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Episode 114 - Dr. Michael Grandner - Could YOU Have Insomnia AND Sleep Apnea?


Hey there, it's Emma Cooksey here and I'm your host, so this week is like the busiest week of my whole year.

I'm getting ready to go to New York to speak at a Project Sleep event, so some of you who listen a lot know that I'm on the board of directors for Project.


We're always trying to come up with ways to raise awareness about sleep health, sleep disorders and sleep equity.

And so this event is for journalists and the idea is they'll get to listen to me and a couple of other patients and share our journeys and especially our delays to diagnosis so that hopefully we can get some journalists interested in writing about sleep and sleep disorders and some topics along those lines.


So that's happening.

And then I'm flying straight to Orlando, where I'm going to be at the Collaboration Cures conference organized by the AAPMD.

So hopefully I'll be doing a few interviews there with various different people that will be there.


There's going to be some doctors and some dentists and all sorts of people involved with Airway health.

So on the other thing that's been happening that's very exciting is I'm finally getting to the point of being able to prelaunch my workbook.


I've got a printed workbook that's called the Six Week CPAP Solutions Workbook and I'm going to talk a lot more about it when it's actually available for you guys to preorder.

But essentially what I did was I wanted to make a guide for new and struggling CPAP users and put in it all of the stuff I wish I'd been told when I first started CPAP.


So if I just had this little workbook and been able to read all the information about what I needed to do to clean my machine and what I needed to do to troubleshoot all my problems like I think I would have gotten on really a lot better much sooner.


And but I would just say if you want to be among one of the first people to preorder the workbook, I am going to offer some 30 minute zoom like coffee breaks with me.


Because the one thing you guys always ask for is I get emails constantly with people saying I just want to pick your brain and ask you some questions.

And obviously it wouldn't be medical advice, but you can just kind of ask me whatever you want to ask me and so that I'm going to send out to my e-mail list first.


So if you want to be one of the first people to preorder the workbook and have a chance of being one of those people, then get on my e-mail list.

You can find the link in the show notes.

Or you can just go to sleep and scroll to the bottom of the page and sign up there.


So on to today's interview with Doctor Michael Granier.

Dr. Granier is the Director of the Sleep and Health Research Program at the University of Arizona.

He's the director of the Behavioral Sleep Medicine Clinic at the Banner University Medical Center and an associate professor in the Department of Psychiatry.


At the UA College of Medicine, with joint appointments in the departments of Medicine, Psychology, UA College of Science, Nutrition Sciences, College of Agriculture and Life Sciences, and Clinical Translational Science.

In addition, he is a faculty member of the Neuroscience and Physiological Sciences graduate interdisciplinary programs.


So without further ado, here's my conversation with Doctor Michael Granier.

So welcome, Doctor Granier.

Thank you so much for joining me.

Thanks for having me.

And so last night I kind of went a bit down a rabbit hole of your LinkedIn and ended up on your academic CV.


And I was.

Scrolling and scrolling and I just wrote down have him introduce himself.

So because you're super impressive, but you have so many different things that you do that I thought maybe it would be good for you to explain it to regular people so they can.

Yeah, I mean, I wear a lot of different hats.


I mean really what it is is.

I'm very interested in how sleep impacts health in the real world, what health and well-being and longevity and all the things that people care about.

And so all the different hats I wear are kind of in surface to that where so, so.


My background is I'm a licensed Clinical Psychologist, Board Certified and Behavioral Sleep Medicine, and So what that means.

I see patients with sleep problems, and we use nonmedication treatments for sleep disorders, mostly in.


Not even though you're doing research as well.


Yeah, Yeah.

So, so, so we've got a clinic here in Arizona with me and a number of other people.

I see patients one day a week.

Some of them see patients more, but we I still see patients every week.

Mostly insomnia but but we work with sleep apnea, hypersomnia disorders, parasomnia, circadian rhythm, sleep weight disorders and and even people with mental health and physical health conditions that are impacting their ability to sleep and we work with that as well work with a wide range of of things.


So that's that's one hat I wear, but also I I'm a faculty in the Department of Psychiatry here in the College of Medicine.

I've got joint appointments and a few other departments, but mostly it's because because the work I do sort of spreads out into some of these other areas.


And as part of that, you know, it's mostly a research position where I mean, to be honest, my my day job is writing grants and writing papers and and supervising grad students and postdocs and and.

Supervising a lot of students.

And well, I mean, I I I was very lucky to have.


Excellent mentors who taught me so much and I kind of see it as my moral obligation to pay it forward and and do that for as many people as I can and so, so and so the work we do is pretty broad from a research perspective where.


For example, some of the projects we have going on right now, it's looking one is say, looking at the role of sleep health at the intersection of psychosocial stress and cardio metabolic disease risk in the US Mexico border community.


Another project is looking at how adding adding a sleep health component How adding a sleep health component can improve smoking cessation.

Because nicotine nicotine's a stimulant, makes you sleep worse.


But quitting smoking actually makes insomnia worse and and the worse your insomnia is, the more likely you are to smoke, especially at night, which tends to disrupt sleep more and increase the stress.


So this is a collaboration with with Freddie Patterson at the University of Delaware where we had this idea of what if we added a sleep component to smoking cessation and it dramatically improved quit rates.


And so right now we're trying to scale that up.

And right now.

We're loving that because it actually impacts people's lives, you know, like they were smoking.

Like, that's really important to know all that.


And so that's what we're and right now we tried to get this funded in smokers in general, but it was but we weren't able to, but what we were able to do is get it funded in smokers with HIV.


Because people with HIV have worse cardiovascular health and smoking is still one of the leading causes of cardiovascular risk.

And so, and they're they're more likely to smoke and they're more likely to have worse sleep anyway.


So that's what we're doing right now.


We've got all their, we've got all kinds of other projects, we're doing some technology development stuff, we're doing some circadian rhythm stuff.

One of the really cool things we're doing right now is exploring this idea.

Called The Sleep of Reason or The Mind after Midnight, which is a, which is a concept that we developed with a collaborator at the University of Pennsylvania, Michael Perlis, where the idea is that you don't know nothing good happens between 2:00 and 5:00 in the morning like ever.


And it turns out that that's true kind of where.

It's not just me.

Yes, not just you.

We're not our best selves at that time.

And this came out of some of this came out of some of the data from insomnia, showing that people with insomnia have higher risk of all kinds of unhealthy behaviors, one of the most prominent actually being suicide, which is a major.


Public health problem, at least here in the US, it's most people don't realize it's the second leading cause of death for all age groups from 10 to 34 and it's still in the top five up to age like 60.

It's really high.

It's a big if it were an infectious disease, we would be mobilizing for a vaccine like nothing else.


Like but it's but it's not.

And I think there's such an odd like our family was touched by suicide because my fatherinlaw.

Died by suicide.

And I think that until that happened, I don't think I realized quite how prevalent it felt because people don't really talk about it.



So many people saying that happened to us, or you know, that happened with my uncle or you know, and you realize why are we not all like, really action stations trying to fix this problem?

I know it's it's just there's a lot of the stigma and and so so Doctor Pros is a mostly an insomnia researcher and and he was one of my mentors when I was at Penn.


We were talking about this idea that insomnia patients talk about being awake in the middle of the night and thinking all of them ruminating on all these these negative thoughts that during the day they look back on and think, why was I so upset about that at that time?

And so we actually found some population level data showing that actually suicide spike in the middle of the night much higher than you would have expected by chance and and we've been, we've replicated it over and over again we've looked in other countries we've you know we we've basically this is an extremely robust finding and and right now.


We're looking at it in terms of other unhealthy behaviors too.

In the middle of the night, actually, we were looking at homicide data.

We showed the same finding on those data we presented at the SLEEP conference and and hopefully they'll be published soon.

And right now we're exploring unhealthy eating in the middle of the night.


You know, so all of the and the idea is that we think all of these have a common pathway where when we're awake, when our body wants to be asleep, when we not only have.

Our sleep Dr. Interfering with our ability to think well and feel, process emotions regularly.


But we also have our circadian rhythms that are at the time when they're supposed to not be doing these things.

And so if we're if, we're sort of at, if we're at low tide in terms of brain function, because we're supposed to be asleep at the same time as awake and and and.


We have our sleep drive high.

And trying to make decisions.


So we're not thinking well.

So we know sleep deprivation leads to next day deficits, but what we're saying is whether you're sleep deprived or not, being awake in the middle of the night leads to leads to problems there.


And so that's another thing that we've been exploring in the lab where we're trying to understand what's actually the neuroscience of this?

Why is it that this happens?

And can we identify ways to minimize the impact that people are going to be awakened over the night?

Like if they're shift workers or if they have insomnia and and you know being awake in the middle of the night is not unusual, it happens.


And so how do we minimize some of that risk.

And so, so that's what that's that's another thing that that we're focused on.

Again, it's this idea of how do we get creative about real world solutions to sleep issues.

So another thing that I do is, is some technology development where we're looking at wearables and trying to figure out how we can use wearables.


Data better in order to improve sleep rather than just measure it or just make guesses and stuff.

Another thing we're we're doing is is we're looking at special populations like different different groups.


So one group in particular we're looking at is athletes, where athletes are a unique situation because.

They they they do have some health risks because of because of the strain they're under there at increased injury risks and things.


But what's interesting is that they they're also, it's kind of an occupational group.

It's kind of, you know, and then they're different.

So swimmers usually are up super early to be in the pool by 5:00 in the morning or like where baseball players, you know like the major leagues they travel like every day while they're in.

So they're playing almost every day and and and night games when their body wants to perform a little earlier and then.


There's all these sorts of issues that come up that become kind of little microcosms of everyone else's life, where where it blows out of proportion certain things that lots of people are struggling with, but they're under these these sort of controlled situations.

So if we can figure out how to solve some of these problems in creative ways that get around all the constraints that they have.


Unless they're super motivated because they right want to figure out how to optimize, like whatever sport they're doing.

And as opposed to people, a lot of other people in the working world who see sleep as a barrier to their success, you know, sleep is a waste of time.

Sleep is time spent not working.



When you're in athletics, sleep is part of recovery, Yes.

And so you can.

You can.

It's sometimes actually been easier to get athletics organizations on board with sleep than, say, corporate.

Large corporations.


How did you get into sleep?


And so.

But if we could show that it works for them, we could show that it works for everyone else too.

Like, did you know somebody was a sleep disorder or did you have issues with your own sleep?

Or you just.

I just always thought sleep was super cool.

Sleep is just super fun.


So, so when I was like, I was always like one of those kids who asked like a million questions and would drive my parents crazy.

And so when I was in in high school.

I worked at the mall bookstore when those things still existed, both malls and bookstores, so whenever.


And I was really interested in dreams.

And I thought dreams were super cool when I was when I was in high school, they were super cool to learn about, read about.

I want to learn all about them.

And every time we would get a book into the store that had something to do with, like dreams and dreaming, I would.

I would get it and I would read it.

And so I learned about a lot of the stuff that it was a job you could have until I was sort of in college and I had a friend who got a job as a tech at the sleep lab on campus.


We have a sleep lab on campus that you could work at.

Like, how cool.

And it turns out that the guy who.

Who was a new faculty person who was setting up that lab, was teaching a course that next semester and sleep.

And I'm like, oh, shoot, I got to sign up for that.


And so I did, and I loved it.

And I volunteered to work in the lab as a as a research assistant and turned into an honors thesis and an independent study.

And you know, he taught me how to go to grad school and like this is this is the thing you could do.

Yeah, that's awesome.

Well, I'm glad you find it.


It's totally your thing.

And so a lot of the people that listen are people who have sleep apnea.

And I feel like there's this thing where until I had a podcast, I was one of these people too, where when you have a diagnosis with whether it's obstructive sleep apnea or another sleep disorder, you kind of think that anything going on with your sleep.


Is to do with that diagnosis.

Right, I come.

Across that all the time, like people are like, you know, oh, I'm having all these issues and I've already been diagnosed and I'm already on treatment for sleep apnea and people don't realize that you can have cooccurring multiple sleep.


Disorders you.

Can have insomnia with sleep apnea at the same time, so I guess I wanted to ask you to help us sort of parse that apart, like so that people can spot.


You know they're having, are they having issues because they have sleep apnea or are they having issues because of a Co occurring insomnia or something else going on.


So somebody has a diagnosis with sleep apnea and they feel like their treatment is working well for that and their doctors all happy with it.

What would show up that they might need to then come to an expert like you to help them further with their sleep?

What's interesting is there's a kind of paradox where once people have sleep apnea, every sleep problem is sort of blamed on their sleep apnea.


Yeah, but until they get the diagnosis of sleep apnea, every problem, none of their problems could possibly be due to sleep apnea.

I'm like, no, no, no, no, no.

I don't have sleep apnea.

I'm just tired, you know?

Is that funny, though?

Like where a lot of people like, no, no, no, I can't have apnea.

And like, I don't, I don't have.


I just snore a little.

It's fine.

I'm just a little tired during the day.

I wake up a bunch of times during the night.

It must be insomnia.

It must be something else.

Couldn't possibly be sleep apnea.

But then they get the diagnosis and then everything is sleep apnea.

Isn't it funny that that's kind of a paradox?

No, that's absolutely what happens.

Yeah, all they do is talk to people about this all the time, so.



Oh yeah.

And and so this is the thing about the real world where people are complicated and and sort of once they have something to attach to, they they tend to see everything through that lens.

And what doesn't help is that a lot of of sleep physicians are so focused on sleep apnea and because sleep apnea.


Could potentially explain all kinds of things that it it's like it becomes, well, I've got a tool to fix this thing.

This thing could potentially be causing the problems that you're facing.

So I'm going to apply that tool and if that tool doesn't fix it, well, it doesn't always work.


Oh well.

And so then people are sort of left and and I sort of see that as a dissurface.

I mean, I'm not trying to throw any colleagues under the bus, but.

Like I'm very like I talked about it's me, I'm all about real world and I'm all about people, right.

And and many problems are solvable.


Not always how people expect and not always to the degree that it needs to be perfect.

So that's another thing.

Another problem sometimes is people's expectations where you know, people say like I, you know, I want to sleep like a baby.

And by the way, anyone who says that has never had children.

Because nobody wants to sleep like babies do.


But what they mean is I want to sleep like an adolescent.

And the truth is, things change.

You're not an adolescent.

And the good news is, that's actually fine.

That's OK.

Your sleep doesn't have to be perfect to be perfectly fine.

But what happens is people feel crummy and then they go to, well, here's the thing about my sleep that I think is wrong.


And so I must fix that thing, or else I won't feel better.

And the truth is, sometimes the actual causes of some of these issues aren't what you think they are.

So, OK, so to to actually get to your question, first of all, a lot of people with sleep apnea also have insomnia.


Insomnia isn't just a symptom.

It's not just a thing that happens.

Sometimes it is.

Sometimes it's like insomnia is like depression.

It's a word that means a lot of things.

Like someone have a someone can have a stressful day and like, oh, I'm feeling depressed today and that could be true.


But that's different from somebody who has a clinical depression that requires medical treatment and they can they use the same word, but it means something totally different.

And I think as a society we've come to understand that a little bit.

But with insomnia, we're still, we still see we still use the word interchangeably to mean lots of things.


And we get confused.

We confuse ourselves.


So there is such a thing as insomnia, meaning I'm having some trouble sleeping.

Then there's sort of what I call insomnia with a capital I, which is that the insomnia disorder.

And so a way to know if you have an insomnia disorder as opposed to just insomnia has a symptom is if it's taking you at least 1/2 an hour to fall asleep once you start trying.


Or if you're awake for more than 1/2 an hour during the night trying to sleep and being unable.

Or you're waking up 1/2 an hour before you want to in the morning and just cannot get back to sleep even if you wanted to.

So if there's more than if there's a 30 minute period of wakefulness when you're trying to sleep and can't, whether it's beginning, middle, or end of the night and that's happening, you know, what if that happens once in a while, No big deal, don't care.


But if it happens more than three, three or more times a week and if that's been going on for at least three months, you might have clinical insomnia and especially if it's impacting your daytime functioning in some way.

So the a lot of people have insomnia for a million reasons.


There's a million causes of of developing insomnia.

It could be anything, could be stress, could be a combination of things.

Could be something happened in your body once that you didn't even know what happened but it kept you up a little bit.

With sleep apnea, what causes it is 2.


Two big things happen with sleep apnea that can that can add insomnia on top of sleep apnea.

First is the especially if the apnea is untreated for a while you get events and when you get respiratory events it activates your body.


Whether it's as you're falling asleep and you have the sleep onset centrals or whatever, or if it's during the night and you have an obstructive event that wakes you up, your body just got massively activated and it's like you just got shot with adrenaline.

You couldn't get back to sleep if you wanted to.


You are physically unable to get back to sleep until that wave of adrenaline then subsides.

You know whatever is causing that activation, if that subsides, then allows you to sleep again, but you don't know that.

So you fight it and fight it and fight it and fight it and fight it.

During that time it becomes a struggle because you have these respiratory events.


So the respiratory events could become an insomnia.

Another is the CPAP machine itself or some of the other treatments can become activating and become uncomfortable in any way that causes that can create activation.

Now the difference between acute short term sort of insomnia that usually goes away on its own, and chronic insomnia.


Actually, even though there's a million causes of short term insomnia, there's really one main cause of chronic insomnia.

Now that's something called conditioned arousal.

What that means is your, so, you know, let's say you have some leg pain and it takes you a little longer to fall asleep, but you eventually get to sleep.


Then eventually the leg pain subsides, or maybe it becomes a little chronic, but your body kind of habituates to it and you can get to sleep.

You can sleep in lots of different things and humans have been able to sleep for ever.

You know every every human has slept pretty much every day of every single life since the first one and before.


Like it doesn't have to be perfect, but it's fun.

But what happens is when the active when the activation leads you to not be able to sleep and that creates stress about not being able to sleep.

And if it goes on long enough and you fight it hard enough, where the stress around not sleeping becomes predictable, remember your your brain's a pattern recognition machine.


If you start recognizing a pattern that trying to fall asleep or awakening during the night or whatever it is, where the act of sleeping becomes stressful, becomes predictably stressful, that itself creates you.

Start anticipating you, you expect it to happen.


And that predictable stress becomes the very activation that keeps you from falling back asleep.

It's sort of like the bed becomes the dentist chair, where you're in the dentist chair.

Nothing's happened yet.

You're already stressed.

You're responding to an event that hasn't even happened.

I mean, think about that.


We're predicting the future.

We're responding to a future that hasn't even happened yet, but we're readying ourselves for it.

And because we can predict it, you're like, you're in the waiting room.

You're already kind of antsy.

You're like avoiding making the phone call for the appointment because you're just thinking about it.


I I don't don't want to tempt fate because I feel like I've said this a few times and I've had, like listeners be like, oh, don't say that I lied because, like, you want to start getting.


But so I would explain.

So what happens with me is often times I wake will be aware that I wake up like in the middle of the night.


I'm a CPAP user.

Sometimes, like, I'll just kind of jiggle around and get more.

Comfortable or something.

And then if I stay awake for a little while, maybe 10 minutes or 20 minutes or something, I might go, oh, I'm awake, but I then start kind of going, Where are we going on vacation?


I don't really think about the fact that I'm awake.

So I don't.

So it's not really a problem in my life.

Like it's just kind of like, so I don't think that I'm somebody who could benefit from insomnia treatment, whereas people who have a similar thing to me and are waking up for a similar reason but then have a different reaction to it.


Like, that's why I said, that's why I said part of the definition isn't just the awakening, it's that it's causing problems.

If it's not causing, if it's not a problem, if it ain't broke, you don't need to fix it.

Your sleep doesn't.

So anyone who's ever had a pet knows that mammals don't get all their sleep in one chunk across 24 hours.


It just it's not natural.

It's not normal.

It's It doesn't and and not only is it unnatural, it's not required the fact that people sleep in a couple of chunks.

Everyone wakes up multiple times during the night.

The average person can wake up 1020 times during the night and they won't remember it because they're going to be super brief that you don't you don't sleep all the way at all.


The no human that I know of that is on drug has actually stayed through.

They hooked them up and actually looked at their brain.

Had 100% sleep, sleep epics sleep chunks through the entire night like it's not 100% sleep, it's just not.


It doesn't happen.

So I think that we all have unrealistic expectations of what good sleep looks like, right?

Which, And that's a problem when you have unrealistic expectations, you set yourself up for disappointment.

So when you do have an awakening, you're like, oh shoot, I'm awake.

Oh, no.



That creates stress, which keeps you awake longer as opposed to, oh, I'm awake.

Well, of course I'm awake.

I wake up a bunch of times.

I must be remembering this one.

Hold on.

Let me see if I can get back to sleep and if I can't.

So it's sort of like when you sit down to eat and you're not hungry.

Like, do you panic about, Oh, no, If I don't finish all this food right now, I'm going to starve today.


You know, like, right, right.

But, like, but, like, so, so, like, if you have someone who doesn't eat, like, OK, OK, you're going to eat a little bit less today.

You're not hungry right now, Maybe.

You know what?

If you don't eat now, I'm just going to be hungry later, Okay.

Well, that you know, it will either.


So maybe you're going to be hungry later and it's going to be a little too late to really eat.


You'll go to bed a little hungry, You'll eat a little more of breakfast and you'll be fine.

You're going to survive and sleep again.

Sleep doesn't have to be perfect and perfectly fine.

The problem is the stress around it.

And sometimes the stress is out of your control.


And that's where, like, actually the insomnia therapies come in.

I mean, there's medications.

That's what I was about to ask you about.

So people are listening to this and they already have some apnea, but they're listening to you thinking, well, that's absolutely sounds like me.

It sounds like maybe I have chronic insomnia, right.


What should they?

I think a lot of people think of sleeping pills and drugs, but what What else?

What should people be doing?

And that's it.


So, so there's so there's two kinds of medication, three kinds of medication for insomnia.


One kind is a lot of stuff that's being prescribed just for its side effects that actually doesn't really show a lot of benefit for treating insomnia.

And this includes things like the probably one of the most prescribed medications in the world for insomnia is Trazodone.


And there's there's very, very weak data supporting.

It's just doctors like it and patients say they like it but doesn't actually do very much to sleep.

And it's not as safe as everyone always thought it was.

But like a lot of things, people are being prescribed to help them sleep that actually don't have much data to support them at all.


So that I I put those all in sort of 1 category of like the the stuff that, like a lot of doctors prescribe it.

They don't even know that the data is as bad as it is if they're not a sleep person.

So then there's the sedative medications, things like the Ambien and the Lunesta and stuff like that.

They work by boosting your sleep Dr. artificially by sedating you.


And for a lot of people with insomnia, that helps a lot of them it doesn't actually.

Sometimes their problem isn't insufficient sedation and tiredness, It's actually they're plenty tired, they just have too much activation on top of it.

So maybe you can overpower it.


People sleep apnea, it becomes problematic because it reduces respiratory Dr. and so there's some worry about that though that the CPAP.

Maybe that'll help but.

I I hear stories all the time that would make your hair curl.

I I, I probably, I've probably heard some of those.




About people going undiagnosed for so long with sleep apnea and being given sleeping pills because they they're saying they're having difficult, they're tired during the day and they think there's something wrong with their sleep and then going so long and that actually makes it worse.


Yeah, making it worse.

And yeah, it's.


And then on top of that, the, the third, the third kind is a newer class of drugs for the duolorexin receptor antagonists or the Doras.

And so this is Suvarex and Lembarexin diary directsant, so is Bell.


Somra, de Vigo and Cuvivic are the ones that are on the market right now.

They work totally differently.

They're not sedating.

A lot of patients actually say they don't like them very much because they don't get that feeling of being dragged and sedated, right.

What they do is rather than it boosts your sleep drive, they actually take out some of the supports of your wake drive.


And so it's sort of rather than drag you into sleep, which is what actually a lot of patients wish even though that's not really good for you, right, It opens, it's that whole like people.

Wanting to take a pill, like just give me a pill or a surgery.




I mean, actually, yeah.

I mean so a lot of stuff that that's why people tend to like the stuff that's less safe because they like the feeling of it being out of their control because they feel very out of control, right.

And so they're like they feel it taking over and it and it and it.

They like the surrender of it, but that it doesn't, it doesn't actually work as well as people think.


But so these drugs work a little bit differently.

They tend to work fairly well, but not patients respond to them a little differently.

But that's the medication options.

On the Another thing that that people should be thinking about is nonmedication options for insomnia.


Now in nonmedication options, one is supplements.

And the first thing I'll tell you is so I I work with a lot of supplement companies.

I know a lot of the data around sleep and supplements.

Sleep supplements can be great and helpful, but generally not for people with insomnia.


They generally sometimes they're helpful.

That they're helpful doesn't surprise me when people say, well it did help me.

OK, maybe it did, but on average it's probably not going to.

No matter what you Google and read.

If you actually look at the data, they don't fix insomnia.


They might improve sleep, but it's sort of like if it's if it's a ball rolling, they might help give it a little push.

But if your insomnia is a roadblock, is a is a big bump in the middle of the road, a little bit of push isn't going to be enough to get over it.


But for someone who doesn't, who has a little bump or no bump, it'll help the ball roll a little faster.

So, like, they do work from that way, but they're just not strong enough usually.

And so that leads people to get very disappointed and then they start micromanaging.

Oh, I took, I did this form of magnesium, of this dose at this time and that they start stressing out about it and micromanaging it when I could have told you that, well, the chances of it working were actually kind of low.


Anyway, that's the division of supplement, the medication.

Supplements, by definition, don't fix medical problems, they said.

All they don't say on there.

This statement is not intended to treat or cure.

Anything I thought I did listen to.

You did Instagram live with Teresa and Drew at the Metro and we see.


I thought that was excellent.

You talked all about this on that.

So I might.

I might link to that.

Yeah, because I thought that that was super helpful.

People are looking for let me take a pill that will solve my sleep, and that's not what.


Supplements are doing so I thought that you explained like about melatonin and all these different things that people are kind of like overdosing themselves on right?

And unnecessarily.

Because again, I don't.

I'm not saying that supplements don't work.

It's just so people say, do you recommend melatonin?


I say recommend melatonin for all the things that it does and for none of the things that it doesn't do right.

And one of the things supplements don't do is cure insomnia typically.

And and that's why that's the difference in the medication.

Supplements can can improve your body's natural functioning, but they don't fix problems.


If they were, they'd be patented as a drug and sold as a drug if the evidence actually existed.

But it doesn't.

So that's one thing.

Another thing is, is behavioral stuff.

So behavioral behavioral treatments for insomnia fall under 3 categories.


One is sleep hygiene, two is cognitive behavioral therapy for insomnia, and three is the other stuff, sleep hygiene.

A lot of people confuse sleep hygiene with actual treatment.

It is not.

It is not.

I don't know how many.

Like even a lot of doctors, I have to tell them stop giving a sleep hygiene handout as a behavioral treatment for insomnia.


It's not sleep hygiene is hygiene.

It's not nothing.

Hand washing is hygiene.

Everyone should be washing their hands.

It's great to wash your hands.

Hand washing can prevent infection, can prevent the spread of infection.

And if you're sick, you should be washing your hands twice as much.


But washing your hands will not replace an antibiotic.

It doesn't work that way, right?

Brushing your teeth as I.

Feel like I almost feel like sleep hygiene.

I think it's great for people who like maybe at the very start of their journey, they're like, I don't think I'm sleeping well.


Well, yeah, try loads of sleep hygiene things for a few weeks or something and then if that doesn't help, go and see your doctor.



It's like brushing.

I would say brushing your teeth is also hygiene.

Everyone should do it.

There's ways to do it better, but you can't brush your way out of braces.


There's no, it's impossible.

And sleep hygiene is so useless for insomnia that we usually use it as the placebo control in our clinical trials, right?

But what sleep hygiene does exactly?

Like you said, it identifies and removes obvious barriers.


If you don't have those barriers, but you still have a bump to get there, maybe it's not a barrier that's in the way.


Maybe you actually have a medical condition and so so.

So please don't confuse sleep hygiene with sleep.

Treatment so that sleep hygiene was the first of the three, Yeah, yeah.


The second one is the most important, which is cognitive behavior therapy for insomnia.

CBTI is recommended.

Every medical organization, even the ones that prescribe the medications that have any guideline for treating insomnia, list this one first for a reason.


It's been around, I don't actually don't know anywhere else.

In all of medicine and all of psychology where you have a condition like insomnia that's this common, that's just reliably tied to outcomes that people care about, where you have a treatment like CDTI that is this well studied for this many decades, in this many studies, in this many different populations, that's shown to be reliably effective in anywhere you do it.


On average, in in pretty much any population, whether they have fibromyalgia, chronic pain, sleep apnea, lung disease, cancer, it still works.

No side effects.

Well, well, I can't say no side effects because everything has side effects.


I mean so like, so, like, and sometimes, you know, doing homework because it requires tracking things, sometimes tracking things can be stressful and sometimes you you.

Compress your schedule which because of the sometimes the schedule compression can make people stressed or like make them a little more tired for a couple weeks before you stretch it back out again like everything's got effects but but but nothing compared to the medication right.


So it's way safer and and when you compare it head to head with medications it actually tends to do as well or beat them.

And over the long term as well.

And over the long term, like with the medication sometimes, you know, sometimes the medication that's Band-Aid like and then you take it away and you're healed.


But sometimes the Band-Aid just covers it over and it never heals.

And when you take it away, you have a problem again.

And so with with CBTI, actually the data show that not only do people get better an equal number or more people get better with CBTI than with medications after the same give it the same amount of time.


But once you stop, a lot of people with medications stay fine and some of them drift worse.

But with CBTI and average people tend to get better.

Like you follow people one year, two years, 10 years later, they're actually better than when they ended because they now they know what to do.

So for somebody with.



I know I'm like hammering at home, but like for somebody with sleep apnea, no matter what treatment option they're doing for sleep apnea, they can do CBTI at the same time like people can.

Well, so your doctor's not going to like it when I tell you this.

A lot of the sleep doctors don't like this, but the data actually shows that you do not wait to treat the sleep apnea first before starting CBTI.


The data.

Are pretty clear the time from doctors they don't know, they don't know the data.

It's not on the board exam.

It's it seems counterintuitive because you think well if there's something medically causing an awakening why would you try and behaviorally quell an awakening that you can't prevent the true the And that's because they they often don't understand the CBTR process really well and what it's actually doing where actually the data show because well first of all the data show that you do them at least at the same time you can and because you can reduce the insomnia which actually helps them in their treatment better so that you're not giving someone with insomnia with severe insomnia CPAP machine that they then can't sleep with.



But, and actually a lot of patients, at least in the US healthcare system, have to wait so long to not only get diagnosed, but to get their treatment.

And that you could go through an entire CVTI process before your CPAP even shows up and it sort of inoculates you against some of those problems.


You might still have some more work to do later but the data actually showed that you can reduce sleep apnea symptoms with just CVTI and sleep apnea patients while they're waiting for their machine because they have less of that activation waking them up and and it reduces the IT it reduces the impact on their next day functioning and the and and they can be more ready to use the the treatment at the time.


So like.

So no the data are not do not suggest on it just do it.

The problem is finding someone to do it is tough.

There's a couple of good directories.

One is the The Society of Behavioral Sleep Medicine is the main professional organization here.


So I can link to that.

So yeah, yeah, go to

There's a, there's a directory.

Another great directory is actually the website is just CBTI directory that's set through the set up to the University of Pennsylvania where they do a lots of trainings and they have a directory of everyone who's ever been through any of their trainings or or or is in the field.


Like, it's another just way to find somebody, and even internationally.

So there aren't really enough of these practitioners, though, right?

Not really.

And I mean, yes, and I mean not really, but there's also a lot of people out there who don't know that we exist.


And so, so like, this is a chicken and the egg problem, honestly, like, one of the reasons there's not a lot of practitioners because nobody goes in, no one gets training in it because they don't see it as necessary.

Yes, you know, And so, well, if we got more referrals, if more people were asking for it.

So like, you know, if everyone asks their sleep doctor, where can I get CBTI, where can I get CBTI?


And the sleep doctor goes to their administrator and says we really need to hire a CBTI specialist.

The hospital would be like, well, do you have enough patients to see that?

Well, I'm hoping everybody listening to this will do that because honestly, that's the same as I feel like everything was like apnea because there's so many treatment options that just aren't being offered to people because there isn't that.


Like, either the doctor doesn't know where to send people, or there's not that knowledge that it's available.

So people aren't asking.

That's why I'm a big believer in patient empowerment, where where where a lot of times, unfortunately, our system is built on patients requiring to be their own advocates.


I wish it weren't that way, but it is.

Oh no, it is definitely that way.

And and and so sometimes, you know, the Doctor be like, well, we don't really have anyone to refer to.

Well, the other thing, the other thing I could tell people is just because there's no one in your area, there's two things that you should know.


First of all, most of the people doing CBTI are psychologists, and the way psychology licenses work is similar to medical licenses, where it's by state, but most of us can see people via telehealth.

So if you live in, say, Missouri, and you're in a city that's 500 miles away from the nearest city that has someone in it who cares?


Just call them anyway.

Got on their schedule for a telehealth appointment.

You're within state, it's all fine.

I mean, I'm not going to sample out Missouri.

It's just I know people in Missouri there's something called side packed, PSYPACT.

What side packed is It's a growing list of states that are recognizing out of state practice for psychologists because there's such a need for not just CBTI, but but any kind of.


Across the board, yeah.

And So what side packed is it's state legislation where if a state signs on to side pack is if a psychologist has a license in any side packed state, they can do telehealth in that state.

So if if I'm in a, if I'm a if I'm a psychologist who who has a license that's filed with CYPAC, who needs the extra, the extra things to get a CYPAC certification.


And I'm in a CYPAC state and you live in a CYPAC state who has no one near you to do telehealth, just call me, we can do telehealth.

I'm allowed now.

OK, I love that.

So, so there's lots more options out there than people even know.


And and again I think this is a chicken and the egg problem.

People keep saying, well there's not enough providers, Well, there's not enough providers because people are, people aren't seeing it as a viable career path.

So people have been like, I need to get training in this.


So that's what that's what we're trying to do.


Tell us a little bit about you're involved with the Sleep Reset app, yeah?

So tell us a little bit about that.

That's that seems like it's really trying to make this accessible to lots of people.


So sleep reset.

So there's a way to automate.


First of all, to take a step back, there's a way to automate aspects of CBTI.

There's there's a number of programs out there like shuteye and sleep EO, and there's a few digital CBTI options.

And the V, the Veterans Affairs, the VA has one that they've been working on, CBTI, even just the basic principles of it are actually not are so simple.


You can actually automate a lot of the process and get people to do it, and it works fairly well.

Not as good as with a therapist, but you know, again, getting access is tough and it's way better than nothing.

And I would imagine, I mean, I'm not clinical psychologist, survivor, but I would imagine that there's a difference between somebody who this is a fairly new problem.


You know they're like for the last couple of months I've been having this issue and versus somebody who maybe has a longer term issue and some other things going on like exactly.

Maybe there's certain people who do, and there's all kinds of complications, right?


So there's apps out there for CBTI itself and there's also books out there.


So some of the best ones are Quiet Your Mind and Go to Sleep by Carlene Carney and and Rachel Namber who are who are some of the leading people in the field.

They joined together in this book.

And the Insomnia Struggle, our instrument brassy is great.

The Insomnia Workbook, I think that's Silverman.


There's a few really good selfhelp books that's sort of, yeah, that walk you through the process.

I could even send you.

Those are just a couple off the top of my head that sort of walk you through the process.

So again, for some people that's super helpful because all they needed was the information.


Once they knew what they were supposed to do, they could do it sort of like with weight loss stuff.

Sometimes all people need to know is what to do.

Most of the time that's not enough.

Most of the time, because humans are complicated, things are complicated.


And and so that's why it's like for the people for whom the information is enough, they're great.


For a lot of people, that's not quite enough, but it's better than nothing.


So where sleep reset comes in, it's actually different from that where this is sleep coaching.

So the way I think about sleep coaching is it's sort of like the difference between supplements and medications, where supplements can help make things better, but they're they're not really there to fix major problems, right?


Another another metaphor is a personal trainer versus a physical therapist where where coach sleep coaching could be like the personal trainer versus people like me who are more like the orthopedist or a physical therapist.

Where like you wouldn't go to a personal trainer with a broken bone or or or chronic pain or whatever where that they can help you.


You know if you had injury recovery that's what the the the licensed professionals are for.

But if you just want to learn how to do squats better or if you just wanna learn like hey am I doing this right?

Or like.

Or have some accountability that someone's gonna ask, someone's just gonna watch you and spot you while you do whatever.


Yes, that's what personal trainers are for.

They're not licensed professionals.

They don't have medical training, and that's Okay, right?

There's a different role, same thing.

And so that's what I think sleep coaching is for sometimes.

Sleep coaching.

The problem is, coaching doesn't mean anything.


It can mean whatever you want it to mean.


In terms of credentials, I think you see that's the rate, right?

And so coaching credentials, they're currently zero with an asterisk and I'll explain it in a minute.

Coaching credentials that have any value.


Firstly, any time I see a coaching credential, I ignore it.

And actually, the more someone touts it, the less I trust them.

Because I know how useless it is, right?

Because there's no legitimate organization that's done them with the ask.

So the CCSH, CCSH is the one exception where it's not really it didn't wasn't supposed to really be coaching, but it is that sort of is sort of sleep coaching.


CCSH is that this is from the BRPT which is overseas the the Rpsgts which do the the so sleep apnea people will know Rpsgts because they're the ones reading your sleep.

Those are the sleep.

Tests and sticking stuff on your head.


These are people.

And So what CCSH came out of was this movement where once there was moving towards more home tests, we didn't need as many people staying overnight all the time.


And So what it was.

So what are some other things to do?

They've got lots of experience and sleep.

What can they do during the day?

And so, but they're not licensed psychologists or doctors or nurses like.

So they don't have medical licenses and related licenses.

So what do you do?


And so that's what the CCS H came as.

Like, let's create an organized way to get them to be sort of paraprofessionals.

And also let's remember that the people, especially the people with sleep apnea.

It really used some one-on-one health and support like you know like adapting to CPAP and and I feel like you know a lot of the people I know who were who have gone the CCSH route, like who started in you know like they may be still are doing the sleep tech thing but they're able to actually have more time with patients and run clinics where they explain a bit more about CPAP.



And I think that that's a great thing.


I mean that's why CCSH is a sort of the one exception.

But the reason I I call it an asterisk rather than one being good is that when most people think of coaching sleep coaching, they don't think of what Ccsh's do.


Ccsh's are mostly sleep apnea paraprofessionals and they can do more.

And actually the side of behavioral Sleep Medicine is working with them to try and increase their curriculum and broaden it a little bit to make it a little more behavioral and something.


Like so, but so, so coaching.

It's still sort of Wild West.

And so with Sleep Reset is it's a coaching platform.

So it's not for people who are who need it as treatment for a sleep disorder.


It's for people who might already be getting treatment for sleep apnea or some other sleep disorder but still have aspects of their sleep that might not be criteria for an insomnia disorder.

Could probably still use some help, some accountability, some guidance, some tips.


Yeah, it's the way I see it is the different what's the difference between therapy and coaching the field is this is a highly controversial area right now.

But I.

Hugely controversial, yeah, but I I usually am happy throwing myself out in front of things and taking the hip.


What do I care for vacation?

Nobody's right, but this is the thing.

But This is why I do it, because it's because you know, as we academics wring our hands, patients are looking for solutions And and either we embrace this and guide it or put our heads in the sand, pretend it doesn't exist or insult it.


But patients don't care.

Patients want help and it's clearly meeting a need so so This is why This is why I've sort of put myself out here only because it's it helps patients and.

It wouldn't be really like from a patient perspective, it would be really nice if there was a clear way, like there was a credential that maybe maybe sort of a beefed up CCSH, you know, like where behavioral Sleep Medicine is working on it.


They're working on a credential.

Yeah, I think for this reason.

Enormously helpful just for people who, because I mean I talked to patients.

All the time.

And I think that sometimes it's just a bit confusing.

Like they don't know, like they're reading people's credentials and it doesn't really mean anything to them.


They're like, oh, you trained with some health coaching and a lot of coaching people.

What they're doing is either glorified sleep hygiene, which can be helpful as coaching.

But what they the thing that annoys me is they they keep calling it CBTI, first of all.


Sometimes by mistake, No.

And sometimes they're doing what they think is CBTI.

Then they call it CBTI.

But like, he stands for therapy.

They're not therapists, right?

This is doing a therapy.

There's a difference between therapy and coaching, yes.




So for the wording is coaching and yeah.

No, I know that is I'm okay with them calling it CBTI based because so, so in my opinion, the difference between therapy and coaching therapy is when you really need to know what you're doing to figure out what tools to use, when to use them and when not to and when to and and so so when there's some sort of risk involved.


But coaching is in my mind.

Anytime you could tell anyone, if it's something you could essentially tell anyone on the street, then it's probably okay to be coaching because it's not risky.

So it's like, it's it's there's stimulus control therapy where we work with people to get out of bed if they can't sleep and we work on on lots of details around.


But that doesn't mean anyone on the street can't learn the principles of stimulus control.

And like, hey, if you're in bed and like, I think anyone can tell anybody, hey, if you're lying in bed for 1/2 an hour, especially if you're stressing about it, get up.

You're not doing yourself any favors.

Get up, take a break, go back to bed later when you can actually fall asleep.


I think anyone could tell anyone that.

So I think it's okay for coaches to talk about sleep, stimulus control, But they're not.

As long as you're not in the realm where you're in these Gray areas of where there's some safety, there could be safety issues, It could be interfering with the medical condition.


It could be doing this other stuff right.

That's more the therapy side.


When it's something you can kind of tell anyone, I think that's fine for coaching because you're it's mostly educated and support, educating and clearly that's.

And I think some of the better coaches that I've, you know, spoken to, I feel like they spend a lot of time like carving out this is exactly what we do.


Yeah, We don't give medical advice.

We're not clinical professionals like you know, and they're also great frontline people and identifying you're coming to me as a coach, you've got a sleep disorder, I need to get you referred to a specialist.

Right, exactly.

Yeah, this is, this is this this this isn't just sleep deprivation.


This is narcolepsy.

You know like you need to I this is out of my this is I need to send me as the personal trainer needs to send you to your orthopedist for this one because I can't fix this this is not this is actually a problem so I think coach and straight so that's what sleep reset is it's what they did is and my involvement was sort of helping them design the program that uses what we know about sleep in circadian science without trying to stay on this line of it being therapy but keeping it as general as possible but but.


Still helpful but still helpful and and so that's that's that's what sleep reset is.

It works.

They've got an app where people it helps people track their sleep and and they have live coaches but it's text based and it's not therapy but they are supportive and they can't help clarify things and they can't help give people some advice.


Mike, you know, and you know, we're defining the space.

We're all still trying to figure out what's the line between therapy and coaching.

But but what I'm trying to do is let's take all the good that we can as opposed to like the crappy coaching that doesn't know what they're talking about or just making stuff up or based on something they read and misunderstanding it.


Well, what if we take the actual science and turn it into coaching based advice, not therapy?

What would that look like?

And then and that's what that's what we're trying to do with sleep Reset.

I mean there's other coaches out there too.

I'm not necessarily saying this is the only one, but but yeah, so it's like, I think it's like the sleep reset.


I mean I think from I just view everything from the patient's perspective and I just think like the more options that we have.

Exactly to be the better.


And actually the coaches, one of the things that we're that I've been working with with the coaches to help them identify when someone should probably be set for a sleep disorder diagnosis and treatment anyway, unless they're already be so, like if you're a sleep apnea patient, you're already be seen by a sleep physician, right.


So this can help fill in some of those gaps.

But if you're if you're someone because the sleep physician doesn't have time to you know, like they have 6 minutes or something.

So it's like they're kind of checking that your Cpaps working how it's supposed to be working or whatever and like higher level than like getting into, you know, sleep, hygiene and.



And what are you doing at night?

And no, maybe you know, like, OK, when when you're you know your mask keeps waking you up.

Well, what you know.

Is there a way we can modify your routine?

To help make this a little easier for you like stuff like that like yeah that's fine for coaches like that's what CCSH has been doing this for a long time anyway and so like so so something like like sleep reset or a different coaching platform could be great for people who are sleep disorders patients and using this to fill in the gaps.


Or also I mean also for just people who are struggling with sleep issues who may not know they have a disorder and then they they can help triage them or or like they don't, you don't have a sleep disorder but you think you could sleep better.

I mean, the data show that when people start this program, the ones who make it all the way through slept way better than they did in the beginning on average.



And the one thing that that sleep reset did that a lot of, even a lot of sleep therapies don't actually increase amount of sleep time very much because.

Like, you know, insomnia treatments are focusing on getting you to sleep, not necessarily getting you sleeping longer.


Average sleeping pills don't increase sleep time by very much, even sleeping pills don't.

CBTI also doesn't tend to increase sleep total time asleep by very much and a lot of patients kind of want that on top of whatever it is.

So that's actually another really good use of coaching is increasing sleep time, because amount of sleep actually isn't a diagnosis.


Like insufficient sleep, like the sleep deprivation actually isn't a medical condition.

It's just it's a symptom.

It's a problem.

It's actually not even a symptom.

It's not one of the criteria for insomnia.

It's not one of the criteria for sleep apnea.

Getting a getting less than optimal amount of sleep isn't it has a huge impact on people during the day and like you know.


And that's the thing.

Well, you blushing can be great for because it's not a clinical issue.


So you're not treating a clinical disorder by helping someone find more time to sleep because it's not a clinical problem.

It's a that's more of a lifestyle issue that coaching can help with.

Yeah, that's another great use.


So yeah so we showed so, so in that when I helped design the program I put that in there so that you know on average the people who went through the whole thing they ended up sleeping a bunch more by the end and I haven't meshed cover half of the if I want to ask you and.

So we could do this again, we could do this again, we could do a follow up thing.


Like I have a whole bunch of questions, but it's all OK.

So just before I let you go and I just saw when I was on your LinkedIn, I saw the thing about the Canyon.


Canyon Ranch.

Yeah, so that's super cool.

So this was an idea that, I mean, tell me really fast, Yeah.


Yeah, so this came from an idea of.

Can we take everything we know about sleep science marry it with sort of like this Wellness retreat concept and the people are already spending a bunch of money for let's just make those better and and so I've been trying for 15 years to find someone willing to do this.


And and so finally I found someone who connected me with someone who connected me with someone who connected me with the the right person.

Canyon Ranch is perfect because they're like a Wellness spa, but they also have physicians on staff and and personal trainers and nutritionists.


They have the actual credential people as well as all the Wellness stuff.

And so we sort of designed this, this program to be like the perfect sleep retreat, the best we could do in four days, four or five days.

We've got everyone gets, actually everyone gets a home sleep apnea test read by a physician and they also, you know, talk about behavioral stuff.


We do wearable stuff.

They meet with the nutritionist, They meet with the the exercise physiologist, they meet with.

They they get a cooking demonstration from the chef about about healthier foods to eat at night.

Like they get, you know, and they get all the spa stuff and it's in this great setting, it's like the best of all the world and it's super cool and the people who do it.


At least from what I've seen, are sort of off the charts.

Happy with it.

It's it's Canyon Ranch, so it's expensive.

But yeah, it's just it's beautiful.

And I would love to figure out a way like this.

Is it what It's just an interesting realworld sleep health intervention?



I mean, I wish there was a way we could make it more accessible, but it's, I just think what they do is great.

They're a great organization and leverage.

You've done this before.

So I guess my question is, have you had people with undiagnosed sleep apnea show up?

I'm sure.


Oh yes, yeah.

This is why everyone this is part of the deal is that everyone gets a sleep apnea test.

So some people knew they had sleep apnea, didn't tell anybody, and it's still there.

Some people knew they had it.

They're using a CPAP, and then we get to see if it's effective.


But there's always a few people who've done this a couple Times Now.

And every time there's always a couple people who had no idea.

And I'm thinking you're spending all this money to spend a week at like one of the world's greatest retreats.


And then and you're time, we're focusing on sleep.


And you're saying and you're here probably because you're struggling with sleep, if you were struggling with sleep, and if one of the main causes was an undiagnosed sleep apnea.

And we did all the other things and we didn't even check.

We'd feel kind of foolish, right?

And a lot of these people just have no idea because a lot of times they they didn't meet the obvious criteria, whether it was like women, women are undiagnosed with sleep apnea more likely because of their like a women who were not like obese or like men who were not over 50 and and Bmi's over 40, but still, you know, maybe they, you know, people, men who were in shape but but we're still feeling really tired and they targeted a ton of them.



And so that This is why, This is why it was part of the deal.

This is why when we did, when I designed the program this tenure just said we got to put this in because it's so important, so important.

Well, listen, Dr. Granier, thank you so much for your time.

Thank you very much.


I really enjoyed it.

Thank you.

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