How Sleep Issues Show Up in Psychiatric Practice with Dr. Avinesh Bhar, CEO of SLIIIP

Journal of Clinical Psychiatry: psychiatrist.com/jcp/

SLIIIP: https://sliiip.com/

Ben Everett, PhD is the creator and host of The JCP Podcast, a series that brings together leading voices in psychiatry to explore the latest research and its clinical implications. Everett earned his PhD in Biochemistry with an emphasis in Neuroscience from the University of Tennessee Health Science Center. Over a two-decade career spanning academia, publishing, and the pharmaceutical industry, he has helped launch more than a dozen new treatments across psychiatry, neurology, and cardiometabolic medicine. His current work focuses on translating complex scientific advances into accessible, evidence-based insights that inform clinical practice and foster meaningful dialogue among mental health professionals.

This transcript has been auto-generated and may contain errors. Please refer to the original recording for full accuracy.

[ 00:00 ] Introducing Dr. Avi Bhar

Dr. Ben Everett: Welcome to The JCP Podcast, where we explore the science and stories shaping mental health care today. I’m your host, Dr. Ben Everett, Senior Scientific Director with Physicians Postgraduate Press, publisher of the Journal of Clinical Psychiatry. On the podcast, we speak with clinicians, researchers, and thought leaders advancing the field of psychiatry, with a focus on not just what’s new, but what’s meaningful for our listeners in their clinical practice.

My guest today is a good friend, Dr. Avinesh Bhar, a triple board-certified physician in pulmonary medicine, critical care, and sleep medicine. Dr. Bhar has spent his career across the full continuum of care, from high-acuity ICU settings to outpatient sleep clinics, and is the founding physician of SLIIIP, a virtual sleep and pulmonary telemedicine platform designed to expand access to high-quality sleep medicine. Dr. Bhar completed his medical training internationally, followed by fellowship training in pulmonary and critical care medicine at the University of Tennessee Health Science Center in Memphis, where we met, and sleep medicine at Washington University in St. Louis. In addition to his clinical work, he earned an Executive MBA from the University of Chicago Booth School of Business, reflecting a long-standing interest in healthcare delivery, innovations, and systems-level solutions.

Avi has held academic appointments, received multiple teaching awards, served in leadership roles within hospital systems and national professional organizations, and has been a visible public educator on sleep health through media and community engagement. Today we’re going to focus on sleep: what it actually does biologically, how sleep disorders drive both medical and psychiatric morbidity, why access to sleep care remains such a challenge, and how evolving guidelines and home-based technologies may help close those gaps. With that, it’s a pleasure to welcome Dr. Avi Bhar to The JCP Podcast.

Dr. Avinesh Bhar: Thank you, Ben. I appreciate the kind words. Thank you very much.

Dr. Ben Everett: Avi, we start every episode with some icebreaker questions. They’re similar, but they’re not always exactly the same, depending on everybody’s expertise. So, let’s start at the beginning for you. What drew you into the field of medicine?

Dr. Avinesh Bhar: My dad, and he’s not even a physician. I think as a 15-year-old, well, I didn’t like math. I was decent at it and at science as well, and I was actually gunning to be a pilot. I loved the uniform, I loved the idea of flying, I loved big planes. But my dad was like, “You need to make some common-sense decisions and maybe consider medicine because you like science and you have a good background in math.” And I’m like, “Okay, Dad.” And that was it. And it’s crazy, I could not fathom myself in any other profession. Like, I see my friends in law and in business and in finance, and I can’t see myself being as fulfilled as I am now. So, it’s kudos to, and I think for parents in general, they have that eye of what your personality fit may be like. So, I’m appreciative of that, and I can’t take any credit for choosing medicine. He chose it for me.

Dr. Ben Everett: That’s awesome because you’re really tall. You’re like six-five, six-six, right? Something like that?

Dr. Avinesh Bhar: Six-five, yeah.

Dr. Ben Everett: I remember Tim Robbins in Top Gun; he’s the navigator in that old F-14. I’m like, “Yeah, I don’t think he’d really fit in there.” Maybe some of the big, like, cargo planes, but those aren’t as fun as the fighter jets, I guess. Anyway, well, so after internal medicine, you decided to do a pulmonary critical care fellowship. After that, you did another fellowship in sleep medicine.

Take me through kind of what made you decide to go from one to another. I know you can get to sleep through pulmonary critical care or through psychiatry, and those are, I think, the only two avenues to get into sleep now. There’s, way back when, I know some family practice physicians and other people got grandfathered in before it became more of an ABIM subspecialty or a psychiatry subspecialty.

[03:48] From ICU to Sleep Medicine and What Clinicians Miss

Dr. Avinesh Bhar: I fell in love with critical care first. It was my first day as an intern in the ICU. I mean, I was brand new in the country, and I was on call on the first night in the ICU, and I didn’t even know the vocabulary. I hadn’t done any training in the United States, and I distinctly remember a nurse coming up to me as I was kind of noting down the labs in my little chart because at that point, the EMR system, we still had paper charts. She comes up to me and she says, “Dr. Bhar, should we titrate down the Diprivan?” And I’m like looking at her, going, “Hmm, what do you think we should do?” And she’s like, “Yeah, I think we should.” I’m like, “All right, yeah, let’s do that.” And she walks away, and I’m looking through my paper pharmacopeia, going, “What the hell is Diprivan?”

I love the clinical nature, the intensity of the ICU, the breaking down of a case from head to toe, because in the ICU, you can’t afford to mess anything up or overlook something. So, there’s a very structured manner in how you see patients, and I love that sort of clarity in a patient and being able to see patients, fix the problem, and then do the next one. ICU was where my first love actually was, and pulmonary kind of fit into that because a lot of patients were on the ventilator and understanding that. As I was going through fellowship, it came to a point, I was in my third year, and we have a mutual friend who at that point was like, “I’m eager to get out of here and start earning some money because my family is growing,” and so on. And I was like, “Hmm, I’m not sure. I think I want to get paid for another year. I want to get underpaid for another whole year as a PGY-7.” And so, I went to my mentor, Dr. Muthiah. He’s one of those that you forget, that your career is built by standing on the shoulder of giants. He is really a giant in my life, and one of those where you know that as much as you aspire to be him, you’ll never be him. It’s just one of those figures that, you know, okay, it’s good to look up at him and kind of be aspirational, but you know you’ll never achieve the levels that he has.

And he was my mentor and our program director, and I went up to him and I said, “You know, I’m kind of still a little restless. I feel like I need to do more, learn more.” And there were two fellowships available: one was interventional pulmonology, and the other one was sleep medicine. But he kind of guided me towards sleep because he felt, and rightfully so, that I could be a better physician to my patients if I understood their sleep issues just as well as their breathing issues during the day as a pulmonologist. And he was spot on. And I had the privilege of doing my sleep fellowship at the Department of Neurology at WashU, and it was very helpful because it gave me a grounding in sleep that was very different from most other departments where sleep medicine is housed under pulmonology and so on in other institutions. And with it under a neurologist, it forced me to learn sleep in a very different angle, and I’m grateful for that. And it’s given me a level of comfort that I think I use every day, actually, in terms of my practice on breaking down cases and understanding sleep as it exists.

Dr. Ben Everett: Yeah, and I know since we’ve reconnected, your passion for this area has really come through. And it’s kind of, who doesn’t have some kind of disordered sleep somewhere here and there, like you were telling me beforehand. So, maybe we’ll set me up with one of these home SLIIIP tests, we’ll see.

Dr. Avinesh Bhar: It’s easy. There’s no excuse nowadays.

[06:52] What Sleep Does Biologically and Why Quality Beats Hours

Dr. Ben Everett: Yeah, that’s right. Before we really dive into actually sleep disorders and technology, system-level issues, all these types of things, let’s just level-set around some basics of sleep. So, when you talk to your patients about sleep, or maybe even other clinicians, how do you describe what sleep is actually doing biologically? Why do we have to sleep?

Dr. Avinesh Bhar: There’s a really good book out there, I think by Matt Walker, Why We Sleep. I’ll try to do justice to that. I think sleep is, you remember those futuristic movies where everyone’s like in a sleep mode in some sort of capsule and they’re hooked up and their brains are hooked up as they’re uploading and downloading stuff and so on. And I think a lot of what we create is based on this sort of futurist that kind of imagines what the world looks like. And I think that’s what sleep really is, is that moment where we allow our bodies to heal and to repair the trauma that it’s gone through the whole day, the chemicals, the trash that it accumulates, the metabolic sort of down-effects of being awake and dealing with the stresses of life. And I don’t mean that in stresses of life in a bad way, just anything that kind of causes us to have to kind of react to something, think about something, and so on, move whether it’s commuting and so on. I think that’s the element of, okay, how do we allow our bodies to heal and repair ourselves? And sleep really is that reparative opportunity.

I think we’ve overlooked it for too long. It’s always in the field, and I think this works in any field of science. When you don’t understand it, you just downplay its significance. And as we’ve gotten better data now around sleep, it just seems to, and now we look at it, we’re like, “Yeah, it obviously makes sense.” But back in the day, and I’m not even talking like a long time ago, I’m talking about 10, 15 years ago, it was not even seen as a major factor. It was an afterthought. It was something you did when you were done with the important things during the day. And now we’ve seen increasingly that sleep really plays a role. And the saying is, “You know, you’re waking up on the wrong side of the bed.” That is literally true because if you don’t sleep well, your whole day changes in perspective. You are in survival mode, and you can’t be your best self, you can’t perform. So whether you’re an athlete or a mom, your performance during the day is so dependent on the quality of your sleep at night. And it really is, going back to your question, a chance for our bodies to equilibrate, to repair itself so that it doesn’t take the garbage or baggage of yesterday into today, which then makes it a burdensome life and it makes chronic diseases fester as well, as we’re not able to clean the slate from one day to another.

Dr. Ben Everett: Can you talk a little bit about quantity versus quality?

Dr. Avinesh Bhar: A lot of us assume that the quantity of sleep that we have is of good quality sleep. And just because you sleep seven, eight hours doesn’t necessarily mean you’re getting good quality sleep. There’s two ways of looking at it, like you said, quality and quantity. And meeting the threshold of seven to eight hours is good. That means you’ve given your body a chance to heal itself. Now, let’s look at the outcome. Are you feeling refreshed? Are you waking up feeling like, “Man, I got a good night of sleep”? And if you’re not, then your quality of sleep may not be adequate, even though you’re getting adequate quantity of sleep. Then the quality may be in question. And I think in patients who might be sleeping well but not allowing themselves enough time so there’s not enough opportunity or the quantity of sleep is reduced, that itself is another issue, but more within our control.

Then the question is, in someone that has, quote, unquote, normal sleep or normal quality sleep, when they do sleep seven to eight hours, how do they feel? Do they feel completely refreshed? Do they feel great, that they can take on the day? Or do they not? And if you don’t, even if you’re getting more hours of sleep from four to seven hours, let’s say someone increases it from four hours when they’re, because of work and so on, are they getting much better sleep at seven hours in terms of how they feel? And that kind of comes back to whether with adequate quantity, are you getting adequate quality sleep? The perception of quality is a very nebulous term because our perception of sleep is like a single-player existence. We only know that in our heads, how we should feel when we wake up. It’s the chest pain of someone that has heart disease or someone that has mental health issues and they’re struggling. And sometimes you can see it on their faces as well. Someone that has a knee problem or arthritis, you can see that they hobble. Someone who has breathing issues, you can tell they’re breathing, it’s very visual. But with sleep, sometimes how we feel, there’s ways of coping. And we’re so resilient that we have coping mechanisms now, whether it’s energy drinks, whether it is off-label Adderall use from your cousin, or it’s cigarette smoking, there’s ways of us kind of coping with a lot of that, and that allows us to carry on the day.

However, if we are honest with ourselves to assess, to say, “How do I feel when I wake up?” And because these changes occur very gradually over years, in your 20s, in your 30s, and 40s, we make up stories for how we should feel when we wake up. And when I hit my 40s, I went through the same experience as well. I was snoozing a little bit more, I was waking up a little bit more anxious in the morning. And I used to love my mornings, but then I realized that, man, this is snoozing 15-minute increments every time. This isn’t me. And then my wife mentioned that, “Oh, I heard you snore recently.” And I was like, “Huh?” I ignored it, and then she called me a freaking hypocrite because she said, “Well, if your patient told you the exact same thing, what would you suggest?” And I’m like, “All right, fine.” So I got a sleep test done, a home sleep test, got the diagnosis. And what blew me away was when I was on therapy, I knew that as a human being, as a normal human being, I would have ignored those signs for at least a decade. I would have coped with caffeine, I would have just trudged through life, one foot in front of the other. And people are doing that every day right now, and they don’t even know they have an issue because they assume that how they feel, the quality of sleep that they wake up with, is their quality of sleep, and it reaches the benchmark of whatever good quality sleep is.

So, for your listeners, I’d say if you’re achieving that seven to eight hours of sleep, you should wake up feeling refreshed. The gauge you would look at is the same way that if you go to the restroom and you do a number two, if you feel fully evacuated, then yeah, that was good, that’s what you should achieve. If you don’t, then you have a problem. And if you go take a leak and you feel halfway through, you’re like, “I don’t feel satisfied, I don’t feel like I’ve fully kind of emptied my bladder out,” that’s a problem as well. So I think the way we look at sleep should be the same way. You should feel refreshed, you shouldn’t wake up groggy or tired consistently. I mean, there’s always a one-off instance that something you do the night before doesn’t agree with you and so on, but generally you should wake up feeling refreshed in the morning. And if you don’t, then you have to check your quality of sleep.

[13:23] Sleep Myths That Keep You Sick and Tired

Dr. Ben Everett: We were talking before we hit record here, pretty much my wife has said exactly what your wife said to you. And I was like, “Oh, it’s just a little, it’s like more a problem for her.” And you were like, “Yeah, let’s get you set up with a sleep study.” So we’re going to be looking into that.

I can tell you another thing is just weight. You know, I think weight loss can help with so many things. I’ve lost about 20 pounds and mine has improved dramatically since then. But yeah, I could still be doing a little bit better. All right, well, let’s move into like some myths versus reality sleep things. I hear people say things like this, and certainly there’s never been a doctor or a nurse practitioner, PA, a scientist that’s ever said anything like this, like, “Oh, I’ll sleep when I’m dead, I’ll catch up later.” “I’ll sleep when I’m dead” got me through grad school and fellowship. “Oh, I’ll just catch up over the weekend.” “Snoring is annoying, but it’s harmless.” “It’s just like, it’s more of a problem for my spouse than it is for me.” And then some people, I used to have a boss who was like, “Oh, I only need four hours a day,” and then he’d be asleep through meetings all day. So, any of these more harmful than others? Or are they all just sort of signs that there could be something underlying that needs to be addressed?

Dr. Avinesh Bhar: They all fall into the same bucket as stories we tell ourselves or we convince ourselves that that’s normal, and it’s not. The data out there about sleep is pretty clear about the hours of sleep that you need. And the one way to find out is to have consistent sleep, wake up at around the same time or go to sleep at around the same time, but wake up without an alarm clock. And you will find as you sleep more consistently that you may wake up without an alarm clock after seven, seven and a half hours. My sweet spot is seven and a half hours. I can tell the difference when I’m not sleeping seven and a half versus like six hours and 45 as a seven, there is a distinct difference. So I think we do tell ourselves these stories to normalize our behavior, just like, “I can have that cupcake, that’s fine. I deserve it. I had a long day.” The donut yesterday was because I did something good yesterday.

So I think we do tell our stories like this so we’re not as hard on ourselves as we need to be or should be. Generally, I think with sleep, it’s because of the whole misconception of, “Oh, it’s a passive process. I’ll do all the important stuff during the day.” So I definitely think we do tell ourselves the story, and that we have ways of coping. Like, your boss may take micro-naps during work and think that’s normal because he’s a type-A personality. He’s showing that he can be always on the fifth gear and never have to slow down to second gear. But I think for us to work optimally, to perform optimally, whether it’s professionally or personally, the basis of all of this is going to be good sleep. Now, of course, that doesn’t ignore nutrition and mobility and so on, but I think sleep is definitely a core function that we all need as an individual, as a collective society. And I think we’ve kind of downplayed the effects of it for too long, and I think we’re slowly coming around to it. And as we get more data now, as people are wearing wearables, they’re seeing the data, which then forces them to question some of these assumptions. Like, “Hey, why am I not getting enough deep sleep?” or “Why does it say I don’t get enough REM sleep?” It’s very insightful for me. I think the clash or the coming together of technology kind of dispels some of these myths that you just described.

[16:24] Sleep Hygiene That Works: Wake Time Consistency and CBTI Basics

Dr. Ben Everett: Let’s talk a little bit about sleep hygiene. I think everybody should have an idea of what it is. There are aspects of sleep hygiene that you think are more helpful or evidence-based than others? To what extent is it just overstated or maybe just misunderstood?

Dr. Avinesh Bhar: The AASM, the American Academy of Sleep Medicine, just came out with some of these recommendations.  They looked at sleep hygiene, and it doesn’t seem to have as much of an effect on our sleep. Now, for each individual, if you’re looking at your screen right before you go to bed, the blue light, could that potentially affect? Yes, we know it can, but does that have any clinical effect on you? I don’t know that we know the answer to that yet. A lot of sleep hygiene is what we would call like entry-level issues that most people would be able to manage on their own. Most people don’t need to be told that if you’re not sleeping well, go to the CVS aisle, go get some Benadryl, go get this. I know you’re grieving, or you have a project that you need to get done and your sleep cycle’s out of whack, or you’re jet-lagged, you need some short-term fixes. I think most people will cope with a lot of these things. And putting your phone away, it’s like the same analogy with someone with diabetes and having the cake, right? If you’re diabetic, I’m sorry, you can’t have the whole cake. You might have a small piece of it, but no, you really can’t. And so, same for someone with sleep issues, if you’re not sleeping well, then you should kind of cut down a lot of these behaviors that may be more detrimental.

So sleep hygiene, I think one of the more important components to it that’s overlooked is the waking up at the same time every morning, more consistently, because the wake time really sets the tone for the rest of the day. We all have the ability to stay awake for about 16 hours a day. That stop clock starts when the lights come in through the room, whether it’s through your windows or your blinds and so on, and feet off the bed. So the physical movement, the light interaction, your stop clock for 16 hours. And I say 16 hours, plus or minus minutes here and there, depending on how much exertion, physical and mental, you’ve had during the day. If you wake up every morning at six o’clock, you will consistently be able to predict your bedtime at night, which then allows you to be able to, because a lot of times when we struggle with sleep, what we do is we compensate by being in bed longer and getting into bed early. “I’m going to get a running head start,” but in actual fact, that may be counterproductive.

We talk about, like in insomnia, when we deal with insomnia, it’s something called cognitive behavioral therapy for insomnia (CBTI). But if you look at specifically within the CBTI, as they call it, for insomnia, there is the element of sleep restriction, which is you don’t get into bed until you’re sleepy or tired enough to sleep, but also stimulus control, which is the part of waking up every morning at the same time, which then sets up that predictability of your ability to fall asleep. Let’s say you wake up at six every morning because you have to go to work, but you’re going to bed at 9 o’clock and you’re wondering why you’re not able to fall asleep. It’s because you’re on hour 15 of your wakefulness. You’re not truly ready for bed yet. And for you to be able to force yourself, it’s very difficult to force yourself to sleep. It’s easy to force yourself awake. But by doing so, by getting to bed an hour earlier, even though it was with the right intentions, you actually then create a problem because when you don’t hit the pillow and fall asleep, your mind starts playing this audio recording about, “Oh my God, you’re going to screw up tomorrow, you have so many things to do,” and it tends to be counterproductive. So, one of those things to remember is to wake up every morning at the same time. That gives you your ability to predict what time your sleep time is, and I think that’s frequently overlooked as part of your sleep hygiene. Obviously, if you have sleep problems, make sure your weekends you don’t shift your sleep schedule so much. Again, that ignores everyone that is, unfortunately, impacted by shift work, and that’s definitely a different kettle of fish.

[19:54] When to Suspect a Real Sleep Disorder Beyond Stress

Dr. Ben Everett: How do you help patients understand when it’s a behavioral issue versus an underlying medical disorder or something? Would you just do a SLIIIP test on anybody who’s curious? How do you make that determination, “Yeah, for you, we need to go ahead and do a sleep test”?

Dr. Avinesh Bhar: As a specialist, most people don’t walk through our doors on their first night of poor sleep. They’ve tried different things. I’ve talked about the CVS or the Walgreens aisle, you’ve tried to put your phone down earlier. If you’re still persistently not waking up refreshed, and even if you have, let’s say you try these things and you’re not waking up refreshed, that’s where, like I talked about going back to doing a number two and you’re not feeling fully evacuated or feeling like you haven’t done your number one and your bladder is not empty. If you’re not waking up refreshed and if you’ve tried some of these things, then you definitely need an evaluation. And that kind of comes back to, are you getting the right quality of sleep? And why not, if you’re not getting the right quality of sleep? So, what sort of daytime impact? Do you wake up refreshed? Do you feel like your energy levels hold up during the day? Do you feel like you need a pick-me-up, caffeine, or an energy drink in the afternoon? Are you struggling with a lot of mental health issues? Are you struggling with behavioral issues, relationship issues, consequences in the daytime?

And then nighttime sort of symptoms, where, are you sleeping restfully? Do you feel like you are sleeping through the night? Are you waking up off and on? Are you having difficulty falling back to sleep again? So, matching the daytime consequences with some sort of symptom at night. And a lot of people put stock in snoring, and it’s a very imprecise symptom which tends to actually mislead a lot of practitioners because their first question to patients is, “Do you snore loudly?” And why do you need to snore loudly? Does everyone have to be a trucker who snores? It’s like that poster child is dead in my eyes, the idea that someone has to fit this prototypical poster child is really misleading. And snoring shouldn’t really even be part of that because honestly, think about this. You are relying on a symptom, like even like a fever, right? You say a fever, you have a cutoff, you know that it’s 100.8, it’s a true fever. Everything else, your body’s just warm and stimulated. Now, same thing with snoring, what sort of decibel are we relying on? It’s purely someone next to you who finds your snoring, one, obnoxious enough to tell you about, or it affects them enough that they’re going to tell you about it.

But unfortunately, like in the stories we all tell ourselves, “Oh, that’s normal snoring. You must be so tired. She must be so tired,” or, “Poor thing, they work so hard.” But in actual fact, we know that there’s more to it. So for me, the learning came from not diagnosing my own wife. Of 10 years at that point, I did not even diagnose her with her sleep apnea because I had hung my hat, or at least in my head, snoring was not even—she hardly even snored. I was a deep sleeper, I wasn’t listening to her through in the fricking morning. Even heavy breathing is a sign of a compromised airway. So if you can hear, because none of us are snoring right now, making any breathing sounds when we’re not talking. So even heavy breathing is in itself a potential sign. So going back to your question, I think a lot of these things need to be looked at, and we tend to ignore them until it’s too late.

[23:00] How Sleep Apnea Drives Heart, Metabolic, and Inflammatory Disease

Dr. Ben Everett: It’s eye-opening for me. I didn’t realize all that.

Well, one of the things I really want to bring out today and hope we can highlight is that sleep disorders, they don’t just coexist with medical illnesses; they can actually drive other illnesses. I imagine we’re all familiar with some of these things, but can you just give us an idea on how sleep can implicate or drive, be causally related to cardiovascular disease, even total mortality? I think I’ve heard that. Afib, there’s all sorts of different things. So, can you just kind of talk about some of these other non-psychiatric things that disordered sleep can drive, and then we’ll tie into psychiatry in a minute.

Dr. Avinesh Bhar: When we talk about sleep, it’s trying to figure out what type of sleep disorder actually drives a lot of this. And I think one that’s, even though it’s been appreciated, I think is still underappreciated, is sleep-disordered breathing, which is the umbrella term for where sleep apnea, obstructive sleep apnea, exists under. The impact on cardiovascular health, and there are so many different, insomnia, for example, can be, but have we ruled out sleep-disordered breathing in the insomniac patients that we have in studies? Have we truly done multiple nights of home sleep testing that might give us a better idea? Because the in-lab test, which is always the polysomnography, which is considered the gold standard, isn’t truly the gold standard because there are false negatives within that too, as well.

When it comes to, in fact, I think a lot of our studies, even with periodic limb movements or restless legs, it’s very important for us to weed out patients with sleep-disordered breathing because they can manifest in very subtle ways. But a lot of the cardiovascular risk is being driven by sleep-disordered breathing. And that is due to two factors. One is the actual narrowing of your airway itself, which is due to the relaxation of your muscles in your airway, just like the muscles in the rest of your body. As you’re getting to deeper phases of sleep, the muscles relax, and they come to a point where sometimes the relaxation occurs to a point where the airway or the airflow gets compromised, and that triggers an awakening. Now, imagine the brain waking up to the fact that you are choking or not breathing well. It’s a stress response. So the sympathetic drive gets kicked in, and we’ve done studies on this where we’ve seen patients actually have the flush of cortisol or sympathetic nervous system activation, as opposed to parasympathetic. We get the sympathetic activation repeatedly because of the compromised airway. So that’s one part of it that triggers this downstream effect of these responses, this sympathetic drive and so on.

But then there’s a secondary part, which is that there’s sometimes an oxygen level drop. I say sometimes because not all apneic events or compromised airways necessarily cause oxygen levels to drop. That’s why pulse oximeters by themselves aren’t the best gauge to diagnose someone with sleep apnea. And so, the drop in oxygen creates a secondary cascade. And I don’t mean secondary as in a less important way, but it’s a second cascade that occurs, which is a pro-inflammatory cascade. So we have this sort of sympathetic drive that gets triggered, and then you have this inflammatory cascade. And that’s what leads to a lot of metabolic activation, the metabolic pathways that tend to get activated, the higher blood sugar levels, the high blood pressure, the cardiac arrhythmias. Because now you have stress responses that your body gets flushed with these stress responses. And we’re going back to your question about what sleep’s role is, is to recuperate the body. You have a stress response during the day, you’re firing away, you’re doing all these impressive things during the day, but at night, you need to decompress and actually clear out all the trash. But if you have sleep-disordered breathing, then your day and night is littered with stress responses. Your body doesn’t actually have time to heal and decompress. Your inflammation continues to persist.

And that’s what drives a lot of these diseases, everything from headaches, chronic headaches, fibromyalgia, chronic fatigue syndrome, atrial fibrillation, atypical chest pain, pulmonary hypertension, airway issues like asthma and sinus congestion because the collapsibility, the persistent collapsibility of the airway triggers a whole bunch of inflammation there, GI symptoms, reflux, IBS. There’s all these symptoms that get thrown off, all these body functions get thrown off when you’re not sleeping well because the idea that there’s some sort of inbuilt sort of timer, chronicity with our cells at a cellular level that depends on this day and night variation of sleep. And beyond mental health, there’s all these facets, or even kidney health is impacted by sleep. Every single organ seems to be somewhat having an effect or affected by sleep. So beyond just mental health at this point. So it does seem to touch a lot of aspects of our care, and that’s why we’re trying to reach out, our practice is trying to reach out to as many practitioners out there to kind of give them the option of actually getting these patients seen. Because frequently identifying or even recognizing is one thing, but secondly, to kind of get them seen is a second obstacle that they face.

[27:51] Sleep and Psychiatry: How Poor Sleep Worsens Depression, Anxiety, PTSD

Dr. Ben Everett: I knew some of that, I didn’t know all that, so again, this is just very informative for me.

Let’s pivot explicitly to psychiatry because we are the Journal of Clinical Psychiatry. Sleep disturbances show up across nearly all major psychiatric disorders as a driver of additional morbidity. I’m familiar with data in PTSD that shows that disordered sleep really increases suicidal ideation and suicidal behavior multiple-fold, just because, especially when you’re having these vivid nightmares, you can’t sleep. And that holds true across depression, anxiety, across a number of other things. When we look at this, is sleep, from your perspective, is it more a symptom of something else, or is it a driver itself of the psychiatric illness? I think it’s kind of a chicken-or-an-egg thing, right? We want to address all the issues, but sometimes you’ve really got to take care of this before we can get to that. Where do you think sleep fits in with psychiatry?

Dr. Avinesh Bhar: I think it does both. I think it’s both a driver and a symptom. And from what we’ve learned, the diagnostic criteria previously, we used to look at insomnia, and that’s where a lot of mental health, you say patients don’t sleep well, they get labeled or self-labeled as insomniacs or patients with insomnia. And we find that in patients like this, the idea that insomnia is primary or secondary is not helpful because it doesn’t change our management. It’s that we should treat that regardless. And so I think that the idea is that even with mental health, sleep issues, regardless of whether it’s a driver, whether it’s a chicken or the egg, you should manage that concurrently. Meaning that even if you’re a therapist or psychiatrist managing mental health, you should also make sure the sleep is evaluated and make sure sleep improves or they get seen by a specialist. Because otherwise, your improvements in mental health isn’t going to reach the level that actually makes the patient feel like they’ve actually turned the corner. You’re just putting on little band-aids here and there.

The biggest gauge is coming back to how they feel when they wake up. If their depression is better, are they sleeping better? Are they waking up refreshed? And if they’re not, then their risk of their depression or anxiety is slightly higher, that they may return because you’ve not truly treated their sleep issue just yet. And don’t ask them whether they snore, because that shouldn’t mislead you about the need for an evaluation. There’s more to it than just a SLIIIP test. I think the idea is that you want to work with a partner that actually, or a sleep practice that actually is able to evaluate the patient alongside you to help you move the needle on mental health. It’s not just about a test, it’s about the evaluation as well. So, I think in terms of mental health, if the patient is, “Oh, I’m feeling better, and yeah, I’m able to fall asleep, thank you for the Seroquel or the mirtazapine or the trazodone.” But are you waking up more refreshed? What’s the outcome of this? Are you feeling like you got a good night of sleep? If it’s like, “I think so, maybe,” that’s a red flag.

[30:35] Solving Access With Home Sleep Tests and Step-Based Care

Dr. Ben Everett: Along with that, access really remains a key issue. It can, there’s obviously geographic issues, there might not be as many sleep doctors in your area, there’s not a sleep clinic, or there is one sleep clinic, but it’s three months out before you can get an appointment. When we reconnected, I had no idea that these home sleep studies were not only available now but are actually guideline-recommended. So just talk to us a little bit about access and kind of traditionally where things were versus utilizing this technology that we have now, and some pros and cons of the traditional in-clinic polysomnograph versus doing a home sleep test.

Dr. Avinesh Bhar: The idea is that we still know that the polysomnography is close to the gold standard as we can get. That’s the most amount of data that we have on patients for their sleep. However, it’s just like for a neurologist, not everyone needs an MRI. More data is good, but do you need more data? Because with the way insurance plans are priced now and the high-deductible plans, patients are on the hook for a higher cost. You don’t want to create a barrier to care by making sure that, “Oh, if I’m a sleep doctor in town, I’m going to be credentialed at a sleep lab, and guess what? A PSG or an in-lab study is going to garner me three times more the RVUs if I’m an employed physician compared to private practice.” And so I’m going to try to get everyone into a sleep lab, but does that do justice to the patient? Because the patient just needs to know, “Do I have sleep apnea or not?” Yeah, I know I might move my feet a little bit, but is that clinically relevant? Do I need to know how my brain waves are if I’m not looking for a seizure?

I think our devices, the home SLIIIP tests, have come a long way, and home sleep testing isn’t new. It’s been around for over 10 years. Even the latest gadgets, the technology is well-validated, and they don’t get approvals for no reason. There are comparisons to an in-lab test, and the correlation is around 90% and above. The beauty with the home sleep test is, like you rightly said, it’s also what insurances want. And I’m not a big fan of insurances, but the idea that someone needs to go to a sleep lab as a first stop, unless, of course, there are truly clinical needs, there’s a strong clinical need for it, you can do a home sleep test, and that allows multiple nights of testing. That’s key here because by doing multiple nights of testing, you actually get a better baseline, you reduce the number of false negatives. And the studies have shown that as well, because we never sleep the exact same way every night, and one night of testing is too much of a hit-or-miss. The other part of that is, yes, you may need an in-lab test, but it should be on a clinical basis. Like, we didn’t get the results we were expecting on the home sleep test, or based on the home sleep test, we went on with therapy, but the patient is not responding to therapy the way we were expecting. And hence, there’s a question, do I need more data? And then you send them to a sleep lab.

If we think of it this way, as an access question, I think that allows us to give home sleep testing a chance because a lot of times when I’ll speak to psychiatrists, they all think their patients are special, that they all need in-lab testing because they have all these kind of cool diseases that may be going on. But the actual fact is, insurances are going to deny it on the get-go unless you have a compelling reason. Number two is that a patient’s out-of-pocket cost is going to drive the decisions. And if they’re paying $700, $800 to go to a sleep lab versus a couple of hundred dollars for a home sleep test, we have to kind of make sure that we right-size the testing for the outcome as well. I mean, not everyone, like I said, going back to that, do you need an expensive MRI for everyone? You don’t. It’s troublesome to get someone into a sleep lab. They have to give up their lives, they have to go leave their homes, they have to take time off potentially the next day, depending on what time they wake up. So there’s all these sort of barriers, and we should wake up to the fact that home sleep testing is a great way to get to the answer quickly. And then there’s a secondary level that you say, “All right, yeah, we’re not getting the results. Let’s go ahead and get them into a lab.” And I think that works in a way that makes sense for a lot of clinicians, and we should, because I think otherwise, we end up staying in the same rut that we’re in where they estimate it is over 85% of sleep apnea patients haven’t even been diagnosed yet.

And that’s because we are, as clinicians, saying, “Oh, I want more data.” Do you really need more data? Don’t you have your clinical judgment based on your interaction with the patient? Doesn’t that already give you an idea whether someone has a potential sleep-disordered breathing? Do you need to know the answer to the sleep-disordered breathing question, or do you need a full-on EEG, and do you need leg monitors? Do you need the full shebang, or can you get away with what you have? And I think that’s what we need to do, is focus on the balance of what the patient needs and what the clinician needs. And we shouldn’t be gatekeepers like, “You come to me, you do what I say, otherwise it’s me or the highway.” Now, previously, that was the truth because most specialist practices are a monopoly upon themselves because there’s not enough of us. I mean, the US, up to this year, we were only producing 150 sleep doctors a year. And up to 2011, you could get grandfathered into sleep medicine, like you mentioned earlier in the show, which meant that a lot of people in their 40s and 50s, they took a few extra credits and they were able to become sleep doctors. However, 20 years down the road, a lot of these people are also retiring. And if the US produces only 150 sleep doctors, except for this year where they produced 200 people were accepted into the class, can you imagine that gulf of demand and supply?

And patients are not being seen in an adequate amount of time. So, whether you’re a psychiatrist or a primary care doctor or a cardiologist or a nephrologist or an OB/GYN, for you to get a patient seen, it takes you six weeks, eight weeks. And then the sleep physician is going to be co-opted by the system to get an in-lab test done because he gets reimbursed higher. Then this whole process goes on for four to six months. At this point, you’re not the only doctor that the patient’s seeing. They’re seeing so many others, they’re paying co-pays, they’re going for visits, they lose interest. And first of all, a patient is, like we pointed out, they don’t think sleep is such an important factor. They think that, “Oh, it’s something I’ll deal with. My heart doctor is super important, my kidney doctor is super important.” The sleep doctor, “Ah, I’ll skip it, it’s been going on. Yeah, I’ll skip the test. I’ll wait for after Christmas. I’ll wait ’til my deductible resets.” All these excuses. And I think we’re doing patients a huge disservice if we’re not talking about, how do we get you to care? How do we get access to care quicker? How do we get you on therapy quicker? Because that’s the only way. And for us, the success has been do it quickly, get them seen the same week, get them tested a few days after, get them seen back again, discuss the results, because our point is to get you on therapy. Yes, it aligns with our financial interests as well because we’re a practice, we provide DME or we provide CPAPs, we also provide oral appliances. But I love situations where our alignment is our patient’s alignment as well, where we can put them on therapy, and then they actually see the difference of what it was like to sleep without therapy and to sleep with therapy. And then you ask these patients whether they want to continue with therapy, and 95% of them say yes because there is a stark difference of how they were sleeping before. But we don’t get to that point of getting them on therapy. Like I mentioned, 85% of Americans still remain undiagnosed with sleep apnea. We estimate like 30-something million people out there, and I think the number is probably underestimated.

Dr. Ben Everett: That would be about 10%. The numbers, like if you look at diabetes, diagnosed versus undiagnosed, and diabetes tends to come with obesity or at least overweight, all these things that we know are also correlated with this. So that number does seem low to me. All right, so to just kind of recap a little bit here, we’ve had a lot of guests on, and so much of this really seems to tie right in with psychiatry and mental health because you’re talking about iterative, step-based care, or you could call it algorithmic care. And the other thing is, you want patients—and a lot of times in psychiatry, our medicines take a long time to work, “Oh, it’s going to be three to six months, and we got to titrate,” all this sort of stuff. But we know that the faster that we can get patients relief, the happier they’re going to be with the response. “Hey, I’m starting to feel better.” And it’s a positive sort of vicious cycle, not that negative vicious cycle where it’s, “Okay, now I got to see a cardiologist, oh, he sent me to a nephrologist.” And it’s all this, and you kind of don’t know what’s going on. The patient’s taking so long, he’s taking a lot of time out of their maybe their work calendar, it’s taking away from, financially, “Okay, I’m spending all these extra co-pays, and I’m having to spend all this money on my deductible,” whereas if we can get patients seen, evaluated more quickly and on therapy to maybe, “Okay, I’m going to bed the same every time, but I’m actually waking up refreshed. I haven’t woken up refreshed in a long time.” So we’re definitely going to be, I’m going to be filling out a form here.

This sounds really good in terms of rethinking this. So we talk about how you’ve worked in a traditional inpatient critical care setting, in hospital settings. So now you’re in this telemedicine, this virtual medicine practice. I think y’all are in 30-plus states, and you’re hoping to go to all 50 states here before too much longer.

Dr. Avinesh Bhar: We should be nationwide in about four months, but yeah, we are in about 38 to 40 states now, just waiting on some insurance credentialing and licensing to come through.

Dr. Ben Everett: In terms of, if you could set up sort of an ideal sleep care pathway from scratch, what would it look like?

[39:33] The Ideal Telemedicine Sleep Care Pathway: Fast Referral to Treatment

Dr. Avinesh Bhar: I think the onboarding process has to be easy. I think the referral process has to be easy. So that’s the first thing, is faxing should be a thing of the past, but we have to live by faxes as well. Our pathway is pretty straightforward, and I’ll kind of explain that. It’s simply going to our website, sliiip.com https://sliiip.com/, S-L-three I’s-P. The three I’s are just the cheapest way I could buy the word “sleep.” S-L-E-E-P was too expensive. And so you just come to our website, there is a referral tab on the top right. So for any practitioners, you just make a referral by adding the practitioner’s name, the patient’s name. It’s as simple as that. If you have the patient’s insurance information, even better, because that allows the practitioner to actually not only make the referral but also book the appointment for the patient. They don’t have to, but it allows, Ms. Smith with three kids who’s overwhelmed in your office to kind of just let you know, “Can you just book it for me for next Tuesday at 3:00? I’m available then,” and you can do that easily for your patients. I think the ease of access, you don’t need a primary care doctor’s office referral because if we check that, we verify everyone’s benefits, and if a referral’s needed, we will go to the primary care and get it ourselves because we don’t want to bother the referring office necessarily if they’re not the PCP. But we want to make sure that we don’t deny access to care because of some insurance requirement.

Then the referral’s made, appointments booked, we verify the benefits, we do the evaluation, note down the symptoms, because the symptoms are key. And that kind of gives me an idea, because all these tests that we do are not 100%. Every layperson in the world beyond the US has learned the idea of false negatives, because during COVID, we all realized that, “Man, I have all the symptoms of loss of taste, I have COVID, I’m sure I have it. My wife has it, I definitely have it,” and I get tested and it’s negative. So everyone understands now what false negatives are, and the same is true as well with sleep testing, whether it’s an in-lab or a home sleep test. So the clinical gestalt is really important. That’s why the idea of people just doing sleep tests without any clinical context or having someone to evaluate them and say, “Okay, yeah, I think my suspicion is you might have sleep-disordered breathing,” because then the test results based on that, or judged against that, is going to help you reduce the number of false negatives. False negatives exist in in-lab testing, it exists with home sleep testing as well. So it’s important for us to always frame the test results against the backdrop of the clinical context.

And the symptoms can be as varied. One of the things that I had as a clinical symptom, this is what drove me kind of crazy in understanding like, “Oh my God, the sleep issue can manifest in so many different ways.” And the saying has been, “There are common presentations of common diseases and uncommon presentations of common diseases.” But if a disease is common enough, even the uncommon are pretty common. And what I mean by that is, even headaches are maybe associated with sleep apnea. TMJ issues, sleep-disordered breathing. Grinding or clenching your jaw, sleep-disordered breathing. Waking up to urinate, nocturia. That’s not necessarily a urological issue; that may be driven by sleep apnea as well. Parasomnias, acting out some of your dreams, having wacky dreams, might be driven by your phase shifts that occur very quickly as you’re drifting off to deeper phases of sleep, but then there’s a phase shift because now you become apneic and you awaken quickly. That may trigger some parasomnias.

So I think, when you look at all of this, it’s kind of mind-blowing. And one of my symptoms was night sweats. Who would have thunk that as a symptom? So, the clinical documentation or kind of the evaluation is important so that we get an idea, am I expecting the test result to be positive? And then you go to the testing, and against that, you figure out. Now, for me, it’s helpful because when I see the clinical notes, I read my sleep studies for myself, for my patients, and for my nurse practitioners as well. And we do have MDs and NPs. And so, I will see, I will look at that note because based on the note, I’ll know what to look for. Because do I need to dig deeper? Is the test result making sense? If I see the initial report and I see it’s negative, but I’m looking at the clinical note, I’m like, “Yeah, this patient…” The way I frame it is, can I explain their sleep issues otherwise? If the test is negative, can I have a reasonable explanation for what’s going on? And if the answer is no, then I need to kind of dig deeper into the test result to see whether I need it.

Because a lot of the testing nowadays, the results are automated. There’s artificial intelligence to kind of do this sort of evaluation, and then they spit out a report. Great. If they get it right, great. However, a lot of the datasets that they have are from large studies that are done on the VA population, Veterans Administration population, and these populations are generally driven by overweight, older males. If that’s where this dataset was trained on, then they’re going to miss out on the average-sized woman or the younger woman in their 20s who has anxiety and so on, and adult-onset ADD. These symptoms are a lot more subtle, and it may not pick up on that. So, understanding the clinical context is important because that’s how we need to interpret the results. And based on that context, then I have to go in. So sometimes if I see a negative result and I’m like, “Ah, this doesn’t make sense,” I actually have to dig into the raw data and actually go, “Okay, yeah, this needs to be scored, this needs to be scored, these were subtle signs that were missed.”

And it helps patients because we stop telling them a falsehood, which is, “Oh, you don’t have it.” Then the question is, yes, can I adequately explain your symptoms otherwise? If I don’t capture it now, I’m putting the patient through potential re-testing because I’m going to say, “Hey, you need a retest.” That’s lazy of me because again, my practice, we earn money from more testing. So can you imagine that conflict of interest? I feel dirty when I have to tell a patient, “Your results were negative and we need to repeat the test.” Man, it’s such a nice way to earn more money because you didn’t do your job the right way the first time. That’s why we insist on doing multiple nights of testing, because even though it costs us money, our devices are out there, it takes more time to turn the devices around, and it hits our pockets, but it’s the right thing to do for the patient. Because the alternative is a false negative, telling a human being that they don’t have an issue, go back to living lives, go back to taking their melatonin, go back to the Benadryl at the CVS aisle, and “This is all normal,” and then they’re blossoming in a completely wrong way with their sleep issues.

You asked the question about what the pathway would be like. I think getting the evaluation, getting the testing done as quick as possible because the urgency with which we do it also translates to the patient’s idea of whether this is important. If we don’t consider it important, if we say, “Oh yeah, I’ll see you in six months,” or, “Our earliest appointment is in three months,” or, “We’ll get you into a sleep lab in two months,” how urgent is it? Is it really that important? Are your actions kind of falling along with the actual words that you’re using? “This is an important thing, but we’ll see, we’ll get the testing done in a couple of months.” I think speed and efficiency is key here to make sure that this issue is not overlooked. It’s not allowed to fester because, like you rightly pointed out, it affects so many other comorbidities. And if we are grappling with the cost of care, we’re grappling with a society where it feels like, “Oh my God, my body’s breaking down, I hit menopause,” or, “I hit middle age, and now I feel everything is coming apart,” we need to figure out what’s driving that. And one of the most overlooked things is sleep-disordered breathing because it manifests in so many varied ways that it’s no longer just snoring, gasping, waking up sleepy, because we know women use different words, we know men use different words. And if you go into a PCP’s office and you say “fatigue,” the PCP is going to have this algorithm for fatigue. “Okay, I’m going to check a TSH, I’m going to check a B12, I’m going to check a CBC,” but no one asks about sleep.

Dr. Ben Everett: So yeah, I think so much of it is a sense of urgency, and patients definitely want to feel like they’ve been heard or listened to. The referral pathway sounds really easy. And I really like what you said just about, you could make like a cardiology or an interventional cardiology type of analogy, right? Yeah, they might get the best data from a cath, but not everybody needs to go to the cath lab. We can still do a treadmill test. It’s step care, and the same thing is that insurance isn’t going to pay to take everybody to the cath lab because it simply isn’t necessary. We can do a treadmill test or a cardiac treadmill test.

Dr. Avinesh Bhar: But I think what drives a lot of that with the in-lab testing, a lot of practitioners I speak to are convinced that their patients don’t have sleep apnea. And I’m like, “How the hell would you know?” Like, I appreciate your specialty and your expertise, but you’re not in sleep, and maybe leave that decision to us. Like, I’ll have even psychiatrists, “Oh, my patients only need CBTI.” I’m like, “Oh, okay. Can we evaluate them first?” “No, no, they just need CBTI.” And I’m like, “Don’t you want the specialist to do their evaluation?” It’s like me going to a patient, going, “Hey, I’m going to send you to the psychiatrist, I’m going to ask them to prescribe you Effexor.” That’s not my role. It’s for you to get evaluated, for me to trust the other provider I’ve sent you to and actually do a due diligence. Because at the end of the day, we want the best outcome for our patients. And I think to do that, I think we need to be able to trust the people we work with.

[48:28] Stop Masking Sleep Problems With OTC Aids and Melatonin

Dr. Ben Everett: The other thing is understanding what medicines patients are on. And that does get to the supplements, and it gets to the OTCs also. There’s a ton of Benadryl use that just would be, “Oh, yeah, well, I take the Tylenol PM, it’s fine.” A lot of people don’t understand that’s Benadryl and really not good for you long-term. There’s plenty of data that suggests that now, plus, I mean, the nighttime falls and really, it should probably be considered contraindicated. Definitely not a good idea for large swaths of the population. But it also, I think it gets to the other thing, is like, “Well, if you’re having to take this every day, every OTC has a maximum time window when you’re supposed to take it,” and I think it’s two weeks. And sometimes it’s even less than that because if it’s going on longer than two weeks, you probably need to be seen by an appropriate healthcare provider to make sure there isn’t something underlying going on. The symptom is likely a flag for something larger that’s going on underneath, and let’s make sure that’s appropriately cared for. Melatonin, I think, is overused too. It’s a great placebo for parents that have kids that struggle sleeping sometimes; I’ve used it for that. But yeah, I mean, the data I’m familiar with just say, yeah, it seems to be effective for like jet lag for a couple of days. It’s like short. Again, if you’re using it every day, you’re pretty much not doing anything.

Dr. Avinesh Bhar: And if you’re cycling with different medications, like, “Oh, I use melatonin, then I use a little bit of CBD, then I’m also using Benadryl,” that’s why the latest study that came out that had this whole thing with melatonin now, it’s because people are using melatonin to treat a symptom like insomnia, but it’s a mislabeled symptom, it’s a self-labeled diagnosis, right, insomnia. And what I suspect, and the point that I’ve been trying to make, is that there is an underlying sleep-disordered breathing that may be overlooked because patients just, trying to understand their symptoms, they go, “Oh yeah, I’m not sleeping well, I wake up frequently at night, I can’t go back to sleep when I wake up in the middle of the night, I have insomnia.” Melatonin is what my friends use, this is what I use, this is what I’m going to use. And that’s why we’ve looked at the study, the studies show now that, oh my God, these patients are having increasing risk of heart disease and so on, and stroke risk. It’s because it’s the same risk factors of sleep-disordered breathing. You’re masking your symptoms.

This is a natural process. Sleep is a fundamental need. And if we all believe, whether you’re an evolutionary person or you’re a creationist, I mean, our bodies are amazing machines. I mean, holy crap, the stuff we don’t even know yet may still overwhelm us about the stuff that we know already. I mean, we may be still be scratching the surface here. So then the question is, why isn’t a core function working, of sleep? If you have to chemically induce yourself for sleep, this is about, like you talked about, chronic situations. I am not talking about these acute situations and so on, I’m talking about chronic. In sleep medicine, insomnia is chronic, considered chronic in three months and above. If you need to be dependent on medications for more than three months, you have to see whether there’s something else at play, because otherwise you’re doing your health a huge disservice. And that blood pressure issue may be related to your sleep. That headache may be related to sleep, your pain issue may be related to your sleep. And this list keeps going on and on and on. If you ignore sleep, even though you think you may not have sleep-disordered breathing, it behooves you to check it out because life is too short, and your expectations of sleep change very gradually so that you don’t even think it’s a problem. But the next time you’re with your provider going through the medication list or going through your diabetes and your high blood pressure, ask about sleep. And I think for all our practitioners listening as well, it’s important for us to ask and make sleep an integral part. There’s all these questionnaires and so on that we have. As a sleep physician, useless. I’m telling you, Epworth Sleepiness Scale, the STOP-BANG, because again, my patients are not five-year-old sleep apnea diagnoses. A five-year-old can make a diagnosis of sleep apnea when they see their grandfather snoring and gasping and falling asleep, right? But our patients are patients, like I said, the uncommon presentation of a very common disease. And so, two questions that you should ask: “Am I sleeping well?” “Am I waking up refreshed?” If the answer is ‘no’ to either one of those questions, the patient needs an evaluation.

[52:33 ] When to Retest and How Treatment Lowers Long-Term Healthcare Costs

Dr. Ben Everett: Well, that’s me. We’re definitely going to follow up.

Well, let me ask you maybe one more question as we move to wrap up, and that’s longitudinal testing. So is this something, once you have a diagnosis, is this, “Okay, I’m going to be on a CPAP or whatever Dr. Bhar prescribed forever? Do I need to have, hey, a couple of years go by and, hey, look, I’ve lost 40, 50 pounds, I got this resolved, I’m off of this, my type 2 diabetes is reversed”? Is there a time where a patient might need a follow-up, or is this kind of a set-it-and-forget-it? As long as you’re sleeping well, we’re just going to keep on doing this.

Dr. Avinesh Bhar: I don’t think the data is out there in terms of one conclusion or another. We now understand sleep-disordered breathing as a chronic condition. We’ve seen this happen when, back in the day, in the early 2000s, everyone was getting UPPPs, which is this uvuloplasty where they used to remove a lot of a chunk of your tissue at the back of your throat. It helped for a few months, but the natural progression of your airway and the narrowing and the collapsibility still proceeded. So, the way I would look at retesting is if there’s a clinical change. If the patient’s on CPAP, had been on CPAP, and sleeping great, no health changes, like if they have a new-onset afib, the question is, is my CPAP now still appropriate for me? Am I maybe worse than my CPAP is not keeping up? Is it an older device that needs an upgrade? So, if you have a clinical change, and weight loss is one of those, if you have weight gain as well, I would say that something is amiss. If you have weight loss, yeah, you want to see whether you’ve cured yourself of sleep apnea. One, but I say “cured” in inverted commas because it really depends on how long it’s been cured for. Because if you got the risk factor now, yes, weight may have driven it or accelerated it, but if you already had a risk factor, then when you age, even if you don’t gain that weight back, now your airway muscles actually become more collapsible.

So as long as you’re honest with yourself about how you feel. So let’s say, let’s say you walk into my office and you’ve been on CPAP for a couple of years and you’re like, “Doc, I lost 40 pounds,” and you were originally like 220, that’s like more than 10% weight loss. I’m like, “Yeah, great.” And the thing I’m going to ask you is this: can you tell the difference on nights when you use your CPAP or when you don’t use your CPAP? If you say, “Yeah, I could still tell a difference,” I’m not going to retest you because I know you’re going to need it. But I retest you if you’re like, “Man, I feel great.” I’m like, “Okay.” But the question in my head, if you feel great, is that you feel great here, you can’t tell the difference when your sleep is 5, 10% off, or are we talking about, “Man, it’s exactly the same”? So that’s why I would do a test on you without a CPAP on and then decide whether, hey, you can stay off CPAP safely. But going back to your question, it will be something that will come back in a year, two years, five years from now. So as long as the patient is well-aware that, hey, when my sleep—the beauty of someone that’s been on therapy and benefiting from it is that their benchmark for sleep quality, they know how they should feel. So then you just have to tell them, “If you start having a deterioration of your sleep quality persistently, not just one or two nights, but like you see more often than not, then come back and we’ll retest you, see what’s going on.” So I think for that reason, definitely retesting is important. But if there’s no meaningful clinical change and the patient’s doing great and health-wise, no change, then they can continue on therapy because they’re just kind of having great sleep every night.

Dr. Ben Everett: That makes sense to me, man. I’ve been taking 20 of rosuva for 15, 17 years now, and I’m not planning on stopping or discontinuing my rosuvastatin. It’s keeping my LDL cholesterol in check; I want to keep it low. So, it certainly makes sense. I’d written this kind of close-out question, “If there’s one, the greatest opportunity to reduce morbidity over the next decade related to sleep,” I think we’ve got it. It’s get people evaluated. If we can address their breathing issues, we can see some significant reductions in morbidities across probably a number of psychiatric as well as cardiometabolic parameters.

Dr. Avinesh Bhar: There was a recent study that was over 400,000 Medicare recipients, and they looked at them getting evaluated and treated. And for those on treatment, not even compliant, but just on treatment, and they looked at both groups, either they were not using any therapy or were non-compliant versus compliant. And they found the patients in the compliant and non-compliant group together, they both showed that over a period of two years—and the study ended after two years, it wasn’t like there wasn’t any improvement after two years, but over two years, on a per-member, per-month basis, that was a cost saving of close to $200. And that’s Medicare, meaning that they’re spending less on medications, they’re spending less on acquiring more healthcare because they’re actually sleeping better. So whatever diseases that may be driven by sleep is also improving. And I think that’s one thing we have to be aware of, is that we’re missing out on a lot of patients. And I would urge all your practitioners listening is that if you manage patients with mental health issues, sleep should be a core part of what you’re evaluating. And if whatever treatment you’ve initiated with them has not resulted in a near-complete resolution, like, “I’m waking up feeling great, doc, thank you so much,” then it behooves you to kind of evaluate them or send them for a further evaluation because it is important for us not to miss this diagnosis from a societal perspective.

I think from the way things are going in terms of cost and also chronic diseases, comorbidities just blossoming. We’ve looked at these wonder drugs, the GLP-1s, and some people have asked me like, “Are you worried with these weight-loss drugs that your sleep apnea patients are going to go away?” I was like, “No.” We’ve always assumed that weight is what’s driving sleep apnea, but we also know that sleep apnea causes weight gain. Many of these patients, we’ve seen this accelerate, like bariatric patients and so on. When they get retested, their sleep apnea doesn’t truly go away. They get a lot better, they feel a lot better. Like you’ve lost weight, you feel better because your symptoms were a 10 and now it’s a 7.5, and you’re like, “Man, I feel great.” The question is, can we get it all down to a 0 or a 1? And that’s where this retesting comes in. I think we do have an opportunity here to move the needle on health, mental health in general. I just want to make sure the word gets out to practitioners out there that the idea that you can send them to a sleep practitioner—because we hear this, we go to quite a few psych conferences, and it’s the usual story, it’s like, “Oh yeah, we send them to a sleep doctor down the road, the test was negative, they send it back to us with a recommendation of Seroquel, increased dose.” That’s not what you want out of a practice because they should be telling you more.

I mean, otherwise, as a psychiatrist or practitioner, you are more than capable of ordering a home sleep test or a sleep test in general. The question is whether the results make sense and what sort of therapy should be initiated for that patient. And I think a lot of people in the sleep field have not really lived up to that billing. I think we have to do better for our fellow practitioners who refer patients to us, and we have to do better for patients to make sure they get access to care as well.

Dr. Ben Everett: Yeah, and I know Seroquel at night is very common just because patients sleep, and then you don’t get callbacks when patients sleep.

Dr. Avinesh Bhar: Problem solved.

Dr. Ben Everett: But that doesn’t mean you’ve really gotten to the underlying cause. And really, you taught me two questions, right? Are you falling asleep well, and are you waking refreshed? How hard is that to add to just your intake or your check-in with a patient pretty much anytime?

Dr. Avinesh Bhar: Are you sleeping well? Are you waking up refreshed? If you have a “no” to either one of those questions, the patient needs an evaluation.

Dr. Ben Everett: Well, look, Avi, this has been great. I appreciate you taking some time to come and spend time with us today. Any parting words of wisdom or anything we hadn’t covered that you want to bring up?

Dr. Avinesh Bhar: I think we covered a lot of it. I’m really appreciative of our colleagues in the field of psychiatry because out of all other fields in medicine, psychiatry has been the most welcoming because they’ve really felt a need to deal with sleep. I hope as well the awareness trickles down to all the other fields in medicine, but I think I love the partnership that we have with psychiatrists because they’re seeing firsthand, like, “Hey, my patient comes back and they’re actually telling me they’re feeling better.” Now, a cardiologist is not going to ask you whether you’re feeling better. They’re going to look at, see whether you have your afib recurrence, they’re going to look at all these other parameters that maybe don’t tie directly, but in terms of mental health, that’s where we see the immediate change, and it’s easy to pick that up when the patient can report back to you how much better they feel. And the de-escalation of medications, I think that’s been a proof. So I want to encourage all our friends in the field of psychiatry to keep kind of looking for patients because they exist within your practice and at a much higher number than you could even imagine. The idea that, “Oh, I have a few patients,” is wrong, dead wrong. You have a lot more patients than you think, and they could be helped. So, look forward to working with each one of you.

[1:01:03] Up Next: Dr. Brett Jones

Dr. Ben Everett: In closing, I want to thank Dr. Bhar for joining us today on The JCP Podcast, for sharing his experiences and expertise in sleep medicine. It’s been great catching up, and I know I’ve learned a whole bunch today, even more than I thought I would. So, thanks for spending the time with us today. I want to invite everybody to join us next time. Our guest is going to be Dr. Brett Jones, and we’re going to be discussing his paper, “Inpatient Treatment of Suicidality: A Systematic Review of Clinical Trials.” It’s going to be a great conversation, and I hope everybody tunes in. Until next time, this has been The JCP Podcast: insightful, evidence-based, human-centered.

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