Diversity In Sleep

Sushrusha Arjyal, M.D.

Sushrusha Arjyal, M.D.

Sleep is an essential phenomenon that plays a crucial role in renewing our energy, consolidating our memory, and improving our overall physical and mental growth.  Among sleep disorders, insomnia is the most common. Studies show that approximately 30-40% of adults in the United States suffer from insomnia, the prevalence being higher in females.1 Officially, the aggregate of symptoms, including sleep disruption, delay in onset of sleep, intermittent awakenings during the night, and waking up early in the morning, is defined as "insomnia" provided that it leads to significant functional impairment during the day.2

As a Psychiatrist and a Sleep specialist, I frequently see patients with insomnia. However, it is not uncommon to see patients with other sleep disorders who have subsequently developed insomnia over time. It significantly impacts their daily life, mental health, functionality, and relationships.  

To understand insomnia, we need to understand sleep. Sleep is a dynamic phenomenon that can vary from one night to another. Sleep can depend on what we do during the day and what we don’t. Sleep patterns can vary with time, season, age, and our daily activities. A regular bedtime, waking up time, moderate exercise, eating a healthy diet, a good bedroom environment and temperature are essential for good sleep. 

These lifestyle changes can be challenging for people who are struggling in different aspects of their life. I have personally treated patients who suffer from sleep disruption because they commute two or more hours, work night shifts or frequently travel across different time zones. Other patients include those too anxious and stressed about their lives that the bedroom provides little or no comfort: single parents with full time jobs or caregivers who cannot afford seven hours of sleep and are exhausted but “too wired” to sleep. Such patients go to bed and lay there for hours because “their mind seems to be going at 100 miles per hour” - their brain tries to work constantly like “a hamster in the wheel” at bedtime and it drives their sleep miles away.  

In these cases, I educate patients about sleep hygiene, giving up excessive caffeine, and the adverse effect of alcohol and other substances on sleep.  I also discuss pharmacological managements, but these measures prove to be less than ideal at times, perhaps due to the fact that insomnia is a symptom that can be affected by several other factors than just poor sleep hygiene.  

Studies support the fact that significant variations in work hours can contribute to disruptions in sleep. People who work more than 40 hours a week tend to have disrupted sleep compared to people who work less than 40 hours. Other factors found to be predictors of sleep disruption include being a caregiver, lacking social and emotional support, and having multiple physical and mental health issues.3 

Sleep and prevalence of insomnia can also vary between races. Several studies have shown that there is a significant disparity in sleep patterns between different races. A study in Chicago showed that there is a deficit in sleep duration in African-American, Hispanic, and Asian participants compared to White participants. The study was conducted after adjusting for apnea-hypopnea index (AHI), gender, age, education, work schedules, body mass index (BMI), smoking status, depressive symptoms, and other comorbidities like hypertension and diabetes mellitus.4 

Furthermore, it would be an oversight not to consider the challenges in accessing mental health care. Sleep issues and mental health care are fundamentally intertwined. Providing more access to mental health care and proper treatment of mental illnesses like depression, mania, and hypomania can lead to better sleep in individuals and vice versa. 

The use of substances can be detrimental to sleep. Access to proper detoxification centers and rehabilitation will give sleep specialists an opportunity to work on bringing individuals more or less back to their normal sleep patterns. The lack of access to proper treatment leads to frequent relapses, which also hinders the overall treatment of insomnia in individuals. 

Lastly, we should talk about financial challenges in treating patients with sleep disorders. Sleep studies, especially in lab studies, tend to be expensive. I have had patients who are already struggling financially who decide to skip or postpone their sleep studies as they focus on saving for other medical expenses. Sleep studies are essential to treat disorders, including but not limited to sleep apnea, periodic limb movement disorders, narcolepsy, and others as they frequently present with overall sleep disruption. Treating them is important to treat their overall sleep.

In conclusion, sleep and sleep disorders do not exist in isolation. Educating patients about sleep hygiene can have a significant impact if we are able to simultaneously address the different factors adversely affecting their sleep. Often, I succeed in treating insomnia by educating my patients about their bedtime, avoiding the use of electronics; and avoiding excessive caffeine and alcohol and even working towards quitting smoking. However, insomnia is a problem that is deeply embedded and co-exists with other medical and psychological problems. Prognosis is deeply affected by social, cultural, and financial aspects of the individual and is adversely affected by these constraints. Our focus on increasing access to the other aspects affecting sleep and focusing on education on sleep will be a step forward towards improving overall physical and mental health. I do have hope that someday, with collective effort, we will be able to achieve this milestone.


  1. Grewal RG, Doghramji K. Epidemiology of insomnia. In: Clinical Handbook of Insomnia. 3rd ed. Attarian HP, ed. 2016. Humana Press.
  2. Black DW, Grant JE, eds. DSM-5 Guidebook: The Essential Companion to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, DC: American Psychiatric Association Publishing; 2014. 
  3. Williams NJ, Grandner MA, Wallace DM, Cuffee Y, Airhihenbuwa C, Okuyemi K, Ogedegbe G, Jean-Louis G. Social and behavioral predictors of insufficient sleep among African Americans and Caucasians. Sleep Med. 2016 Feb;18:103-7. doi: 10.1016/j.sleep.2015.02.533. Epub 2015 Mar 28. PMID: 26514614; PMCID: PMC5070606.
  4. Carnethon MR, De Chavez PJ, Zee PC, Kim KY, Liu K, Goldberger JJ, Ng J, Knutson KL. Disparities in sleep characteristics by race/ethnicity in a population-based sample: Chicago Area Sleep Study. Sleep Med. 2016 Feb;18:50-5. doi: 10.1016/j.sleep.2015.07.005. Epub 2015 Jul 26. PMID: 26459680; PMCID: PMC4728038.