Sleep difficulties are a feature of nearly every mental health difficulty, including depression, anxiety, trauma, substance use issues, bipolar disorder and psychosis or schizophrenia. Take Depression for example. Up to 90% of individuals with Depression have sleep difficulties, and two out of every three have significant enough sleep problems to also have a diagnosis of Insomnia.
Worse still, Insomnia does not tend to go away on its own without appropriate treatment. This is because once people start to sleep poorly, they tend to develop ways of thinking and behaving around sleep that make their problems worse over the long run.
Fortunately, there is a treatment out there that can improve your sleep. It’s called Cognitive Behavioural Therapy for Insomnia (CBT-I), which directly targets these unhelpful thoughts and behaviours around sleep.
CBT-I is an effective treatment for insomnia, with many studies showing it to be similar to sleeping pills at improving sleep in the short-term, and much more effective than sleeping pills at improving sleep in the long-term.
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 sleep difficulties coming back once people with insomnia stop taking them.
Sleeping pills are also not recommended for use beyond 2-4 weeks at a time, because they stop working after a while and people need to take bigger doses over time to get the same effects. Sometimes doctors prescribe them more because they think they will work faster for patients, but even one session of CBT-I has been shown to make a significant difference to one’s sleep at night!
CBT for Insomnia consists of four main components:
- Psychoeducation: This provides people with helpful information around sleep, including homeostatic pressure, circadian rhythms, hyper-arousal and sleep hygiene recommendations. Sleep hygiene means having a comfortable bedroom environment, minimising light exposure before bed, exercising during the day, minimising caffeine and alcohol and doing things to wind down or manage worries before bed.
- Sleep scheduling: This provides people with helpful information on when they should be going to bed at night, the time they should be arising from bed in the morning, and the ideal amount of time that they should be in bed for each night. Stimulus control and sleep restriction are the two main interventions included in sleep scheduling, and both are scientifically supported for improving sleep quality and sleep efficiency if done properly.
- Relaxation techniques: Because hyper-arousal plays a huge role in Insomnia, it is important to help people develop strategies to quieten the mind and calm the body, during the day, before bed and in bed. Relaxation techniques can include imagery training, meditation, biofeedback training, deep and slow breathing and progressive muscle relaxation.
- Cognitive Therapy: This provides people with the skills to challenge their unhelpful or unrealistic beliefs about sleep. A lot of individuals with Insomnia attribute all of their tiredness, mood difficulties or poor performance at work to their sleep difficulties, and this puts too much pressure on them to get a good night’s sleep. It is therefore important to get them to see the other factors that may contribute to how they feel during the day, present them with data that challenges their fears, and help them to develop realistic expectations about their sleep.
In Vanuatu, there is currently only one psychologist located at the Mind Care Unit in Port Vila who is trained in CBT-I. Please come down to receive this effective treatment if you or a family member is struggling with poor sleep. Until then, there are other sleep strategies that you can try:
BEST SLEEP INTERVENTIONS OVERALL
In 2017, Dr Damon Ashworth, Clinical Psychologist and Sleep Researcher, ran 26 two-week experiments on his sleep to determine which interventions were most helpful for him.
He gave each intervention a score out of 100, based on how effective he found the strategy (25 points), how easy it was to apply and use the strategy (25 points), and how much scientific evidence there was that showed that this strategy could improve sleep (50 points).
Here are all of the sleep interventions he tested, ranked from best to worst based on their overall score out of 100:
- Stimulus control = 85/100
- Winding down before sleep = 85/100
- Sleep restriction = 81/100
- Relaxation strategies pre-sleep = 81/100
- Meditation = 77/100
- No alcohol = 75/100
- Wearing blue-light blocking glasses before sleep = 75/100
- Listening to music in the evening = 73/100
- Yoga/Pilates = 72/100
- Constructive worry or writing down plans = 71/100
- Avoiding TV before bed = 69/100
- Melatonin = 68/100
- Aromatherapy = 68/100
- Sauna or hot bath in the evening = 68/100
- Morning sunlight = 65/100
- Reading or listening to audiobooks pre-sleep = 63/100
- Exercise during the day = 61/100
- No caffeine = 58/100
- Food that helps sleep = 57/100
- Controlling temperature = 57/100
- Massage in the afternoon = 57/100
- Comfort of sleep surface = 56/100
- Sleeping alone = 53/100
- Creativity in the evening = 52/100
(Stepanski & Wyatt, 2003)
- Decrease time in bed – Sleep efficiency is a better predictor of satisfaction with sleep and daytime mood than total sleep time. So if you only get 7 hours of sleep per night, spend 7.5 hours of time in bed. This will allow for better sleep over time.
- Regular bedtime and arising time – Reducing variability in your sleep can make a huge difference in how long it takes you to get to sleep, how restful a sleep you have, and how refreshed you feel in the morning. Have a set bedtime, and whenever you feel sleepy around this time, go to bed. Then set an alarm so that you can wake up at the same time each day. If you want to sleep in on weekends, allow yourself no more than one hour later than you usually wake up. Following this regardless of how much sleep you get helps to strengthen your circadian rhythms and build up your homeostatic pressure to ensure better sleep over time.
- Exercise – Vigorous exercise prior to bedtime is actually unhelpful for sleep, but expending more energy during the day is likely to lead to better quality sleep at night. The earlier in the day it is done, the greater the effect it will have.
- Less caffeine and alcohol – Minimise these substances where possible, especially within 4 hours of bedtime as they both have significant effects on sleep quality. Alcohol can reduce worries and result in getting to sleep quicker, but results in poorer sleep quality in the second half of the night. Alcohol can also can lead to more snoring due to the loosening of the throat muscles. Caffeine boosts cortisol levels, a.k.a. stress, and results in less deep sleep and more awakenings.
- Do not try to sleep – It is something that has to come on naturally. The harder you try to get to sleep, the less likely you will be able to, as trying activates the autonomic nervous system, which also increase how stressed you feel. The more you allow yourself to relax, the more likely sleep is.
- Do not keep looking at your phone or alarm clock during the night – If your alarm is set, then there is no need to know the time in bed. This will only increase performance anxiety if you look and see that you have not slept for very long. Put it in a draw, cover it with a shirt, or face it the other way.
- Keep naps short – Napping during the day reduces your pressure for sleep by the time you get into bed at night. If you have to nap, keep it less than 30 minutes so that you don’t go into a deep sleep, and do it before 4pm so that sleep pressure can build up again by the time you go to bed that night.
- Engage in relaxing activities before bed – Just like waking up, going to sleep is a transitional process. Don’t expect that your mind will shut off immediately as soon as you get into bed. Whatever it is, do something relaxing as a pre-bed routine. Watch some T.V., read a book, listen to some music, have a hot bath, practice yoga, mindfulness or relaxation techniques. Then maintain that relaxed state in bed and allow sleep to come.
- Use the bedroom only for sleep and sex – This means no reading, eating, internet surfing, game playing, phones, T.V., planning, worrying etc. in bed. Want bed = sleep.
- Make worry list before bed – To prevent your mind from racing in bed, reflect on the day about 2 hours before you want to sleep, write down any worries, concerns or problems you may have, create a to-do-list, or plan for the day ahead. Then if thoughts come up in bed, remind yourself that you have already sorted them out or that they can wait until tomorrow.
- Leave the bed if awake – Sometimes no matter what we try, you may find yourself awake in bed. If you do not fall to sleep within what feels like 20 minutes, get up, go to another room, and do something relaxing until you are sleepy before returning to bed. Over time, this will recondition the bed with sleepiness rather than frustration and allow you to fall asleep quickly. If you are worried that you may never sleep if this was the case, give it a try for a week. It may be the most difficult recommendation to follow initially, but it produces long-lasting results quickly.
Dr Damon Ashworth