A sleep medicine physician shapes insomnia treatment guidelines at the national level, helping patients everywhere get a good night’s sleep

When Clinical Professor of Medicine Salma Patel, MD, MPH, was an internal medicine resident, she wasn’t getting enough sleep — which attracted her to an elective in sleep medicine. She fell in love with the specialty because of its profound impact on patients’ lives. In turn, her patients inspired her toward a career as a physician-scientist.

“We kept telling our patients, ‘You shouldn’t sleep with your pets. They’re going to disrupt your sleep,’” she recalled. “I kept hearing, ‘I can’t sleep without my dog! They make me feel so much more secure and I have fewer bad dreams.’ I asked myself, ‘What is the evidence behind that recommendation?’ I looked, and there was nothing that supported that, absolutely nothing.”

In response to the lack of research on how pets affect human sleep, Dr. Patel conducted a study on 40 humans and their 40 dogs — and found that the two species could share sleep space without compromising sleep quality. Her study helped reverse some of the bad advice doctors might give to patients.

That early foray into patient-centered research inspired her to continue to seek answers that would directly improve care. Now, she is celebrating her most recent victory: collaborating on national treatment guidelines for chronic insomnia.

Marshaling evidence

While she considers herself a clinician first and foremost, Dr. Patel has remained steadily involved in research, which she believes is crucial to providing patients with the best care possible.

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Because there was little guidance on combining the two most common treatments for chronic insomnia, Dr. Patel joined an American Academy of Sleep Medicine taskforce. Their review and recommendations were recently published.

“I see firsthand how profoundly insomnia affects every aspect of someone’s life — their health, relationships, work and emotional well-being,” she said. “Being able to contribute to national guidelines that help clinicians across the country and internationally deliver evidence-based care was both a privilege and a responsibility.”

She joined a multidisciplinary group of researchers to sift through all the evidence and figure out where it pointed.

“They were looking for folks who brought different things to the table — sleep medicine physicians, clinical psychologists, methodology and evidence synthesis. I brought medical physician expertise. We all put our heads together to come up with good guidelines for our patients,” she said. “It was humbling to realize that not one of us has the answers, but if we were to work together, we’ll come up with better answers.”

There are two main ways to treat chronic insomnia: cognitive behavioral therapy for insomnia (CBT-I) and medication. Treatment guidelines were in place for each modality in isolation, but there were none for using them in combination — which is a common tactic.

After evaluating all available evidence, the team reinforced CBT-I as the first-line approach for treating chronic insomnia.

“Ideally, you’d start with cognitive behavioral therapy for insomnia — it addresses the underlying causes,” she said. “If it doesn’t work, you can consider adding a medication, but medications do not address the underlying causes and can have side effects. The effects of the pill last only as long as you take it, so you would only go to medication alone as a last resort.”

Treating chronic insomnia — effectively and without drugs

When Dr. Patel helps a patient with chronic insomnia, she incorporates the two tenets of CBT-I: stimulus control and sleep restriction. Both hinge on the idea that healthy sleep patterns are established when we associate the bed with sleep — not with working on our laptops, watching television, or tossing and turning.

“If you’re awake for more than 15 or 20 minutes, you need to get up, do a boring activity and come back when you feel like you’re tired enough,” Dr. Patel said, explaining the concept of stimulus control. “You don’t want to associate the bed with being awake, because that leads to anxiety, worry and stress.”

Dr. Patel says most patients with trouble sleeping might spend more time in bed to increase their opportunity for sleep. But sleep restriction relies on the counterintuitive notion of spending less time in bed — not more.

“If you were to restrict someone’s time in bed to five hours a night — let’s say midnight to 5 a.m., no daytime napping — within a few days, they will fall asleep and wake up with an alarm clock,” she explained. “Then you extend it slowly until you’ve hit your sweet spot.”

She adds that, if patients want faster relief from insomnia and are less concerned about daytime symptoms, the patient and clinician can decide together whether to use both CBT-I and medication instead of CBT-I alone.

Dr. Patel discusses the need for expanded guidelines, the evidence behind the recommendations, and what they mean for patients and clinicians.

Dr. Patel, who is also an associate dean and professor at the Mel and Enid Zuckerman College of Public Health, says one of the most rewarding aspects of her work is hearing her patients attest to the transformative power of successful treatment.

“I hear comments like, ‘My wife loves me again’ or ‘I’m doing great at work now’ all the time,” she said. “Those moments remind me that I am not just helping people sleep better — I’m helping them reconnect with their families, succeed at work and enjoy life again.”

Inspiring tomorrow’s physician-researchers

In the future, Dr. Patel says she’d love to see one of her students or residents conduct a follow-up study to the research she conducted during her own residency — perhaps on humans and cats, or humans and multiple dogs.

“That was a really fun project,” she said. “I got pictures all day, every day — study participants and their dogs going to bed or playing. People love their pets.”

Now, Dr. Patel has come full circle, from her days as a resident asking questions at the bedside, to guiding medical students, residents and fellows to incorporate research into their clinical work.

“Keep the best interests of the patients in mind — that’s something I try to model for my students and trainees every day,” she said. “It’s important for us to provide compassionate care, ask questions and do the study that will answer those questions. It takes our medical practice to a whole different level.”

Below: View a photo gallery of Dr. Patel and her trainees at the SLEEP Conference, jointly held by the American Academy of Sleep Medicine and the Sleep Research Society. Dr. Patel says, “They are incredibly impressive and will hopefully make better physicians than me one day!”