Transform Your Sleep With A Holistic Approach

Introduction and Guest Background 0:00

Hello, everyone, and welcome back to the Sleep Deep Summit: New Approaches To Treating And Beating, Sleep Apnea And Insomnia. I'm your host, Dr. Audrey Wells. And today, I am thrilled to have Dr. Sarah Silverman to talk to. We're going to dove into some behavioral treatments for sleep problems. We're going to talk about your internal rhythms. And we're going to talk about sleeping pills, both prescribed and over-the-counter. And I know you guys have questions about this. Now, Dr. Silverman is a Stanford trained behavioral sleep medicine specialist, and she's a wellness consultant used to addressing the whole entire person.

So already she has my respect. Dr. Silverman, welcome. It's great to have you here. Thank you so much for having me. I am so excited to be here and chat. Sleep. Definitely. Let's let's geek out a little bit, shall we? Yes. Let's do it. I wonder if you can tell the audience maybe a little bit more about yourself and the people that you help? Absolutely. Absolutely. So as you mentioned, I am a behavioral sleep medicine specialist, so I really try to help folks improve their sleep naturally. And part of my role as more of a holistic sleep specialist is to help really teach people specific skills to really master their sleep without medication or spending years in therapy.

So that is my passion. I love helping folks improve their sleep quality and really just have a better understanding of what's taking place within the body when they're preparing for sleep, which happens during the day and often actually starts in the morning. But then also, of course, before bed in the habits and things that might be playing a role. So I specifically tend to work with a lot of folks who have chronic insomnia. So that of course looks a little bit different for everyone. But usually that's either a difficulty falling asleep difficulties staying asleep, waking up too early, or maybe a combination of those two or three problems.

And I also work with a lot of folks who have sleep apnea. So comorbid with insomnia as well, and folks who have circadian rhythm disorders, which we can certainly dove into. But for example, folks who are extreme early birds and those who are extreme night owls as well as shift workers. Wow. That's so many sleep problems sort of encapsulated in the work that you do. I really love that. And I think it sort of helps to underscore the idea that it's not at all uncommon for people to have more than one challenge to their sleep.

So you mentioned coexist saying sleep apnea and insomnia. This is something that I see a lot in the work that I do with people who are struggling to use CPAP therapy. I certainly think that behavioral treatments are potent and powerful and durable.

CPAP Adjustment Tips for Insomnia 3:34

I wonder if you can speak to somebody in the audience who right now is struggling with their CPAP machine, maybe it's causing their insomnia, or maybe it's exacerbating their insomnia. What are some quick tips that you can give them to even feel better starting tonight? I love this question because you're absolutely right. It is so common to have both insomnia and sleep apnea. And I just want to start off by saying it is very normal to have a little bit of difficulty adjusting to a new CPAP machine.

That is something that I tend to help folks with. Troubleshoot the mask fit. And oftentimes what we find is maybe there's some anxiety or fear around using a machine. So one of the things that I always like to start off with is really just starting to get used to wearing the gear. So this is kind of under the umbrella of somewhat of an exposure therapy to some extent. So this may sound silly, but to start, you know, someone's really struggling with using their CPAP machine or their doctor is telling them that they need to use their machine for insurance purposes.

For example, wearing the head gear around the house so it's not hooked up to the tube or plugged in, but just getting comfortable with actually wearing the headgear. And then once that feels comfortable upgrading to maybe plugging in the tube to the machine and maybe turning the machine on and just using the machine for a few minutes while, say, watching TV or reading a book, doing something sedentary just to get really comfortable with the pressure settings and how the machine actually feels. So I'm sure you see this in your practice as well.

But the goal is to take folks through kind of a hierarchy of steps to slowly get used to using the mask so that it becomes second nature. I mean, that really is the goal is for the brain to associate using CPAP as kind of a normal part of your nightly routine. And so it does often coincide with insomnia. And I have to agree with you, it's kind of a chicken or the egg question, you know, was insomnia present before and then the sleep apnea made things worse? Or was sleep apnea in the picture all along, which maybe caused some sleep maintenance, insomnia or difficulty staying asleep, you know, and then that worsened over time.

So it is very unique to each individual, but there are definitely ways to help troubleshoot CPAP use and to make the treatment a little bit easier for folks. But it is very normal to have some difficulty at first just getting acclimated to using CPAP. Yes. And I think kind of normalizing that in a way that helps people not feel so alone when they're having these struggles can go a long way to just resetting a perspective that, you know, you're going to do this short term investment of practicing with the mask.

It's like a dress rehearsal before your nighttime performance. But I like to point out that, you know, when you're doing this in the middle of the day, you don't have that pressure to sleep. And so you're not eating into your nighttime sleep routine. So I think those are great tips, wearing it around the house and then sort of graduating to putting the pressure in and doing something distracting, like watching TV. Yeah, fantastic. One thing that I think comes up in people's minds is, you know, I'm really struggling with this.

I sure I practiced, but it's not going the way I want to. And they start having questions about a prescribed sleep medication, or they might start looking in the pharmacy for over-the-counter sleep aids. In my world, Ambien and trouser don are two medicines I see a lot in in sort of the prescribed category. I wonder if you can talk to the audience about the effects of these medications and the side effects, even long term. Fantastic question. And I have to agree. I see Ambien and Trazodone quite often.

They're commonly prescribed for sleep issues and I've seen most commonly prescribed for insomnia. And, you know, these medications, they can be a helpful tool on a short term basis, but they don't address the underlying root cause for why someone may be struggling in the first place. So they aren't necessarily the best long term solution for most folks. And, you know, I actually like to describe sleep medication, whether prescribed or over-the-counter, as a tool. And just like any other tool, there are going to be times when it's appropriate for use and maybe times where it doesn't make sense for use.

So neither good nor bad, but simply a tool that can be used effectively when appropriate. And so, you know, medications like Ambien, it has its own I'd say Ambien more kind of a traditional sedative, hypnotic, very commonly prescribed for insomnia, trazodone as well. You know, these medications, what a lot of people don't realize is they can actually change your sleep architecture. So change the time that you spend in your, I would say, your restorative stages of sleep so they can change the time

Sleep Medications: Benefits and Risks 9:35

that you might spend in REM sleep or dream sleep or and slowly sleep or deep sleep so they can have direct effects on the perception of how you're sleeping and how restorative your sleep feels as a result. And in the short term, I'd say side effects are incredibly common, and that goes for prescriptions like Ambien and Trazodone, as well as over-the-counter sleeping pills or side effects. With those as well, they're not necessarily a safer option. You know, things that I tend to see are things like, you know, feeling hungover in the morning so morning, grogginess or irritability, more anxiety as a result.

Also Ambien and it on specifically can potentially increase the risk for vivid dreams nightmares and with Ambien. Parasomnias, we know that some people can sleepwalk and sleep eat, and so those side effects can be incredibly scary on a short term basis and also just a feed into how someone might feel and function during the day. So I know a lot of folks will be taking these medications and they're not necessarily sleeping any better. But it's this idea that, you know, they're getting some sleep with these these aids.

So on a short term basis can be a helpful tool. But there is the risk of these side effects. And long term wise, you know, I think we have some pretty good data that potentially shows that there is an increased risk for mild cognitive impairment and potentially dementia. And that isn't just for Ambien. It's also been studied in diphenhydramine, which is Benadryl. So whether prescription or over-the-counter, there are still a lot of these long term risks. And not just cognitively, but I would say safety wise, you know, can change the way someone feels during the day, whether that's feeling tired or sleepy and potentially, you know, put someone at risk while driving.

Of course, there are other folks in the car as well. But really, for the safety of everyone on the road, there are many potential short term and long term side effects. So of course, like any tool, sleep aids can be helpful. But when it's appropriate, when it makes sense for that individual. And I hear you saying to that because you view it as a short term solution and always sort of paired with good behavioral techniques that you almost it sounds like you create an exit plan for the sleep medication as well.

Do I have that right? Yes, that's correct. So a lot of the folks that I work with will come to me on some form of a sleep aid. And the goal is to pair that with specific cognitive and behavioral techniques to build up what I like to call sleep confidence, because a lot of people over time, they tend to lose confidence in their own natural sleep ability. And it's almost like these sleep aids, you know, help a little bit with that confidence. So the goal in learning very specific techniques that are going to be geared more towards the cognitive and behavioral side of sleep.

Building up that sleep confidence over time and really just getting someone feeling comfortable in knowing that they do have some control over their sleep or certain aspects of how to prepare themselves for sleep. And then once there is some sleep confidence that has built up, then it is actually coming up with a very realistic exit strategy and working in tandem with the individuals prescribing physician or health care provider. So that is usually done very slowly, you know, with caution, never want to do anything cold turkey.

Although I do have some folks who are ready to rip the Band-Aid off. You know, I think it's usually going to be much more sustainable when things are done slowly and very realistically. So plan that is going to be comfortable to implement for, you know, over the course of usually a couple of months, but can be longer than that. Yeah. Yeah. And I think that a lot of people have some hesitations, maybe even some skepticism about the success of these behavioral tools that you're talking about. I wonder if you can put that to bed a little bit.

There's a pun there. I think. So. You know, if if I'm someone who says to you, you know, Dr. Silverman, I've been on Ambien at the same dose for five years and I can take it and go to sleep. But I just don't know if it's good for me. The for the long term, I'm just not sure that these behavioral techniques are going to work for me. Seems like I've tried everything. How would you advise a patient like that? It's actually something I very commonly here. I do tend to get a lot of skeptics at first because there are a lot of misconceptions about working with a behavioral sleep medicine specialist and specifically when someone is looking into starting cognitive behavioral therapy for insomnia or CBT, which is considered the first line treatment for chronic insomnia in adults.

There is this idea that CBT is the same thing as sleep hygiene, which is, you know, everything that you read about online. If you were to Google, you know how to get better sleep, those sleep tips would most likely fall under this category of sleep hygiene or healthy sleep practices. So CBT II is not sleep hygiene there. I would say sleep hygiene is one component of CBT. So it is involved in the treatment, but it is not sleep hygiene on its own. In fact, there's a lot of data that has looked at CBT over the years and a lot of the control groups in data is usually sleep hygiene.

So CBT being compared to groups of folks who are just doing those kind of general sleep tips or healthy sleep practices. Sleep hygiene is very important. It is absolutely key to have those practices in place. But for a lot of folks who have a primary sleep disorder, like insomnia, like sleep apnea, you could be doing all the sleep hygiene tips in the world, but it may not be enough to really address the underlying root cause. So CBT is, I would say, one step up or one step further tries to really address the underlying root cause for why someone isn't sleeping well and has very specific techniques that have been backed by decades of research to be much more effective than just sleep hygiene alone.

And what the data tells us is typically for folks who complete a full course of CBT, about 70 to 80% of folks will experience a significant reduction or total remission of insomnia symptoms. So the majority of folks. And so just like any other treatment, there may be a small percentage who don't necessarily see as much benefit. But I know over the past decade and working with folks, I haven't worked with someone who didn't get something new out of the treatment because there's so much information out there about sleep.

But it's really kind of focusing on the exact steps that are going to really lead to improving sleep quality. And it's actually having a customized plan, which you can't necessarily get with those generic sleep hygiene tips. Exactly right. And that gives so much hope to people who are struggling. I think the majority of people can get better and resolve their problems with sleeping, build up that confidence, build up that trust. And, you know, the idea that this is a tailored program

CBT-I vs Sleep Hygiene 18:18

specific to an individual seems to require a human component, a behavioral medicine specialist like yourself, who has that expertize to really take somebody through a proper cognitive behavioral therapy regimen to get them feeling better and sleeping better, but I know there are not enough of you to go around. Tell me, you know, how does somebody find a CBT practitioner in their area and are there alternatives like remote options or even any sort of AI or apps that could be used as well? Yes. So I tend to think about behavioral sleep medicine on this step care model.

So there are many apps available these days that are CBT programs that you can download and do on your own, like a self-paced program. Then a next step would be, say, an online course. So something that's a little bit more comprehensive, but something that you would do on your computer and potentially have like a coach or something guiding you, but may still be very much kind of what I like to call cookie cutter. And I think for some people, apps and online programs will work very well. But there are a lot of folks who have been dealing with sleep issues for decades and who may be on a number of different sleeping pills and who really do need that personalized touch to come up with a custom tailored sleep action plan, as I like to call it.

And so the next step up from, say, the remote options would be seeing someone either virtually or in person. So I do think that there is immense value in trying out a program on your own, but sometimes it just isn't enough. Sometimes it can be really helpful to work with an expert who can take the principles of CBT and those techniques and really modify them to make them work for you. So, you know, as you mentioned, it's really hard sometimes to find a behavioral sleep medicine specialist. And part of that is because there's just not enough of us that have been properly trained.

In fact, the last time I checked, there was less than 800 in the world. So as you can imagine, like millions of folks who are really struggling, less than 800 of us, it's really hard to meet the demand. And so that's where I also think CBT apps and programs can be really helpful if you live in an area where you can't work with someone that's close to you, that might be a great starting point. And in terms of finding a behavioral sleep medicine specialist, I would say there's two main resources that are available.

There are two directories. So the first is going to be the Society of Behavioral Sleep Medicine. That's kind of the starting point for most a behavioral sleep medicine specialist in the country as well as you can search for providers around the world. And then the sister directory is the University of Pennsylvania CBT I directory. So those would be the two places to search for someone near you. And just to add to that, most behavioral sleep medicine specialists are typically clinical psychologist or sometimes social workers or mental health counselors.

So usually in the mental health field, although that is expanding, I know there are a lot of nurse practitioner and doctors who are also trained in behavioral sleep medicine. So that is expanding. But because the majority of behavioral sleep medicine specialists are usually psychologists, they're often bound by licensure restrictions. So they can't see you unless you're a resident of the state in which they're licensed. So fortunately, there is a new ruling called PSI Pact, which is kind of an interstate practice.

So further expanding the ability for psychologists to see people across state lines. And so with that, it's actually going to be a little bit easier to find someone who maybe doesn't live in your state, but through this PSI pact ruling can now see you virtually. So I think that's going to be really helpful for behavioral sleep medicine specialist so we can make our treatments more accessible. Well, that really sounds fantastic. And it sounds like it's not quite ready yet. Any ideas when that will be released for use?

Yeah. So so it has been enacted in some states in the US. I'm based in Florida and they just recently enacted side pack. So a couple of months for me. So I guess it depends on where the provider is located, if they're going to join the pact. That's so interesting and I'm glad to hear it. Great resources and I'll repeat those at the end so that if people didn't have a chance to jotted down, I will review that in the summary. I think too, when when somebody is sort of making a commitment to engage in improving their sleep, there's a certain amount of there's a certain amount of personal responsibility that they're taking for their sleep.

And one thing that I've noticed is that people tend to have a sleep identity, especially if they've gone through multiple attempts to improve their sleep. They may start characterizing themselves as a bad sleeper or nothing ever works for me. And unfortunately, I find that that really entrenches their mindset into a fair amount of stagnation. So it seems that sort of opening up one's mind and one's attitude can improve the chances of these behavioral techniques working.

Finding CBT-I Support and Remote Options 24:58

Can you comment on that? Yes. And you bring up such a great point here, because I see this probably once a day where I'm working with someone who has identified as a bad sleeper for decades, maybe even their entire life. And, you know, these labels start to define the person. And sometimes it is really hard to think about letting go of that identity and what that would look like. And it often does keep a lot of people feeling stuck and being able to move forward and make changes. And, you know, when it comes to any lifestyle change, whether it is, you know, trying to eat better or losing weight, sleep is no different than improving sleep.

There is a lot of behavior change involved. But I think the mindset around changing is also sometimes the first step towards getting started. And that's certainly something that a behavioral sleep medicine specialist can help with is, you know, learning how to shift that bad sleeper identity into someone who's actually a great sleeper. And, you know, not that sleep is ever going to be perfect for anyone, but to really help remove that label so it doesn't continue to define that individual and doesn't get in the way of making profound change.

And so that is certainly, I would say, part of building what I like to call a competent sleep mindset. And that's a huge part of being able to improve sleep. That's fantastic. And I want to highlight the fact that everybody has an innate ability to sleep. Our brain is sort of preprogrammed that way, and we can do things to make sleep more possible or less possible. So that's a good sort of shift over into some internal rhythms. And I want to start with the idea of Chronotype. Now you've come out in the world as a night owl and I identify as an early bird, and these are kind of the two opposite ends of the chronotype spectrum.

And then in the middle is kind of the third bird, which is probably the most common Chronotype Can you sort of nutshell for the audience what chronotype means when you're trying to sort out your sleep problems? Yes, I love talking about Chronotype because I think it's so important that everyone knows their specific chronotype because when you do, you can really align your sleep schedule and also your activities that you do during the day, like when you eat your meals, when you have your activity or our exercise times, it is all related and they all influence each other.

So as far as Chronotype, that's essentially your unique circadian rhythm. So I'll give you some examples here in terms of sleep, oftentimes I would say the majority of folks will have what's considered a typical sleep schedule and 11 p.m. to 7 a.m. or 10 p.m. to 6 a.m. schedule. For folks who maybe identify as more of an extreme morning person, they may get into bed 8:09 p.m. and then wake up four or 5 a.m., no problem. And then on the other side of that spectrum, those who identify as more of an extreme night owl, they don't get into bed or don't get sleepy until typically after two or three in the morning and then may want to wake up ten, 11, 12, when I mean, I've really seen folks across the spectrum and I tend to think of Chronotype as being on a spectrum.

You know, they, they, you can think about sleep and the different sleep schedules is kind of falling really anywhere from typically like 8 p.m. all the way up to 6 a.m.. So it really is unique to each individual and we only very recently discovered that it's actually genetic. So there's a specific gene that determines whether you're going to be more of a morning person or more of an evening person. And of course, lifestyle plays a big role in that as well. But when it comes to Chronotype, it is very much biological.

So meaning it is not something that you can necessarily change. There are things that you can do to modify your chronotype, but as far as your kind of innate biological predisposition for sleep, that is often very much set in stone. Got it. Well, I wonder then how do people determine or even confirm what their chronotype is? It's a great question.

Sleep Identity and Mindset Shifts 30:18

And I say that because there is it is a great way to really test for that. And I say that because there are a couple of ways, but there usually in research settings, there really isn't anything yet in the mainstream. But I think that's going to change in the near future. For example, there is a specific melatonin type that has been used in research to study people who have these earlier or later chronotype. So I'd say knowing that there isn't necessarily like an at home test or something like that, it's the best way is to specifically think about when you would optimally like to get into bed and fall asleep and like to wake up if you didn't have any responsibilities and you could really pick an optimal sleep schedule when you naturally feel sleepy and naturally feel wakeful.

That usually is pretty telling in terms of where you might fall. And I think it also it's helpful to kind of think about when you feel most alert during the day. When do you feel most mentally alert? When do you feel most productive? I can tell you that as a night owl, that is not going to be in the morning. So. So I think based on how you feel at certain points throughout the daytime, that can also inform where you're chronotype likely is. And I think if someone is really interested in working with a behavioral sleep medicine specialist to tease that apart and to really set up a schedule that aligns with that specific chronotype.

Got it. That's so interesting. And I, I think it's fun to meet somebody on the opposite end of their chronotype spectrum. I've heard that to society, academics. You know, there's some things that work against night owls. I wonder what your experience has been and how you kind of accommodate your chronotype to fit into your life. Thank you for this question because it is definitely challenging as an extreme night owl to live in a world that often does cater to the early bird. And, you know, that is something that I struggled with for many years growing up, whether it was school at first, but then eventually transitioned into my job, my full time job.

So knowing that, it was very difficult to manage my sleep schedule in relation to my work schedule, I knew once I had a good understanding of chronotype and circadian rhythms, I knew that the best solution was to really create a work schedule that best aligned with my natural rhythm. So that is part of why I ended up pursuing my own business, my own private practice and with that being able to choose my schedule, I can really make it so that, you know, I'm not seeing a focus in the morning and I can adjust my schedule accordingly so that I can sleep in my biological sleep window.

Understanding Chronotype and Circadian Rhythms 33:38

And that often is, you know, my my best recommended patient. If it's possible for someone who does identify as more of a night owl to try to align their work schedule with their natural sleep schedule, because they're just going to get better quality sleep and feel so much better during the day. And I know that's not always possible for everyone, but that is how I've finally been able to align my chronotype with my daily responsible wishes. That makes sense. And I have to tell you, there's a little bit of irony in this sleep medicine world, because I've always had a soft place in my heart for sleep texts that stay up overnight to conduct sleep studies.

And a lot of them seem to self-select into an overnight job. But I'm thinking of one woman in particular that really weighed heavily on my heart. She was a sleep tech, and it just was not her chronotype. And despite the fact that she was a really great sleep tech, I always worried about her, you know, working against her grain, so to speak, and then, you know, driving home in the morning and not sleeping well during the day and then trying to stack night after night of work. So I think it can definitely inform a person's choice of job or work hours.

It can affect family life, it can affect mental health and productivity. And all of these things go together to create a sense of being well or unwell. So knowing your chronotype is pretty important. Yeah, I think it's incredibly important for overall well-being. And as you said, it affects various aspects of your overall daily functioning, whether that is family or social life. Mental health is is one of the biggest areas that I see impacted as well as work productivity. You know, if we lived in a world where everyone could sleep in their natural sleep window, we would actually have a, I would say, much more productive folks.

And that isn't always the case for everybody. And of course, a lot of people have never really even heard of chronotype or circadian rhythms. And I'm so glad that we're talking about this. And I think now employers are starting to listen and want to make adjustments when it comes to sleep. But there still is, I would say, a long way to go. And I just wanted to add, you know, in the sleep community, we often think about chronotype from an evolutionary perspective. So like thinking back in the caveman days and our ancestors, there always used to be someone up at all times of the day versus night order to protect the tribe, so to speak.

So the sleep quality believes that we've evolved to have these different sleep schedules, these different chrono types for survival purposes. And so I think it makes sense, but it is a lot more challenging in our society today for those folks who maybe don't have a quote unquote typical chronotype or sleep schedule. Yeah, I totally agree. And that's a great explanation. And another example of how differences among humans are actually healthy and productive. But you need to honor your own internal rhythm.

Thank you so much, Dr. Silverman. I feel like this has been a great discussion, and I want to just briefly run through the highlights. So we talked about bringing awareness to coexisting insomnia with sleep apnea and kind of helping to normalize that, but also reduce sleep problems by practicing some exposure therapy with the CPAP mask. We talked about medication both prescribed and over-the-counter as a tool for improving sleep. Ideally a short term tool because in the long term there is risk of cognitive impairment even up to, you know, some dementia diagnoses that is to be revealed with these longer term studies of sleep aids.

And they should always be paired with behavioral techniques which are potent and powerful and durable. The cognitive behavioral therapy does not equal sleep hygiene. So it's kind of the next level that a person get to when sleep hygiene techniques are aren't working and working one on one with a an experienced practitioner such as yourself is kind of the pinnacle of treatment because it allows for personalization and a really deep dove. Aside from that, there's apps and online courses that can be done.

And the more someone can show up with an open mindset, the more they're going to get out of that information. You mentioned the Society of Behavioral Sleep Medicine and the University of Pennsylvania CBT-I Directory as to resources to find someone who can deliver CBT-I. And finally, we landed on Chronotype and honoring your own biological rhythm in order to make sleep more successful. Dr. Silverman Can you tell people where they can find you? Sure. I am @drsarahsleep on most social forums. I would say I'm the most active on Instagram and LinkedIn and I'm @drsarahsleep on all of those and I'm also at drsarahsleep.com If you are looking at to potentially explore working together, I have a couple different ways to do so.

And I also recently launched my own CBT-I online course called the Holistic Sleep Academy, and it is a step by step roadmap to helping you improve your sleep without medication. So a way to work with me in sense, but for those who maybe don't live in the states in which I'm licensed, so those are the best places to find me and I'm always happy to be a resource to you. Now, I wonder, as we wrap up, is there anything else you'd like to add or underscore? Thank you so much for that wonderful summary.

Yes, I would say the one thing I want to add here is just to emphasize that there is hope when it comes to improving sleep. I know a lot of people feel like they wake up each feeling tired and it's just part of the normal grind the day to day. And it doesn't have to be that way. Just because it's common, it doesn't mean that it's normal. And I want everyone to know that there is hope. There's there's a lot that you can do to improve your sleep quality and really that in turn improves your quality of life and, you know, helping you feel like you have more energy during the day, feel like you can be present for your friends and your family and the people in your life that truly matter to you.

So sleep can impact all of these other areas and I think everyone knows it's so important, but sometimes there's this idea that there isn't much that you can do and there is absolutely a lot that you can do with the right strategies and the right support. I think that's also important. It's not just throwing spaghetti at the wall and trying all these different things. It's really having a streamlined approach and knowing what techniques are going to be the most effective for you. Because sleep is so individualized, there isn't a one size fits all approach when it comes to sleep and again, know that there is hope in improving your sleep.

You're so right. I love that. And I'll just end by saying skills, not pills, everybody. There is hope. I love it. Take good care. Dr. Silverman, it was a pleasure to speak to you today. Likewise. Thank you so much for having me. Bye bye.