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#95 Sleep and the College Student: Problems and Pathways to

Successful Intervention Programs

J. Roxanne Prichard Birdie Cunningham

ACHA 2012, Chicago

University of St. Thomas

J. Roxanne Prichard – Psychology/Neuroscience Faculty, Sleep Researcher

Birdie Cunningham – Wellness Center Health Educator

Urban, Catholic, Liberal arts, 6,000 undergraduates

Sleep is an acquired habit. Cells don't sleep. Fish swim in the water all night. Even a horse doesn't sleep. A man doesn't need any sleep.

-Thomas Edison

Outline

• Brief introduction to sleep in emerging adults– Sleep Timing– Sleep Deprivation

• Large Survey of College Student Sleep– Measures– Outcomes– Regression analyses

• Intervention Strategies– What’s been done– Breakfast Club Program– Faculty/Student Research Projects

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Objectives

1. Describe “typical” sleep for college students.

2. Identify factors that disturb sleep in college students.

3. Describe the effectiveness of intervention programs designed to improve sleep.

Sleep Architecture

Sleep timing is controlled by multiple internal and external factors.

Circadian RhythmsSleep Homeostat

Zeitgebers

Pharmaceuticals

Circadian Rhythms

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“Lark” or “Owl” Chronotypes change during childhood and adolescence .

By the age of 25 your time of day preference is well established, but most 18 – 21 year olds are undifferentiated.

Sleep in Emerging Adulthood–A Perfect Storm

MA Carskadon 2011

Sleep Deprivation: Cognitive Effects

• Microsleep

• Poor decision making

• Slowed reaction time

• Difficulty communicating

• Forgetfulness

• Fixation

• Lethargy

• Bad mood

• Paranoia

Alhola, P., & Polo-Kantola, P. (2007). Pilcher, J., & Huffcutt, A. (1996).

Sleep Deprivation & Cognition

• Cognitive performance:– Tracking task on computer– No change for 12 hrs– Drops from 12-24 hrs

Nature 1997Dawson, D.; Reid, K. 1997

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Sleep Deprivation & Psychiatric Illness

•35 – 50% of people with chronic sleep problems have mood disorders.

•Most patients with mood disorders experience disrupted sleep.

Sateia, M. (2009) Peterson & Benca (2006)Vgontzas et al. (2001).

Sleep Deprivation enhances night time cortisol secretion.

Sleep & Immune System

Sleep deprivation is correlated with a significant reduction in cellular immunity (reductions in T-cells) (Lange, & Born, 2011)

Men who received just four hours of sleep a night for four straight nights after receiving a flu shot produced half the antibodies as the control group (Weintraub, 2004)

In lab rats, total sleep deprivation for four weeks can cause death by infection (Stapleton, 2001)

Sleep & Cardiovascular System

Sleep deprivation increases concentrations of cytokines & C-reactive proteins in the body

This inflammation can damage the inner walls of the arteries, leading to possible stroke or heart disease

Blood pressure and heart rate are higher following sleep deprived nights

Men who sleep 5 hours or less a night have 2x as many heart attacks as men who sleep 8 hours or more

(Voelker, 1999)

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Sleep Deprivation & Fat Homeostasis

• Healthy young men were forced to sleep 4 hours a night or 9 hours a night for 4 days straight.

• Short sleepers had a 18% drop in leptin, the fat satiety signal (equivalent drop to subtracting 1100 calorie a day diet).

• 25% Increase in hunger, 45% in appetite for junk foods

Van Cauter, 2004

Sleep Deprivation & Pre-Diabetes

• Chronic sleep deprivation leads to insulin resistance

• This resistance can result in high blood glucose concentrations, leading to diabetes

• Men who sleep 4 hours a night for 6 straight nights lose 30% of their ability to respond to insulin

Gottlieb et al., 2005

Sleep Deprivation is epidemic on college campuses

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National

How many of the past 7 days did you get enough sleep so that you felt rested when you woke up in the morning?

Sleep Debt: 8 hrs.

A typical student’s sleep schedule

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Another example of college sleep

Only 30% - 40% of Lost Sleep Can be restored

Design

• Email request sent to all undergraduate students

• 1125 respondents (18% response rate)

• Survey included:•Profile of Mood States•Epworth Sleepiness Scale•Subjective Units of Distress Scale•Horne-Ostberg MEQ•Pittsburgh Sleep Quality Index•Questions about Drug/Alcohol use•Sleep Hygiene

0 – 21 scale

Scores greater than 5 are considered poor quality.

Epworth Sleepiness Scale

Situation

• Sitting and reading

• Watching TV

• Sitting inactive in a public place

• Being a passenger in a motor vehicle for an hour or more

• Lying down in the afternoon

• Sitting and talking to someone

• Sitting quietly after lunch (no alcohol)

• Stopped for a few minutes in traffic while driving

Total score (add the scores up)

0 = would never doze or sleep.1 = slight chance of dozing or sleeping2 = moderate chance of dozing 3 = high chance of dozing or sleeping

0 – 24 scale

Scores of 10 or greater are indicative of excessive daytime sleepiness.

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• Approximately what time would you get up if you were entirely free to plan your day?

• How easy do you find it to get up in the morning (when you are not awakened unexpectedly)?

• You want to be at your peak performance for a test that you know is going to be mentally exhausting and will last two hours. You are entirely free to plan your day. Considering only your internal "clock," which one of the four testing times would you choose?

Morningness Eveningness ScaleRESULTS: Evidence of chronic, restricted sleep

• Mean total sleep time was 7.02 hours

• Only 11.6% got >8hrs sleep a night

• 20% pulled all-nighters at least once in the last month

• 35% stayed up until 3AM at least once a week

• 25% excessive daytime sleepiness (ESS >10)

• 15% fell asleep in class >1x/week

Only 37% of male students and 33% of female students met the criteria for healthy sleep on the PSQI.

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HS 9 HS 10 HS 11 HS 12 College

Fresh.

College

Soph.

College Jr. College Sr.

Year in School

Bed

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e

week

weekend

The first year in college is associated with an abrupt shift in sleep schedule.

High School Data from2006 Sleep in America Poll (n = 1,602)

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8:087:59 8:03 7:59

9:54 9:52

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HS 9 HS 10 HS 11 HS 12 College

Fresh.

College

Soph.

College Jr. College Sr.

Year in School

Ris

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weekend

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Despite similar TST, females have higher daytime sleepiness.

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Male Female

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Weekday Weekend

Male Female

For both, p < .001 p = .053

Epworth Sleepiness Scale PSQI

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Stress 35%Noise 33%

Co-sleeping 7%

7.02 hrs

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Weekday Weekend

Male Female

Students are stressed, especially the women.

p < .001 p < .001

SUD

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Tension Depression Fatigue Vigor Anger Confusion

Male Female

Students are fatigued, especially the women.

p < .01 p < .01

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John H. PryorHigher Education Research Institute at UCLA

These data are consistent with national trends in college student mental health.

Stress and

Mood (d.f.) F p

Post

hoc

Optimal

>6

Border

line

6-7

Poor

7<

Anger 2,897 66.8 <.001 O<B<P 7.48 9 10.61

Confusion 2,897 32.2 <.001 O<B<P 8.6 9.56 10.31

Depression 2,897 71.2 <.001 O<B<P 7.01 8.76 10.66

Fatigue 2,897 146.2 <.001 O<B<P 9.44 12.09 14.92

Tension 2,897 81.1 <.001 O<B<P 8.29 9.96 11.82

Vigor 2,897 28.4 <.001 O>B>P 14.29 13.38 12.09

Distress (SUDS) 2,916 72.4 <.001 O<B<P 49.9 59.9 70.7

Those with poor sleep quality have worse moods.

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Sleep & Mood

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day of study

Stress

Hours of Sleep

What’s responsible for the poor sleep quality?

Insomnia for at least one month + presence of at least one of the following:

Perhaps Inadequate Sleep Hygiene Disorder?

Frequent daytime napping Highly variable bedtimes or rising times Routine use of nicotine, alcohol or caffeine Mentally stimulating, physically activating, or emotionally

disturbing activities in bed Spending excessive amounts of time in bed and/or using bed

for non-sleep/sex purposes

Perhaps psychoactive substance use/abuse?

Motivation for

taking substance

Alcohol Caffeine Marijuana Nicotine

Intoxication 67% 1% 88% 37%

Relaxation 58% 8% 74% 74%

To be social 93% 10% 74% 79%

Enhance meals 22% 66% 5% 21%

Alertness 1% 65% 7% 11%

Sleep 9% 0% 42% 5%

Wakefulness 3% 74% 5% 5%

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Depressants suppress REM sleepStimulants increase sleep latency & reduce deep

slow wave sleep

0%

10%

20%

30%

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50%

% Binge

Drinkers

% Nicotine

Smokers

%

Marijuana

Users

Morning

Neither

Evening

Substance abusers are more likely to be evening types and have lower quality sleep.

Students who drink alcohol to induce sleepiness consume significantly more alcohol and caffeine than those who use drink for social reasons.

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Weekend Alcohol

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Undiagnosed Sleep Problems can morph into substance abuse!

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However, for most students, stress, but not drugs, influences sleep

Dependent

Variable Independent Variables β SEM t p-value

Sleep Quality

(PSQI) Stress & Negative Mood (SUDS, POMS) .434 .007 7.87 <.001***

Morningness/Eveningness (MEQ) -.252 .020

-

4.52 <.001***

Alcohol weekly consumption .030 .028 .532 0.595

Caffeine weekly consumption -.032 .021

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.573 0.567

Model Summary

R

R

Square

Adjusted R

Square

Std. Error of

the Estimate1. Tension .443 .197 .194 2.807

2. Tension, MEQ .508 .258 .253 2.702

3. Tension, MEQ, SUDS .542 .294 .287 2.640

Predictors of PSQI score in Males (n = 333)

Excluded variables: alcohol, caffeine, TV/Video game time, exercise duration, bedtime & risetime delay, depression, anger, confusion

Predictors of PSQI score in Females (n = 550)

Excluded variables: alcohol, caffeine, TV/Video game time, exercise duration, bedtime & risetime delay, tension, confusion

Model Summary

Model R

R Square

Adjusted R

Square

Std. Error

of the

Estimate

1. Depression .471 .222 .221 2.815

2. Depression, SUDS .521 .272 .269 2.726

3. Depression, SUDS, MEQ .537 .288 .284 2.698

4. Depression, SUDS, MEQ, Anger .547 .299 .294 2.680

Major Findings from Lund 2010 study.

• Evidence of chronic restricted sleep in college students.

• Poor sleepers have more problems with depression, anxiety and anger (and vice versa)

• Stress & negative moods seem to be the strongest predictors of poor quality sleep.

• In general, college women show more stress and mood induced sleep disturbances than men do.

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Major Findings from Lund 2010 study, cartoon format

• Because insufficient sleep exacerbates mood, anxiety and substance abuse disorders, health care providers should work toward managing the distinct psychological factors that disrupt sleep in young women and men.

• Determine what treatment/education programs would increase sleep quality.

Next Steps: Interventions

Theoretical Approaches to Making Change

Structure Agency

Thinking about improving sleep…

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“Within the last 12 months, have any of the following been traumatic or very difficult for you to handle?”

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UST

National

Our program: The Breakfast Club

3 Week Intervention Program– Open to first year full-time students

• 200 invited• 13 filled out pre-survey• 9 completed the program• 7 completed the post-survey

– Students received free breakfast, health and wellness information, prizes and a drawing for $500 bookstore gift card

– Students had to commit to 5 of 6 breakfasts per week

– Students were not aware that this was a sleep study.

“Serve the People, Body and Soul.”

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Breakfast Club Schedule

Weekday morning – Students arrive at an on-campus

private dining room at 8:15 AM – Eat and find out the topic of the

day or activity – Presentation & Discussion– Program over by 9:15

Weekend MorningMeet at 9AM to walk 15 – 30

minutes to a local restaurant for breakfast.

Topics Covered– Nutrition: Dietician & Health Professor

– Sleep: Psychology Professor

– Friendships: Communications Professors

– Romantic Relationships: Psychology Professor

– Finances: Business Office & Financial Aid Rep

– Alcohol: Wellness Educator

– Emotions: Clinical Psychologist & UST Counselor

– Academic Resources: Enhancement Services

– Drugs: Psychology Professor

– Stress Relief Activities: Bowling, piano concert, walks

E-delivery comparison group

• Received same information, but just over daily emails.

• 17 people (of 200 invited) filled out the pre-survey.

• 12 of those filled out the post-survey.

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Why didn’t you choose to participate in the Breakfast Club?

Didn't want to wake up that early 55%

Other 20%

Too much of a time commitment 15%

Didn't know about it 5%

Not interested in health 5%

E-delivery comparison group

Schedule

• Fall Semester: Schedule Speakers, reserve rooms, approve IRB

• February 1 – 20: Recruit students

• February 21- 25: Pre-surveys (30 minutes)

• February 26- March 16: Breakfast Club Meetings

• March 17 – 26: Spring Break

• April 16 – 20: Post-Surveys (20 minutes)

Outcome Measures

• Clinical Measures: PSQI, ESS, SUDS

• Self-Reported Behaviors

• Motivations to Change

• Program Assessment

• Interviews (Breakfast club only)

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Total Sleep Time

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Pittsburgh Sleep Quality Index

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Epworth Sleepiness Scale

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... used an energy drink or caffeine pill to keep you alert

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Stages of Change: Sleep

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Preparation

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What about Stress Management?

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Felt confident in your ability to handle personal problems

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…dealt successfully with with day-to-day problems

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... created a to-do list & prioritized tasks

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...made a schedule and stuck to it

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Stages of Change: Stress

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...have you eaten breakfast

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Student Assessment

Statement 1 SD 5 SA Breakfast Club E-deliveryI enjoyed this program. 5.0 3.6

I would recommend this program to another student. 5.0 3.6

I learned more about resources UST offers its students. 4.4 3.7

I prefer to get this information by email rather than in group

meetings.

1.6 4.5

My sleep has improved as a result of this program. 4.3 2.9

My stress management has improved as a result of this

program.

3.4 3.2

My health and fitness have improved as a result of this

program.

4.1 2.9

My overall wellness has improved as a result of this program. 4.3 3.4

I feel a sense of kinship/camaraderie with the students who

completed this program.

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n 7 11

Next Steps

• Meet once a semester with original breakfast club crew

• Do a sophomore assessment to see if gains made continue

• Share data with administrators

• Incorporate into Freshman Orientation?

• Look for funding

Other Interventions/Programs at UST

• adjUST – 10 week project designed to improve student sleep, nutrition, and physical activity. Collaboration between Videograrphy class and wellness center.

• Independent student research projects- 6 week laboratory projects on sleep-related topics in neuroscience & psychology courses

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Experimental Ways to Measure Sleep

CortisolELISA Assay

Sleep

Apps

Temperature

Tracking

Student Project: Cortisol Levels Reflect Student Reported

Psychological Stress

BN temperature rhythm over 6 days

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BF temperature rhythm over 10 days

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Student Project: Circadian Temperature Rhythms in

Structured vs. Unstructured Schedules LE temperature rhythm over 10 days

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SM temperature rhythm over 9 days

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Higher levels of CRP are correlated with mental stress in patients with stable coronary artery disease (Burg, et al., 2006).

Student Project: C-Reactive Protein Levels in Structures and

Unstructured SleepersOther Student Research Projects on Sleep

• Digital Phantoms: The effects of electronic media on sleep quality

• Effects of short-term sleep deprivation on specific prefrontal cortex dependent abilities

“Being enrolled in ROTC in college presents a conflict between staying up late to study or get some sleep so you can be well rested for the same wake up call that occurs almost everyday of the week. Taking this class and learning about the vital need for quality sleep has changed my perception of sleep, making it a big priority. Freshmen year brought multiple sleepless nights for me as I crammed for exams which lead to multiple severe illnesses that kept me out of important track meets and hindered optimal retention of class material during lectures. After making sleep more of a priority, I have found class material easier to learn and remember as well as a significantly stronger immune system.”

…I also didn’t realize how complex sleep mechanisms were, or how devastating lack of sleep can be. Again, I put sleep off because who has time to sleep when I should be studying. The lack of sleep mimics increased cortisol levels which again surprised me at how damaging neural and chemical interactions can be. These are things I can only control or alter by changing my habits…

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Acknowledgements

• UST Loftus Fund for Diversity in Health Care

• Stephan D. Weiss Mental Health Fund

• Hannah Lund, M.S.

• Casey Speaker, Masters student in Wellness Center

• Undergraduate student researchers Lauren Knapp & Stephanie Mankowski

• Physiological Psychology students