Some healthcare can safely wait (and some can’t)

Among the many remarkable things that have happened since the COVID-19 pandemic began is that a lot of our usual medical care has simply stopped.

According to a recent study, routine testing for cervical cancer, cholesterol, and blood sugar is down nearly 70% across the country. Elective surgeries, routine physical examinations, and other screening tests have been canceled or rescheduled so that people can stay at home, avoid being around others who might be sick, and avoid unknowingly spreading the virus. Many clinics, hospitals, and doctors’ offices have been closed for weeks except for emergencies. Even if these facilities are open, there’s understandable reluctance to seek medical care where an infected person may have been just before you. So which health concerns can safely wait — and which should not?

What can wait?

It’s safe to put off some healthcare for a number of weeks or months.

• Routine screening tests. For example, a mammogram may be recommended every year or two for women at average risk of breast cancer. In that situation, it’s unlikely that having that test a few months late will affect your health. Similarly, if you’re due for a screening colonoscopy because you’ve turned 50 or your last one was 10 years ago, having it a few months late is not a risky delay. For some tests, there are alternatives you could have in the meantime. For example, there is home testing available for colon cancer screening that checks the stool for blood or abnormal DNA (findings that could indicate the presence of cancer). Each person’s situation is a bit different, so if you’re due for a screening test and can’t have it due to the pandemic, call your doctor about how to proceed.
• Routine vaccinations. Usually, it’s safe for adults to briefly put off routine vaccinations. Ask your doctor which vaccinations are time-sensitive and which can wait. For example, a shingles vaccine requires a second dose within a specific window of time after the first dose.
• Routine physical examinations. If you are feeling well and you have no pressing health concerns, delaying your exam for a few weeks or months is fine. In fact, the usefulness of routine annual physical examinations has been debated for some time, so even if you skip a year, it might not matter.
• Elective surgery. A good example is knee replacement for osteoarthritis: if you had surgery planned in April, there’s a good chance it was cancelled. That might be fine if you are able to get around and can tolerate the arthritis pain with medications. Hopefully, you can reschedule within a few weeks of the original date. But some elective surgery is more urgent than others, so review the timing with your doctor.

Thank goodness for telehealth

Video conferencing and telephone visits with doctors, nurses, and other healthcare professionals have filled the healthcare void admirably. We are realizing that a lot can be accomplished without coming into the office or hospital. Especially with the help of home equipment (such as a blood pressure cuff), you can be monitored well for hypertension, diabetes, asthma, and a host of other conditions with virtual visits. Mental health care can often be successfully provided by telehealth.

Sometimes your presence is required

Of course, some medical care simply cannot be provided by telehealth. Your doctor cannot perform procedures (such as draining an abscess) or an operation without your physical presence. A physical examination to feel a lump or search for an enlarged liver, an x-ray or other imaging test, and most blood tests require you to come in. It can be hard to evaluate a rash, look in your throat, or assess a sore joint without your being there. And if you had an abnormal test (such as a mammogram), you may be encouraged to come in for follow-up testing or evaluation. While a month or two of delay may not matter for some of these issues, for others it does.

Some healthcare cannot wait

What problems should prompt you to seek medical care even during a pandemic?

In recent months, reports from news media and healthcare providers in some parts of the US suggest that fewer people are coming to the emergency department with heart attacks, strokes, and other non-COVID health problems (see here, here, and here).

How can this be? Some problems, such as injuries from car accidents, may have become less common because people are staying in and driving less. But many conditions that land people in emergency rooms don’t go away during a pandemic. So what happened to the people having these problems?

The answer is almost surely that they are staying home and riding it out, avoiding exposure to those who might be infected with the new coronavirus, or wanting to do their part to limit emergency room overcrowding. Some may be concerned they’ll be turned away if they do show up.

But it’s risky to put off medical care for potentially serious problems, such as those on the list below. Complications of these conditions can be life-threatening, and a trip to the emergency room or urgent care is warranted.

When to seek emergency care

Call 911 or seek emergency medical care right away if you experience

• trouble breathing
• persistent chest pain or pressure, especially if you have a history of heart problems
• persistent and severe pain, such as abdominal or pelvic pain
• unexplained loss of consciousness, confusion, or a change in mental state (such as being unusually agitated or speaking incoherently)
• unexplained and persistent weakness in muscles of your arms, legs, or face that affects your ability to move or speak
• loss of vision
• an accident that impairs function, such as falling and then not being able to bear weight on your hip
• uncontrollable bleeding
• coughing up or vomiting blood
• suicidal feelings or acts.

Use your own experience as a guide. If you’ve had a serious illness in the past and now have the same worrisome symptoms, seek medical attention.

Thinking of heading to the ED?

Many emergency rooms and hospitals are crowded right now. It’s a good idea to call ahead, so the emergency providers know you’re coming and can give you advice about where to show up. If there’s time, put on a mask and wash your hands once more before leaving for the ED.

One other caveat: if you have typical symptoms of COVID-19 and your symptoms are not severe, call your doctor or local public health officials for guidance. In that situation, it may be best to avoid the emergency room; arranging testing and managing at home may be recommended.

The bottom line

The pandemic is teaching us a lot about what happens when non-urgent healthcare largely shuts down. Some of what we learn will be useful long after the pandemic is over. For example, if virtual visits are proven to be just as effective as an in-person visit, we can expect telehealth to become much more common. We may learn that we can safely take care of many chronic conditions with fewer visits. Years from now, researchers may be able to sort out what types of visits were just as good virtually and which ones were most prone to mistakes. And we might even find out that some medical care previously considered important is actually unnecessary after all.

In the meantime, here’s some advice that’s unchanged by the pandemic: if you have an emergency, seek medical care right away. And if you aren’t sure how to proceed, don’t hesitate to discuss it with your doctor.

Follow me on Twitter @RobShmerling

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How to respond to tantrums

As Murphy’s Law would have it, children’s tantrums seem to happen at the most inconvenient times. Your toddler or independent-minded 3-year-old turns red, screams, stomps, and appears possessed when you’ve finally gotten everyone geared up for a family walk, or wrangled that video call you spent days coordinating with relatives to get everyone live at once — or even worse, when you need silence for your weekly video conference call at work.

“What’s gotten into you? We don’t have time for this!” you might think. Everything you say and do seems to make the tantrum worse, and it takes all of your remaining resources not to throw a tantrum yourself. What can you do instead when your child throws a tantrum? Below is a three-step strategy that can help.

Validate the emotions behind the tantrum

Validating someone’s emotions means acknowledging them. You are not agreeing or disagreeing with the feelings; you are demonstrating that you hear the other person.

You likely have noticed that logic does not go over well with a child throwing a tantrum. For example, let’s say your child throws a tantrum while demanding a cookie before dinner. “Why are you so unhappy? You know you cannot have dessert before dinner,” you point out logically. Most likely, the child’s ears will close, and the tantrum will escalate because they don’t feel heard. Instead, validating their emotions can help them identify how they are feeling, which is one step toward helping them regulate or calm their emotions.

In this case, you can state, “You’re angry with me because I won’t give you a cookie before dinner.” Sometimes, you might just validate the feeling and leave it at that. Other times, a second clause helps illustrate that two opposing statements can be true at the same time: “You’re angry with me because I won’t give you a cookie before dinner, and you can have one after dinner.” If you’re trying this, it’s important to use the conjunction “and” and not “but.” That way, you won’t negate the first part of the clause.

Your child probably won’t smile and agreeably walk away. However, validating can prevent an escalation of the tantrum and curtail the intensity of the emotion.

Actively ignore dandelions

Any behavior that gets attention will continue. Imagine a garden: your child is the rose that needs just the right amount of sunlight and water; the dandelions are the unhelpful behaviors, such as tantrums. If you so much as blink in a dandelion’s direction, you know that you will have a garden full of dandelions. This is why after validating once, the next step is to ignore.

Some parents are concerned that they aren’t doing anything when they ignore. You are; you are ignoring actively, which takes effort. This will be very tough. Expect the behavior to get worse before it gets better (what is known as an “extinction burst”). Remind yourself that you are ignoring the dandelions and not your child. Pay attention to anything else: pick the lint off your sweater, do the dishes, or count the clouds in the sky. Do not water the dandelions, though. If you ignore actively for 10 minutes and then eventually shout at your child or just give the child the cookie, the child will learn that he needs to push longer to get attention or the desired outcome. Then you will have even more dandelions in your garden.

Praise cooperative behavior

The moment your child re-engages in a cooperative manner, praise your child enthusiastically and specifically. For example, “Way to go on joining us at the dinner table respectfully! I am really proud of you.” If you start to hear pleading for a cookie again, go back to ignoring the dandelions. When the rose — your child — returns, provide more praise. You may feel silly bouncing back and forth, but it’s important to water the appropriate flower in the garden — that is, the behavior you want to see.

These strategies apply even when you are in public. Understandably, you may be concerned about what others think of you as a parent while you actively ignore the tantrum. Some parents worry that others are imagining that they do not know how to handle their children. You also might feel utterly humiliated and helpless that you cannot control your child’s behavior.

As you take a deep breath, remember this: you certainly are not the first parent to have a child throw a tantrum in public. Other parents around you likely were in your shoes not long before you. If you feel compelled to do so, you can let others around you know that you are ignoring actively to help your child settle down.

No matter where the tantrums occur, validate your feelings, too. Feeling frustrated or embarrassed is understandable. Remember, though, that the rose will return if you do not water the dandelions.

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I have inflammatory bowel disease (IBD). What should I eat?

One of the most frequent questions that patients with inflammatory bowel disease (IBD) ask is: what should I eat?

It is clear that in addition to genetic factors, certain environmental factors, including diet, may trigger the excessive immune activity that leads to intestinal inflammation in IBD, which includes both Crohn’s disease and ulcerative colitis (UC). However, the limited number and high variability of studies have made it difficult to confidently advise patients regarding which specific foods might be harmful and which are safe or may actually provide a protective benefit.

New IBD dietary guidelines

To help patients and providers navigate these nutritional questions, the International Organization of IBD (IOIBD) recently reviewed the best current evidence to develop expert recommendations regarding dietary measures that might help to control and prevent relapse of IBD. In particular, the group focused on the dietary components and additives that they felt were the most important to consider because they comprise a large proportion of the diets that IBD patients may follow.

The IOIBD guidelines include the following recommendations:

Food	If you have Crohn’s disease	If you have ulcerative colitis
Fruits	increase intake	insufficient evidence
Vegetables	increase intake	insufficient evidence
Red/processed meat	insufficient evidence	decrease intake
Unpasteurized dairy products	best to avoid	best to avoid
Dietary fat	decrease intake of saturated fats and avoid trans fats	decrease consumption of myristic acid (palm, coconut, dairy fat), avoid trans fats, and increase intake of omega-3 (from marine fish but not dietary supplements)
Food additives	decrease intake of maltodextrin-containing foods	decrease intake of maltodextrin-containing foods
Thickeners	decrease intake of carboxymethylcellulose	decrease intake of carboxymethylcellulose
Carrageenan (a thickener extracted from seaweed)	decrease intake	decrease intake
Titanium dioxide (a food colorant and preservative)	decrease intake	decrease intake
Sulfites (flavor enhancer and preservative)	decrease intake	decrease intake

The group also identified areas where there was insufficient evidence to come to a conclusion, highlighting the critical need for further studies. Foods for which there was insufficient evidence to generate a recommendation for both UC and Crohn’s disease included refined sugars and carbohydrates, wheat/gluten, poultry, pasteurized dairy products, and alcoholic beverages.

How would observing these guidelines help?

The recommendations were developed with the aim of reducing symptoms and inflammation. The ways in which altering the intake of particular foods may trigger or reduce inflammation are quite diverse, and the mechanisms are better understood for certain foods than others.

For example, fruits and vegetables are generally higher in fiber, which is fermented by bacterial enzymes within the colon. This fermentation produces short-chain fatty acids (SCFAs) that provide beneficial effects to the cells lining the colon. Patients with active IBD have been observed to have decreased SCFAs, so increasing the intake of plant-based fiber may work, in part, by boosting the production of SCFAs.

However, it is important to note disease-specific considerations that might be relevant to your particular situation. For example, about one-third of Crohn’s disease patients will develop an area of intestinal narrowing, called a stricture, within the first 10 years of diagnosis. Insoluble fiber can worsen symptoms and, in some cases, lead to intestinal blockage if a stricture is present. So, while increasing consumption of fruits and vegetable is generally beneficial for Crohn’s disease, patients with a stricture should limit their intake of insoluble fiber.

Specific diets for IBD?

A number of specific diets have been explored for IBD, including the Mediterranean diet, specific carbohydrate diet, Crohn’s disease exclusion diet, autoimmune protocol diet, and a diet low in fermentable oligo-, di-, monosaccharides, and polyols (FODMAPs).

Although the IOIBD group initially set out to evaluate some of these diets, they did not find enough high-quality trials that specifically studied them. Therefore, they limited their recommendations to individual dietary components. Stronger recommendations may be possible once additional trials of these dietary patterns become available. For the time being, we generally encourage our patients to monitor for correlations of specific foods to their symptoms. In some cases, patients may explore some of these specific diets to see if they help.

New guidelines are a good place to start

All patients with IBD should work with their doctor or a nutritionist, who will conduct a nutritional assessment to check for malnutrition and provide advice to correct deficiencies if they are present.

However, the recent guidelines are an excellent starting point for discussions between patients and their doctors about whether specific dietary changes might be helpful in reducing symptoms and risk of relapse of IBD.

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And now for some good news on health

When it comes to health concerns, the COVID-19 pandemic is top of mind for most people right now. And that’s for good reason.

But there is some very good non-COVID health news that may not be getting the attention it deserves. According to the CDC, the rates of six of the top 10 causes of death in this country, which account for about three-quarters of all deaths, have been declining. That’s remarkable. And these improvements are occurring despite an aging population and an obesity epidemic that affects several health conditions.

Six positive health trends

Let’s look at the trends in these conditions and their rank as causes of death in the US:

• Heart disease (#1) and stroke (#5): Deaths due to cardiovascular disease, including heart attacks and stroke, fell by about 36% between 2000 and 2014. The decline for heart disease since 2014 appears to have continued through 2018. After leveling off for several years, stroke-related deaths dropped again (by 1.3%) from 2017 to 2018.
• Cancer (#2): The drop in cancer deaths was about 2% between 2017 and 2018. Over the last 25 years it has dropped by 29%.
• Unintentional injuries (#3), including drug overdoses, and chronic lower respiratory diseases (#4), such as emphysema and asthma: Each of these categories dropped by nearly 3% from 2017 to 2018.
• Alzheimer’s disease (#6): Deaths fell 1.6%, even though the prevalence of this devastating illness is increasing.

The cholesterol connection

Another positive trend is that cholesterol levels across the US population have been moving in the right direction over the last 20 years. About 18% of Americans had a high total cholesterol in 1999; as of 2018, just 10.5% had high levels. Meanwhile, about 22% of the population had low HDL (“good”) cholesterol; that number fell to 16% in 2018. Because high total cholesterol and low HDL cholesterol are risk factors for cardiovascular disease, these improvements may at least partly explain why cardiovascular disease mortality rates are falling.

And fewer people are smoking

There’s also good news with respect to the popularity of cigarette smoking. According to the CDC, the percent of the population that smokes cigarettes is dropping significantly. In 2017 it fell to 14%, an all-time low since such statistics have been collected. This represents a steady drop from 2006, when nearly 21% of people were smokers.

Over time, fewer smokers means lower rates of smoking-related illness, including several of the top 10 causes of death like chronic lung disease, lung cancer, and cardiovascular disease.

Notably, this survey did not include vaping, which has been rapidly gaining popularity in recent years. Some former cigarette smokers are now vaping, as are many adolescents and young adults. So the good news about falling smoking rates could be at least partially offset by potential negative health consequences of vaping, including e-cigarette or vaping-associated lung injury (EVALI).

What about life expectancy?

Life expectancy in the US was estimated to be 78.7 years in 2018, a small increase from 78.6 years in 2017. Between 2014 and 2017 life expectancy had been falling in the US, largely due to suicide and unintentional injury (especially drug overdoses). While the improvement in 2018 is small, it’s still welcome news to see estimated longevity tick upward.

Some caveats

It’s worth emphasizing that the data that demonstrate these positive health trends are at least a year or two old. And, importantly, improvements in life expectancy and certain causes of death are not shared equally among all groups of people: those living in poverty and a number of ethnic and racial groups have experienced less health improvement than the population as a whole.

In addition, these trends preceded the COVID-19 pandemic, a disease that has quickly become a leading cause of death. In fact, as of April 7th, 2020, COVID-19 was the number one cause of death in the US when the number of deaths per day (rather than the yearly number) were considered.

And of course, focusing only on causes of death does not provide a complete picture of a nation’s health. Disability and quality of life are essential measures of health as well, and for many people these are more important than longevity.

The bottom line

The good news is real and reason to celebrate. Yet there is plenty of room for improvement in the health of Americans, especially for four causes of death that are not falling: influenza and pneumonia, suicide, diabetes, and kidney disease. And there is no guarantee that the positive trends will continue. My hope is that we can figure out how to make even more progress more quickly, and to extend that progress more evenly throughout the population.

Follow me on Twitter @RobShmerling

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New warning on coronavirus symptoms in children — what parents need to know

While most children who get COVID-19 have a mild or even asymptomatic illness, there are new reports that some children may have a complication that can be severe and dangerous.

Called pediatric multisystem inflammatory syndrome (PMIS), it can lead to life-threatening problems with the heart and other organs in the body. Early reports compared it to Kawasaki disease, an inflammatory illness that can lead to heart problems. But while some cases look very much like Kawasaki’s, others have been different. Experts think that PMIS is likely a reaction of the body to either a current or past COVID-19 infection — but there is much we don’t understand, including why some children with PMIS have negative tests for COVID-19.

What are the symptoms of the new inflammatory syndrome known as PMIS?

Symptoms of PMIS vary from case to case, but can include

• prolonged fever (more than a couple of days)
• rash
• conjunctivitis (redness of the white part of the eye)
• stomachache
• vomiting and/or diarrhea
• a large, swollen lymph node in the neck
• red, cracked lips
• a tongue that is redder than usual and looks like a strawberry
• swollen hands and/or feet
• irritability and/or unusual sleepiness or weakness.

There are many other conditions that can cause these symptoms. For example, strep throat can cause fever, rash, swollen lymph nodes, and a “strawberry tongue,” and there are plenty of common viruses that cause stomachache, vomiting, and diarrhea. Doctors make the diagnosis of PMIS based not just on these symptoms, but also on their physical examination as well as medical tests that check for inflammation and how organs are functioning.

What parents need to know about PMIS

We are just learning about PMIS. At this point we have many more questions than answers. But here is what parents need to know about this syndrome:

• It is rare. While there is a lot about it in the news, the number of cases is actually low, especially when you consider how widespread COVID-19 has become. Parents should not panic if their child gets one of these symptoms, or if they are diagnosed with COVID-19.
• It is treatable. Doctors have had success using various treatments for inflammation, as well as treatments to support organ systems that are having trouble. While there have been some deaths, most children who have developed this syndrome have recovered.
• It is serious. That’s why it’s important to be vigilant. Call the doctor if your child develops symptoms on the list above, particularly if they have a prolonged fever (more than a couple of days). While it’s especially important to call if your child has been diagnosed with COVID-19 and develops one or more of these symptoms, you should call even if they haven’t. If your doctor isn’t concerned, that’s great — but if the symptoms get any worse or just don’t improve, call again or bring your child to an emergency room.

Many parents are afraid to take their children out of the house during the COVID-19 pandemic, let alone to a doctor’s office or hospital. That’s understandable, but it’s important not to let that fear endanger your child’s health. If you are worried about your child — for this or any reason — call your doctor. Together you can figure out how to get your child the care they need.

Follow me on Twitter @drClaire

For more information on coronavirus and COVID-19, see the Harvard Health Publishing Coronavirus Resource Center.

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SMall Incision Lenticule Extraction (SMILE): It’s what’s new in laser vision correction

The goal of laser vision correction (LVC) is to eliminate or reduce the need for glasses and contact lenses. LVC treats three basic refractive errors: myopia (nearsightedness), astigmatism (blurring of vision due to non-spherical shape of the eye), and hyperopia (farsightedness).

During an LVC procedure, the cornea — the clear dome on the surface of the eye — is reshaped in order to correct the refractive error. The different techniques to perform LVC are laser in situ keratomileusis (LASIK), phototherapeutic refractive keratectomy (PRK), and small incision lenticule extraction (SMILE).

LASIK and PRK

LASIK, the most commonly performed laser vision correction procedure in the US and the most famous of the techniques, was approved by the FDA in 1998. It is well known for its quick recovery. LASIK combines the application of excimer laser and a hinged corneal flap. The excimer laser is a computer-controlled laser that allows precise control over the amounts of tissue that are removed from the cornea. The corneal flap is a layer of the cornea that is folded back to provide access to a deeper layer of the cornea that is reshaped by the excimer laser during the procedure.

LASIK has a much quicker and more comfortable recovery compared to PRK. After LASIK, patients typically experience a scratching and burning sensation that significantly improves within one day. Most patients have excellent vision the day after LASIK. In the first week especially, patients need to be mindful of the corneal flap, which has a small chance of moving or dislocating with rubbing or hard blinking. Even months after the procedure, there is a small risk of flap dislocation with significant trauma.

The most common side effect or risk of LVC is dry eye. Typically, the dryness goes away within a week or two, but in other cases it can require ongoing treatment. The refractive surgeon should screen for dry eye at the preoperative consultation, and treat it prior to the procedure to reduce risk of chronic issues afterward. LASIK is thought to have a slightly higher risk of dry eye compared to SMILE and PRK.

PRK was approved by the FDA in 1995 and was the first type of LVC performed. During PRK, the outer layer of corneal skin cells is removed, followed by the use of the excimer laser to reshape the corneal tissue to correct vision. Patients typically experience 48 to 72 hours of scratching, tearing, burning, and light sensitivity after PRK, often requiring short-term pain medication. Most patients have functional vision during this time, and are able to drive and resume most activities by the fourth or fifth day after the procedure. The PRK recovery is longer and less comfortable than recovery after LASIK and SMILE. The main benefits of PRK are no flap and reduced risk of dry eye. PRK is an excellent option for patients with thinner corneas.

SMILE

The FDA approved SMILE, the latest advance in laser vision surgery, in 2016. It has been shown to be as effective and safe as LASIK, and it is currently available for the treatment of myopia and myopic astigmatism. SMILE combines advantages of PRK and LASIK: it requires only a small incision, does not require a flap, and has a quick, LASIK-like recovery, with the additional benefit of no postoperative restrictions.

With one laser and in approximately 30 seconds, a thin contact lens-shaped layer just beneath the surface of the cornea is created with the laser. This layer is then removed through a tiny 2–3 mm opening, and the surrounding tissues heal together. The procedure is extremely comfortable, with a quick recovery, and requires no postoperative restrictions (unlike LASIK and PRK). It also avoids any potential risk of flap complications, in contrast to LASIK. The SMILE procedure is growing in popularity, but it is currently not as widely available as LASIK and PRK in the US. As surgeons and laser centers continue to adopt the technology, the volume of procedures is expected to grow.

On the day of the SMILE procedure, as with LASIK, most patients experience a sensation that they have something in their eye, as well as tearing and burning for several hours afterward. Visual recovery is quite rapid, and after one to two days most patients have 20/20 vision. With no postoperative restrictions after SMILE, patients are back to all normal activities, including wearing makeup and working out, the next day. One downside of SMILE is that certain prescriptions, including farsightedness, cannot be treated. The most common risks of SMILE are over- or undercorrection of the prescription, dry eye, or more rarely, visual distortions including halos.

SMILE has become a first-choice option for many patients. Many police and army combat personnel are now choosing this flapless option.

Laser vision correction is generally safe and effective

Laser vision surgery is not without risks, and there are times when a patient will experience either an over- or undercorrection of their prescription, as well as issues with healing or dry eye. Everyone’s body can respond differently, and even in a single individual, the left eye may heal differently from the right eye.

Overall, however, all LVC techniques are predictable and safe, with excellent results and minimal risks. It is important to see an experienced surgeon for a consultation. He or she can recommend the best technique for each patient.

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Why your sleep and wake cycles affect your mood

It’s no accident that most people tend to sleep at night and are awake during the day. Our sleep-wake cycle is determined by our circadian rhythm, the body’s internal clock. Like old-time clocks, this internal clock needs to be reset every day, and is adjusted by first exposure to light in the morning.

How does circadian rhythm work?

Our circadian rhythms are controlled by multiple genes and are responsible for a variety of important functions, including daily fluctuations in wakefulness, body temperature, metabolism, digestion, and hunger. Circadian rhythm also controls memory consolidation (the formation of long-term memories occurs during sleep); the timing of hormone secretion (for example, the hormones controlling body growth work mostly at night); and body healing.

While the circadian sleep phase typically occurs at night, there are a range of times during which the sleep phase can occur, with some people programmed to sleep from early evening to early morning (known as morning larks), while others stay up late and sleep late (known as night owls). In addition to determining the timing of their sleep, a person’s circadian tendency can also affect their choice of emotional coping skills, such as assertiveness or rationalization, and their predisposition to psychological disorders.

How does your circadian rhythm impact your mood?

An irregular circadian rhythm can have a negative effect on a person’s ability to sleep and function properly, and can result in a number of health problems, including mood disorders such as depression, anxiety, bipolar disorder, and seasonal affective disorder.

A recent study suggested that the night-owl type might have a greater predisposition to psychological disturbances. The authors found that the different circadian types were likely to have different coping styles to emotional stressors, and the ones adopted by the morning larks seemed to result in better outcomes and fewer psychological problems. This was a correlational study, so the reason for adopting different styles wasn’t explained, but this study emphasizes the great impact circadian rhythms have on health and functioning.

Depression and circadian rhythm

Most of the evidence on the relationship between mood problems and circadian rhythm comes from studies of shift workers, whose sleep periods are out of sync with their circadian rhythm. Multiple studies show an increased prevalence of depression in night-shift workers. One meta-analysis showed that night-shift workers are 40% more likely to develop depression than daytime workers. Conversely, circadian rhythm disturbances are common in people with depression, who often have changes in the pattern of their sleep, their hormone rhythms, and body temperature rhythms.

Symptoms of depression may also have a circadian rhythm, as some people experience more severe symptoms in the morning. The severity of a person’s depression correlates with the degree of misalignment of the circadian and sleep cycles.

Many successful treatments of depression, including bright light therapy, wake therapy, and interpersonal and social rhythm therapy, also directly affect circadian rhythms. (For the impact of circadian rhythm on the occurrence and treatment of depression related to bipolar disorder, please see this blog post on light therapy for bipolar disorder.)

Anxiety and circadian rhythm

Misalignment of the circadian rhythm may also provoke anxiety. Shift work results in a sleep disorder when your nighttime work shifts affect your ability to fall asleep and stay asleep, causing you to have excessive sleepiness during the day that in turn results in distress and affects your ability to function normally. Nurses with shift work disorder have increased anxiety scores on questionnaires. In a study on jet lag, in which travel changes the time of the external environment so that it is no longer synchronized with the internal clock and disrupts sleep, travelers had elevated anxiety and depression scores.

Seasonal affective disorder and circadian rhythm

In seasonal affective disorder, people feel down and depressed in the winter months. Researchers believe this is due to changes in circadian rhythms as a result of seasonal changes in the length of daylight. People with seasonal affective disorder feel better using artificial morning light to realign their circadian rhythm with their sleep-wake cycle.

What can I do to alter my circadian type?

There is no way to change your circadian type since it is genetically determined, though there is some natural change that occurs during your lifespan. For example, our circadian sleep phase tends to shift later during adolescence (more owls) and advances earlier as we age (more like the lark).

If you find that your circadian sleep phase is out of sync with your desired schedule, you can either shift your social life to match your circadian rhythm, or try to shift your circadian rhythm to match your social life. It may be easier to try to shift your work and social life to your circadian rhythm: an example would be a person who has a delayed circadian rhythm and likes to sleep late and wake up late switching from a job with a 7 AM start time to a job which allows him or her to start working later — around 10 AM. The other option would be talking to a sleep physician and doing ongoing work to try to shift your circadian rhythm to match your work and social life to an earlier wakeup time.

In general, the best way to improve your mood is to get a good night’s sleep by matching your circadian rhythm to your sleep-wake cycle. Exposure to light in the morning helps synchronize the clock. Exposure to bright light at night, including bright artificial lights and screen time on laptops, tablets, and phones, can cause disruption in circadian rhythm and may contribute to worsening mood and negative consequences for health.

Tips to improve your sleep and mood

• Get a full night’s sleep. Most adults need at least seven to nine hours.
• Get up at the same time each day, seven days a week. A regular wake time in the morning leads to regular times of sleep onset, and helps align your circadian rhythm with your sleep-wake cycle.
• Avoid screen time and bright lights at least 60 to 90 minutes before bedtime. Try activities like reading a book in dim light, listening to audiobooks, guided meditation or mindfulness talks, and soothing music.

The post Why your sleep and wake cycles affect your mood appeared first on Harvard Health Blog.

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