Melanie Cole, MS (Host): Welcome to It's Your Health Radio with Henry Mayo Newhall Hospital. I'm Melanie Cole. Today we're offering up Sleep 1 0 1 Melatonin. What it really does. To your body. We all wonder about this And we hear about it a lot. We're gonna learn about it today. And joining me is Dr. Sam Kashani.

He's a sleep specialist at UCLA, and he is also the president of the California Sleep Society. Dr. Kashani, thank you so much for joining us today. I wanna jump right in with what is melatonin? We hear the term we see it at, at, you know, our local pharmacy on the shelf there.

What is it?

Sam Kashani, MD: first of all, thank you so much for having me. It's great to be here with you. as far as melatonin, the more popular use of melatonin is as a sleep aid. as you mentioned, you can find it over-the-counter. It's a supplement. As such, it is a poorly regulated supplement.

There's also not a whole lot of research, or at least longitudinal long-term data looking at melatonin, but essentially it's most commonly used as a sleep aid. And for some people that does work, meaning they do take melatonin and feel a little bit more drowsy and can get to sleep.

But the few studies that do exist on melatonin as a sleep aid actually don't really have consistent results, and that's why you have such variability in terms of people's response when they take melatonin. Many people will take it and. Tell you that it works really well and it gets 'em to sleep quickly, And then there are plenty of people that take it and it does absolutely nothing for them.

So that being the case, it is used kind of as a treatment for insomnia, which as sleep doctors, we define insomnia as any difficulty falling asleep, any difficulty staying asleep. Waking up too early in the morning or any combination of those three things. So it's not an evidence-based treatment for that problem, although it does help some people with that problem.

But there are actually a few clinical uses of melatonin that are different than using it for insomnia, which I can go into of course.

Melanie Cole, MS (Host): Well, thank you for that. So what does it actually do to help you with sleep? How does it help you if it works for that individual person?

Sam Kashani, MD: Yeah, there are two clinical evidence-based uses for melatonin that we as sleep physicians will most commonly use it or prescribe it to patient's. they're typically not for insomnia, like we said, even though plenty of people take it for that reason. But the two more evidence-based uses of melatonin are number one.

Using it to correct somebody's circadian rhythm, just because melatonin, similar to bright light, is what we call a Zeit giver or, something that essentially modulates or controls our circadian rhythm, which is the 24 hour sleep wake rhythm that our body operates by. for people who have circadian rhythm issues, like, for example, delayed face syndrome, which is when a person has adopted sort of a gradual shift in their circadian rhythm, such that they're naturally falling asleep late.

And naturally awakening late, kind of like your classic teenager sleep pattern. So in that particular setting, melatonin when timed meaning not taken at bedtime actually, but timed a few hours before, strategically, that can actually have an effect to move or pull the rhythm of the sleep period earlier. So a person can kind of gradually, as they're taking melatonin, move their sleep schedule earlier and earlier and earlier.

If they desire to do so, not that there's anything wrong with being a night owl, sleeping late and waking up late, especially if that works for the person and they have, you know, a swing shift schedule at work, then it could work perfectly. Or a college student who schedules all their classes in the afternoon and evening.

but that's one use of melatonin is essentially shifting a person's circadian rhythm in the direction that they desire. The second evidence-based use for melatonin that we as sleep physicians will often prescribe it to patient's for is for the treatment of what's called REM Sleep Behavior Disorder. And This is a sleep disorder.

Uh. Which essentially is characterized by dream enactment behavior. So normally when we're having dreams, we're in REM sleep, which is that really deep and unique stage of sleep. And typically when we're in that stage of sleep and exclusively during that stage of sleep, our muscles get paralyzed. And that's kind of a normal mechanism that our brain does to prevent us from acting our dreams out.

Because imagine if our muscles weren't paralyzed when we were having dreams or nightmares, we would all be acting our dreams out. So essentially, when somebody has REM sleep behavior disorder, that function in the brain is not. Working properly as a result, you have totally uninhibited movements and behaviors that correlate with what the person is doing in their dreams.

So they'll be having a nightmare that they're in a fight or they're being attacked or chased, And then they start swinging and punching and kicking. And then next thing you know, they're actually physically doing those things in bed and they end up injuring themselves or injuring their bed partners falling out of bed, breaking their hand, punching the nightstand.

So. For that particular condition. Melatonin actually has this unique property that it kind of melatonin essentially augments that normal paralysis function that the muscles should be undergoing during that stage of sleep. So even the most violent dream enactment behaviors can actually be controlled with the right dose of melatonin.

So all that to say that these are the more common clinical uses of melatonin. Treating somebody who physically acts their dreams out or giving it to somebody to shift their circadian rhythm one way or the other, depending on what their desired schedule is

Melanie Cole, MS (Host): Well, thank you for that. So if we were gonna start it, I mean, as you say, it's not really regulated, so how do we know how much to take? I.

Sam Kashani, MD: Read the manufacturer's bottle. Honestly, that's the issue is that, like you said, because FDA supplements that are over-the-counter are so poorly regulated, so poorly studied, it's one of those things where there isn't a specific evidence-based dose that one would recommend for any of these things. So if we prescribe it as sleep physicians for one of those two conditions we were talking about either a circadian rhythm disorder or for the treatment of dream enactment in someone who has REM sleep behavior disorder.

We'll typically start at a low-dose and just work our way up until the problem is resolved. And specifically for dream enactment behavior. In REM sleep behavior disorder studies have demonstrated safety and efficacy in doses up to 20 milligrams. But usually people who physically act their dreams out actually don't more often don't need that much just because it's such an effective treatment for dream enactment behavior that, as I mentioned, even some of the most violent behaviors during dreams and nightmares can be controlled on a low-dose of melatonin So, It really just depends.

Melanie Cole, MS (Host): Can it interact Dr. Kashani with any other medication? If someone's on medications, should they be a little bit more careful with melatonin?

Sam Kashani, MD: I think the fact that for some people when they take melatonin, they do feel very sedated, which is again, the more common reason that people want to take it and buy it over-the-counter is to help as a sleep aid to get them drowsy so they can fall asleep quicker.

So depending on that. Whether or not the person experiences that effect. And also if they're taking other medications that might be centrally acting, meaning that they can also cause sedation, then of course you can have kind of a multiplicative effect where the person might feel over sedated. so that's something to consider.

If a person is taking more than one medication that might cause sedation or drowsiness, that melatonin might compound that. similarly, melatonin has a relatively common side effect or. The two more relatively common side effects of melatonin are vivid dreams as well as next day grogginess or morning grogginess. So again, depending on what else a person is experiencing, what other medical issues they have, what other medications they have, they might just wanna look out for these things as potential side effects.

Melanie Cole, MS (Host): Similar to being pregnant. Vivid dreams. Wow. Those are wild. And Dr. Kashani, before we wrap up, I'd love for you to give us. I mean, you're an expert can you give us some sleep hygiene? Because we know that our kids in their teens and their twenties with the lights And the phone and TikTok and they're sitting there And then they don't sleep and whatever with their sleep schedules.

But as we get older, and women in my age group, sleep can be elusive, can you give us your best advice for sleep hygiene and, and really tell us how we can get our best night's sleep?

Sam Kashani, MD: Sure. when it comes to talking about sleep hygiene, there's a couple of important points to keep in mind. first of all, when we use the term sleep hygiene, we're just. Referring to general habits, that can promote better sleep. Like for example, ensuring that you're sleeping in a sleep promoting environment, that your bedroom is cool, dark and quiet.

making sure that you're not engaging in activities or using any substances that may interfere with sleep or be too close to the sleep period as to cause an issue with it, or delay the onset of sleep General habits and a good pre-B bedtime, nighttime routine are kind of what we refer to when we're talking about sleep hygiene.

But I think it's really important to note a couple of things about it. Number one, sleep hygiene is not a treatment for any sleep problem, and that's something that when people go on the internet and search for ways to improve their sleep or ways to treat their insomnia, for example, oftentimes all they're kind of seeing is sleep hygiene recommendations.

Somebody who's been experiencing 20 years of insomnia associated with depression and anxiety and nocturnal rumination, keeping us up at night. Just a couple of sleep hygiene habits is not gonna be enough to resolve that. So I think the most important thing to keep in mind is good sleep hygiene or good sleep habits, or things that everybody should have.

Just like good dietary habits. Everybody should have good dietary habits. It doesn't matter whether the person has. Metabolic disease or obesity, or they're totally fit And in shape. So that's kind of how sleep hygiene is. Everybody should have good sleep habits. However, if somebody's experiencing a problem, like insomnia, for example, all the sleep hygiene in the world is not gonna resolve that.

So that's one important thing to keep in mind. Another important thing to keep in mind in terms of just general sleep tips, I always say that the most important sleep habit is to sleep. Sleep when your body is asking for it. And it's something that we're guilty of in the sense of burning the candle at both ends.

A lot of us, this day and age, especially with technology and social media, we wanna stay up later and later and push ourselves to the latest that we can And then of course, curtail the end of our sleep period by waking up early in the morning. And then what you have is a chronically sleep insufficient society.

so all that to say that. Sleep hygiene habits and having a good routine at nighttime is definitely something that, like we said, everybody should have, but bottom line, it's not gonna be the solution to a sleep problem. And there's no more important sleep habit than giving your body the sleep that it's asking for, rather than depriving it.

Melanie Cole, MS (Host): So important, and as you say, we are a sleep-deprived society. Dr. Kashani, I wanna thank you so much for joining us and telling us what melatonin was because I think a lot of people really don't know. Do you have some final thoughts you'd like to leave us with about melatonin, about sleep, and about.

Seeing a specialist when you do have one of these myriad of sleep disorders.

Sam Kashani, MD: Absolutely. I'm glad you mentioned see a specialist because while there are over-the-counter solutions and biohacks, as people call them online, that can help with sleep and. Various other health issues. I think more importantly, And the more appropriate thing to do is to always consult with your doctor, and if there's any doubt that there might be a sleep issue you're experiencing, just ask for a referral to a sleep specialist and kind of go through the process of being evaluated by a sleep specialist.

Sometimes a person might think that their problem is insomnia, but what they have is actually something totally different, like for example, sleep apnea or narcolepsy or restless leg syndrome. All of which can sort of present as insomnia or make a person feel like they have insomnia just because of how much disruption they cost to the nocturnal sleep.

So because it's impossible to tell these things, and unless you really do testing and have a proper evaluation, you can't really fully know. I think it's important to always start there and always start with your doctor and if needed, see a sleep specialist. Now, apart from that, I would say that.

In terms of using medication, whether they're over-the-counter supplements like melatonin or even prescription sleeping pills, if we're treating insomnia, the most common sleep disorder in the world, the most effective treatment for that problem is actually not medication at all. It's what's called CBTI, and that's stands for Cognitive Behavioral Therapy for insomnia.

It's recommended by the American Academy of Sleep Medicine as first-line therapy for adults with insomnia, and yet we see sleeping pills being prescribed all the time, and there's nothing wrong with that. Plenty of people do well on sleeping pills, many people do not and experience side effects or issues, but if you really wanna know what the most evidence-based, effective way to treat insomnia.

It would be cognitive behavioral therapy for insomnia. Medications should always be either per the person's preference, or as a last resort if these non-pharmacologic behavioral measures don't work.

Melanie Cole, MS (Host): That is so interesting. I've not even heard of cognitive behavioral therapy for specifically insomnia. Thank you so much, Dr. Kashani. That is really great information and thank you so much for joining us today. And you can book an appointment with Dr. Sam Kashani by calling 3 1 0 4 4 9.

Oh 9 3 9, or you can always visit our website@henrymayo.com. That concludes this episode of It's Your Health Radio with Henry Mayo Newhall Hospital. I'm Melanie Cole. Thanks so much for joining us today.