My Sleep Research
Being part of an innovative sleep research team was what led me to do my Doctorate of Clinical Psychology at Monash University. Professor Shantha Rajaratnam is a world-leading expert in Chronobiology, and has received major grants for his research. His results have been published in excellent journals, and I knew that I wanted to learn from his expertise.
Given the difficulties that I had faced with my sleep, I wanted to help people function as effectively as possible during their waking hours, and sleep as efficiently as possible at night. Shantha encouraged me look at the relationship between insomnia and depression, and see how we could help individuals who were suffering from both conditions.
Up to 90% of individuals with Depression suffer from sleep difficulties, and 67% have significant enough difficulties with their sleep to warrant an additional diagnosis of Insomnia. Insomnia is considered a chronic problem after only one month, and unfortunately doesn’t tend to go away on its own without treatment.
Interestingly, Insomnia usually precedes the onset of Depression, and can actually bring on Depression or trigger a relapse if it persists. Sleep difficulties therefore need to be directly treated for optimal Insomnia and Depression outcomes.
This is what our research found. By targeting sleep through four sessions of Cognitive Behavioural Therapy for Insomnia (CBT-I), we were able to significantly reduce both Insomnia and Depression severity across the treatment and by three month follow-up in comparison to a control group. The control group were given the same information about how to improve their sleep, but were unable to talk with a qualified therapist trained in CBT-I about their individual sleep difficulties. CBT-I participants were ten times more likely to be in remission from both their Insomnia and Depression by the follow-up, indicating a much lower risk of relapse.
Other research shows that CBT-I consistently reduces the time taken to get to sleep, decreases the amount of time spent awake during the night, and improves sleep quality and efficiency, with improvements persisting after treatment finishes. This is unlike sleeping pills, which typically lead to rebound Insomnia and ongoing sleep difficulties once they are discontinued.
CBT-I is similar in effectiveness to sleeping pills for Insomnia in the short-term and much more effective than sleeping pills in the long-term. It is therefore concerning to see that nearly 90% of individuals who go to GPs with Insomnia complaints are given sleeping pills over a referral for CBT-I. Sleeping pills (typically Benzodiazepines such as Temaze or Valium) are not recommended for use beyond 2-4 weeks at a time, and recent research even links long-term Benzodiazepine use with a greater risk of premature cognitive decline.
Hopefully the awareness of CBT-I as an effective alternative to sleeping pills will continue to increase, but please pass the message on to whoever you know that may be suffering from Insomnia. Even one session of CBT-I was recently shown to be effective for significantly improving Insomnia that had been occurring for less than one month. The more people ask for CBT-I referrals, the more doctors will become aware of this effective treatment and/or feel more comfortable in referring patients for this treatment, and the less our society will be impacted by Insomnia, Depression, and dependence on sleeping pills.
What I Did to Improve My Sleep
By learning what I did through my research and CBT-I treatment, I began to make the following changes to my routine. These steps slowly started to make a huge difference for my sleep, fatigue, alertness and concentration:
#1: I reduced the variability in my sleep from day to day.
I now sleep consistently between 11:30pm and 6:30am, give or take an hour on each side (sleep onset usually between 11-12 and rise time between 6-7am), even on weekends. There are some rare exceptions when I stay up later, but I always make sure that I get out of bed no later than 8:30am, so that I don’t push back my circadian rhythm further. I also never spend more than 8 hours and 30 minutes in bed, and usually find that 7.5 hours in bed is more than adequate to feel energised and refreshed during the day.
#2: I cut down on caffeine, especially in the afternoons.
Anything under 300mg daily is fine for me, and usually doesn’t noticeably impact my sleep at night. However, it is still much better for me to eat healthily, drink plenty of water, take regular breaks, and get outside and exercise if possible when I am feeling tired. By drinking caffeinated beverages or eating high sugar or high fat foods and pushing through my fatigue, I was elevating my arousal levels during the day and making it more difficult for me to switch off and sleep well at night.
#3: I stayed away from bright screens in the last two hours before bed, and stopped doing work if I had any at this time too.
By doing this, I helped my brain identify that it was night-time, and my melatonin production began earlier and helped me feel sleepy and transition to sleep more effectively. Looking at bright screens before bed can suppress melatonin release by as much as 22%, and lead to a later sleep onset, reduced sleep duration and poorer sleep quality.
#4: I tried to seek sunlight exposure when possible in the mornings.
This helped my brain identify that it was daytime and helped increase my energy levels and alertness, which meant that I could concentrate better during the day. For individuals with DSPD, timing is everything, so it is important to discuss with a Sleep Physician the exact times that light exposure should take place for optimal alertness and phase-shifting benefits.
#5: I exercised regularly during the day, but not in the three hours before bed when possible.
By doing this it increased my energy levels and alertness during the day, lifted my mood, reduced my stress and anxiety levels, and improved my sleep pressure for that night. I then felt more tired and ready for bed at around 11:30pm when I wanted to go to sleep.
#6: I made sure that I did things to wind down and relax before bed each night.
This typically took place in the last two hours before bed, and varied between chatting with friends or family that I felt calm around, reading a book, engaging in a creative task, listening to a podcast or music, having a hot bath (but not right before bed), or practicing relaxation exercises or mindfulness meditation. It is important to do anything that can reduce arousal levels before bed and can help bring on feelings of sleepiness earlier. As soon as I experienced these signs of sleepiness (eyes or body feeling heavy, losing focus, yawning), I went to bed, assuming that it was around 11:30pm.
#7: Once in bed, I didn’t force myself to sleep.
I allowed it to occur on its own, and tended to focus on positive experiences that went well for me during the day or things that I was grateful for instead. I sometimes practiced imagery, and imagined myself lying on a beach or hiking in the mountains. If that didn’t work, I returned to mindfulness meditation or relaxation exercises, and focused on keeping my breath slow and deep, and exhaling all of the air with each breath. Before I knew it, I was usually asleep. I sometimes woke up occasionally during the night, but had minimal difficulty in returning to sleep if I did.
#8: I ignored sleep inertia.
One of the biggest traps for individuals with DSPD is judging how they’ve slept or if they need more sleep immediately upon awakening. Given that I was typically waking up before my body clock wanted me to, I almost always felt tired immediately upon awakening in the morning, and would have no difficulty hitting the snooze button or resetting my alarm for later and returning to sleep. I used to do this a lot before I knew about sleep inertia, and even after two more hours of sleep I would still feel the same way upon awakening. Now I get up no matter how I feel when the alarm goes off, shower and have breakfast or go to the gym, and then review how I’m feeling. By delaying my judgment, it becomes a much greater indication of how well I’ve actually slept and how I’m likely to function for the remainder of the day. I typically feel energetic and less fatigued during the day, and am able to pay attention to whatever it is that is most important to me in each moment. Even without the extra sleep.
I hope that you find some of my personal strategies helpful. If you are struggling with sleep difficulties, change one thing at a time where possible, try it for a week or two, see if it makes a difference to your sleep or how you feel during the day. If it helps, keep it up, and then introduce another change if needed.
Once your sleep is better, it is important to introduce some flexibility so that you don’t become too preoccupied with needing all of the right conditions in order to be able to sleep. Good sleepers will tell you that they do nothing to sleep well, and could sleep almost anywhere under any conditions if needed, so it is important to try to relax where possible and not over think it.
If you have tried a number of things but your sleep isn’t getting any better, please seek a referral to a Sleep Physician or a Psychologist who is trained in CBT-I. They will be able to help you understand your sleep difficulty more, let you know if there is any possible underlying condition that may be making your sleep difficulties worse, and give you individualized instructions based on validated research. By putting into practice the strategies that have been shown to be the most effective treatments for the sleep condition(s) that you have, you are giving yourself the best opportunity to become a good sleeper (again, or for the first time). It has worked for me and thousands of others, and it can work for you too!
Dr Damon Ashworth