Interview with Dr. Hrayr Attarian

Thanks for joining me today. You have such an impressive resume. Would you mind telling me about yourself and how you got into sleep medicine?

While studying for my undergraduate in biology, I took a class in abnormal psychology, and one of the lectures was about dreams, which piqued my interest in psychology and sleep in particular. I went to medical school to be a sleep physician. At the time, a psychiatrist was the only person in my medical school who researched sleep. Consequently, I wanted to be a psychiatrist but didn’t like the rest of psychiatry, so I switched to neurology. My neurology residency, two years of EEG, and a neurophysiology fellowship helped to build a solid foundation for my sleep education. I then did another fellowship in sleep medicine for one year and then started working as an assistant professor in July 1999. I have been focusing on sleep medicine exclusively since July 2003.

You describe sleep deserts as regions where large numbers of people are experiencing sub-optimal sleep. Can you elaborate on this concept?

The first time I thought of the idea of sleep deserts was in 2005. I was in California attending a conference. A pediatric sleep pioneer was showing her proven method of helping toddlers sleep. She suggested that a parent or parents and toddler sleep in separate bedrooms. My first thought at the time was, what if the household has only one bedroom? Another example is when people suggest healthy eating, but how will people eat healthy when they don’t have money for a car or the means to go to a grocery store in a wealthier neighborhood even if they could afford the food there? While in their local neighborhood, the only food is coming from the corner market.

Neighborhoods can do things to improve these deserts, such as providing residents with healthier food options and green spaces to walk. Addressing the food and exercise deserts will indirectly also improve sleep deserts. They can provide people with community greenhouses and help them grow fresh fruits and vegetables. And now they’re able to eat a little healthier, feel better and sleep better.

There is a large, multi-country study in a prestigious science journal called Cell. The study involves remotely collecting data from wearables around the world. Obviously, the study is limited to countries where people can afford to buy wearables, but there is a huge variation in income even within these countries. The sleep data collected revealed a significant disturbance between rising ambient temperatures and a reduction in sleep quality and duration.

While this phenomenon affects people everywhere, poorer countries closer to the equator are affected even more. We are writing a call for action paper summarizing these and other causes of sleep inequities and suggesting an actionable list of items. Because in addition to climate change and the economic issues around poor housing, racism, and discrimination impacts sleep tremendously.

In a study, standardized questionnaires assess that an increased self-perception of a person who feels discriminated against is associated directly with poor sleep quality compared to somebody in the same environment who does not experience discrimination. This discrimination has been shown to affect multiple groups, including ethnic as well as sexual minorities. For instance, structural racism that affects the health of African Americans may extend into the medical office, where healthcare providers may dismiss patients’ complaints and assume non-compliance with recommended treatments based on implicit bias.

Can you share details about your paper discussing problems around physician burnout and circadian management?

The number one issue for medical burnout is administrative tasks such as requesting medication approvals from insurance companies. Of course, we should not ignore sleep and circadian issues. We all know that depending on one’s unique internal rhythms, people feel most alert at different parts of the day. For instance, somebody with an intermediate or what’s considered a normal rhythm sleeps from 11 pm to 7 am. When that person first wakes up, they are not in peak alertness, which usually occurs three hours later, in this case around 10 am. Yet surgeons still schedule their hardest cases first thing in the morning, assuming that they are the least tired then.

Sleep deprivation is a huge problem for shift workers. The more sleep-deprived a person is, the less likely they are able to recognize their own limitations. This affects judgment, lessens tolerance for stress, and creates a situation where people are more prone to burnout. In a study we conducted among physicians, we found that one of the biggest reasons for sleep deprivation was the number of hours worked per week, not necessarily the hours available to sleep at night. In other words, if you work over a certain number of hours, you are more likely to be sleepy, fatigued, and sleep deprived, even if you allow yourself a full eight hours of sleep.

When addressing burnout, the number of hours worked per week matters more than the number of hours slept. Working extra hours is a big part of the problem, and there’s very strong resistance to working fewer hours. For instance, in 2003, a federal law limited the number of hours that residents were permitted to work. Before this, New York was the first state to restrict working hours because of the famous Libby Zion case. Once it became law, there was a concentrated effort by different medical organizations to undermine it, claiming that limiting the number of hours worked did not matter. Today, there are still moves to rescind that protection. I imagine the field of medicine before 2003 was even less appealing.

In European countries, the training is much longer, but the hours are more humane compared to the United States. Some of the most essential professions in society are in trouble. During the pandemic, we saw the mass resignation of nurses and teachers, and now we’re looking at physicians. We are at a breaking point in the physician crisis, particularly among primary care providers. And if you look at the health outcomes in the US compared to other wealthy countries, the only place we excel is in cancer treatment. Infant mortality is at the level of middle-income countries, not those of high income. Our life expectancy has obviously dramatically declined during COVID, but even before COVID, it was the lowest among all the wealthy countries.

Can you elaborate on your work with refugees, and how their lack of sleep affects their quality of life?

I collaborated with a Ph.D. colleague in Jordan. They were seeing an increased number of sleep disturbances in refugee populations due to the current wars in the Middle East. Poor sleep quality is the strongest element impacting their quality of life, more so than other health issues, financial strain, etc. We compared refugees who lived in the city and were more integrated into Jordanian society versus those who lived in camps. Those who lived in camps had poorer sleep and health-related quality of life. Part of it could be they were newer, more recent arrivals, but also, the amount of space is a huge factor. Their living quarters are in crowded, poorly built, unsafe areas polluted with noise, light, etc.

Sleep education has dramatically increased over the past 20 years, yet medical schools don’t emphasize enough the importance of sleep, in my opinion. And these refugees were being taken care of by local volunteer doctors who were stretched thin already.

I reached out to a colleague, Dayna Johnson, who is an epidemiologist who studies sleep inequities in the United States. Actually, a lot of the problems that affect refugees also affect poorer neighborhoods. Crime is higher in poorer neighborhoods and, therefore, a stressor. To deter crime, more streetlights are installed, which creates light pollution and interferes with sleep. Also, the buildings don’t necessarily have central air or central heating, so they may be too hot in the summer and too cold in the winter.

On the topic of families who share multigenerational homes. Do we need to provide elders whose sleep quality declines with age with a certain amount of space so that they can get better sleep?

You need to provide older people with better light exposure in the morning because the corneas yellow with age, so they don’t get as much of the blue wave light in the morning. They need brighter lights so that they get adequate amounts of blue and green wave light. In addition, older people have age-related degeneration of circadian circuitry in the brain. If they don’t get enough light, they’re more likely to nod off during the day, which leads to a primary disturbance of their sleep at night. Being awake at night because they slept during the day causes them agitation because there are no external cues to direct their circadian rhythms. This phenomenon is called sundowning.

In fact, it’s been known for around 30 years that the number one determinant for when an older person with dementia gets institutionalized is their disturbed sleep. The family feels obliged to be with them to make sure they don’t get hurt, and that they don’t leave the house, or make too much noise, and it becomes too much of a strain on the caregiver. There is some data from both medical and architectural research that supports designing nursing homes to maximize light exposure during the morning hours.

I adapted my refugee/caregiver education project for the Community Health Center (CHC) here in Chicago. Simultaneously, one of my colleagues, Dr Justin Fiala, opened a free sleep clinic at the center.

Can you share more about this clinic? How long has it been operating?

The free sleep clinic has been open for about a year. The only requirement of the grant is that people have to be a patient of the CHC, which means they cannot have medical insurance. So if you have any kind of insurance, regardless of whether or not it pays for sleep health, you are ineligible for treatment at this clinic. I partnered with him and another colleague who runs a rotation for medical students from Rush. Because that clinic’s population is largely non-English speakers, medical students distribute handouts in English, Spanish, and Polish. Some refugees have been here since 2014. For people who are illiterate, we also recorded videos of doctors discussing the information and screening process. Since starting this education campaign, the clinic has seen a dramatic increase in insomnia and sleep apnea cases, and we’re preparing to write up a paper and then hopefully use that as pilot data to justify wider sleep education campaigns.

In order to provide free sleep tests, Dr. Fiala’s clinic uses manufacturer-donated equipment and purchases consumables with grant money. Patients leave the clinic with three items: a smartphone-sized device that connects to a hose to place over their ears and under their nose to monitor breathing, a device to be placed on their finger, and either one or two belts to monitor effort. Patients return to the clinic with the devices, the clinic downloads the data, the consumables are discarded, and the non-consumables are sanitized and reused.

So it’s an unsupervised, self-administered sleep study?

Yes, and then there’s the second one, which is called a PAT device which is simpler to use. PAT devices measure the level of tension in the peripheral blood vessel. A drop in tension correlates with an apnea. In addition to monitoring oxygen, this Fitbit-like wristwatch helps assess your light, deep, and REM sleep amounts.

Studies are conducted using either of these procedures. Then, we discuss treatment information. For those with insomnia, we provide basic sleep hygiene information, but we still don’t have somebody to administer behavioral therapy. For those who have sleep apnea, Dr. Fiala’s clinic distributes donated CPAPs, which are professionally disinfected and cleaned at Northwestern.

In your physician video, you mentioned that you’d rather treat sleep conditions with natural approaches rather than chemical ones. Can you share more about these natural methods?

After I rule out sleep apnea or any condition that requires a device or medication, I generally treat it with natural methods. When I make the diagnosis of chronic insomnia, I tell the patient, “you’re going to fix your sleep, and I’m your coach. I’m no longer the doctor giving you something to make you better. You’re going to make yourself better, and I’m going to guide you.”

I work closely with a couple of psychologists who help me. When people have trouble sleeping, they act in good faith, but sometimes it backfires. For instance, when you feel tired, you go to bed and fall asleep right away. Then you wake up as soon as you’re out of your deep sleep, and you can’t go back to sleep. So you think it makes total sense for you to just stay here snug in bed rather than get up and go out and do something. But that’s actually counterproductive. What you’re doing is creating an association in your brain between the bed and not sleeping. Therefore that conditions your brain to be hyper aroused every time you get in bed.

I read that one solution to deal with insomnia is to leave your bed, sit in a dark place, sit up and wait for yourself to grow tired while sitting in the chair. Do you agree with this method?

Yes. Another thing people do is get up in the middle of the night. They know to get up, so they stop getting frustrated in bed. And they say, we all have a laundry list of things to do so since I’m awake, I should take advantage of this time and do some of the things I need to get done. No, you shouldn’t do that. Why? When you accomplish things, you feel rewarded. And the brain’s reward chemical, dopamine, is a very powerful stimulant.

And the reality is that when patients try to fix their insomnia, for the first two or three days, they feel totally exhausted and doubt the methods are working. In fact, they feel more tired than before they sought treatment. But that tiredness harnesses your sleep drive to make sure you sleep the following night. I always tell them things get worse before they get better.

Unfortunately, the research isn’t well done in the area of natural sleep supplements for two reasons. One big part is funding. Majority of medical research funding comes from industry and some comes from NIH. Usually, NIH or government organizations want to fund research that are more disease oriented like finding out what causes a certain disease; they’re not going to fund the study looking at this herb versus that herb. The second is that the herb supplement market in the US is not regulated, so you don’t know what you’re getting. One old study that looked at several brands of ginkgo, and three didn’t even contain any ginkgo, just placebo. The key is finding supplements that are correctly formulated. For melatonin, the two companies that we found to have higher purity melatonin are Life Extensions and Pure Encapsulation.

So melatonin is excellent for shift work, for jet lag, for circadian rhythm, but these are not why most people take it. While it could be very sedating, it’s not necessarily sleep-inducing if your primary problem is insomnia and not a circadian rhythm issue.If you take it at the wrong time, it can be worse than a circadian rhythm problem. The right time would be 3-4 hours before your desired bedtime.