The Sleep Experiment: Safety Assessment

This first step could be very important to your overall health. In this step you will complete screening forms to look for illnesses that are associated with sleep disturbance but require prompt treatment on their own.  The illnesses that we are screening for are listed below:

·         Sleep Apnea:

o   Sleep Apnea is a common disorder that is associated with weight gain and snoring.  Tissue in the neck falls against the back of the airway while sleeping.  This can cause air to stop flowing in while breathing in.  With no air flowing in, the oxygen level in the blood stream drops causing tissue hypoxia and inflammation.  Sleep apnea is associated with an increase in risk of high blood pressure, heart disease and stroke.  Most patients with sleep apnea describe poor sleep throughout the night and they awake not feeling refreshed in the morning.  Sleep apnea is a serious condition and if you have it, it needs to be addressed right away.  We consider a high score on the screening test for sleep apnea to be an exclusion from our sleep experiment, because it such a serious condition.

·         Alcohol or Drug Dependence:

o   Dependence on alcohol and drugs including marijuana is a common condition where you begin to need the alcohol or drug to modulate your mood.  Dependence often begins during stressful periods of life and is very common in people who are anxious or depressed.  Dependence on alcohol and drugs is a serious condition and the second exclusion from our sleep experiment.  We can almost guarantee that your sleep will improve if you get treatment for your dependence as will many other aspects of your life.  After treatment, you can return to the sleep experiment.

·         Dependence on Sleeping Pills:  Remember, sleep is a passive process.  There is no easy way to force a good night of sleep particularly with prescription medicines.  There are some sedative medicines on the market that are marketed for this purpose but virtually all of them are known to create dependence and disturb sleep.  Weaning off sleeping pills is complicated and needs to be done in collaboration with your doctor.  All of the interventions in the sleep experiment can help with the weaning process, but to try and do this without attempting to wean the pills will likely not be fruitful.  For this reason, we consider dependence on sleeping pills to be an exclusion from the sleep experiment.

·         Anxiety and Depression:  Anxiety and depression are very common and are strongly associated with sleep disturbance.  The relationship between anxiety, depression and sleep is bi-directional, meaning that anxiety and depression can lead to poor sleep and poor sleep can worsen anxiety and depression.  While not an exclusion from this experiment, we strongly encourage concurrent treatment for anxiety and depression as you go through the sleep experiment.

Sleep Apnea Screening Questionairre

Snoring? Do you snore?	Yes	No
Tired? Are you tired when you wake up in the AM?	Yes	No
Observed apneas?  Has anyone observed your breathing to stop while you are sleeping at night?	Yes	No
Pressure?  Is your blood pressure elevated or do you take medicines for blood pressure?	Yes	No
BMI > 35?  Is your body mass index more than 35?	Yes	No
Age > 50?  Are you older than 50 years old?	Yes	No
Neck Circumference > 16 in?  Is your neck size more than 16 inches?	Yes	No
Gender: Male?  Are you male?	Yes	No
Total Score:

High Risk: 5-8, Intermediate Risk: 3-4, Low Risk: 1-2

Count the total yes scores on the screening test.  Enter the score on the forms at the end of the stage.  If your score is anything more than 2 you should consult your physician immediately as you may need an overnight test for sleep apnea.

Screening for Depression: PHQ9

Over the past 2 weeks how often have you been bothered by any of the following problems?	Not at all	Several Days	More than half the days	Nearly Every day
Little interest or pleasure in doing things	0	1	2	3
Feeling down, depressed, or hopeless	0	1	2	3
Difficulty falling asleep or sleeping too much	0	1	2	3
Feeling tired or having little energy	0	1	2	3
Poor appetite or overeating	0	1	2	3
Feeling bad about yourself, a failure or that you have let yourself or your family down.	0	1	2	3
Trouble Concentrating on things	0	1	2	3
Moving or speaking so slowly that others have noticed.	0	1	2	3
Thoughts that you would be better off dead or of hurting yourself.	0	1	2	3
Total Score

None-minimal: 0-4, Mild: 5-9, Moderate: 10-14, Moderately Severe:  15-19, Severe: 20-27

GAD-7:  Anxiety Screening

Over the past 2 weeks how often have you been bothered by any of the following problems?	Not at all	Several Days	More than half the days	Nearly Every day
Feeling nervous, anxious, or on edge	0	1	2	3
Not being able to stop or control worrying	0	1	2	3
Worrying too much about different things	0	1	2	3
Trouble relaxing	0	1	2	3
Being so restless that it is hard to sit still	0	1	2	3
Becoming easily annoyed or irritable   .	0	1	2	3
Feeling afraid, as if something awful might happen	0	1	2	3
Total Score

Minimal Anxiety:  0-4

Mild Anxiety: 5-9

Moderate Anxiety:  10-14

Severe Anxiety:  15-21

AUDIT-C Questionnaire

Within the past year, how often did you have a drink of alcohol?

□ a.  Never

□ b.  Monthly  (e.g. Special occasions/Rare)

□ c.  2-4 times a month  (e.g. 1x on weekend - “Fridays only” or “every other Thursday”)

□ d.  2-3 times a week  (e.g. weekends – Friday-Saturday or Saturday-Sunday)

□ e.  4 or more times a week  (e.g. daily or most days/week)

2. Within the past year, how many standard drinks containing alcohol did you have on a typical day?

□ a.  1 or 2

□ b.  3 or 4

□ c.  5 or 6

□ d.  7 to 9

□ e.  10 or more

3. Within the past year, how often did you have six or more drinks on one occasion?

□ a.  Never

□ b.  Less than monthly

□ c.  Monthly

□ d.  Weekly

□ e.  Daily or almost daily

Scoring:  a = 0, b = 1, c = 2, d = 3, e = 4 points.  For men, a score of 4 or more is considered positive and for women a score of 3 or more is considered positive.

DAST-10  Drug Abuse Screening Test Questionnaire (Yes-No)

These questions refer to the past 12 months. 

1. Have you used drugs other than those required for medical reasons?

2. Do you abuse more than one drug at a time?

3. Are you always able to stop using drugs when you want to? (If never use drugs, answer “Yes.”

4. Have you had "blackouts" or "flashbacks" as a result of drug use?

5. Do you ever feel bad or guilty about your drug use? If never use drugs, choose “No.”

6. Does your spouse (or parents) ever complain about your involvement with drugs?

7. Have you neglected your family because of your use of drugs? No 0 Yes

8. Have you engaged in illegal activities in order to obtain drugs?

9. Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?

10. Have you had medical problems as a result of your drug use (e.g., memory loss, hepatitis, convulsions, bleeding, etc.)?

Scoring: 

No problems reported:  0

Low Level: 1-2

Moderate Level: 3-5

Substantial Level:  6-8

Severe Level:  9-10

Sleeping Pill Dependence

1.      How many times in the past month have you used a prescription sleeping pill to fall asleep?

2.      How long have you used those sleep pills for?

3.      Have you ever been diagnosed with dependence on sleeping pills?

4.      Do you feel like it would be difficult to fall asleep without a sleeping pill (of any kind)?

Screening for Sleep apnea, depression, anxiety, substance abuse related to alcohol and regular use of sleeping pills and other substances.

If you have screened positive for any of the illnesses describe above, you should discuss your diagnosis with your doctor before proceeding to the next Step.  Specific treatments for each illness are described below:

·         Sleep Apnea:  If your STOP-BANG questionnaire was positive, you may have sleep apnea.  This is an illness where the breathing is cut off due to excess tissue in the neck when you lay back in bed to fall asleep.  You need a sleep apnea test, which your doctor can arrange, and you should start on treatment for the sleep apnea before proceeding with the next step.

·         Depression and Anxiety:  There is a bi-directional relationship between poor sleep and depression and anxiety.  In other words, poor sleep can make you feel depressed or anxious and feeling anxious or depressed can disturb your sleep.  A high or even moderate score on the screening tests for depression and anxiety should prompt an immediate discussion with your doctor before moving on to the next step.  In some cases, an insomnia program is appropriate, but in many cases, you will need full treatment for those illnesses before you proceed.

·         Alcohol Dependence:  Alcohol has a profound impact on sleep.  If you screened positive on the questionnaire it may mean that you have some dependence on alcohol.  Alcohol dependence is a serious problem and can affect every aspect of your life including sleep.  If your test was positive, you should immediately discuss with your doctor.

·         Drug Dependence:  As much as alcohol will have a profound and disturbing effect on sleep, drugs will as well.  Drug dependence is a serious illness and any attempt to work on sleep will essentially be futile.  If you have screened positive for drug dependence, you should put aside the book for now and immediately discuss this with your doctor.

·         Dependence on Sleeping Pills:  If you screened positive for dependence on sleeping pills, it will be difficult to treat your insomnia until you are able reduce your dependence on those pills.  This is a complex process and you should discuss it with your doctor before moving on to the next step.

If you have screened negative for all of the issues above, or if you have already addressed these issues with your doctor and you want to proceed, then move on to Step 2: Sleep Tracking.