

Yes, you can actually make some of it up. You have it, for some reason there's a very short-term loan. The promissory note on sleep is really brief, it's like seven to 14 days, so you can get it back within a small window, but after that it's gone, and it's done its damage. You'll now die three hours earlier than you otherwise would have because of that sleep loss. That's a made-up fact. [crosstalk 00:12:41]

Rob Bossarte: I was going to say, is that real?

Dan Shook: The most dangerous that can happen to me [crosstalk 00:12:43]-

Cara Stokes: I believed it-


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Dan Shook: Because [crosstalk 00:12:45] of a lack of sleep would be that I would fall out of my chair in the afternoon, but when I worked with the State Patrol in Ohio, some of these younger troopers had three or four different shifts in a matter of a month. I always felt like they had such a job that required, they needed to be at the top of their game to be able to have good reaction time and be able to make good decisions, that putting them in a deficit or into a situation like that, caused them to be at risk of hurting themselves or others, making bad judgments.

Wil Pigeon: Yeah, absolutely, sleep loss has immense consequences. There was an interesting study at Henry Ford some years ago about a researcher named Tim Roehrs, and he and others thought of sleep deprivation as synonymous with getting drunk, having some substance in your system that begins to take away your ability to perform in various measures.

He did a fairly ingenuous study in which he compared what happened when people were sleep deprived for two hours a night, four hours a night, six hours, or an entire night, and how they performed on a number of tasks, and then compared that to the performance of people who were at BACs of .04, .08, .12, point really hammered. People who are sleep deprived for just four hours performed like someone who's right about at the .08 level.

If someone who is completely sleep deprived for an entire 24-hour period, they're just hammered. Think about it. For folks who have done an all-nighter in the recent past, just think how, there are certain points of the next day where how awful do you feel, right? Just awful. If you then go to a lecture, like an 8:00 a.m. or 9:00 a.m. lecture and you're listening to the world's most interesting lecturer, you're nodding off, right? [crosstalk 00:14:46] That's how powerful sleep loss is.

Dan Shook: It's kind of interesting with your husband being a physician, why they have these residency programs, these physicians that work these ungodly hours [crosstalk 00:14:58] making life and death decisions. [crosstalk 00:15:03]

Rob Bossarte: Those people are unable to see who Dan was just referring to, Wil does not have a husband, that was for Karen. [crosstalk 00:15:08]

Dan Shook: That would be okay if he did, but-

Rob Bossarte: Yeah, but the point of reference may be lost, yeah. All this makes perfect sense, but you apply this to suicide, an suicide prevention?

Wil Pigeon: That's a long ways from here to there, isn't it?

Rob Bossarte: I know, yeah.

Wil Pigeon: Yeah.

Rob Bossarte: What does it mean for suicide prevention?


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Wil Pigeon: I think I need to throw a dot out so that we can at least connect the two dots-

Rob Bossarte: Yeah, please-

Wil Pigeon: That you've just asked me to connect and put one in the middle. The other things

that sleep loss impacts are a number of medical and psychiatric conditions. We've just been talking about the effect that poor sleep can have on our day-to-day lives. Over time, poor sleep can begin to have an impact on mood, for instance. A couple weeks of poor sleep, and I'm pretty irritable. What about two years of poor sleep? You're depressed.

At this point, there's years of research and actually even a couple meta-analyses showing that for people who weren't depressed to begin with, if you add a sleep disorder, in anywhere from one to three years, you increase the rate of having first incidence major depression by two to three, by two to three-fold.

Rob Bossarte: I was going to ask, is there a specific amount of time that's required? If you're struggling with sleep for two or three months-

Wil Pigeon: It's hard to say. Yeah, so how long does it need to have an impact? Here we get into individual variance. If someone is very vulnerable, then a little bit of sleep loss is enough. For instance, if you're bipolar, if you have bipolar disorder, and those are the folks who have manic episodes and depressive episodes, but it's latent, it may be you haven't had your first episode yet, have a good bout of sleep deprivation and see what happens. Manic episode.

For some people who are vulnerable, it could be just one brief burst, but for others, over time. That's the middle dot of connecting sleep does bad things to our ability to function, and the middle dot is, and over time, it impacts mental health conditions and physical conditions.

Extended sleep loss can cause hypertension, of all things. It's been associated with increased risks of fill the blank, any number of things. One of the fill the blanks is psychiatric illness, mental illness, depression, and then here we go then, to potential first suicide.

Rob Bossarte: The risk for suicide is primarily through the risk for other psychiatric, or for psychiatric disorders?

Wil Pigeon: Part of it is. Part of it, I think there's both a direct and an indirect route to suicide from sleep. The direct route is I already have enough on my plate, and this is one additional stressor that just makes me not able to cope with the stressors that I already have, that makes me less able to think rationally about decisions that I might make. I think that's the direct route-

Rob Bossarte: That's about decision-making, because if you equate it to being intoxicated and you


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add, you add it to existing stress, and maybe some underlying vulnerability, and now you've got impaired decision-making?

Wil Pigeon: Absolutely. I think that's the perfect example, right? [crosstalk 00:18:27] Extended sleep loss may be like having a buzz on and not thinking very well-

Rob Bossarte: While being under tremendous stress and having other things [crosstalk 00:18:36] going on-

Wil Pigeon: Having life events that just happen or have continued to happen, so it's one more thing. Indeed, sleep loss is negatively impacts decision-making, executive function. Think about even ourselves or think of yourself in episodes when you haven't slept well and it's three o'clock in the morning and you're staring at the clock. The thoughts you have a 3:00 a.m. are really not as rational as thoughts that you have a 3:00 p.m.

Rob Bossarte: That's not normal thought time.

Wil Pigeon: Right?

Rob Bossarte: Oh yeah, no.

Wil Pigeon: You're not thinking well.

Rob Bossarte: That's when I get my best ideas.

Cara Stokes: Best ideas are not normal thoughts?

Dan Shook: You know, making, referring back to shift work, do shift workers tend to have greater incidence of depression or suicide rates than people that work normal-

Rob Bossarte: We know that physicians and residents do, that's a recognized high-risk group-

Cara Stokes: Ah, would we say that's attributed to sleep loss, or maybe a combination of many things?

Wil Pigeon: Hard to tease that [crosstalk 00:19:30] out. Shift workers, I know, have a higher incidence of mood disorders. I don't know about suicide, right, so I don't know. That's a good question.

Rob Bossarte: We'll find out. [crosstalk 00:19:45]

Wil Pigeon: There you go, dissertation number two.

Cara Stokes: Yeah, yeah.

Dan Shook: Is there a, I'm sorry, if you want to jump in go ahead-


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Rob Bossarte: No, please-

Dan Shook: I was thinking about is there a genetic connection between people who have

difficulty sleeping and versus not, and connected to a suicide gene, if there is such a thing?

Wil Pigeon: We've not gotten there. I ain't no genetic researcher, so I don't know.

Rob Bossarte: I think the answer to that's always yes, right? [crosstalk 00:20:19]

Wil Pigeon: There is some work showing that twin studies, that insomnia, for instance, runs in families. I've been talking broadly about sleep loss, sleep disturbance, but there are a number of specific sleep disorders, and I just threw one out, insomnia, inability to fall asleep or stay asleep, and that keeps happening. Those questions with respect to genetics are ... The data shows that there are some ties to specific sleep disorders like insomnia.

Rob, you were on a roll I thought, were you?

Rob Bossarte: It was just by accident [crosstalk 00:20:59]-

Wil Pigeon: I forgot what I was going to say, so I wanted to just take the microphone away from myself [crosstalk 00:21:02]-

Cara Stokes: He was having a 3:00 a.m. thought but it went away [crosstalk 00:21:06].

Rob Bossarte: It was brilliant, I just, it will never come back. I was just trying to piece it all together. It sounds like, of course, an incredibly complex set of conditions and processes that happen that result in a person perhaps not making the most rational decision, in due part to lack of sleep or the effects of lack of sleep. Then everything that could be increased because of that lack of sleep as well, perhaps, depression or-

Wil Pigeon: Right, so both direct and indirect, so right. It could simply be that it's not about poor decision-making, it's about making depression worse.

Rob Bossarte: Right.

Wil Pigeon: Yeah.

Rob Bossarte: Right, individual variability, and it's going to be different for every person.

Wil Pigeon: Right.

Rob Bossarte: How much do substances play a role in this? How often are sleep disorders and substance-abuse disorders, how often do they co-occur?


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Wil Pigeon: They often co-occur, and I am hard-pressed to think of mental health conditions

that do not co-occur-

Rob Bossarte: Oh sure, right-

Wil Pigeon: With sleep problems.

Rob Bossarte: I guess I was thinking are they more prevalent because people use alcohol, or rather substances as a way to try to compensate for their difficult sleeping?

Wil Pigeon: Yeah, alcohol and substances, the relationship of alcohol and substances to certain sleep disorders, and let's use insomnia in this case, it's bi-directional, and it's a bit difficult to tease out. Some others, it's a little simpler, but with substance abuse, exactly like you say, it could be I begin to self-medicate my sleep problem and now I develop a substance-abuse problem. Conversely, if I drink long enough, hard enough, I actually will develop sleep problems because of that.

Rob Bossarte: So I have heard. I am not a sleep researcher, but you hear that any amount of alcohol actually interrupts the normal sleep process, and you're actually less rested after drinking.

Wil Pigeon: True. The natural progression through those stages of sleep is disrupted as alcohol is metabolized. If you still have some amount of alcohol in the system as you're falling asleep, especially a few hours after you've fallen asleep, then it's going to disrupt your sleep, so yeah. There is a kernel of truth in there, that you want the alcohol to be metabolized, or largely metabolized by the time your head hits the pillow.

Cara Stokes: When you say disrupt, you mean not able to reach three in REM, Stage Three in REM?

Wil Pigeon: To some extent, that your sleep will be a bit more fragmented, so fragmented, more awakening, lighter sleep or light sleep interrupts the deep sleep, yeah.

Rob Bossarte: People who are regular drinkers, perhaps having a nightcap before they go to bed, if that's still a term that people use, but-

Cara Stokes: It is-

Rob Bossarte: Having a drink right before you go to bed is not a great idea.

Wil Pigeon: Not a great idea.

Rob Bossarte: It can actually lead to a long pattern of disturbed sleep?

Wil Pigeon: It can certainly, I don't know about the long pattern, but it can disrupt that night's


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sleep.

Rob Bossarte: Right, but if you do it again the next night and then [crosstalk 00:23:44]-

Wil Pigeon: Then over and over, absolutely, yeah.

Cara Stokes: You're just increasing that debt, right? The sleep debt?

Wil Pigeon: [crosstalk 00:23:50] Somebody's got to pay the banker at some point.

Dan Shook: My wife.

Rob Bossarte: Your wife? Fay's the banker?

Dan Shook: Yeah.

Rob Bossarte: I am fascinated by what you told us so far and the fact that you spent the past 15 years-

Wil Pigeon: Right-

Rob Bossarte: Studying sleep, and it all started with a job that you took on as a student?

Wil Pigeon: Right.

Rob Bossarte: Yeah, there was just something about being in that lab that struck a chord with you?

Wil Pigeon: I have another story, and it's only interesting to about 12 people in the world.

Rob Bossarte: We are going to find them with this podcast.

Wil Pigeon: When I was an undergrad, I took a couple courses in psychology, so I was a psychology major. Took a couple courses in psychology, and unknown to me, I was taking a course with one of the pre-eminent sleep researchers in the world at the time, and I had no idea. At that very time, he was doing a number of seminal pieces of work in sleep research. I had no idea until 10 years later when I was in grad school and I applied for this job, and I said, "Yeah, and here's my CV and I had this, I had accommodation for this class from this guy, Dr. Peter Harey," and the person I was interviewing with who was the lab director, was at that time, he was a psychiatry resident who with this Dr. Harey, formed the third oldest sleep lab in the country.

That's where I ended up working, but 10 years earlier I was a student in this guy's class and had no idea. That's a story about how stupid we can be as students and not take ... I don't know if I got some of that in my brain 10 years prior, and if not, then yeah. Total coincidence. I was interested in dreams, but so are most people,


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so dreams, cool. Part of the attraction was wow, I'm watching dreams go across the monitor, perhaps.

Rob Bossarte: Or-

Wil Pigeon: Or-

Rob Bossarte: You were always meant to be a sleep researcher. Sounds like an incredible series of events.

Wil Pigeon: Yes, and to tie it all back together, so what are some of the folk ways that we tell people to help people sleep?

Dan Shook: Count sheep.

Wil Pigeon: You count sheep. You count sheep, man. [crosstalk 00:26:15]

Dan Shook: Count your sheep.

Rob Bossarte: I was right there. [crosstalk 00:26:17]

Wil Pigeon: I'm hoping to start a line, and I'm going to announce it here today, do a kickstarter campaign-

Rob Bossarte: An exclusive, go ahead-

Wil Pigeon: Sleep sheep. You can buy your own share of a lamb and we'll send you videos of it.

Rob Bossarte: How much does a share of a lamb cost?

Wil Pigeon: 1.99.

Rob Bossarte: For which part of the lamb?

Dan Shook: The chop.

Rob Bossarte: There are so many questions here.

Cara Stokes: I don't even know what the bad part or a good part is.

Dan Shook: I don't want the ass.

Wil Pigeon: [crosstalk 00:26:50] You get a holographic share of the entire lamb.

Rob Bossarte: Oh, it's not a literal part of a sheep [crosstalk 00:26:57]?

Dan Shook: In addition to the sheep, if I want to be well, what would my sleep look like,


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because I'm not well.

Wil Pigeon: At your age, what do you want, man?

Dan Shook: [crosstalk 00:27:08] I'm just a heartbeat.

Rob Bossarte: How much time do you possibly have left?

Wil Pigeon: No, one myth is that our sleep just naturally gets worse as we age, and that's actually a myth. Our sleep should remain fairly consistent through most of our adulthood until that time where we just physically do start to tank [crosstalk 00:27:27] and then-

Rob Bossarte: Then you sleep all the time.

Wil Pigeon: What your sleep should look like, as whatever your old adult, is what it looked like when you were 25, 26, seven, so in the early 20s your sleep is almost bulletproof for a lot of people. It's not going to look like that, but we should sleep seven to eight hours a night. It should not be completely uninterrupted. We're going to wake up two, three, four, five times a night. One run to the bathroom, maybe two. We should wake up and roll over and fall back asleep within two or three minutes, most nights. On average, we should get somewhere between six and a half, seven and a half, up to eight hours of sleep.

Rob Bossarte: You're going to make it worse, aren't you, if you when you wake up, let's say you wake up and go to the bathroom at one o'clock in the morning. If you get on your phone and start looking at news or getting on social media, start activating that brain again, it's going to be harder to go back to sleep, right?

Wil Pigeon: Absolutely, right, yeah, so it's really hard to be awake and asleep at the same time. [crosstalk 00:28:36]

Dan Shook: I don't play my little games when I wake up, but maybe it's got to be just a state of mind, because when I wake up, I'm thinking I can't go back to sleep, so then I'm up. You're saying that maybe I just need to tell myself I should go back to sleep. But if I sit there and roll around, what do I do?

Cara Stokes: Just going to be making Sandra mad.

Dan Shook: Count sheep?

Wil Pigeon: In addition to the sheep, what I've got for sale is a five-minute therapy for people with insomnia. I'm making it up right now.

Rob Bossarte: We've had two exclusives today.

Wil Pigeon: That's right, and 10% of all profits will flow back to the university.


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Rob Bossarte: We appreciate you announcing them here.

Wil Pigeon: A couple things. Imagine, remember Pavlov's dog?

Dan Shook: Mm-hmm (affirmative).

Wil Pigeon: The drooling, salivating Pavlov's dog? The dog was conditioned to then salivate

when bell was rung and food was not even presented anymore, right? That's one type of conditioning. Think about being awake in bed and being frustrated and looking at the time and beginning to do math, like, "Son of a bitch, if I don't fall asleep within the next two hours, the best I can do is six hours," and then you keep looking every half an hour and go, "Aw, now it's 3:12. Why is it always 3:12? Every time I wake up it's 3:12," or whatever your version of that is.

Now you're doing math and you're frustrated and your partner, your spouse is sleeping and you hate him or her even more because they're sleeping and you're not, and you hear the cat in the other room and you want to shoot the cat. Whatever our version of that is, and that happens night after night, or it happens four or five nights out of the week. We begin to condition ourselves to have that continue to happen when we stay and bed and keep going through our routine.

The longer we are awake in bed, the more we condition ourselves to be awake in bed. It's okay to wake up, but here's the rule. That was the back story. The rule is, if awake for longer than 15 or 20 minutes, get keister out of bed and move it to somewhere else in the house, and let somewhere else in the house be associated with wakefulness. Even though you may not get any more sleep and potentially less, over a small period of time, you can begin to break the association between wakefulness and bed, so that now, bed is now only associated, or mostly associated with sleep. Wake is elsewhere, sleep is here, so brain begins to say, "Oh okay, fine, it's bed."

Dan Shook: Are you going to bill me for this session?

Wil Pigeon: I understand they make bourbon in this part of the country.

Rob Bossarte: We're a state away, yeah-

Wil Pigeon: Well all right-

Rob Bossarte: It's close.

Dan Shook: It's right in my office.

Rob Bossarte: Or there's Dan's office, which is a lot closer than Kentucky.

Wil Pigeon: That was thing one. Do I have time for thing two?


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Rob Bossarte: Yeah, all the time that you would like.

Wil Pigeon: Thing two is, for a period of one to three weeks, sleep boot camp, and sleep boot

camp looks like this. Figure out on average how much sleep you're getting, and what do you think that is, on average per night?

Dan Shook: In one session? Three hours.

Wil Pigeon: No, the whole, that 24-hour period, on average, how much sleep do you think you get?

Dan Shook: Maybe four to five.

Wil Pigeon: Let's call it five, to be kind. For the next week, decide what time you want to get out of bed and allow yourself only five hours in bed. That means if you have to get up at, what time do you have to get up? Have to or want to [crosstalk 00:32:32]-

Dan Shook: I don't have to get up until like maybe six o'clock, but I'm up at 1:00 or 2:00.

Wil Pigeon: Oh, you go to bed really early?

Dan Shook: About eight o'clock, nine o'clock, it's late and I get a lot of grief from my wife.

Rob Bossarte: You go to bed at eight o'clock at night?

Dan Shook: 8:00 to 9:00, which is wrong, I mean I've never done that before-

Cara Stokes: I do, too.

Dan Shook: Oh, that's sad-

Cara Stokes: I'm not even 30, so-

Dan Shook: That's a sad life. I have a sad life.

Rob Bossarte: I was just going to ask you where you keep the cot, where the other kids [crosstalk 00:32:59] sleep.

Dan Shook: Then I get up at one o'clock, then I take care of the dogs, I wash the dishes, I mean I just, I just hang out, watch Rachel Maddow.

Rob Bossarte: Is he going to bed too early?

Wil Pigeon: I think so. This is not going to be quite as straightforward as I had hoped.

Dan Shook: I'm sorry.


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Wil Pigeon: Thanks a lot, but nonetheless, all I'm going to suggest is, wow, I wonder if my

liability insurance covers me giving advice like this? Probably not.

Rob Bossarte: You're fine [crosstalk 00:33:31]. If there's a microphone in front of you, we don't take it seriously.

Dan Shook: What's your name again?

Rob Bossarte: Tom, yeah.

Wil Pigeon: Go to bed two hours later, or two to three hours later, and make it consistent.

Dan Shook: Make my wife happy.

Wil Pigeon: Then set alarm for five, five and a half hours, some amount of time later. Still get up at that time and do that consistently for a week. The challenge obviously is going to be, it sounds like you get sleepy in the early evening. It's going to be staying up later, but here, so what this is called, this is actually called sleep restriction therapy. It was one of the first therapies tried for insomnia, and it alone is pretty darn successful.

What happens here is we're purposely sleep-depriving people, but sleep depriving them in that time period, so you squish the amount of time that you actually allow yourself to get sleep, and not forever, and the goal is that the amount of time that you're asleep in that five hours begins to be 85% of the time, maybe 90% of the time, so 80% of five hours is still only four hours, that's terrible, but four hours divided by eight hours, that's 50%, that's a failing grade.

On a percent basis, we want that percentage to go up, and when it begins to go up, you slowly then expand the five hours to five and a quarter for a week, and then five and a half, and then three-quarters, et cetera. What will happen is the brain will figure out what the heck's going on, and will begin to get you more consolidated sleep a little bit at a time so that you can actually just ... Like you're making a pizza crust, and you're rolling the dough out a little bit of the time. Right now you have holey dough, man. You have holes all over your [crosstalk 00:35:22].

Dan Shook: They're going to smell pepperoni, that's right. Do I like olives and mushrooms.

Cara Stokes: Oh my God.

Rob Bossarte: Didn't expect to discuss the size of pepperoni today, but thank you Dan, for that. I would be remiss if I didn't ask you a couple questions about suicide though, and injury prevention. What proportion, how big is the effect on risk for suicide? Do you know what proportion of people who die from suicide have had a sleep problem? How big, how much it increases risk if you have a sleep disorder? I know that's a very broad question.


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Wil Pigeon: Those are broad questions. They should be easy to answer, and here's why they're

not. A third of the population has a sleep problem.

Rob Bossarte: A third?

Wil Pigeon: Yeah, 5 to 10% have insomnia disorder that's diagnosable.

Rob Bossarte: Is it getting worse in our population or are we seeing-

Wil Pigeon: I don't know-

Rob Bossarte: More sleep disorders?

Wil Pigeon: I don't know, it's hard to say. We don't measure it the same way over decades.

Rob Bossarte: There's no national sleeping tracking system?

Wil Pigeon: There's a national survey that's done each year. Some of the questions are similar. What happened is the amount of time on average that people are sleeping each year was almost a linear decrease for about 10, 15 years and has now plateaued at a nice low level.

Rob Bossarte: What is the average amount of time a person sleeps in the U.S.?

Wil Pigeon: I don't know this year's figure but it's under seven hours and it was closer to eight.

Dan Shook: Would electronics have something to do with it? I mean I understand it can disrupt you going to sleep, but throughout the day since we're just bombarded with phones and computers and things, I mean [crosstalk 00:37:01]-

Wil Pigeon: Somebody may know the answer to that, I don't. I do know that if you're in front of electronics in the last hour to two before bedtime, it is definitely going to have an impact. You can buy, for 10 bucks, you can get blue wave, so blue light wave-

Rob Bossarte: I've seen these, yeah-

Cara Stokes: The glasses?

Rob Bossarte: Block just those glasses, yeah, so 10 bucks, and that's going to limit the amount of the spectrum of light that actually impinges.

Dan Shook: Will those have little sheep going across them too, or-

Wil Pigeon: Oh my God, oh-

Rob Bossarte: There's product number three-


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Cara Stokes: I was just going to say that [crosstalk 00:37:35].

Wil Pigeon: Oh, nice. One problem, sleep problems are so prevalent that it's hard to pull that

out. However, if we look at people with and without sleep problems and see how many of those develop thoughts of suicide, have a non-fatal suicide attempt, or a death, the rates are somewhere between one and a half to three times higher in those who have a sleep disturbance than those who do not. That's across probably, at this point, 30 to 40 reasonable studies, yeah, and then a dozen or so nice epidemiologic studies.

Rob Bossarte: That's meaningful risk. I mean that's something that we should be paying attention to.

Wil Pigeon: Yeah, and not all of the studies, so some of the folks around the table will know, that you need to control for all sorts of things, and in this discussion, the one thing you want to control for is depression. Still, there are a handful of studies that have done a very nice job controlling for other factors that might account for that relationship and it stands, the finding stands.

Cara Stokes: I think it's interesting that you brought up the word develop, because from an epi standpoint, my whole interest is temporality. Which came first essentially, the chicken or the egg? The chicken being maybe sleep deprivation, and the egg being suicide ideation, so it's interesting that you brought that up.

Wil Pigeon: It is, it is, and you know I told you that there were some conditions where it's clearer than others. Depression happens to be one of those conditions where yes, there's a bi-directional relationship, but there's a very strong relationship between sleep causing depression, as opposed to depression causing sleep problems.


Cara Stokes: Yeah.

Wil Pigeon: Yeah.

Cara Stokes: That's interesting. I didn't know that.

Dan Shook: Would you use sleep as an adjunct to psychotherapy or behavioral therapy on some patients, or-

Wil Pigeon: I absolutely, absolutely would, and do, and would like that to be promoted widely as an approach to reach more people who have, for instance if we ... Just focusing on depression for a moment, for people who have depression and insomnia, which often go hand in hand, so 80% of people with depression have insomnia, 90% have a sleep problem, so the other 10% is something other than insomnia. If we address everybody with depression by first treating insomnia, I think we could make a


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bigger impact than having the entire planet who has depressed mood on some SSRI, some anti-depressant.

Cara Stokes: When you say treatment, you mean more like the umbrella term of CBT type of treatment, like you were telling Dan earlier, or what are your thoughts on medications?

Wil Pigeon: In this context, I meant treat the sleep. Get the sleep better, and what you raise is there are two main kinds of treatments for insomnia, and one is insomnia medications, and the other is non-pharmacologic interventions, and that's mainly something called cognitive behavioral therapy for insomnia, CBT for insomnia. The two things that I was telling Dan, the two tips I gave you are two of the four components of CBT for insomnia.

Cara Stokes: That's cool.

Wil Pigeon: Yes, and if I had to choose one or the other, I would choose CBT for insomnia as the most recent clinical practice guidelines also now choose.

Cara Stokes: Really?

Wil Pigeon: For decades, the recommendation was for insomnia, you can use as first-line treatment, either a sedative hypnotic medication or CBT, behavioral intervention. In the last two years, two different very at-large guidelines have come out and said you know what? The first-line treatment is behavioral therapy. Go to medication if that didn't work or it's unavailable. The problem is, it's often unavailable, and then the default becomes medication.

Cara Stokes: [crosstalk 00:41:38] Is there a lot of resistance to, sorry.

Wil Pigeon: Not enough providers.

Cara Stokes: People love pills, right?

Wil Pigeon: Not enough [crosstalk 00:41:43] referrals by who provides, which is primary care providers, and even when they try, they like, "Who do i refer to? I don't know, and I don't have anybody here to do it."

Rob Bossarte: Is it an awareness problem on the part of primary care just to educate them about the most effective interventions for insomnia?

Wil Pigeon: It is partly that, but it is still mainly a supply problem on the behavioral therapy side.

Rob Bossarte: Just not enough trained practitioners?

Wil Pigeon: Not enough trained practitioners. What's coming however, and actually what's


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already here are internet-based, web-delivered CBT for insomnia programs, some that you can pay for, some that will soon be free, some apps, which are not very good, but the internet-based, web-delivered interventions work well. Yeah.

Cara Stokes: That's good to know.

Rob Bossarte: That was my next question.

Wil Pigeon: There are a dozen books [crosstalk 00:42:37], but there have been books for everything for decades, so you've got to read the book and you've got to do it. For some reason, people do better hearing the instruction over an avatar than reading the book and putting it into practice.

Rob Bossarte: Books always put me to sleep.

Wil Pigeon: Well [crosstalk 00:42:54], see I often suggest reading.

Dan Shook: I read with my iPad though, but that's bad, right?

Rob Bossarte: You've got to get the $10 [crosstalk 00:43:01] glasses.

Wil Pigeon: You have like five things going on that are just-

Cara Stokes: You're a mess, Dan, you're a mess.

Dan Shook: I got two dogs, and a wife, and a king-sized bed that are like 80 pounds apiece. Not my wife, but the two dogs. [crosstalk 00:43:15]

Wil Pigeon: I think you should come on tour with me and we'll just say, "Okay, here's what not to do."

Cara Stokes: Everything.

Wil Pigeon: Look at the wrinkles on this guy [crosstalk 00:43:22].

Rob Bossarte: Dan's only 25.

Dan Shook: Yeah, these wrinkles, man. Does having, getting sleep help with the wrinkles?

Wil Pigeon: Yeah, so hey, ask me about the research that I've been doing lately.

Rob Bossarte: You know Wil, could you tell us about the research you've been doing lately?

Wil Pigeon: God I'd love to, yeah.

Dan Shook: Hey, this is about us, not you.


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Wil Pigeon: Given everything I was talking about, at some point I had to stop saying sleep's a problem, sleep's going to kill you, yeah, I'm really smart, I know how to treat sleep, and I had to-

Rob Bossarte: People aren't receptive to that message?

Wil Pigeon: It hasn't really-

Rob Bossarte: It hasn't caught on yet-

Wil Pigeon: Hasn't changed anything around me. I had to demonstrate that in fact, these interventions that I think are really awesome, can do something for more than insomnia. They can actually improve mood and improve other mental health conditions.

Cara Stokes: Which makes sense, right? Yeah.

Wil Pigeon: It makes sense, and I'm not the only one that's done so, but in the last five or so years, a couple nice handfuls of studies have shown that when you treat insomnia in patients who have other conditions, the other conditions get better. Not only does the sleep get better, the other conditions get better.

We just finished a large, a fairly large trial, a hundred-plus people, who had, these were women who had been exposed to interpersonal violence and from that event in the past year, had post-traumatic stress disorder, major depressive disorder, and insomnia. Some of these may have been on broad beforehand, but they got worse where or they were initiated after this event.

We treated them with, they weren't getting any other treatment and we treated them with four sessions of CBT for insomnia. That's it. Their depression improved by 60%, their severative depression. PTSD severity in the 40% range, insomnia just almost went away. The insomnia got a lot better, which we expected.

We demonstrated that in people with some pretty severe comorbid stuff, four sessions, four sessions over a month, and you improve the sleep until it's almost normal, depression severity gets cut in half, and PTSD severity is diminished a good deal.

Then, compared to people who got a control condition, and then we allowed people in both condition allowed, well we provided to people in both conditions, a PTSD treatment, so they got a trauma therapy. That means that everybody got a trauma therapy, but only half of them got the sleep therapy and the trauma therapy.

Rob Bossarte: The people that got the sleep therapy, their PTSD symptoms improved?

Wil Pigeon: They had already improved, and now they get the PTSD severity, and it improves a


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lot. The people that who reach remission and meaningful response are at incredibly high rate-

Rob Bossarte: I was just going to say, I'm really glad you gave us that example of a study because I think often times when we think about sleep disorders, we think about improving sleep, and we forget to think about the person's quality of life overall. If their depression is improving and their PTSD symptoms are getting less severe, and their sleep is getting better, sounds like their quality of life is dramatically improving, as well, which is going to happen if you improve your sleep, I imagine, but if it's going to affect all these other conditions and symptoms, as well, it would be much better.

Wil Pigeon: Now let's take people who have suicidal thoughts and do the same thing.

Rob Bossarte: Are you?

Wil Pigeon: Yeah, so we've just finished a small study, demonstration study, so 50 people who had either depression or PTSD, these happened to be veterans, so this was a study done and funded by the Department of Veteran's Affairs, 50 people who had depression and/or PTSD and were currently endorsing suicidal ideation. Again, we treat only the insomnia, and in this case, insomnia gets better, depression, PTSD get better, and intensity of the suicidal ideation gets a little better.

Rob Bossarte: Oh really?

Wil Pigeon: He says, with a softer voice. Sample size of 50, and the effect size was, for effect-size people, it was .44.

Rob Bossarte: For suicide ideation?

Wil Pigeon: For suicidal ideation [crosstalk 00:47:40]-

Cara Stokes: That's not bad-

Wil Pigeon: Not bad at all, and that's what you get with CBT for suicidal ideation, but so our sample size, we were just not powered to find a significant effect. We're pretty pleased with that effect.

Rob Bossarte: That's sort of a point in time assessment, right? Would you anticipate that as their sleep continues to have sustained improvement, as their depression is better, that suicide ideation may [crosstalk 00:48:08]-

Wil Pigeon: That's a great, yeah, absolutely. [crosstalk 00:48:12] Yes, one would hope, one would expect, or it could be that it just fluctuates all over the place and maybe not. We're about to start a four-year study to answer that exact question-

Cara Stokes: Awesome-


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Wil Pigeon: With 240 people.

Rob Bossarte: You'll come back in four years and tell us all about it?

Wil Pigeon: Tell us that it was a great idea.

Rob Bossarte: Dan probably won't be with us.

Wil Pigeon: At that point, at that point, I don't know, I'll probably retired-

Dan Shook: Oh that hurt-

Wil Pigeon: With my sheep business [crosstalk 00:48:31]-

Rob Bossarte: With your sheep.

Wil Pigeon: Well, sleep sheep.

Rob Bossarte: Sleep sheep [crosstalk 00:48:35]-

Dan Shook: Gaaaaaaaby.

Rob Bossarte: I forgot the name, yeah, so I'm buying into it today.

Wil Pigeon: Good. Oh, a founding member.

Rob Bossarte: I'm going to be the first, the premiere membership. I'll go 2.99, we're talking $2, right, not $299.

Wil Pigeon: Oh, so you want the gold fleece level?

Rob Bossarte: I do want the gold fleece, yes [crosstalk 00:48:51].

Wil Pigeon: Gold fleece.

Cara Stokes: You want half of a sheep.

Rob Bossarte: I want half a sheep. I want the front half of a sheep. All right, so we had intended to ask you what you were doing, but I think we know what we're doing. I think the one outstanding question that we have for you is to tell us the one thought you want to leave us with. What should we take away from all of this?

Wil Pigeon: The message that I've been delivering in various ways is that sleep is incredibly important for optimal functioning. If we could, if we could all join hands and sing some sort of Christmas carol that's about sleep, the world needs sleep, sleep is the world, I would be quite pleased.


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Rob Bossarte: What the world needs now. Yeah, do you have said carol or is this something you're expecting us to make up on the fly?

Cara Stokes: Sleep sheeps are going to come up with it, I would imagine?

Wil Pigeon: I was hoping, given the talent around the table [crosstalk 00:49:48]-

Rob Bossarte: That we could do something? Cara, you're a graduate student.

Wil Pigeon: To be a little more serious, so it's a simple message, but it is that, that sleep is incredibly important for our psychological and physiological well being-

Rob Bossarte: And physical?

Wil Pigeon: All, so we need sleep, we need adequate sleep, we need good sleep. In addition, sleep disturbances are rampant in this and other societies, but we have approaches, we have treatments that can improve sleep in people who have poor sleep, so let's do that. Let's do that.

Rob Bossarte: Fair enough. All right, well thank you.

Wil Pigeon: You're very welcome.

Rob Bossarte: I think we've reached sort of the near end, right? We have a couple of messages for our vast listening audience.

Cara Stokes: The viewers, or not viewers, listeners, listeners.

Rob Bossarte: Yeah, nobody's watching but us in here.

Cara Stokes: They should be watching, it's very [crosstalk 00:50:43].

Rob Bossarte: We'll start the web thing later, the web [brow 00:50:47], yes.

Cara Stokes: All right, so we here at Oompf, we would really like to encourage people to interact with us on social media. We want to thank you again for tuning in to hear our conversation with Dr. Pigeon. If you have any questions or comment for all of our guests, namely Dr. Pigeon, or any of the co-hosts, make sure that you share them with us on Twitter or Facebook, using #askwvuicrc. Again, that's #askwvuicrc.

Rob Bossarte: Before we move to the next thing, because this is suicide prevention, I need to let everyone know about resources that are available to you or anyone that is in your family or friends that are in distress. Help is available 24 hours a day, seven days a week. There is a national toll-free number you can call, 1-800-273-8255. If you're a veteran or calling about a veteran, or family or friend of a veteran, you can push 1 and reach the National Veteran's Crisis Line, which is located where you live, Wil, up in upstate New York. It's one floor above your center, correct?


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Wil Pigeon: That is correct, and the military crisis line as well, so it's co-branded.

Rob Bossarte: Then for those who do not push 1, there is a National Suicide Prevention Lifeline,

and bot the crisis line and the National Suicide Prevention lifeline have, or crisis line have websites and texting services. I believe they both do. If you don't want to call, you can text, and please know help is always available.

Cara Stokes: All right. We hope that this conversation helped you think about suicide prevention in a new way. Please share, please share, what? Be sure, can't read, let's cut all that out [crosstalk 00:52:18]-

Rob Bossarte: No, you're good, keep that, please-

Cara Stokes: Be sure you watch for future podcasts and webinars. Goodbye from your friends here at Oompf. We're really trying to make injury control cool.


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