The intersection between mental health, substance use and sleep

Celeste: Welcome to the Nursing and Midwifery Health Program Victoria podcast series where we will be diving into issues that impact the way nurses and midwives navigate today's changing world. I'm Celeste Pinney, a registered midwife and senior clinician at the Nursing and Midwifery Health Program Victoria and host of this podcast series.

The Nursing and Midwifery Health Program is a support service which provides care and assistance to nurses, midwives and students by experienced nurses and midwives.

NMHPB provides a space where our colleagues can bring with them any sensitive health issues impacting their wellbeing. The program is voluntary and importantly, it is free to access, confidential and independent.

Joining me today is Rowan Ogiel, who is the Strategic Lead of the National Addiction and Mental Health Surveillance Unit at Turning Point and Senior Research Fellow at Monash University. Rowan has come to talk to us about the connection between sleep, mental health and alcohol use. Rowan, thanks for coming on to the podcast. Thanks so much for having me today, Celeste. It's great to have you here. Could you tell our listeners a little bit about what you do in the research field regarding substance use, mental health and sleep?

Rowan: Sure, so I've had quite a number of different roles and been involved in lots of studies. Since I did my PhD at Monash in 2012, looking at the drug MDMA and its effects on sleep and circadian rhythms. I subsequently moved to Turning Point, which is a leading centre for addiction research, treatment and education in Richmond, Victoria, where I undertook a Peter Doherty fellowship to look at alcohol, other drug use and mental health in shift workers. This led me to some work overseas, and I was lucky enough to be an Australia Harvard fellow, and I worked over in Massachusetts for a little while. And now I'm back in Australia doing more public health-related studies. In my current role as the strategic lead of the National Addiction and Mental Health Surveillance Unit, I'm looking at alcohol and other drug mental health harms in emergency settings.

Celeste: Great, thank you. Well, sounds like you've got a lot of experience in the area and we'll really look forward to hearing more about what you've learned and what you know. Thank you. So let's get into it. Nurses and midwives generally understand the importance of sleep, being health professionals. Could you give us a quick overview of why good sleep is important for mental health?

Rowan: Sure, sleep is an active and quite a complex neurobehavioral state and I say that because so much happens inside our brain and bodies when we sleep so good sleep and by that I mean both the time spent sleeping and the quality of sleep is important for rest and recuperation so things like replacing hormones proteins neurotransmitters that we've used while we're awake. But in addition to this rest function, sleep does a whole bunch of other things. It's vital for memory encoding, that's consolidating new things, like tasks that we've learned throughout the day, and important for maintaining our attention, cognition, and performance.

Now, you specifically asked about mental health, and there's a really solid evidence base here showing that sleep is critical, not only for physical health, but mental health. And poor or insufficient sleep has been found to increase negative emotional responses to stress and to decrease the experience of positive emotions.

And we also know that sleep problems can contribute to the onset or worsening of different mental health related problems, including things like depression, anxiety, and even suicidal ideation.

Celeste: Oh, wow. So it has such an incredible impact on all facets of health, but particularly for preventing many mental health issues.

Rowan: That's right. And, you know, if you look at an average day, the majority of people would probably spend about a third of it asleep. And I think that just if you take the actual proportion, that highlights how important it is for overall health and wellbeing.

Celeste: Yeah, it's something we can't really skip, is it?

Rowan: No, I wouldn't recommend it.

Celeste: Yeah, absolutely. And when you do, you feel pretty terrible. So it's important to prioritise. And what type of sleep problems might people suffer from, particularly when they work shift work? And what do you know about the prevalence of this and what type of treatment is available for people who do suffer from some of the more common sleep problems?

Rowan: Yeah, so given how complex sleep is, there's many different things that can go wrong. It's not like it's just you sleep well or you have a sleep problem, but sleep disorders in general are conditions that impair your ability to sleep well on a regular basis. And so some of the most common ones that your listeners may hear from a general population point of view, insomnia, that's difficulty falling asleep, staying asleep or waking up too early and not being able to get back to sleep. So that can be short-term or a chronic condition. And obstructive sleep apnea, which is where breathing repeatedly starts and stops during sleep.

And we know that a diagnosed sleep disorder, and when we take all of the main ones, occurs in about one in five adults. Now, on top of that, people who work shift work can also experience shift work sleep disorder or shift work disorder, which is a disruption to the internal body clock that regulates the 24-hour cycle of biological processes. And this is one of the circadian rhythm disorders others in that category are things like jet lag or delayed sleep phase disorder and in common across all of these are that your internal biological clock is out of sync with I guess the environmental external cues that help drive sleep and wake.

Celeste: And in terms of prevalence, we know somewhere between a quarter and a third of shift workers do experience shift work sleep disorder, according to recent systematic reviews. That's a really high percentage, isn't it?

Rowan: Yeah, it is. It is. I mean, maybe the part two to your question was about treatments, but we know different treatments are available. So for insomnia, things like cognitive behavioural therapy for insomnia is an evidence-based recommended treatment. For OSA, obviously CPAP is the gold standard and something that has very strong evidence base. But also for those circadian rhythm shift disorders. And for shift workers, you know, there's some really key things that can be done. So it's important to prioritise sleep in a 24-hour period, even if that's not the night time. We know that naps can be an effective tool for those particularly who work rotating shifts. And things like developing a shift schedule like you would for a work or task-based schedule are really important for maintaining routines. And we also know for the circadian rhythm disorders that the impact that light has, light's a very powerful synchronizer of the body clock and so controlling when light exposure occurs and when it doesn't occur is super important for shift workers.

Celeste: Great. Okay. Well, that's really good to know. And in terms of the prevalence of shift workers who have a shift work disorder, is that mostly people who would be working night shift, so rotating from days to nights, or is that anyone who's working outside the sort of standard kind of nine to five daylight hours?

Rowan: So that's a really good question. And it does depend slightly on the population where these studies have been done, whether they're in a medical or health-based workforce, whether they're in transport or other long-term, you know, like driving trains, planes, whatever, or fly-in, fly-out workers. So the prevalence does depend on which group. But in general, somewhere between that 25% and 30% is what we see across the board.

Celeste: Well we know that most nurses and midwives do have to rotate onto night shift, at least the people that are working in a hospital setting so you know it's good for people to hear this information because it would apply to a large population of the nursing and midwifery profession.

Rowan: That's very true, Celeste. And we also know that the rotating style shifts are the hardest on your body clock. If you work permanent days or permanent nights, that can be easier because you're not constantly shifting. Having said that, that comes with other negatives, such as impacts on social, family and friends.

Celeste: Yeah, very interesting. Okay, and could you tell us a little bit about what you know regarding the prevalence of alcohol use among nurses and midwives?

Rowan: Sure. So we know that many people in Australia who are adults consume alcohol and we can look at studies done that are done on a national setting, such as the National Drug Strategy Household Survey. And the last iteration of this showed that, you know, two thirds of adults consumed alcohol in the last 12 months. But that one in three which equates to about 6.6 million people consumed alcohol at risky levels which contravenes national guidelines. So we can use that as a starting point and then say that nurses and midwives obviously make up a proportion of that and we know from different surveys again that 20% of nurses and midwives have reported using alcohol as a sleep aid, some to quite high levels. And, you know, I think there was a study done by, it was colleagues of yours, Celeste, that showed, you know, risky drinking, again, to those national guidelines, occurred in somewhere between a quarter and a third of nurses.

Celeste: Quite a high percentage. And what effect does alcohol have on mental health and wellbeing? Does it increase the risk of developing mental health issues such as depression, anxiety, which are usually the more common mental health conditions that people can experience?

Rowan: So look, alcohol has significant effects on health. Now, how it affects an individual depends on a few different factors, such as how much alcohol has been consumed, over what period of time, and then some individual factors such as your kind of age, health, and your previous experience really consuming alcohol as well. So what we do know is that alcohol is a depressant drug, so it slows down the brain and the nervous system and it disrupts neurotransmitters that regulate mood emotions and thus mental health. So initially alcohol can create those feelings and provide people with some confidence but as you know as the effects wear off, we know that they can disrupt or worsen feelings of anxiety and depression, making it harder to maintain emotional stability.

Celeste: And is there a certain amount of alcohol that would lead to that occurrence of, you know, the change in neurotransmitters and ability to regulate emotions? Or is it when it gets to a more risky level that that is more likely to happen? Or is it even when people are drinking at lower levels, say, you know, one or two glasses of alcohol a day?

Rowan: Yeah, so that's a good question. It very much is affected by individual experience and previous exposure. So we do know that even low levels of alcohol can affect those states. And I'm sure we're all aware from big public health campaigns that we set really stringent limits on driving after using alcohol. And I think that really provides a good example that even small amounts, even when they're had infrequently, do affect things like performance. They do affect your ability to undertake tasks. But importantly, they also affect your mental health.

Celeste: Do you think people are aware of this, that that can occur at even low levels? Or do you think people notice when maybe their performance has been affected? Or is it one of those things that it's more subtle and perhaps not as noticeable in some instances?

Rowan: That's a really good question and I think it probably depends who you ask, and you know no doubt listeners to this podcast will have, you know, quite a high level of knowledge from being in the health workforce about alcohol and its effects on others or will have seen that in different settings and we know that, you know, quite a high proportion of people for example who call an ambulance or end up in emergency settings are affected by alcohol or another drug. And that would be immediately apparent to, you know, many people within your workforce. Now, having said that, if you ask a more general population, they may not have that same reflection, unless they've seen it in, you know, a friend, a family member or loved one.

Celeste: But really good for people to know that if they are going to choose to drink, that there is a potential for it to result in some of these concerns. I think it's just good for people to have that knowledge.

Rowan: Yes, for sure. And, you know, there is some work going on at Turning Point and other centres as well that say, you know, what are the motivations that people are having to consume alcohol? Is it to cope? And then is it to cope for a long period of time? Then, you know, we know that treatments are available and effective and there are resources, you know, things like the support service, also statewide services like DirectLine or Counselling Online where people can reach out if they're concerned about their drinking or someone else's drinking.

Celeste: Yes, and I think it's good that people are aware of what help is available and there is a lot of help available online I assume in most states, but I know you're talking about Victoria specifically. And I think that's really important that we're aware that if we are struggling with an alcohol or drug problem, that we can get the support we need. The research you conducted examined the impact of shift work on health and wellbeing. Shift workers tend to report poorer physical and mental health. Does being a shift worker lead to an increased use of alcohol, do you think?

Rowan: So being a shift worker doesn't necessarily lead to increased use of alcohol. There's likely to be high variability based on individual factors which we discussed before, but also situational or environmental ones. And they can be things like, are there opportunities to drink or are establishments open when people finish shifts at different times to the nine to five workforce? You know, we're currently working on a project with colleagues from the Centre for Alcohol Policy Research at La Trobe to look at risky drinking in some higher risk workforces. And we've chosen to look at nurses and also lawyers. So these groups often work with vulnerable people in the community, we know that as we mentioned high proportions of these workforces can drink more than is recommended and so this poses, you know, I think risks to the long-term well-being, mental health and safety of those individuals and also the collective groups and people that they're supporting, so yeah, I think there's, you know, a collection of different uh factors there but just being a shift worker doesn't necessarily lead to increased use of alcohol.

Celeste: Okay. There was a study done by the Sleep Health Foundation that found that a very high percentage of Australians, which I believe was around 50%, turned to alcohol to help them sleep better. As you mentioned before, shift workers often attempt to sleep at biologically difficult times. And research has found, like you said, that quite a high percentage of them suffer from difficulties initiating and maintaining sleep, and there is some evidence that suggests that they may employ sleep aids, particularly when stress at work makes it difficult to relax. Is alcohol an effective sleep aid or does it create a false sense of restfulness?

Rowan: That's another really good question. So, yes, that survey that you mentioned conducted by Sleep Health Foundation did find that many adults report using alcohol as a nightcap or to relax, and initially alcohol can be very effective in playing that role. It will reduce your, what we call onset to sleep latency or the amount of time that it takes you to fall asleep however your body quickly becomes tolerant to that so in order to have the same effect you need to have, you know, more and more alcohol so if you're doing this over a series of nights you might find that the amount of alcohol needed ends up being a lot more than you planned or wanted to drink. Alcohol will make you feel sleepy, but it actually has substantial disruptive effects on your underlying sleep architecture. And by that, I mean, it's the different stages of sleep that your body cycles through over the course of the night. So you end up with a highly fragmented or disrupted sleep episode, poor sleep quality, and probably not feeling great the next day or feeling quite sleepy. We know that if you drink alcohol you're more likely to have more frequent awakenings partly due to those destructive effects on the architecture, but you know, nightmares are more frequent, getting up to go to the bathroom because of that diuretic effect that's also you know more frequent after you've had alcohol.

Celeste: So perhaps what starts off is, you know, it feels like people are able to get to sleep more easily with the use of alcohol becomes a vicious cycle because then they're not sleeping well and they're continuing to try to, you know, promote better sleep by using alcohol which is continuing to make the sleep worse.

Rowan: Exactly yes, it can end up in a quite a vicious cycle.

Celeste: And people who struggle with sleep like you said sometimes turn to alcohol to improve sleep and people who use alcohol often have sleeping problems according to your research which as we said sounds like a vicious cycle. Instead of using alcohol do you know of any useful strategies that nurses and midwives might be able to use to improve sleep? I know you did mention earlier about light exposure, is that something you can talk more to if possible?

Rowan: Sure, so yes we know that, you know, light is the most potent synchronizer of our body clock or circadian rhythms, and we actually, in our eye, in addition to rods and cones, which are important for vision, we have melanopsin, which is a novel photoreceptor that really links those external light cues directly to the body clock. And the purpose of that of course is to try and make your body ready for a day and ready for sleep at night. So we know obviously for shift workers, you know, you're trying to circumvent that system in a way, so using a bright light before work or turning up lights during a night shift can help you feel more awake. And when you're shifting between different shifts, if you're on a rotating schedule, applying light therapy in the morning may help shift your rhythm so that you can wake up and fall asleep earlier. The converse is also true, so applying bright light in the evening can shift your rhythms later, helping you adjust to an upcoming night shift. We also know that you need to avoid light at different times as well, so things like wearing sunglasses, trying to keep a relatively dark room when you don't want to have those effects is also important.

Celeste: And in terms of going outside and using daylight for example, I mean it depends on the time of the year if it's winter, you know, you don't get much sun before 7.30, but is it a good idea for people to try to reset or just improve their circadian rhythm to get some outside daylight exposure like earlier in the morning, or is there a point where it's more powerful for helping to keep your body in a good rhythm that will help improve sleep?

Rowan: Yes, it's hard recording this with you over a Melbourne winter semester. It's very dark.

Celeste: Yeah, exactly.

Rowan: It remains dark in the evening as well. And we're quite fortunate where we're recording this here in Australia that we don't really have periods of the year where light happens all the time or there's an absolute light all the time. So trying to get natural light is super important for, I'd say, mental health as well. You know, being outside, being in that environment is good. Having said that for shift work if that's not possible or you're on a time where whenever you're getting up that that's not going to be available to you, there is light boxes and if you’re interested you know, listeners may reach out to the psychologist or the sleep health foundation to find out you know how those things work and where they'd be available from.

Celeste: Okay so the sun isn't accessible there is a backup you can look at a light box which can give that same sense of light to the brain, that's right and I just encourage people if they can when they're on a morning shift to go outside on their tea break or lunch break even, I mean I know that's not always possible and depends on the weather, and where you're located, things like that but if you can go out and get that even, if it's just five minutes of light I think that can really help people.

Rowan: Definitely. Yeah, I mean, even day workers, I can say that, safely say, you know, that just getting outside, having fresh air, having exposure to light is super important, not just the circadian rhythms, but I think overall well-being.

Celeste: Yeah, I learned about the light exposure many, many years ago when I first started doing the degree in my graduate year. And I found that when I went outside in the morning, even if it was just five minutes, it felt almost the same as having a coffee in terms of it would really increase my alertness and ability to focus. And it would often reduce feelings of fatigue. And I was very surprised at that. Okay, and could you tell us a little bit about the study you authored that examined police officers and their use of sleep promoting drugs and the findings on mental health and well-being? What do we know about the use of sleep promoting drugs and its effect on conditions like burnout and stress?

Rowan: Yeah, so this was a collaborative study that I led with some colleagues over in the US. It had about 5,000 police officers from North America who partook. And we found that over the past month, 20% of those police officers had reported using a sleep- promoting drug or a drug that caused sleepiness. And that wake-promoting agents were used by about a third of police. So that included things like quite high levels of caffeine or the use of nicotine or smoking to stay awake as well as other prescription drugs, so the next kind of question we said was okay well we've kind of got a prevalence number here of who's using what but are they associated with any negative outcomes? And we found that you know, high caffeine use, smoking to stay awake on a night shift were associated with an increased odds of subsequently reporting a fatigue related error, stress and burnout. So yeah that was I think super interesting finding to us we also found that you know, use of sleep promoting drugs was independently associated with poor health again using those stress and burnout measures and performance including more likely to report a fatigue attributable error at work or near crash or crash post a shift.

Celeste: And do you know what would be considered a high level of caffeine in that study?

Rowan: Yeah so we used a common scale to kind of convert different beverages primarily but also some foods that contain caffeine and I think the number related to you know more than 400 milligrams of caffeine, so we're talking more than four or five cups of coffee, yeah something that.

Celeste: Well I mean I'm not sure how many cups of coffee most people drink but that seems like it would probably be higher than average you can imagine

Rowan: Yeah it's actually a really tough thing to work out too because even if we take coffee or tea which are you know two of the common beverages that the way that that's prepared whether it's a filter coffee espresso an instant you know that does change very much how much caffeine is being delivered. The one thing I would say is that you know, perhaps rather than looking at the exact amount if people are saying I need a coffee to get through or I need another coffee or an energy drink or, or something you know, perhaps that's your body saying actually I’m tired, and we need to think about other solutions, so not sort of relying too heavily on caffeine or nicotine but you know trying to listen a little bit more to the body about what it's trying to tell you in terms of improving rest in other ways.

Celeste: Yeah, that's really good to know. I wasn't aware of that and that's really insightful. Great. And if you had, just wrapping up now, if you had one takeaway message to offer to nurses and midwives about sleep, mental health and alcohol use, what would it be? Big question, sorry.

Rowan: Look I think you know, the number one takeaway would be prioritise your sleep and do so unashamedly so at the top of the podcast we talked about the importance of good sleep but we often I think fall into the trap of prioritizing every and everything else in life. That could be work, social schedules, families, friends, or using devices to maybe listen to the latest podcast like this one. Don't listen late at night. You know, when I say prioritise, I mean, you know, practice good sleep hygiene, try and keep a consistent schedule where possible, be mindful of awake or sleep-promoting drug use and the reasons underlying that, and also not to be overly worried. You know, we all have... Even good sleepers would say that they have bad nights of sleep occasionally, but if it becomes a regular thing or you're concerned, then I think that's when you reach out to your healthcare professional.

Celeste: So in terms of if people are struggling with sleep resources and where they can go to help obviously there's your GP, we mentioned the Sleep Health Foundation before, they would be one organization, is there anything else you could suggest?

Rowan: So the Sleep Health Foundation is a good one. I mean, they have a lot of local relevant information for the Australia and New Zealand kind of field, things like fact sheets, talks or events that, you know, listeners here may find useful. The Australasian Sleep Association is another one that has a lot of practitioners in the field that you can look up to. So I think there are a couple of fantastic resources.

Celeste: Beautiful. That's good to know. Well, thank you so much for joining us today, Rowan. We really appreciate your time. It was great to hear all about your research.

Rowan: Thank you so much for having me, Celeste, and I really enjoyed chatting to you as well.

Celeste: Yeah, lovely. Thank you. And for any nurse or midwife in need of support, you can reach us on 9415 7551. Thank you for listening.