“The economic crisis has greatly worsened the sleep problems of the Portuguese”

Marta Gonçalves
Marta Gonçalves, president of the Portuguese Sleep Association, psychiatrist and expert in sleep medicine, advocates the creation of a sleep medicine course for medical studies and totally agrees with the creation of a sleep medicine specialty by the Portuguese Medical Association. Her clinical practice makes her aware that “the economic crisis has greatly worsened the sleep problems of the Portuguese”. She believes that the Nordic people commit much less “sleep hygiene mistakes” than the Portuguese.


Would you highlight any developments in sleep occurring in Portugal in the last 20 years?
In terms of the general public, I would highlight a growing understanding of the importance of sleep in peoples’ lives and, in that sense, a greater demand for specialized consultations at a much earlier stage. With regard to health professionals there is growing interest in differentiation in this area, as evidenced by the recent creation of the Sleep Medicine specialty by the Medical Association. In terms of postgraduate education, I would highlight the first Master in Sleep Sciences at the Faculty of Medicine of Lisbon, coordinated by Professor Teresa Paiva, who at the time was an international pioneer. More recently, in 2011, a Sleep Medicine module was also created in the Ph.D. program in Neuroscience and Clinical Psychiatry at the Faculty of Medicine of Oporto, coordinated by myself.

And are there still things to be done?
In my opinion, it would be important to integrate the subject of sleep medicine in the various medical courses, so that knowledge in this area begins to be part of the skills of newly trained doctors.
It seems undeniable that the Portuguese are now more aware of the issues around sleep. But would you say that this increased interest has improved the sleep hygiene behaviours and translated into better sleep?
Although there is increased awareness and knowledge with respect to sleep, unfortunately I do not think that sleep hygiene behaviours are being implemented efficiently and that they result in better sleep. At the same time there is another side to that which overlies greater knowledge regarding sleep. The constant encouragement to become more competitive, with frequent need to work overtime, the use of computers and tablets at night without rules, and easy entry into the night, particularly in young people, usually accompanied by excessive use of stimulants, end up hindering the practical applicability of good sleep hygiene rules.

From your clinical experience, what are the differences between a long-term patient with insomnia and sleep disturbances and a patient of current times?
Today’s patients seek help earlier, they are much more informed and they clearly prefer non-pharmacological therapies.

Would you say that the economic crisis has greatly increased sleep problems of the Portuguese population?
Although I have no nationally representative figures in this regard to evaluate the sleep of the Portuguese, I would say yes based on my clinical sense. I think that it is easily understood that an economic crisis of this magnitude, with no end in sight, which changed both personal expectations and family structures, generates feelings of helplessness and hopelessness that lead to chronic stress levels. Increasing anxiety levels are noticeable in sleep, which in turn facilitates the onset or worsening of insomnia.

In times of economic crisis, have cognitive-behavioural therapies been neglected over pharmacological treatments, which frequently are faster and cheaper?
I do not get that impression from specialized consultations. On the contrary, I believe that people are more receptive to psychotherapeutic techniques, as they are also more informed about their long-term benefits as well as of the side-effects of some of the so-called sleep medicines.

You entered medical school in a troubled political time, just after the 25th of April… Was the atmosphere calmer in Oporto than in Lisbon? Although I was living in Lisbon at that time, I do not think that the atmosphere in Oporto was more moderate then.

Which teachers were most important to you throughout your medical career?
Professor Rui Mota Cardoso, Professor Casimiro de Azevedo and Professor Sobrinho Simões.

You worked at Conde Ferreira Hospital, a reference in Portuguese psychiatry. How would you describe the experience?
In terms of clinical learning, I think it was an exceptional experience. I had excellent teachers whom I will never forget. From them I learned much of what I know about psychopathology, communication in psychiatry and respecting psychiatric illness.

You have received training in several countries. Did you become aware of different sleep habits and sleep hygiene behaviours compared to Portugal?
You perceive different sleep habits if you look at the Nordic countries and at the Mediterranean, especially in terms of bedtime and waking-up hours, and, I think, also a generally better sleep education and less sleep hygiene mistakes in the Nordic countries.

How does this improved sleep education reflect in practical terms? And what do you mean by less sleep hygiene mistakes?
It reflects on a better understanding of sleep and, in that sense, in a choice of healthier and less erratic behaviours in relation to sleep. I mean less use of caffeinated drinks in the afternoon and evening, less use of computer, tablets and mobile phones at late hours, especially in bed, and less late and sleepless nights, which are so common in our youth and already accepted by most as a perfectly normal behaviour.

You received training at the famous Stanford University. What impression did this institution leave on you? Would there ever be a similar campus in Portugal?
My experience at Stanford was great and it broadened my views on Sleep Medicine when this area was still undeveloped in Portugal. Many of my current projects have at its base some inspiration from the Sleep Medicine Centre at Stanford, where I interned.

You are active in developing training in sleep medicine skills for psychiatrists and physicians from other specialties. Is it becoming increasingly important to have special training in sleep medicine among physicians in general?

There is no question about it. Family doctors and general practitioners are the first line of contact with the patient; they may be decisive in early diagnosis of various pathologies of sleep. In more complex cases it is they who can make an early referral of patients to specialized centres. I consider this to be a preferred investment area from a public health perspective.

What about recognizing sleep as a specialty?
Yes, the Sleep Medicine specialty is fully justified because the diversity, interdisciplinarity and complexity of knowledge in sleep already require a level of dedication and differentiation worthy of a specialty. I think that it will soon be a reality!

You remain president of the Portuguese Sleep Association (PSA). How would you evaluate PSA’s work so far? And what can you say about the future?
I have been doing it for seven years now, which corresponds to two terms of three years; last year I carried on duties. I think I have done my part with great commitment, dedication and enthusiasm, but now there is need for renovation; new and different ideas are needed.
The end result is very positive, in my opinion. Terms of office were demanding and had great activity and some international visibility, and I learned a lot. At the time I hesitated to assume the presidency of PSA, but I think it was worth it.
I coordinated a campaign that I will never forget – the WAKE UP BUS – and which was one of the biggest challenges of my life. The project included an awareness campaign conducted in successive stages in 12 European cities, a study of sleepiness at the wheel and road accidents in 19 European countries, as published in the Journal of Sleep Research, and a symposium on the subject in the European Parliament. Giving unity and body to the whole project, a group of 6 people visited the various cities involved on a bus, from Oporto to Brussels on 3-15 October 2013.
As for the future of the Association, I hope to still bring many pleasant surprises, such as innovation in the area and some international visibility, so that Portugal may always be noted for good reasons. I think that the Association may also come to play a role of great importance in the future, stimulating scientific papers and more Portuguese publications in the sleep field.

Finally, which literary passage about sleep or dream would you recommend?
“Man is the size of his dreams”, by Fernando Pessoa.