Staff Perspectives: A Follow-Up to “Debunking Common Misperceptions about Sleep Interventions”
Recently we hosted a webinar titled “CDP Presents: Debunking Common Misperceptions about Sleep Interventions” that addressed how as behavioral health professionals we can critically evaluate the regular barrage of claims we hear about sleep “tips” and products. I say critically not necessarily in a pejorative sense – that is, as a disapproval although that may end up being the case – but rather in the sense of approaching claims with a consistent evaluative framework. This kind of approach allows us to compare claims against scientific knowledge and evidence.
To recap, here is a framework we recommended (we being my outstanding fellow panelists Drs. William Brim, Carin Lefkowitz, Tim Rogers, and Maegan Paxton Willing) to help you debunk what you might hear about sleep:
- Explore peer-reviewed scientific studies (if any) about this claim: Who funded and wrote the studies? How did those who used the intervention compare to those who didn’t, rather than just a before and after comparison? Was this a one time finding, or can the outcomes be repeated whenever and wherever the intervention is studied?
- What professional organizations have endorsed this intervention, and why?
- Circle back to the promotional materials: Are claims exaggerated or one-sided, perhaps sound too good to be true or marketed as a cure-all? Is the intervention regulated in any way and if it should be, is that accurately described?
A lot of claims that sound really neat on the surface came up in the chat on our webinar. To name a few: tart cherry juice, l-theanine, calming teas, “REM promoting” sleep music, lavender, CBD oil, valerian root, supplement patches, sleeping with pets, vaping melatonin, inositol, etc. There are even more we thought of when chatting afterward: cooling pillows, forehead devices, smart mattresses, masks, salt lamps, “bioceramic” pajamas, colored lights, lotions, calming sprays, etc. Neat!
We were asked in chat over and over – isn’t this one different, doesn’t this one actually work? Certainly, that’s what the hype would have you believe.
Let’s apply our framework to an example instead of taking someone’s word for it. I’m going to pick tart cherry juice because I was asked about that twice in a week and told the National Sleep Foundation recommended it.
Claim: 100% tart cherry juice treats insomnia
Peer-Reviewed Scientific Studies: A PubMed search initially returned 21 articles including reviews, 8 of which were clinical trials. An early 2012 trial showed an increase in urinary melatonin levels and an increase in total sleep time and sleep efficiency (about 5%) on actigraphy but not on subjective sleep logs, in healthy adults without prior sleep problems (https://pubmed.ncbi.nlm.nih.gov/22038497/). Other studies had a small sample size, focused on a very narrow group (e.g.,males, hockey players), or found very small effects (10 minutes’ difference from placebo). In one study, authors concluded that effects were “considerably less” than evidence based treatments for insomnia such as Cognitive Behavioral Therapy for Insomnia (CBTI) and hypnotics (https://pubmed.ncbi.nlm.nih.gov/20438325/).
Professional Organizations: Indeed, I did find a blog article on cherry juice (https://www.sleepfoundation.org/nutrition/tart-cherry-juice); reading it I notice a lot of “may”s and reminders that context matters – say, as part of a winddown routine to boost the likelihood of better sleep versus a treatment for insomnia. No set recommendation to use cherry juice is made. Then I noticed…this is not the National Sleep Foundation (NSF) page! It is a media brand’s for-profit site not affiliated with NSF – they bought the domain name several years ago. Not neat. Neither the American Academy of Sleep Medicine, the Society of Behavioral Sleep Medicine, the Sleep Research Society, nor the actual NSF page has any guidance I could find.
Circle back to marketing: Yikes. Well, the NSF didn’t recommend it. There isn’t a specific company pushing this claim since there is generally no branded product, although cherry juice capsules and branded juice versions do exist.
My take: Cherry juice might taste good, but I wouldn’t recommend drinking it solely for insomnia. For those with insomnia, CBTI can restore sleep efficiency to a normal range unlike cherry juice outcomes, and is a learned skill that doesn’t have to be purchased and can’t run out. For those without insomnia, a good individualized winddown routine can provide benefit and it’s not clear cherry juice adds to that.
I went back to our esteemed panelists and asked for their parting thoughts about sleep misperceptions. I noted in our conversation that as providers we should really ask ourselves what any claim adds to the already known effective, gold standard treatments such as CBTI or continuous positive airway pressure for obstructive sleep apnea. Why would we not offer our patients recommended, effective treatments? Why would we reinforce the search for some external “cure” rather than internal behavior change? Dr. Lefkowitz added – don’t blindly accept “backed by research” promises that try to make something sound as evidence-based and critically appraise claims yourself.
You might wonder – is this science-informed mindset really that important? Should I really use this framework myself? Well, certainly as a presenter and behavioral sleep medicine provider I am biased, but just in general as a psychologist I would say yes, to ethically provide behavioral health care we should take a deeper dive approach to claims that impact the care we provide (see my earlier thoughts on this here). If our patients ask us about a sleep-related claim, I recommend we model critical thinking for our patients by walking them through this framework; how did we come to our conclusions if we have heard of the claim, or how might we make an informed conclusion if we have not. Modeling an evaluative framework facilitates collaborative, tailored recommendations so many of you mentioned as important during the webinar chat and teaches patients to apply critical thinking independently in the future. Our patients trust us – let’s honor that trust by only providing evidence-based treatment recommendations rather than misconceptions, opinions or marketing hype.
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Diana Dolan, Ph.D., CBSM, DBSM, is a clinical psychologist serving as a Senior Military Behavioral Health Psychologist with the Center for Deployment Psychology at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. In this capacity, she develops and presents trainings on a variety of EBPs and deployment-related topics, and provides consultation services.
Recently we hosted a webinar titled “CDP Presents: Debunking Common Misperceptions about Sleep Interventions” that addressed how as behavioral health professionals we can critically evaluate the regular barrage of claims we hear about sleep “tips” and products. I say critically not necessarily in a pejorative sense – that is, as a disapproval although that may end up being the case – but rather in the sense of approaching claims with a consistent evaluative framework. This kind of approach allows us to compare claims against scientific knowledge and evidence.
To recap, here is a framework we recommended (we being my outstanding fellow panelists Drs. William Brim, Carin Lefkowitz, Tim Rogers, and Maegan Paxton Willing) to help you debunk what you might hear about sleep:
- Explore peer-reviewed scientific studies (if any) about this claim: Who funded and wrote the studies? How did those who used the intervention compare to those who didn’t, rather than just a before and after comparison? Was this a one time finding, or can the outcomes be repeated whenever and wherever the intervention is studied?
- What professional organizations have endorsed this intervention, and why?
- Circle back to the promotional materials: Are claims exaggerated or one-sided, perhaps sound too good to be true or marketed as a cure-all? Is the intervention regulated in any way and if it should be, is that accurately described?
A lot of claims that sound really neat on the surface came up in the chat on our webinar. To name a few: tart cherry juice, l-theanine, calming teas, “REM promoting” sleep music, lavender, CBD oil, valerian root, supplement patches, sleeping with pets, vaping melatonin, inositol, etc. There are even more we thought of when chatting afterward: cooling pillows, forehead devices, smart mattresses, masks, salt lamps, “bioceramic” pajamas, colored lights, lotions, calming sprays, etc. Neat!
We were asked in chat over and over – isn’t this one different, doesn’t this one actually work? Certainly, that’s what the hype would have you believe.
Let’s apply our framework to an example instead of taking someone’s word for it. I’m going to pick tart cherry juice because I was asked about that twice in a week and told the National Sleep Foundation recommended it.
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Claim: 100% tart cherry juice treats insomnia Peer-Reviewed Scientific Studies: A PubMed search initially returned 21 articles including reviews, 8 of which were clinical trials. An early 2012 trial showed an increase in urinary melatonin levels and an increase in total sleep time and sleep efficiency (about 5%) on actigraphy but not on subjective sleep logs, in healthy adults without prior sleep problems (https://pubmed.ncbi.nlm.nih.gov/22038497/). Other studies had a small sample size, focused on a very narrow group (e.g.,males, hockey players), or found very small effects (10 minutes’ difference from placebo). In one study, authors concluded that effects were “considerably less” than evidence based treatments for insomnia such as Cognitive Behavioral Therapy for Insomnia (CBTI) and hypnotics (https://pubmed.ncbi.nlm.nih.gov/20438325/). Professional Organizations: Indeed, I did find a blog article on cherry juice (https://www.sleepfoundation.org/nutrition/tart-cherry-juice); reading it I notice a lot of “may”s and reminders that context matters – say, as part of a winddown routine to boost the likelihood of better sleep versus a treatment for insomnia. No set recommendation to use cherry juice is made. Then I noticed…this is not the National Sleep Foundation (NSF) page! It is a media brand’s for-profit site not affiliated with NSF – they bought the domain name several years ago. Not neat. Neither the American Academy of Sleep Medicine, the Society of Behavioral Sleep Medicine, the Sleep Research Society, nor the actual NSF page has any guidance I could find. Circle back to marketing: Yikes. Well, the NSF didn’t recommend it. There isn’t a specific company pushing this claim since there is generally no branded product, although cherry juice capsules and branded juice versions do exist. My take: Cherry juice might taste good, but I wouldn’t recommend drinking it solely for insomnia. For those with insomnia, CBTI can restore sleep efficiency to a normal range unlike cherry juice outcomes, and is a learned skill that doesn’t have to be purchased and can’t run out. For those without insomnia, a good individualized winddown routine can provide benefit and it’s not clear cherry juice adds to that. |
I went back to our esteemed panelists and asked for their parting thoughts about sleep misperceptions. I noted in our conversation that as providers we should really ask ourselves what any claim adds to the already known effective, gold standard treatments such as CBTI or continuous positive airway pressure for obstructive sleep apnea. Why would we not offer our patients recommended, effective treatments? Why would we reinforce the search for some external “cure” rather than internal behavior change? Dr. Lefkowitz added – don’t blindly accept “backed by research” promises that try to make something sound as evidence-based and critically appraise claims yourself.
You might wonder – is this science-informed mindset really that important? Should I really use this framework myself? Well, certainly as a presenter and behavioral sleep medicine provider I am biased, but just in general as a psychologist I would say yes, to ethically provide behavioral health care we should take a deeper dive approach to claims that impact the care we provide (see my earlier thoughts on this here). If our patients ask us about a sleep-related claim, I recommend we model critical thinking for our patients by walking them through this framework; how did we come to our conclusions if we have heard of the claim, or how might we make an informed conclusion if we have not. Modeling an evaluative framework facilitates collaborative, tailored recommendations so many of you mentioned as important during the webinar chat and teaches patients to apply critical thinking independently in the future. Our patients trust us – let’s honor that trust by only providing evidence-based treatment recommendations rather than misconceptions, opinions or marketing hype.
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Diana Dolan, Ph.D., CBSM, DBSM, is a clinical psychologist serving as a Senior Military Behavioral Health Psychologist with the Center for Deployment Psychology at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. In this capacity, she develops and presents trainings on a variety of EBPs and deployment-related topics, and provides consultation services.