The Snooze Button

Dr. Mark Boulos from Sunnybrook Health Sciences Center in Toronto has just won the 2020 Wayne A Hening Sleep Medicine Investigator Award from the American Academy of Neurology (and he's Neil's sleep doctor).

Mark joins the show to talk sleep apnea, where we are with diagnosis and treatment, and new ways of treating sleep apnea that go beyond CPAP.

Dr. Michael Grandner from the University of Arizona is back, too, with a look at what we've learned about sleep from what might be the largest science experiment in human history.

Photo credit: Doug Nicholson, Sunnybrook Health Sciences Centre

• Mark Boulos’s 2020 Wayne A. Hening Sleep Medicine Investigator Award
• Why sleep apnea matters in stroke and TIA
• Neil’s original periodic limb movement index of 82
• What happened to that PLMI during CPAP titration
• Why Neil’s dramatic CPAP result should not be generalized to everyone with PLMS
• Mirapex/pramipexole, dopamine and restless legs syndrome
• Richard Allen’s argument for looking closely at iron
• The major 2024–2026 shift away from routine dopamine agonists for RLS
• Why iron evaluation now occupies a central place in RLS treatment guidance
• How the pandemic accelerated interest in home sleep apnea testing
• Boulos’s later SLEAP SMART trial after stroke and TIA
• Why CPAP remains highly effective — and why alternatives still matter
• The early research on dronabinol and sleep apnea
• Why cannabis is still not a recommended OSA treatment
• Oral appliances, hypoglossal-nerve stimulation and other non-CPAP options
• The 2024 FDA approval of tirzepatide for obesity-related moderate-to-severe OSA
• Why snoring alone does not prove sleep apnea
• How little sleep medicine historically appeared in medical-school curricula
• Michael Grandner on the pandemic as a giant natural experiment in sleep timing
• What later Fitbit data showed about sleeping longer and later during lockdowns
• Why later school start times fit adolescent circadian biology
• “COVIDsomnia,” nighttime worry and difficulty detaching
• Food, activity, mental health and sleep as an interconnected system
• Why sleep is the third leg of the health stool

Mark Boulos, MD, FRCPC, CSCN(EEG), MSc, is an Associate Professor in Neurology at the University of Toronto, Medical Lead for the Sunnybrook Sleep Laboratory and Program Director for the University of Toronto Sleep Neurology Fellowship. His research examines the relationship between sleep disorders and stroke, TIA and other neurological conditions, along with home sleep monitoring and novel approaches to the diagnosis and treatment of sleep disorders.

Photo credit: Doug Nicholson, Sunnybrook Health Sciences Centre.

Michael Grandner, PhD, MTR, is a clinical psychologist and behavioral sleep medicine researcher at the University of Arizona. His research examines how sleep connects with physical and mental health, cognition, social conditions and population health.

Dr. Mark Boulos — University of Toronto

Boulos’s current faculty profile, research focus and clinical leadership roles.

Mark Boulos — University of Toronto Department of Medicine

Dr. Mark Boulos — Sunnybrook

Sunnybrook profile with his research focus and selected publications.

Mark Boulos — Sunnybrook Health Sciences Centre

Wayne A. Hening Sleep Medicine Investigator Award

The American Academy of Neurology award discussed in the episode.

American Academy of Neurology — Hening Award

SLEAP SMART: Sleep Apnea Screening Using Mobile Ambulatory Recorders After TIA/Stroke

Boulos’s 250-patient randomized trial comparing home sleep apnea testing with in-laboratory polysomnography after stroke or TIA.

Read the SLEAP SMART trial

Treatment of Restless Legs Syndrome and Periodic Limb Movement Disorder

The current AASM clinical practice guideline that changed the role of pramipexole and elevated iron and alpha-2-delta ligands.

Read the RLS/PLMD guideline

Changes in Periodic Limb Movements of Sleep After CPAP Therapy

A 14-study meta-analysis showing why Neil’s PLMI response to CPAP should be treated as an individual result rather than a general rule.

Read the CPAP/PLMS meta-analysis

Medical Cannabis and Obstructive Sleep Apnea

The American Academy of Sleep Medicine position statement explaining why cannabis is not recommended as OSA treatment.

Read the AASM cannabis/OSA position statement

Cannabinoids for Obstructive Sleep Apnea: A Systematic Review

The 2024 review of the small and still short-term evidence base.

Read the cannabinoid systematic review

FDA Approval of Tirzepatide for Obstructive Sleep Apnea

The December 2024 U.S. approval of Zepbound for moderate-to-severe OSA in adults with obesity.

Read the FDA announcement

Changes in Sleep Duration, Timing and Variability During COVID-19

Large-scale Fitbit data that later confirmed the delayed and generally longer sleep Grandner was observing in 2020.

Read the Fitbit pandemic-sleep study

School Start Times, Sleep, and Youth Outcomes

A 2022 meta-analysis of 28 studies and more than 1.7 million participants.

Read the school-start-time meta-analysis

Delayed School Start Times and Adolescent Sleep

A 2026 meta-analysis estimating the effect of delayed starts on sleep duration and depressive symptoms.

Read the 2026 meta-analysis

Fitbit sleep trackers made the cash register ring 16 million times in 2019, according to one report. But how much of the sleep data is actually usable?

Fitbits seem to have risen as the cream of the sleep tracker crop, especially considering that the crowded field includes ridiculous items like phone-based apps that claim to be able to track your sleep while they're sitting on your night stand.

It's a subject we've spent time looking at before on The Snooze Button podcast, but this week's guest has based a ton of research on real-world sleep tracker data from Fitbits in particular. We've even featured an interview with the lead sleep scientist at Fitbit, Dr. Conor Heneghan, about Fitbit's "sleep score", with details about how it's calculated and what it means.

Among the most troubling things about sleep trackers, though, is that people can get so obsessed with the numbers their devices are spitting out that the stress associated with small changes can create their own brand of sleep issues, branded as orthosomnia - a legit sleep disorder that's causing real-world issues for people who haven't considered whether their tracker is even generating accurate data to begin with.

The bottom line?

Dr. Michael Chee - the award-winning researcher who basically put Singapore on the world sleep map - says there is one nugget of data from a wearable sleep tracker that you can depend on, and that deals with whether there's an overall trend. Sleep staging? Nope. Sleep quality? Nope. Sleep duration? Yeah, kinda.

Michael fills us in on the details. Additionally, you can grab some of Michael's research on wearable sleep trackers here.

• Why “sleep quality” is not the same thing as sleep duration or a device-generated sleep score
• What Michael Chee’s adolescent Fitbit validation study actually found
• Why wearables can be useful even when the absolute numbers are wrong
• Why night-to-night trends can matter more than minute-level precision
• How much confidence to place in deep-sleep and REM estimates
• How wrist wearables use PPG to measure pulse
• Why sensor contact and individual characteristics affect accuracy
• Orthosomnia — and why it is a clinical concept, not a formal sleep-disorder diagnosis
• Fitbit versus Oura versus an EEG headband
• Why long-term wearable data and one-night polysomnography answer different questions
• Michael Chee’s 2025 World Sleep Society recommendations on consumer sleep trackers
• What newer validation studies say about modern Fitbit, Oura and Apple sleep tracking
• Brooke Mason’s SLEEP 2020 work on nighttime phone use and mental health
• Alexa Gozar’s SLEEP 2020 work on nighttime phone use and productivity
• Why those smartphone studies show association rather than simple causation
• Do Not Disturb, notification whitelists and taking control of interruptions
• Why blue light is only part of the nighttime-device problem
• Grandner’s “stand next to the bed” and grayscale tricks
• Circadian timing, shift work and what sleep-friendly employers can actually do

Michael Chee, MBBS, is Professor and Director of the Centre for Sleep and Cognition at the Yong Loo Lin School of Medicine, National University of Singapore. His research spans sleep, cognition, neuroimaging, sleep restriction, cognitive aging and the use of wearable and smartphone technologies to understand sleep in the real world.

Michael Grandner, PhD, MTR, is a clinical psychologist and behavioral sleep medicine researcher at the University of Arizona. His work examines the links among sleep, mental and physical health, cognition, social conditions and population health.

Professor Michael Chee — NUS Centre for Sleep and Cognition

Chee’s current laboratory and research profile at the National University of Singapore.

NUS Sleep and Cognition Laboratory

Validation of a Consumer Sleep Wearable Device With Actigraphy and Polysomnography in Adolescents Across Sleep Opportunity Manipulations

Chee and colleagues’ 2019 multi-night Fitbit Alta HR validation study in 58 adolescents.

Read the Fitbit validation study

Multi-Night Validation of a Sleep Tracking Ring in Adolescents Compared with a Research Actigraph and Polysomnography

Chee’s group later tested the Oura Ring across multiple nights and sleep opportunities.

Read the Oura validation study

World Sleep Society recommendations for wearable consumer health trackers that monitor sleep

The 2025 international recommendations led by Michael Chee.

Read the World Sleep Society recommendations

State of the science and recommendations for using wearable technology in sleep and circadian research

A 2024 Sleep Research Society review of what modern wearables can and cannot reliably contribute to sleep research.

Read the 2024 wearable-technology review

Performance of consumer wrist-worn sleep tracking devices compared to polysomnography: a meta-analysis

A meta-analysis of 24 studies and 798 participants showing persistent differences between consumer devices and PSG.

Read the meta-analysis

Accuracy of Three Commercial Wearable Devices for Sleep Tracking in Healthy Adults

A 2024 PSG comparison of Oura Ring Gen 3, Fitbit Sense 2 and Apple Watch Series 8.

Read the device-comparison study

Orthosomnia: Are Some Patients Taking the Quantified Self Too Far?

The three-patient 2017 case series that coined the term.

Read the orthosomnia case series

Use Of Mobile Devices At Night Associated With Mental Health In Young Adults

Brooke Mason and colleagues’ SLEEP 2020 abstract from Grandner’s SHADES study.

Read the mental-health abstract

Mobile Device Use in Bed and Relationships to Work Productivity: Impact of Anxiety

Alexa Gozar and colleagues’ SLEEP 2020 abstract on nighttime phone use, productivity and anxiety.

Read the productivity abstract

Fitbit’s New “Sleep Score,” and What It Means

The Snooze Button’s earlier interview with Fitbit sleep scientist Dr. Conor Heneghan.

Read the Sleep Score article

Dr. Michael Grandner is back for a wide-ranging discussion on a ton of sleep topics, including why sleep doesn't get a ton of attention in med school, and a new study that explores the link between daytime sleepiness and suicide.

• Michael Grandner’s reaction to Jason Ellis’s acute-insomnia work
• Why the pandemic looked likely to accelerate sleep research
• Sleep as a bridge between social disruption and biology
• The early SARS-CoV-2 spike/neuropilin-1 pain hypothesis
• Why the “seven minutes of sleep education” number needs correction
• What UK medical-school surveys actually found about sleep teaching
• Why sleep health needs to reach schools and communities, not just doctors
• The NIH-funded PRIDE Institute and diversity in sleep research
• Damien Léger’s French lockdown study on media exposure and sleep
• Why cross-sectional pandemic surveys cannot prove cause and effect
• Nocturnal wakefulness and suicide risk
• Andrew Tubbs’s early work on morning wakefulness and suicidal ideation
• How that research became the Mind After Midnight hypothesis
• The $3.8 million NIMH-funded Mind After Midnight study launched in 2026
• Why daytime sleepiness was not the significant finding in the study named in the episode title
• Sleep duration, sleep disturbance and suicidal ideation in NHANES
• Sydney Phan’s study of what people do in bed
• Why reading in bed turned out differently from worrying, working or watching TV
• What a 2024 stimulus-control review says about rigid bedroom rules

Michael Grandner, PhD, MTR, is a clinical psychologist and behavioral sleep medicine researcher at the University of Arizona. He directs the Sleep and Health Research Program and the Behavioral Sleep and Circadian Medicine Clinic, and his work examines how sleep connects with cardiometabolic health, mental health, cognition, social and environmental conditions, and population health.

Dr. Michael Grandner — University of Arizona

Current faculty profile and overview of Grandner’s research and clinical work.

Michael Grandner at the University of Arizona

Medical student education in sleep and its disorders is still meagre 20 years on

The 2020 UK medical-school survey that helps correct the “seven minutes” claim.

Read the UK sleep-education study

Sleep education for medical students: A study exploring gaps and opportunities

A 2024 look at what final-year medical students recall learning about sleep and where curricula still fall short.

Read the 2024 medical-education study

NYU PRIDE Institute in Behavioral Medicine and Sleep Disorders Research

The NIH-supported mentoring program discussed by Grandner.

Read the PRIDE program evaluation

Poor sleep associated with overuse of media during the COVID-19 lockdown

Damien Léger and the COCONEL group’s survey of 1,005 French adults.

Read the lockdown/media study

SARS-CoV-2 spike protein, neuropilin-1 and pain signaling

The University of Arizona mechanistic work later published in PAIN.

Read the spike/neuropilin-1 study

Nocturnal Wakefulness as a Previously Unrecognized Risk Factor for Suicide

The 2016 analysis that helped launch the nocturnal-wakefulness research thread.

Read the 2016 study

Population-level Suicide Ideation: Impact of Combined Roles of Sleep Duration, Sleep Disturbance, and Daytime Sleepiness

The 2020 conference abstract behind the episode’s daytime-sleepiness discussion. In the adjusted analysis, sleepiness itself was not significant.

Read the SLEEP 2020 abstract

Nocturnal and Morning Wakefulness Are Differentially Associated With Suicidal Ideation

The later nationally representative study extending the conference work.

Read the 2021 national study

The Mind After Midnight

The 2022 paper developing the nocturnal-wakefulness hypothesis into a broader model of behavioral dysregulation.

Read The Mind After Midnight

Mind After Midnight — 2026 clinical study

The current NIMH-supported mechanistic study led by Grandner, registered as NCT07438912.

View the registered study

Reconsidering Stimulus Control: Activities in Bed Associated with Sleep-Related Outcomes

Sydney Phan and colleagues’ 2020 abstract examining reading, TV, work, worry and other activities in bed.

Read the SLEEP 2020 abstract

The effectiveness of stimulus control in CBT-I

A 2024 systematic review and network meta-analysis revisiting which stimulus-control instructions matter and why.

Read the 2024 systematic review

Dr. Jason Ellis is regarded as one of the heavyweights of sleep science, particularly when it comes to his work with Cognitive Behavioral Therapy for Insomnia, or CBT-I.

In this episode, we talk about Jay's book, The One Week Insomnia Cure, and how a quick hit of CBT-I worked in 73% of patients with acute insomnia.

It really is a fascinating and wide-ranging discussion that includes everything from melatonin to med school, and what "the system" can do to make things better.

“I think that [the COVID-19 pandemic] is actually going to create a lot of opportunities for sleep and sleep funding in the future. In the general population at any given time point, a snapshot of how many people might have acute insomnia works out to about 8% of the population. When I’ve extrapolated the data from Italy and from China, it looks like it’s going to be about 45%. So we’re going to see a huge uptake in acute insomnia. And I think that that’s going to drive more funding in the future.”

“There is actually one study which demonstrates that CBT-I does decrease the symptom profile of RLS/PLMD. Now, what that study showed was, it’s not as if it stops somebody from having those periodic limb movements. But what it does do is it keeps them asleep during that time. And so one of the things [CBT-I] does is it deepens sleep. And if you deepen sleep enough, even somebody who’s in chronic pain will wake up a lot less. That’s why we see CBT-I works quite nicely in lots of pain conditions. And this one study did demonstrate that although people would have those arousals, they wouldn’t be woken up by them. So CBT-I is an option.”

“Certainly in the UK, the amount of teaching in the area of sleep is minimal. I think it works out something like seven minutes overall.”

LINKAPALOOZA

Jay's book, The One Week Insomnia Cure on Amazon

Jay's study about quick-hit CBT-I and acute insomnia

• Why Jason Ellis’s own go-to after a bad night is stimulus control
• Getting out of bed before frustration becomes part of the bedroom
• Sleep pressure and why staying awake temporarily can make the next attempt easier
• Where acute insomnia ends and chronic insomnia begins
• Why the three-month threshold is a diagnostic convention rather than a biological switch
• Ellis’s research into the transition from acute to chronic insomnia
• The original 2015 “single-shot” CBT-I randomized trial
• What the famous 73% number actually represented
• Why “73% cured after one hour” oversold a promising small study
• The 2026 randomized primary-care trial of one-session CBT-I
• What newer research says about extending time in bed after a poor night
• Why CBT-I remains first-line treatment in current insomnia guidelines
• Why access to trained CBT-I providers remains a problem
• Alcohol as a sedative — and why it can fragment sleep later in the night
• Ellis’s early COVID-era prediction of a surge in acute insomnia
• What later pandemic sleep meta-analyses actually found
• CBT-I when restless legs or periodic limb movements are also present
• Why treating insomnia is not the same as eliminating RLS or PLMs
• The unusual pilot study using lucid-dream training for insomnia
• Why promising pilot results are not the same as an established treatment

Jason Ellis, PhD, is Professor of Psychology at Northumbria University and Director of the Northumbria Centre for Sleep Research. His work focuses on insomnia, the transition from acute to chronic insomnia, cognitive behavioral therapy for insomnia, behavioral sleep medicine and new ways of delivering effective insomnia treatment in settings where traditional multi-session therapy can be difficult to access.

Professor Jason Ellis — Northumbria University

Ellis’s current faculty profile, research interests and recent publications.

Jason Ellis at Northumbria University

The One-Week Insomnia Cure

Ellis’s 2017 book applying CBT-I, mindfulness and related behavioral approaches to sleep problems.

The One-Week Insomnia Cure — Penguin

Treating Acute Insomnia: A Randomized Controlled Trial of a “Single-Shot” of CBT-I

The 2015 randomized trial at the heart of this episode: 40 adults, one CBT-I session plus a pamphlet versus wait-list control.

Read the 2015 study

Group vs. Individual Treatment for Acute Insomnia

A later pilot testing whether Ellis’s one-shot intervention could retain its effect when delivered in groups.

Read the group-treatment study

One-Session CBT-I in Integrated Primary Care

The 2026 randomized preliminary study showing that the one-session approach is still being actively tested.

Read the 2026 primary-care trial

Sleep Opportunity Extension and the Transition to Chronic Insomnia

A 2026 study of 1,243 participants, co-authored by Ellis and Michael Grandner, challenging the idea that extending sleep opportunity after a poor night is the main driver of chronic insomnia.

Read the 2026 natural-history study

Cognitive Behavioral Therapy for Insomnia in Restless Legs Syndrome

A randomized study of CBT-I for people with RLS and comorbid insomnia.

Read the RLS/CBT-I study

Managing Insomnia Using Lucid Dreaming Training

The Ellis, Joseph De Koninck and Célyne Bastien open-label pilot discussed at the end of the episode.

Read the lucid-dreaming pilot

2025 VA/DoD Clinical Practice Guideline for Chronic Insomnia

Current guideline recommending CBT-I for chronic insomnia and favoring it over medication as first-line treatment.

View the guideline resources

Dr. Ryan Vandrey from Johns Hopkins University is one of the leading authorities on cannabis, CBD and their impact on sleep and insomnia. He joins Neil for an update on the science related to cannabinoids, and whether cannabis and CBD have a measurable, beneficial impact on sleep, or if the claims about their efficacy as treatments for insomnia are merely marketing hype.

Among the key takeaways in this week's episode:

"There is data to support that it'll help you get to sleep faster, and that's going to be specific to THC. That has not been demonstrated with CBD."

"Cannabis and CBD are being extolled as cures for all kinds of stuff. So we have this interesting scenario where this is an industry born in the illicit drug use market - and it's become licit and legal, but it's not very tightly regulated. So people are making all kinds of claims and marketing and trying to get people to use it for anything and everything. There needs to be some level of skepticism with the claims. And as a scientist, I always say, "Show me the data."

"The other thing that's really limited in understanding the effects of cannabis on sleep - especially as a treatment for sleep problems - is that most of the studies have been done have been on healthy individuals without sleep problems."

Along with Ryan, Dr. Michael Grandner is back with the latest in sleep science. (And we follow up on a Twitter exchange that revealed a fun blast from Michael's past!)

LINKAPALOOZA:

Dr. Ryan Vandrey's bio on the Johns Hopkins website (with links to much of his work)

Ryan's 2014 study on the intersection of sleep disorders, PTSD and substance abuse

Our ranking of The All-Time 15 Best Songs About Sleep

The study Michael refers to about a blood test for sleeplessness is here.

• Dr. Ryan Vandrey on what cannabis research could — and could not — support in 2020
• Why THC and CBD should not be treated as interchangeable
• Research on THC as a sleep aid going back to the late 1960s and 1970s
• THC and sleep-onset latency
• Why evidence for CBD as a sleep aid was much weaker
• REM sleep, slow-wave sleep and inconsistent sleep-architecture findings
• Why most early studies did not actually involve patients with diagnosed sleep disorders
• Tolerance, dependence and cannabis withdrawal
• Why withdrawal insomnia can be mistaken for proof that cannabis is necessary for sleep
• Vivid dreams and REM rebound after stopping heavy cannabis use
• PTSD, nightmares and the limits of the early evidence
• Why route of administration, THC/CBD ratio, dose and formulation matter
• The problem of standardization and quality control in cannabis research
• Why “it worked for me” is meaningful but not universal evidence
• What 2025 randomized evidence says about cannabinoids and subjective sleep quality
• Why CBD-only interventions still have not demonstrated a clear sleep benefit
• What the 2025 sleep-architecture meta-analysis says about REM suppression
• A 2026 Ryan Vandrey co-authored trial in people with diagnosed insomnia
• Michael Grandner’s secret past as a college radio DJ
• Christopher Depner and Kenneth Wright’s metabolomic search for a blood marker of insufficient sleep
• Why one biomarker is probably not enough to measure sleep deprivation
• How that biomarker research had advanced by 2024
• Dr. Daniel Buysse, brief behavioral treatment for insomnia and “insomnia judo”
• Using sleep pressure as part of behavioral insomnia treatment

Ryan Vandrey, PhD, is Professor of Psychiatry and Behavioral Sciences at the Johns Hopkins University School of Medicine and works with the Behavioral Pharmacology Research Unit and Cannabis Science Lab. His research includes cannabis dose and formulation, route of administration, pharmacokinetics, medicinal use, cannabis-drug interactions, cannabis product testing, cannabis withdrawal and Cannabis Use Disorder — including the effects of cannabis use and withdrawal on sleep.

Michael Grandner, PhD, is a clinical psychologist and behavioral sleep medicine specialist at the University of Arizona. In this recurring segment, he joins Neil to translate new sleep research into something useful — and, occasionally, to reveal that he once had a radio voice of his own.

Dr. Ryan Vandrey — Johns Hopkins Medicine

Vandrey’s current faculty profile and research interests.

Ryan Vandrey at Johns Hopkins

Cannabinoid therapies in the management of sleep disorders

The 2020 systematic review co-authored by Vandrey examining the preclinical and clinical evidence for cannabinoids and sleep.

Read the 2020 systematic review

Interactions between disordered sleep, post-traumatic stress disorder, and substance use disorders

Vandrey and colleagues’ 2014 review of sleep, PTSD and substance use.

Read the PTSD, sleep and substance-use review

Effectiveness of cannabinoids on subjective sleep quality

The 2025 meta-analysis of six randomized trials and 1,077 participants, including separate analyses of CBD-only and non-CBD interventions.

Read the 2025 randomized-trial meta-analysis

Cannabis and sleep architecture: A systematic review and meta-analysis

The 2025 review of objective polysomnographic evidence, including REM sleep and withdrawal.

Read the sleep-architecture meta-analysis

Acute Effects of Oral Cannabinoids on Sleep and High-Density EEG in Insomnia

The 2026 pilot randomized trial in 20 adults with diagnosed insomnia, co-authored by Ryan Vandrey.

Read the 2026 insomnia trial

Cannabis and sleep disorders: What clinicians need to know

The American Academy of Sleep Medicine’s 2024 overview of the evidence and clinical cautions.

Read the AASM overview

Developing preliminary blood metabolomics-based biomarkers of insufficient sleep in humans

The Christopher Depner / Kenneth Wright paper Michael discusses in his weekly science segment.

Read the 2020 metabolomics paper

Accurate detection of acute sleep deprivation using a metabolomic biomarker

A 2024 machine-learning study showing how far the biomarker idea had progressed after this episode.

Read the 2024 sleep-deprivation biomarker study

Efficacy of brief behavioral treatment for chronic insomnia in older adults

Daniel Buysse and colleagues’ randomized trial of the brief behavioral insomnia treatment behind Michael’s “insomnia judo” discussion.

Read the BBTI trial

Songs About Sleep — The 15 Best Of All Time

The Snooze Button list that Michael’s former-radio-DJ story sends Neil back to.

Read the list