Sleep and Suicide

Welcome to Sleep Talk, the podcast about all-things sleep brought to you by sleephub.com.au. Here are your hosts Dr David Cunnington and Dr. Maury Younger. So welcome to episode number 59 of Sleep Talk, the podcast talking all-things sleep and welcome again Maury. Oh, good day. It's been a long time. It has been a long time. We were sort of waiting for the pandemic to ease, that all to just go away, life to get back to normal. Yeah, here we are. I think we thought we'd got through something and then it's probably worse than ever this year. Yeah, and it's, you know, we're both health care workers and providing health care and it's been pretty tough for health care workers and both trying to maintain a service for people and people are pretty distressed in the community as well. Yeah, a great, extraordinary amount of stress, extraordinary amount of sleep with servants and extraordinary amount of people expressing suicidal ideation as well as sometimes not so much suicidal, but just just sort of thinking, I just don't know what I haven't got much hope in life. I don't know what's worth living for at the moment, not all those sorts of things, which has prompted us to do the topic that we're doing today, which I'll get you to introduce. So we are going to talk about suicide and its interaction with sleep. There's a number of people who have done a lot of research in this area, but we wanted to talk to Professor Ian Hickey because he's published a lot on the relationship between sleep, mood, distress and the natural consequence of that being suicide. Ian's the co-director of the Health and Policy Unit at the University of Sydney's Brain and Mind Centre. So thanks a lot for helping us out with the podcast, Ian. Pleasure. And how big a problem is suicide in Australia? So the leading cause of death in young people in Australia between 25 and 44, leading cause of death in people under 25, over 3,300 people in Australia lose their lives to suicide every year, 65,000 people at temps suicide every year. You know, it is the biggest cause of productive years of life lost. So we need to talk about, you know, because basically talking about younger people, so 115,000 productive years of life lost every year. Now, cardiovascular disease, which comes number second, comes long second at about 78,000 and then various cancers come after that down in the 50,000. So I then think most people are aware, the extent to which we're talking about loss of life, loss of productive life due to a health problem, that suicide is streaks ahead, very sadly of those other common and frequently very well treated health conditions. So you focused on young people, what about other subgroups where you might see suicides a bit overrepresented. So you see suicide overrepresented in middle-aged men, you see it in certain groups, you certainly see it in our indigenous populations and there are groups in older people, particularly older men who are on their own, where suicide rates go up. Now, the so-called comorbidities come into play here. So when people have other medical conditions, like chronic pain, another of the difficulties, certainly drug and alcohol and related other problems, and certainly when the situation is complicated by other social factors, social isolation, loss of jobs, loss of relationships, marital breakdown, and other factors combine to put people at considerable risk. And it's been great to get you on to speak with us today, because you've been a real flag flyer for the link with depression and sleep. And we'd like to talk further about this, what are the links between suicide and sleep, and do we actually know yet? Well, we certainly know about the relationships between various types of depression, and the certain types of depression have various different types of sleep, and then sleep like cycle disturbance. So I often talk about sleep like cycles rather than just sleep. Sometimes I think when people just talk about sleep, they think it only about the 80 hours a day, but actually it's the 24 hour sleep like cycle that most fascinates me in terms of the different types. And I say that because of different types of sleep disturbance, and there are associated with different types of neuropsychiatric disorders and then with their consequences, like suicide, are very interesting. Although you can look at epidemiological studies directly at certain kinds of sleep disturbance and suicidal behavior, and try and unpick the particular relationships. So I think one of the problems we've had in psychiatry is to assume that sleep is just sort of an epiphenometer or a secondary phenomena. You have to be depressed first or you have to have some other major problem first and sleep is just of course one of those physiological things that go as wrong. The work I'm associated with goes the other way around. There are certain kinds of sleep like cycle disturbances which are fundamental. In fact, we would argue, for example, in bipolar disorder, previously known as manic-depressive illness, that circadian disturbance is actually the fundamental biological mechanism that the clock goes off, goes off in winter and spring. It goes off and leads to people not being able to sleep at all when they're manic or being totally oversleeping, becoming high-bendinating bears in winter when they're depressed. And it's really an energy sleep like cycle of disturbance and the mood is actually the secondary phenomena. This is of course heresy amongst my psychiatry colleagues, but basically treating that. And in fact, the world's most effective treatment is covered in Melbourne of all places. Lithium, in fact, moderates the regularity of the clock. A number of our any depressants, unfortunately, sometimes go the wrong way in making people more light-sensitive and disturbing their clock. So I think in some areas we argue not only is it important, it probably is the causal mechanism for the other phenomena that we see. And I raised this you're bipolar disorder in particular, because it has a very high rate of suicide. And it's very hard to treat also with conventional any depressants. So it doesn't do well with conventional any depressants. In other areas of the sleep wake cycle, many of our selectively serotonin reuptoking him as the pro-jector-like drugs actually makes some people more light-sensitive. Again, discovery is made in Melbourne by Sean Kane and his colleagues about light-sensitivity. And that that may make people more likely to become unstable. So some of the side effects of some of our common antidepressants might be due to their effect on the sleep wake cycle. Some of the SSRIs again disturb people's sleep. However, on the other side of the coin, there are certain kinds of anxious kinds of sleep problems. So people can't fall asleep, an issue in Somnia, ruminating thoughts, very anxious with things like SSRIs, but actually really good treatments and eventually help people to sleep by reducing their anxiety and rumination and effects on an issue in Somnia. So an issue in Somnia tends to run with anxiety. The great majority of depressants are anxious to depressions, anxious kids become anxious to press teenagers, become depressed substance-abusing adults. That's a lifetime change in the phenotype, but same underlying problem of anxiety type factors. And that's often associated with an issue that Somnia broke in sleep, daytime fatigue and other sets of problems. Of course, on the suicide bit in classical, very severe depression in middle-aged and older people, early morning wakeening, when the circadian clock has shifted actually in an opposite direction to teenage. So in teenage we sleep delayed sleep type factors, kids who won't go to sleep, we won't get up and we see young people depression very severe phase shifts in those directions, kids who become basically nocturnal, they're not awake during the day and expose themselves to life. You know, older people, we see the reverse, they're waking up at three in the morning, very agitated and very unwell and are highly likely to attempt suicide in those early hours of the morning. I mean, the tragedies that we see where someone has killed themselves at five in the morning out of a very disturbed sleep cycle. Other epidemiological work in the United States have worked with Catholic Mary Kangus and my colleagues there. Where teenagers get dragged out of bed at an ungodly hour as five and six a.m. to bus to school to start school early, really disrupts their adolescent sleep where you normally should sleep later. And that's associated with mood disturbance and probably the suicidal behavior too. So it's in recent times, there's been much greater interest amongst my epidemiological colleagues, but also my clinical colleagues in Hang on a second. This sleep stuff is not just a secondary epiphenomena. It's something that a public health level and also at a clinical level, we should put much, much more emphasis on. What do you think about distress as another mediator of that relationship between sleep and suicide? So I think one of the great things at the moment, and I think for those of us who are being affected by the COVID situation, the moment and losing our daytime routines, and it's generally distressed by loss of social connection and situational living in, is if you're distressed, you don't sleep. If you don't sleep, your stay distressed. Now, the great sleepers in the world have that marvellous phenomena where they're distressed all day, but they go to sleep. And then they wake up and they're like, oh, that wasn't so bad. You know, the distress has gone. They haven't remained anxious and aroused during their sleep. Unfortunately, and you don't, this is a temperamental or an inbuilt characteristic. The genetics to this are quite strong. Some people say, well, I don't sleep properly. Why don't you? We go, well, very fortunate that you do, but not everyone does. Those two stay aroused during so distressed during the day, aroused during sleep, of course, wake up distressed. They don't experience that relief that is essential every day to everyday functioning. So that's a really major function of sleep is to break the distress cycle. And you see that in a psychological sense, you see it in aroused or mechanisms that are recorded during sleep. People can't recognize that by the number of times they wake up during sleep, then I'm tossing a turn at it, but basically waking up tired. They haven't been refreshed. And I think increasingly we're starting to understand the brain mechanisms of repair and regeneration that take place during sleep. So distress messes with all of that. So I think one of the things, of course, people do other stuff then. They drink alcohol more. They do other things. They try and cope in various ways to reduce the distress in result of which is typically to make actually their distress worse, but more importantly, to disturb their sleep. So they don't actually get relief from the distress within that 24 hour period. And that's where distress becomes really risky in terms of suicide. If you never experience a reduction, and if you don't get a break, it just goes from day to day to day, then that feels very quickly. And some people that reaches a crescendo very quickly. Most of us cannot survive very many days without breaking that cycle of distress. What do you think about what further research needs to be done in this area? Well, a lot more work needs to be done, I think in both ways, that a lot of work we've done with people with lived experience, particularly young people, in a clinical world, often people aren't really asked about their sleep patterns and their total sleep cycle patterns to find out what they really do. And then they don't really look at whether taking interventions daytime exercise, morning light exposure, various types of other approaches. What effect in their particular situation that has on their mood, but also on their sleep pattern. So if people aren't often encouraged, the kind of experiment to find out the best way to manage that. And if managing their sleep work cycle pattern better actually translates into better, for example, depression treatment or anxiety treatment and those particular kind of situation. So the lack of information and the lack of doctors and clinicians sharing that information, it becomes really important to manage the whole particular kind of phenomenon. I think at a public health level as well, there's a lot of issues around increasing awareness about the importance of monitoring physical activity, monitoring, making use of course in Australia or daylight light exposure, the timing of activity is in addition to the total amount. And managing your sleep work cycle is one of those things that you can do. And if you don't have a very robust cycle, I mean, if you're classically like me, more an evening person than a morning person, morning people, can I say I really don't like morning people, I've said this number of times, I've received a lot of hate mail. Morning people tend to have very regular sleep work cycles. So they're up in the morning, bright and chirpy, and they tend to not be perturbed much. They maintain those cycles. More evening type people are more easily perturbed by what's going on, by disruptions, by worrying about things and staying up and have more unstable cycles. And those more unstable cycles are associated with high rates of depression and particular issues. So if you're one of those people who really needs to use more effort, daytime activity, physical activity, various kind of things to maintain a regular cycle, but you need to know that about yourself. So I think when we're teaching kind of health literacy, we don't actually teach much about it. Lots of people who run into particular periods, of course, the periods of life, like having children, childbirth, other things that happen, where people need to know that managing their sleep work cycle and trying to maintain a regular cycle is very important to maintain their overall health. Particularly, they're mental health. They'll cope better. The difficulty is people only seek help when things have gone really wrong. And then people say, I can't sleep. The tendency to say, okay, well, take a sleep medicine, or there's a crisis or something. And it's the first time in their life that they're really aware that if they don't sleep, they can't cope. But then they go for a very short term, you know, benzodiazepine type approach, or some sort of hypnotic immediately as the solution without really working out, hang on. What is my own intrinsic sleep cycle actually like? Or if they have other problems, snoring and sleep up in the air and other things, are they all pain, or other things that are interfering with their sleep, that they're not kind of effective that will be on their mood, on their cognition, and put them at considerable risk. So I think there's quite a lot to be done in education type way. And I think, of course, this is where the research really matters. And I think what I like was happening at the moment is the personalisation within that, the increasing use of activity, things, you know, fit-bit type things, other sorts of measures, things your phone measures, I hate my phone, it tells me what I haven't done under the friday, in terms of activity compared with weekends, you know, but that kind of feedback, personal feedback, and then understanding that you can actually take steps within that to manage that more effectively, and if it's working or not working, and you do need further medical assistance or psychological assistance, that you're building the evidence about yourself, and what your own cycle is like. And if there are things in your life, you know, work, work commitments, child care responsibilities, you know, new child, new baby, whatever else, these are periods in which, you know, sleep is going to be disrupted. Other areas, for example, say quite a lot of middle aged women passing through menopause, whose sleep is disturbed by a temperature of dysregulation during that particular period, and other things which have never been really discussed, you know, but having major effects on their lives, a lot of my work is occurring with teenagers, you know, and trying to make sure that teenagers all over have a shift to sleeping later and getting up later, don't become nocturnal, do stay day time active, do have light exposure, and use exercise and sleep-based cycle regulation to regulate their mood, I don't know if it's even touched, but teenagers can be a bit moody and can find themselves. It's a great age to learn the extent to which management of these sorts of activities, sleep-based cycle kind of promotion. I can say I hate the word sleep hygiene, it sounds like staying clean, staying clean, if you're going to just wash your hands or something, you know who? It's got that pure, pure technical sort of thing to it about good people are clean around sleep, and it's like, you know, that's why the late night types are seen as lovingly, and, you know, didn't you know that? Yes. Well, I think that's why they're unshaven and unwashed and unclean, and the morning people are clean and tidy, and they say this because some of my best friends are surgeons, and they always insist they have these meetings at 6.30 in the morning as morning people. Mind you, they never turn up, they never there, but the mornings, you know, and those of us, you know, barely being able to come to consciousness at that point are sort of, you know, well, not very verbal, unwashed. Yes, so the sleep, you know, and I think we need to, therefore, I think we need to change the way we present that away from that kind of simplistic sleep hygiene, philosophical information, to this much more personally informative type idea, and there's a lot of discussions, you know, in medicine that made between sort of personal either as medicine or what the geneticists prefer to call precision precision medicine. I prefer the personalized bit working out what works for you, you know, maybe the timing when you get up early morning light exposure, other sets of issues, does physical activity works for you, certain kinds of other, on the other side of the coin, certain kinds of relaxation activities, meditation, mindfulness yoga, other various things that you need to do to deactivate in the evening in order to go to sleep rather than going to sleep work out with you, if you very much ruminate learning sort of cognitive techniques to control rumination, and I think we've seen a lot of advances in the psychological care for those sleep type sets of issues, so that although sleep's not something you're aware of when you're asleep, it's something you can do quite a lot about, you know, when you're awake. Exactly, and I really like your point about sort of people understanding their sleep type, you know, we centre our teenage just so the career cancelled are in high school, but why not the sort of understand your individual characteristics to set yourself up for a life of sleeping, sleep to win, you know, sleep with your characteristics, undertake your daytime activities to match your underlying type so that you're not constantly fighting against the tide, because it seems a good time to teach people those skills. I do think we really struggle in public health, to my public health colleagues don't mind me saying so, with individual differences. So we tend to want to have one message, you know, there's one set of messages, you must do this all of you, you know, don't drink, don't smoke, you know, sex education, and it's sort of, it's sort of, we've got to keep the message simple, but the message isn't that simple at the individual level, because it doesn't work, and trying to get people to, for example, far out against their own chronotype is not always that productive, or for a group, for teenagers, for teenagers, the same as middle-aged adults, in terms of what is actually happening to them. So there's phase appropriate things, because of course this is true with kids in trying to settle kids into regular cycles, it's not necessarily that easy, you know, not necessarily a bad parent. If you can't get your kids to sleep that kind of easily, and they're not easily settled, they're not easily settled into cycles, a lot of that is built in. So just coming back to the research area that I think a lot of the research through the genetics, through the individual phenotyping, through the interventions needs to pay more respect to this degree of individual difference that exists, and then what is the best match between interventions and types. And I think in the public health sense, learning, particularly in high school, learning as a teenager, the relationship, the fundamental to this, discussion, we're having the relationship between sleep, wake cycles, and mood, and anxiety, and capacity to cope. You know, it's funny how in health, we go on and on and on about risk to cardiovascular disease. You know, we're talking to teenagers about risk to cardiovascular disease, something might happen to you in your 70s, not that relevant. You know, all we go on and on and on about obesity, you know, and it's long-term consequences or weight gain or whatever, you know, kind of stuff. We go, no, no, no, what I'm talking about here is, you know, actually you're actually to cope tomorrow, right, and moodiness, and whatever. And in fact, with younger people, that means a lot, actually. And things like coping with exams or coping with life stresses or particular things. I mean, there are other excellent, you know, periods, women who are having babies, and I must say the dads as well, you know, disruptions are going to happen around the perinatal period, the ones that are mature around menopause. If you do have other physical illness, you know, we don't actually, I think we miss the opportunity to take that down to a level that becomes meaningful. And if you know certain things about yourself, or even more, if you know that it runs in your family, you know, those particular dialysis, hilarious, with families that I'm attached to, hilarious discussions about the shared coronatimes, etc. And in various of my in-laws outlaws, they'll be aware of this. I love seeing that, you know, we're always the partners. I think it's their fault that all these people share these terrible sleep waste cycles in common. They're like, oh, you have a cause that at all. You're all living with it. They've all got that in common. They just, unfortunately, as a group, have inherited rather unstable cycles that are easily perturbed and a particularly, you know, of the late night, total, others who are fortunate to have those more stable morning-type patterns and whatever else are less risk. So as in much of health, I understand your own risk, but taking proactive steps to moderate that risk and finding out what really works for you at certain phases of life. I think it's become more important in terms of my maintaining daily routines, what a daily routine actually years from a clock point of view, or from a sleep waste cycle point of view, as a thing from a work or, you know, other aspects of one's life. What about those of us that the audience, mostly, are people working in sleep, like clinicians, researchers? What are your thoughts on how best to assess suicide risk? Any how to best support people we're working with? And in, obviously, we focus on improving sleep, but a lot of us don't have discussions around suicide risk and what we should be really looking for. Yeah, so I think there has been, if you like, fault from both sides. Many of the clinicians I work with, who ask about suicide and depression, barely ask about sleep, right? I think on the other side of the fence, there's a lot of people working sleep and I've very famous people around the world. I have these discussions with what are those delayed sleep deprivation people? Aren't they all depressed? Oh, yeah, but we don't ask them. You know, what about all those people with insomnia and room and anxiety? I'm so sorry, they're incredibly anxious, yeah, but we don't we don't don't dwell on that. You know, so I think one of the problems is we have sort of super specialization in the areas we are. And we're looking for a particular phenotype, particular characteristics, a particular types of disorders that may not have been fully diagnosed before. I mean, the world of health, you know, it's all just insomnia and it's all just messy sleep. And we're looking for as, as more specialized conditions often define the specifics. And I think people themselves are often looking for more of the specifics, but we tend to just row down one creek. So we ask a lot about sleep and don't ask about mood or don't ask about anxiety. And then, of course, suicide is by its nature a hard topic. And the danger, of course, is if you ask, they might say, yes, when people are like this, they often feel that they can't cope. They often get to the stage, particularly this sleep's been very poor, they feel a lifespan, because you can't enjoy anything. Actually, you can't sleep. My favorite topic is is actually anodonia, right? Like the absence of head and is an absence of pleasure. If you want to make sure that you can't enjoy anything, just lose your circadian system. You know, don't sleep. Most of us had jet lag to be aware of the fact, to be on the other side of the world, to be awake, but enjoying almost nothing. You just feel so out of kiln out of whack and the lack of enjoyment. So I think the issue is encouraging clinicians, particularly sleep conditions, to go down that track and see what the particular other characteristics might actually be. And emphasize the link between sleep, mood, and not being able to cope, and that not being able to cope at times, the distress associated that may become, in fact, suicidal behavior. Now, depends how comfortable you are. I mean, everyone I see who's depressed, I just assume they're suicidal. If they say they're not, I assume they're lying to me, because you know, most of the people who said they weren't, when they recover, go, I was, but I just want to tell you, you know, so I think making the assumption that if people are really struggling with their sleep, they're going to have mood or anxiety problems and a proportion of those are going to really feel that they would send with that. And that's fine. That's actually the recognition of that. It doesn't mean you suddenly have to jump and ring the police or ring an ambulance or send people to hospital or whatever, which is often what people fear that if you raise the topic, there will be a sort of catastrophic response to it. There's a stink from people living with it in their head and they're terrified of actually acknowledging it. In case somebody does something, in case they lose control themselves, it's a stink from saying no, no, no, no, no, that's really important. That's quite common. So this discussion we're having today is really important to say actually it's quite common in those situations. You know, sleep disturbance is a big thing. It's not a trivial thing. You know, I think it's one of those things we easily say, I've had trouble sleeping, you know, as a marker of distress, got happening in my life, of course, it disturbs your sleep. If that persists, if it's severe, it's then going to be associated with mood disturbance, with loss of capacity to cope, and inevitably, inevitably in that situation is life worth living. So I think in all of the suicide crises we see, you see that crescendo of that particular thing where the person has not went out of sleep for a particular period, they've not been able to relieve their distress in the usual kind of ways and that becomes part of the straw that breaks the criminal's back. So whether sleep conditions like it or not, you're actually sitting there with a population that underneath actually has quite a high rate of anxiety and depression, and within that, or associated with that, will be at a degree of suicidal thoughts and behaviours, often not overtly expressed, but better dealt with by being expressed. And I think his point is that with some confidence in inventions around those areas will produce benefits. I think that I think people worry about an alley area, is there's nothing that can be done or the treatments don't work, or focusing on the particular thing, or maybe even with asleep people, maybe I should even discuss it with asleep people, they're just here to discuss my, I'm always fascinated, when people say I went to the sleep doctor, so I'm going to discuss sleep, I went to scatress, so I'm going to discuss anxiety and discuss sleep, you know, as if the doctor on the anir end or the clinician or the psychologist on the anir, and he has one skill, or he has one thing, you know, actually, you know, actually, they'll do a better job if they know more of what is happening. I didn't mention my drug and alcohol problem, because that was a sleep doctor, you know, I didn't mention my chronic pain, because that was a sleep doctor, I didn't mention the depression was a sleep doctor. We have victims of our own specialisation, I think, and somewhat of our own narrow sense of inquiry in certain areas. Even the common mobility, I think it's a terrible word, you're seeing a range of phenomena of disturbed function, and they are going to affect sleep cycle, they're going to affect mood, they're going to affect cognition, they're going to affect the person's metabolic function, concurrently immune function, concurrently, so the person's sick, you know, they're sick, but which of the interventions could we focus on that might have the biggest effect, and specifically focusing on sleep and sleep, wake cycle interventions may have big effects on all those other factors, and I think that's where the areas of sleep medicine, the areas of circadian medicine have been underrated in terms of their potential, they have multiple good outcomes, not just on the target, if you like, or better sleep. Thanks, that's really helpful for, and helpful for me, so I won't be so frightened to ask in terms of asking about that, and I like your framework of just assuming, okay, they're probably thinking about it, so you know, as we'll put it on the table and talk about it. People, I can just say with David, people who speak into great deal of relief often when they do that, I don't know the thing, and they might get distressed, I'm the most important thing I have in my office is a box of tissues, and I've a joke with my OPA, the bigger Buffy of the blow could come in, get a big box of tissues, okay, because it might be the first time that they've expressed that distress, a lot of distress expressed to a health professional is very protective against the opposite, which is actually suicidal behaviour when people are on their own, so yeah, people might get distressed, and often better to assume they're gonna get distressed, but that's okay, that's what we're kind of there for, and interestingly, if you're looking at who people do distress expressed that distress to, not a lot of people end up in the hands of a psychiatrist, that's a very small proportion, people do it with a general practitioner, they do it with a hairdresser, talking with physio's recently, physio's get told, enormous amount of stuff while moving people's joints around, and so I think we just got to take it from a suicide prevention point of view, I'd make this serious point, we've got to take the opportunity, which ever set of health professionals, people are in the sector with, there's an opportunity there to pick up that and really put out the positive message that many of these problems can actually be dealt with, even if they're terrifying, even if people are ashamed of them, even if people are afraid of them, we've actually got interventions that will really help, and I think sleep positions and sleep conditions generally can make the point, it's highly likely that if their interventions are effective that people's mood and cognition will improve, that they will not just sleep better, they'll feel better and they'll think better and they'll think straight better, being up your earlier point, they'll experience relief from their distress in a way which then on the following day or the day after, they'll be able to cope, and suicide prevention, that's really important, it's getting through the next hour to the next day that often matters, so that people can then with their own coping mechanisms, but also the social world around them can respond, so tragically in many of the death spies to a side we have missed the opportunity that would have otherwise been there if it had been expressed and people through their own mechanisms, but also through social support had been able to respond. Ian, thank you so much for speaking to us today, it's been fantastic, really insightful, I think it's a lot of useful information for all our listeners and yeah, thank you, thank you very much, thanks for the opportunity, well that was fantastic having Ian speaking with us, what were your take-homes from that conversation? Yeah, that is interesting that if we're looking at the link between sleep and suicide, it could be mediated via a range of different things, they're really, I'd really like that concept of looking at the whole sleep-wake cycle and the circadian influence, and as we've talked about in other episodes, that circadian influence really pervades all aspects of life, and then how distress mediates that relationship as well, because if you think of the patients we see, often there's high distress, which is what escalates them to coming to see specialists like ourselves in this area, and understanding that's a high risk. It was fantastic that he rounded it around, I mean obviously it is around that just the bottom of it all is the coping, like you know, if you feel like I can't cope anymore, and you could probably cope until you perhaps had a baby or going through a minute pause or something, you know, something big changed and then you just thought, well, I just, my circadian system plus my mood, plus my relationships, plus, other than distress, it's just higher and higher, and I think that obviously, obviously even it's specialists and real big sort of thinker in this area, so I was just, yeah, I thought it was just, we could have talked for a lot longer, couldn't we? We could probably have a whole day teasing it out a bit more. So if you want to hear more of Ian talking about mental health and a range of other issues, check out his podcast called Minding Your Mind, available via all the usual podcast apps and streaming services. Ian's group have also published a number of key papers in the last 12 months looking at the relationship between mood, depression, circadian rhythms, and we'll put the links to those in the show notes. Moira, so what's your clinical tip? I think the clinical tip, when Ian touched on this anyway, and I think he pressed it even better, I think it's to remind Alison and clinicians particularly that we probably do need to assume whether it's expressed or not that people are experiencing a really quite a deep level of distress and they may not want to even go into how bad they're actually feeling. So I think that we can always, we should always have it's part of our assessment, it's just actually asking how they're going. But sometimes it's less obvious and you're just not quite sure what they mean by that. The clinical tip is definitely pick up on that, but definitely say can you tell me more about that? Are you saying that you don't want to live or you're talking about suicide? That really just actually helped them to bring it out. It's something they're finding difficult to express. And for us to sit with that and not have to, I think it's really important, you don't have to rush off to a triple low. It's very often, you know, very mostly it's something to sit with, it's something they're just expressing and you can actually still support them without having to feel like you are a mental health specialist. So what's your pick of the month? So I've been reading a book this month that I really like called The Body Keeps the Score by Bessel Vander Kolk. And it's about trauma, particularly developmental or early life trauma and how that changes the way both the body responds and how people respond. And for me, what really resonates is it fits with many people I see in clinical practice who are coming to see me later in life with issues sleeping, high levels of distress, difficulty switching off. But probably began as some early life or developmental trauma that's actually changed the way their brain responds and given it that heightened excitability and difficulty switching off. And yeah, really interesting. And the just a nice connection for me is Bessel actually worked with Alan Hobson in Massachusetts and Alan Hobson, the psychiatrist, he's recently died unfortunately, who I really found a wonderful mentor when I was in Boston for a couple of years, learning a lot about his work on dreams and his work on consciousness and how that relates to sleep. And so they'd actually work together. So it was really nice for me reading some of what Bessel had written about his experience as working with Alan Hobson many years ago when he was sort of early in his work with trauma. Fantastic. Well, put that on my list as well. What about for you, Mora? What's your pick? Well, I've been doing a bit of reading, of course, around preparing for this podcast today. And also you'll be aware, I've been touched by suicide on a personal level recently as well, someone close to me. So I've just been reading, looking at what kind of what sort of research is a doing stuff around the world is specifically looking at sleep and suicide behaviours and that protective role perhaps of sleep and something that I think, you know, we know that people who perhaps not sleeping so well, perhaps using drugs and alcohol a bit more to actually disguise or to help with that distress, to get some sleep, to help to get some relief and first to turn our attention to that. So there's just a nice paper that was by Bishop and colleagues. It's been published in 2020 in sleep medicine, called sleep suicide behaviours and protective role of medicine. I think we'll put that in the show notes too because I think that's just something that after we're working in this like field, I'm sure some of the reasons we're interested in that too. Tell us what's coming up in the future episodes, Dave. Well, as you know, we're working up a couple of other episodes at the moment, one on burnout, which is something again, we see a lot of in clinical practice and another on dreaming and lucidity during dreaming and this concept of lucid dreaming, knowing your interest in some of the social and economic determinants of health, also building an episode looking at sleep and are there social and economic determinants around sleep. So there are a couple of the things we're working on. People should also look out for the sleep down under conference, which is again gone virtual this year and that's going to be October 11 to 13. Check it out, register for the meeting, we've both been involved in putting together parts for the program and it's going to be a really great meeting and a very stimulating meeting. So make sure you look out for that and register for the meeting. Yeah, it can be wonderful. Let's just hope we can meet face to face soon. 2022. Yeah, he's hoping. So thanks for listening, it's actually really great to be back. Send us any suggestions at [email protected] and the email we have. We really love to feature early career researches particularly and really want to hear about your work if you want to job as a line. And if you like the podcast, review us on iTunes and subscribe via your favourite podcast app. Tell your friends and work colleagues and we'll see you next in your podcast feed. This podcast is not intended as a substitute for your own independent health professionals advice diagnosis or treatment. Always seek the advice of your physician or other qualified health provider within your country or place of residency with any questions you may have regarding a medical condition.