When Dr. Soohyun Nam meets with female members of predominantly Black churches, the conversation often shifts from her advertised topics of obesity and sleep difficulties to what the women perceive as the source of many of their health problems: stress.
“We would be talking about eating and diet, and then all of a sudden it became about stress, stress, stress,” said Nam, Associate Professor of Nursing at Yale School of Nursing. “We all have stress, but as the data have shown us, women can experience more pervasive stress, and Black women often experience pervasive stress because of daily encounters with racial discrimination. And this has a significant impact on health.”
Excessive stress can lead to insomnia, a condition that is undertreated and more common in women than men. It is defined by sleep difficulties that are associated with anxiety, moodiness, fatigue, irritability, poor work performance, headaches, unhealthy eating, and sedentary lifestyles. People with chronic insomnia are more likely to also have cardiometabolic disease — cardiovascular disease combined with obesity and diabetes. In fact, people who have insomnia are 41 percent more likely to have a heart attack and 55 percent more likely to develop coronary heart disease or have a stroke than people without the disorder.
“Insomnia is not just a sleep problem,” Nam said. “If we provide treatment to improve insomnia, maybe we can improve cardiometabolic health and save lives.”
Currently, 30 percent of American adults suffer from some form of insomnia, but the condition affects Black women disproportionately. For example, even when studies account for socioeconomic status, Black women report shorter total sleep time than White women and greater difficulty falling asleep and staying asleep. However, there have been no studies published to date that focus on psycho-behavioral interventions for Black women to address their sleep deficits.
The most common treatments for insomnia are sleeping pills, which carry the risks of side effects, tolerance, and dependence without addressing the underlying causes of sleeplessness. The most common non-pharmaceutical therapy for insomnia is called cognitive behavioral therapy (CBT), an evidence-based treatment that seeks to help patients develop coping skills and change the way they think, feel, and behave. While used for conditions as diverse as depression, anxiety, and substance use disorders, CBT for insomnia can be difficult for much of the public to access because of cost and its practice being largely limited to academic medical centers. In addition, although effective, CBT only prevents recurrence of the insomnia 40 percent of the time.
With a grant from Women’s Health Research at Yale, Dr. Nam is testing — for the first time — an evidence-based stress-reduction intervention for insomnia that has shown potential for addressing the underlying causes of sleep difficulty in a manner culturally sensitive to the needs of Black women.
“When lying down in bed, someone might fixate on a troubling incident from earlier in the day, leaving her hyper-aroused and unable to sleep,” Nam said. “This triggers worries about not sleeping and not functioning the following day, which makes it even harder to fall asleep. We need to break that cycle.”
Dr. Nam’s approach uses a mindfulness-based therapy for insomnia (MBTI), an eight-week group therapy program in which participants gain an awareness of their thoughts that fuel the stress they feel and the skills to regulate their responses to stress. The program includes daily home practice and is designed to cultivate non-judgement, self-compassion, and present-focused awareness.
In this study, Nam and her team are comparing the amount and quality of sleep experienced by the MBTI participants with another randomly assigned group receiving general education in healthy eating, physical activity, and proper sleeping strategies.
Participants are measuring their body weight and height using portable electronic devices and evaluating daily stresses and sleep practices through remotely conducted surveys. Participants are wearing a device on their wrist called an actigraph to detect periods of activity and rest, supplemented with a daily diary and text message reminders. The researchers are also using home saliva kits to collect and analyze samples for levels of cortisol, a hormone associated with stress.
Dr. Nam anticipates that the group receiving the MBTI intervention will show improved sleeping results and reduced levels of stress compared with the control group. With these data, she plans to design a much larger trial to justify the widespread dissemination of this intervention for the benefit of this underserved population of women.
“Mindfulness focuses on how you live with the stress, not just get rid of it,” she said. “You regulate your emotion. And hopefully, we can help women achieve the rest they need so they can better maintain their health and well-being.”