Unmet Needs in Treating Insomnia - Episode 7
Focusing on treatment options for insomnia, experts consider the added value of sleep hygiene.
Michael J. Thorpy, MD:We all agree that in some areas, this an important condition that needs to be treated, so let’s turn to treatment. We hear a lot about sleep hygiene. Karl, tell us a bit about this. What is sleep hygiene? Does it really work, or does it not work? Who should undertake sleep hygiene?
Karl Doghramji, MD: These are some of the behaviors we like to have our insomniacs do to mitigate the problems with insomnia. I should say that what they did on sleep hygiene doesn’t show that it works as a sole treatment, so it’s not sufficient to treat insomniacs. On the other hand, without it, many of our other treatments don’t work very well, so it’s necessary but not sufficient. It’s the cornerstone of good treatment of insomnia, so 1 of the dos of sleep hygiene is to keep a regular bedtime. Going to bed at the same time is helpful, but it’s even more critical to get up at the same time every morning to be able to reset that circadian pacemaker in a proper way. Getting exposure to light in the morning [is important]. When you get out of bed, make sure there’s plenty of light around as a way of making sure our circadian rhythms are reset in the proper direction. Make sure that you do something relaxing before bedtime. The old medical student syndrome of going to bed with Grey’s Anatomy or the textbook and worrying about the exam and closing the book and going right to bed doesn’t work well.
In addition, some don’ts of sleep hygiene: don’t do too much caffeine in the afternoon or alcohol close to bedtime. Don’t make the evening very bright. The evening should be a time when there’s some darkness or a dim light in the bedroom. Avoid napping as much as possible, although napping may not be such a bad thing for shift workers and narcoleptics. For patients with long-term insomnia, excessive napping for many hours may be detrimental. There are many other sleep hygiene tips, but it’s important to review these with every patient in the context of insomnia treatment.
Michael J. Thorpy, MD:Vikas, do you have any sleep hygiene tips that you find particularly helpful?
Vikas Jain, MD, FAASM, FAAFP, CCSH, CPE: One of the biggest things I tell patients, “Don’t teach your brain how to not sleep in bed.” Many patients, when they don’t sleep, they say, “I need to spend a longer time in bed so I can get some rest or get more opportunity to sleep.” But most of the time if you’re lying in bed awake, you’re teaching yourself how to get good at not sleeping well in bed. The bed itself can become a trigger for insomnia, where they feel sleepy on the couch, but they go into the bedroom and all of a sudden, they’re like, “Why am I so awake right now?” They become conditioned to be awake in those scenarios.
Nathaniel Fletcher Watson, MD: This is a little between sleep hygiene and just general advice about addressing this is for people to not look at the clock when they wake up at night. When is looking at the clock ever been good news to a person who wakes up and who was sleeping and then wakes up? It’s never a good thing. Either they weren’t asleep long enough—“Oh my gosh, I just woke up; how am I going to get back to sleep?”—or it’s a couple hours before their intended wake time. They begin to think about the day ahead, so that’s a little thing that I throw out there for my patients quite often. The only person who can prioritize sleep is the individual. There are so many things in our society that fight against you sleeping. Netflix doesn’t want you to sleep. Amazon doesn’t want you to sleep. If you’re sleeping, you’re not consuming those things, so there’s a message for people. It’s like, “Look, take care of yourself, prioritize your sleep, and follow these great sleep hygiene recommendations that Karl mentioned. Get yourself on the right track to having good healthy nighttime sleep.”
Michael J. Thorpy, MD:One thing I find particularly important is that in addition to what Karl mentioned about going to bed at the same time at night, get up at the same time in the morning. That’s the amount of time the person spends in bed. I always think of the story of the older person who complains about their insomnia. They say, “I go to bed every night at 8 o’clock, and I get up regularly at 8 o’clock in the morning.” He’s in bed for 12 hours. Of course, there’s no way he can get 12 hours of sleep, so he’s got to have at least 4 or 5 hours of wakefulness at night. Thus, in addition to going to bed at the same time, getting up at the regular time in the morning, the person should not be in bed any more than 8 hours if they have insomnia. If any insomniac gets 8 hours of sleep, they’ll be perfectly happy, but they shouldn’t spend prolonged periods of time in bed.
Transcript edited for clarity.