Delegate: D Douglas Smith, MD
Activity: Inquiry into Mental Health and Addiction in New Zealand.
DATE: 5th June, 2018
SUBJECT: Proposal on Sleep Health
SUBMITTED BY: Doug Smith, MD
INTRODUCTION
I am a psychiatric physician working for the Tairawhiti DHB, and am writing with a brief proposal to
include sleep at the forefront of New Zealand’s health promotion efforts. This pragmatic and
implementable proposal identifies a major unmet need related to how New Zealand can better prevent
mental health and addiction challenges. Before detailing what this entails, let me share some
background.
On the 28th of April, a charitable event took place in Gisborne called “Fishing For A Solution –
Supporting Mental Health,” hosted by two young men from Campion College with Sir John Kerwin as
the invited speaker. As a new psychiatrist in town, I hadn’t heard about it until that same afternoon
when I was evaluating another teenager, a lovely young woman who had tried to take her own life the
day before and was ready to leave the ICU. After we had made a plan for her safety and ongoing care,
the girl’s family told me about the benefit taking place and encouraged me to attend. The evening talk
by JK was inspiring, as was the sincerity of the two young hosts. Afterwards, I kept thinking about the
name they had chosen for their community “impact project” – FISHING FOR A SOLUTION.
The first thing that came to mind was how naive it is to assume that there is one solution to all of the
many challenges that fall under the mental health umbrella. A single solution implies a single problem.
If there was one lesson I had learned over a 30 year career, it is that mental health problems are
complex, multilayered and different for each individual, requiring a wide range of equally complex,
multidisciplinary, individualized solutions. For this reason, psychiatry is often hardest medical specialty
to do well and the easiest to do badly. Unfortunately, in the face of this complexity, uncertainty and
terrible suffering, many in field yield to an optimistic yearning for simplicity – one theory, one therapy,
one pill, one solution. The tragic results of these blind crusades have been predictable. The ancient
Greeks understood this, and they called it Hubris.
Nevertheless, I found myself wondering about the two teen boys who set out fishing, with optimism,
for the solution to our nation’s growing mental health crisis. What might such an elusive solution look
like? And how could they possibly pull it up from Tangaroa’s murky depths?
We know there isn’t a single solution to how mental health is promoted and supported in New Zealand,
but what if abundant research had identified a way to prevent the most common cause of brain
dysfunction and reduce risk for widespread health and social problems? What if this solution involved
safe, simple, low-tech, low-cost approaches that everyday people could use by themselves?
Such a solution, the “big one” of our dreams, does exist. I have seen it. In fact, we all have. It is called
sleep, and though it is just one of many things needed to improve mental health, it may be the biggest
single evidence-based factor no one is talking about.
Public health campaigns centred on sleep as a solution to myriad public health problems have recently
been proposed by national agencies in the USA and UK, but not yet implemented (see attachments).
Perhaps it is time we New Zealanders set about learning how to catch and haul this public health
solution into our waka.
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SLEEP and HEALTH
Proper sleep is critical for a healthy brain and there is compelling evidence that it reduces the risk of
many physical, mental, behavioral and performance problems. This should not surprise us given the
fact that the functions of our brains are what guide our perceptions, cognitions and behaviors and shape
our physical, mental and social health. This becomes more and more the case as we navigate through a
world of growing complexity. On the other hand, inadequate sleep is associated with significantly
increased symptoms and worse outcomes for nearly all physical and mental health problems, including:
Performance problems from inadequate sleep…
Impaired frontal lobe function (executive functions)
Reduced mood regulation
Impulsivity
Impaired attention and concentration
Difficulty remembering and learning new information and skills
Misperception and false memory for events
Reduced stress tolerance
Anger and frustration
Impaired communication skills
Impaired socialisation
Errors, misunderstandings and disagreements
Greater marital conflict and poorer relationships satisfaction
Temper tantrums in children, and violence and interpersonal conflict in adults
Impaired decision-making
Reduced creativity
Impaired multi-tasking
Malaise and avoidance of common activities (school, sports, work, exercise, socializing)
Being unemployed
Qualifying for benefits
Mental health risks from inadequate sleep…
Anxiety and hyperarousal
Overeating, gambling, drug and alcohol intoxication
Alcohol and drug dependency and relapse
Increased sedative and stimulant use
Higher risk of suicide – sleep disturbance (such as insomnia and nightmares) is associated with
an almost threefold increase in completed suicides.
Psychiatric relapse
Anxiety and panic symptoms
Depressive and manic episodes
Paranoia and psychotic symptoms
Delirium with extreme sleep deprivation
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Physical health risks from inadequate sleep…
Heightened stress response
Disorders of the Hypothalamic-Pituitary-Adrenal (HPA) axis
Impaired immune function and increased risk of infection
Increased cancer risk
Increased blood pressure, cardiovascular disease and stroke
Impaired glucose tolerance, metabolic abnormalities, weight gain & obesity
Thermoregulatory problems
Lowered seizure threshold
Body aches due to inflammation and impaired pain regulation
Chronic fatigue
Road traffic accidents, injuries and deaths
Accidental falls, fractures and injuries to oneself and others
Repeat prescribing
Less likely to attend appointments
Longer hospital stays
Earlier admission to long-term care
Earlier onset of dementia
These well-established impacts of inadequate sleep on mental and physical health are highly relevant to
the Government Inquiry into Mental Health and Addiction (the Inquiry). Compared to other solutions,
improving sleep in Aotearoa could have the single biggest impact on the main goals of the Inquiry:
Building positive mental wellbeing for all New Zealanders
Helping people to deal with mental health challenges early (before specialist treatment is
required)
Enabling people to avoid becoming addicted to something that causes harm
Preventing people from taking their own lives
Making it easier and faster to identify when someone is facing mental health or addiction
challenges and get them help more quickly
Improving the quality of the support and interventions given to those who need it
Soliciting any other ideas for improving mental health and wellbeing in Aotearoa
Although there are many determinants of brain health and function beyond sleep, none are as
significant or as suitable for a national public health campaign. Improving NZ sleep health is essential
and achievable. It is the low-hanging fruit for improving mental health. Here are eight reasons why.
1. Inadequate sleep is a common and growing problem.
2. Māori are more likely than Non-Māori to report usual sleep duration longer or shorter than
recommended. Higher rates of unemployment, night work, and socioeconomic deprivation
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among Māori contribute to these differences. Growing evidence suggests that poor sleep is an
important mediator of many health disparities.
3. Inadequate sleep increases the incidence, severity and costs from physical and mental health
problems, accidents and illnesses, interpersonal conflict, and educational, social and
occupational difficulties.
4. Because sleep is the foundation for the collective brain health on which our society depends, the
many benefits of improved sleep health will be woven through various inter-related policy
areas, strengthening our social fabric. For this reason, the potential for improving our national
sleep health should be a source of great hope.
5. At the individual level, non-medical approaches to improving sleep health can be low-tech and
risk-free. They are generally low or no-cost, take little effort, and are sustainable. Improved
sleep is often the first step on the path to self-care, recovery and empowerment.
6. At the community level, public health initiatives to improve sleep health can likewise be lowcost,
low-risk and relatively easy to deploy.
7. At the national level, once an attitude that prioritizes adequate sleep is established and sleepskills
are widely shared, they can become a self-sustaining part of Kiwi culture – a crucial part
of a shared tikanga that embraces a healthy body, brain, mind and spirit.
8. New Zealand can lead the way in making optimal sleep and brain health a global health priority
for humanity.
PROPOSAL
It is proposed that a top health goal for the Government, employers, educators and healthcare providers
should be to improve sleep health and reduce sleep deprivation in New Zealand. We have local
expertise at the forefront of this area, such as the New Zealand Sleep/Wake Centre at Massy University.
It is also proposed that these local experts take the lead on helping the public to view sleep as central to
our nation’s health, and on helping guide the development of specific initiatives. Using the
recommendations of the Royal Society for Public Health (RSPH) as a starting point, here are some
suggestions:
NZ Governement
The Government should develop, adopt and publish a national sleep strategy that recognizes the role of
sleep in protecting against physical and mental health problems, ageing, accident and injury, and in
underpinning a range of key health behaviours; alongside the need for effective treatment of disorders
of sleep such as insomnia and sleep apnoea.
The evidence is overwhelming that sleep is of primary importance to physical and mental health, yet it
has not been viewed as a priority area for public health and disease/accident/conflict prevention. For
example, the preventative health/wellness initiatives listed on the Ministry of Health’s website include:
Family violence, Healthy Families NZ, Immunisation, The Mobility Action Programme, Nutrition, Oral
health, Physical activity, Sexual and reproductive health, Social Bonds, Tobacco Control and screening
programmes for bowel, breast and cervical cancer, newborn hearing and metabolic disorders. However,
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despite clear evidence that sleep is a hugely important public health issue and one of the most
important components of health protection and improvement, there is no mention of sleep health.
The Ministry’s online resources on wellness include a section on “Food, activity and sleep,” yet it treats
sleep as an afterthought. For example, there is “Guidance on nutrition and physical activity for
workplaces,” but no guidance for workplaces regarding sleep. There is a “National Healthy Food and
Drink Policy” and a “Healthy Food and Drink Policy for Organisations,” but none for sleep.
Finding similar neglect of sleep health in the UK, the RSPH has recommended:
Its value to the health and wellbeing of the population means that sleep should have
parity with other public health issues and should be officially recognised in the remit of
government Ministers . . . The multi-dimensional nature of sleep means that crossdepartmental
responsibility may be needed. Sleep has wide-reaching implications for
disease, physical and mental health, healthy ageing, education, transport, employment,
the NHS and business. Addressing all of these issues will need work across a number of
departments under the direction of a Minister of State.
Employers
Sleep deprivation and sleep disorders are independently associated with risks of falls, fractures, and
industrial and road traffic accidents. They also reduce job performance, and contribute to absenteeism
and disability. Because of this, RSPH has recommended that the Health and Safety Executive (i.e.
WorkSafe New Zealand) should enforce employers’ health and safety duties when it comes to sleep:
Employers have a legal duty to make sure reasonable measures are in place to remove or
control the risks of work activities, including hours worked and how they are scheduled.
As evidence emerges that risks of sleep disruption due to shift work are severe, employers
must be made to show they are up to date with best practice for reducing the health risks
from sleep and face legal consequences if not. Employers who operate shift or long hours
work should provide information to employees on how to achieve healthy sleep and
signpost them to effective online self-help resources and health services.
Educators
Sleep should be covered in the secondary school curriculum. It is well established that insufficient
sleep associates with reduced attention, impaired learning, and poorer academic performance. As RSPH
observed:
Studies have shown teenagers deprived of sleep are more vulnerable to poor
communication, decreased concentration and cognitive performance, unintended sleeps,
decreased motor performance, increased risk taking and depression. Reducing levels of
sleep deprivation among adolescents should be a key public health priority, as it
impacts on a range of other health outcomes for young people into their adult lives and
so research in this area is of the highest importance.
Sleep education programs have been shown to significantly improve sleep onset latency, sleep
efficiency and total sleep time which associated with an improvement in academic achievement in
mathematics and English. Sleep education should be included as part of the knowledge, skills and
attributes needed to stay healthy and safe, and to prepare for life and work in contemporary New
Zealand.
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Consideration should also be given to later start times for high schools. Several schools in the UK have
decided to push back their opening hours to a time that may be better suited to the adolescent circadian
rhythm.
Health and Care Professionals
GPs, nurses and other health workers typically ask service users about diet, physical activity, alcohol
and drug use and sexual activity, but may neglect to inquire about sleep health even though clinical
level insomnia is thought to affect a great number of people with numerous adverse impacts on health
and functioning. UK data demonstrate that sleep disturbance (more so than depression, anxiety, worry)
is actually the most common form of mental disorder, in men/women, of all ages and ethnic groups,
and prevalence is increasing.
Sleep should be embedded in all primary health care training, and should be assessed as part of all
routine assessments. The Sleep Condition Indicator (SCI) is a UK screening tool that could be used for
this purpose, and can be administered quickly in either a 8 or 2-item format. For some whaiora, having
difficulty sleeping is less stigmatising than having Depression or an alcohol problem, so focusing on
insomnia can be the first step to recovery.
There is also concern that there may be an over-reliance on treating the disorder with sedatives and
other pharmaceutical solutions. This is perhaps the greatest danger in the effort to raise awareness of
the importance of sleep health, as dependence on habit-forming sedatives can worsen both sleep and
mental health and increase service utilization and costs.
RSPH recommends a training agenda be developed for all health and social care staff, especially
focused on non-pharmacologic therapies and ways to minimize harms if medications are used. There
are online programmes in sleep medicine specifically for health professionals seeking further
knowledge and expertise in the management of sleep disorders (see: https://www.ndcn.ox.ac.uk/study/
graduate-students/online-programme-in-sleep-medicine).
Cognitive behavioural therapy (CBT) is safe and effective for persistent insomnia but under-used. It
can be made available in accessible formats (e.g. small groups, booklets, digital/web/mobile therapy).
ATTACHMENTS
U.S. Centers for Disease Control, Raising Awareness of Sleep as a Health Behavior (pdf)
Royal Society for Public Health, Waking up to the Health Benefits of Sleep (pdf)
Massey Sleep-Wake Centre, Summary of research (pdf)
CONCLUSION
I encourage members of the Inquiry to consider this proposal for a national sleep initiative as a prime
opportunity to save lives, to reduce suffering and interpersonal conflict, to improve mental and physical
health, to boost learning and productivity, and to cut the unnecessary health costs for NZ businesses
and government agencies.
Improving sleep health comes from the perspective of preventing mental health and addiction
challenges and promoting mental well-being, and it also addresses mental health challenges across the
full spectrum from mental distress to enduring psychiatric illness, as well as those facing challenges
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from addictions, intellectual disabilities and physical health problems. In other words, supporting sleep
health also supports the breadth and depth of prevention, resilience, treatment and recovery.
Furthermore, this proposal recognizes that there are significant disparities in sleep health for Māori, and
that sleep has a critical role in the prevention of suicide.
The proposed sleep health initiative includes both short and long-term solutions that are actionable at
the national, local and individual levels, and the broader health and disability sector (in community,
primary and secondary care), as well as other sectors, including: education, social welfare, corrections,
workplace relations and safety systems. The proposal also has potential to reduce the rate of accidents,
injuries, aggression, interpersonal conflict, and physical illness such as diabetes, cardiovascular disease
and cancer. By reducing demands on mental and physical health and social services, this proposal
could improve service access and reduce the severity of resource and workforce shortages.
Undoubtedly, it will also provide opportunities for leadership in sleep research and global health policy.
At its widest scope, beyond traditional health and welfare initiatives and beyond sleep research,
improving the sleep and brain health of our people is likely to have synergistic benefits in helping
Kiwis to better think through and work together on solving the many other challenges we face. In this
way, better sleep can help lead the way in transforming our nation into one that is healthier, safer,
smarter, more compassionate, more creative, more resilient and more sustainable.
Thank you for your dedicated efforts to improve mental health in New Zealand. Please do not hesitate
to contact me if you have any questions.
Submitted by: D. Douglas Smith, MD, Gisborne
Attachments:
1. Proposal on Sleep Health (final)
2. CDC – Raising Awareness of Sleep as a Health Behavior