Staff Perspective: The Problem with Sleep Hygiene
SrA Pruitt slumps in the chair in her primary care provider’s exam room. She’s frustrated she hasn’t slept much in the past five months since her promotion and just wants a magic bullet to help her fall asleep faster and stay asleep longer. She clearly did not expect her provider to ask her to see me; she crosses her arms and says bitterly “…but I’ve already tried all those things that are supposed to make my sleep better.”
This complaint is probably the number one refrain I hear from patients referred to me, a behavioral health provider, someone who treats sleep issues from a cognitive and behavioral perspective. I can see the confusion-how would a behavioral health provider help? Isn’t sleep a medical or physical problem? And most importantly, why bother trying anything else when they have already tried all of the behavior changes that supposedly improve sleep, like earplugs, a new mattress, and tea before bed?
Ah, yes. Supposedly. If only someone with poor sleep would just change their sleep environment—making it quieter, darker, cooler, or more comfortable—or perhaps change their routine—avoid pre-bedtime bright lights, limit caffeine and alcohol, a warm bath—or even add in some stress management—journal, a glass of hot milk, lavender spray—shouldn’t their sleep improve? Wouldn’t these changes do the trick? These tips and strategies to promote good quality sleep are collectively known as sleep hygiene (see here for sleep hygiene specifics). I have had so many patients with chronic insomnia desperately try all of these strategies and more, including various herbal oils and diet changes and special pillows and white noise machines. Yet here they sit with me, struggling with difficulty falling or staying asleep.
Here’s the unfortunate truth: sleep hygiene does not work for chronic insomnia, or difficulties sleeping lasting three months or more. Yes, it can be helpful to improve sleep further in mostly normal sleepers. Yes, it can be helpful for those who would otherwise be able to sleep but have a poor sleep environment. Yes, it can be helpful for those experiencing a few bad nights, such as adjusting to stress and changes like a return from deployment or move. In some cases, implementing sleep hygiene early on can prevent long-term sleep difficulties. It just doesn’t work once chronic sleep difficulties set in.
The American Academy of Sleep Medicine (AASM) says in their Clinical Practice Guideline for Chronic Insomnia that “Although all patients with chronic insomnia should adhere to rules of good sleep hygiene, there is insufficient evidence to indicate that sleep hygiene alone is effective in the treatment of chronic insomnia. It should be used in combination with other therapies” (Schutte-Rodin et al, 2008).
For example, in one study, a comparison of a technique called sleep restriction in addition to sleep hygiene tips to sleep hygiene alone found that sleep hygiene alone did not normalize sleep efficiency, sleep onset latency, or early morning awakenings (Taylor et al, 2010). In contrast, sleep restriction was effective with moderate to large effect sizes, and those who had sleep restriction were able to largely eliminate medication use and maintained their improvements for a year. Even relaxation has been shown to be more helpful for sleep than sleep hygiene (Morin et al, 2006). In many studies, sleep hygiene is used as a control condition as opposed to an active condition; that is, researchers equate sleep hygiene with no or minimal treatment.
So, what’s the problem with sleep hygiene? Well, here are my thoughts:
- Given time pressures in busy medical and mental health clinics, often the only attention paid to sleep problems is to hand over a sleep hygiene pamphlet or perhaps have a brief discussion. One provider I spoke with said “But it’s so much easier to give patients a handout [than provide CBTI].” Sleep hygiene displaces interventions that are known to be effective.
- A worse cost may come when patients actually try these recommendations and inevitably fail. We may know because of the above research that of course these recommendations are unlikely to be successful, but the patient made a good faith effort and may now give up or even develop a sense of hopelessness about sleep. Sleep hygiene may prevent these patients from seeking further behavioral treatment or following up on a referral to a behavioral sleep medicine provider.
- If patients do present for behavioral treatment such as CBTI, hopelessness from sleep hygiene efforts may hinder adherence. If this happens, low adherence can translate into poor CBTI outcomes thus resulting in a self-fulfilling prophecy.
One of the biggest challenges to behavioral treatments for many conditions isn’t so much effectiveness-it’s getting patients to engage in treatment. Imagine what patients think if after a referral for yet another effort to improve their sleep ability they are told to try the same old-same old? Instead, acknowledging to patients presenting for chronic sleep problems that it’s not surprising sleep hygiene tips did not work for them may not only validate their experiences, but also increase buy-in and engagement in behavioral strategies that are effective.
Unfortunately, to make matters more confusing to patients and providers alike some sleep hygiene sheets include small elements of other techniques, such as guidelines from sleep restriction or stimulus control. Just keep in mind that even in that case, these pieces are not implemented in a systematic fashion during self-monitoring and in combination with other techniques as found in the evidence based treatment Cognitive Behavioral Therapy for Insomnia (CBT-I). CBTI, by the way, is recommended as the first line treatment for chronic insomnia not only by the AASM but also by the American College of Physicians (Qaseem et al, 2016). Some CBTI protocols do not even bother to include sleep hygiene at all. So it makes sense to bypass sleep hygiene altogether and go straight to CBTI for these patients.
I highly recommend all medical and mental health providers whose patients report chronic insomnia to go beyond providing a sleep hygiene handout, and consider referral to a provider trained in CBTI (Certified Behavioral Sleep Medicine) providers and Society of Behavioral Sleep Medicine members; for Service members and Veterans, Military Treatment Facilities and VAs often have trained providers on site) . Even better, consider seeking CBT-I training yourself! (CDP conveniently offers CBTI training in a two-day workshop with post-consultation available; check out our upcoming training events.) Sleep hygiene can be helpful in some cases, but in my opinion it shouldn’t be the only tool in the sleep toolbox.
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
References:
Qaseem, A., Kansagara, D., Forciea, M.A., Cooke, M., & Denberg, T.D. (2016). Management of chronic insomnia disorder in adults: a clinical practice guideline from the American College of Physicians. Annals of Internal Medicine 165(2): 125-133.
Morin, C.M., Bootzin, R.R., Buysse, D.J., Edinger, J.D., Espie, C.A., & Lichstein, K.L. (2006). Psychological and behavioral treatment of insomnia: update of the recent evidence (1998-2004). Sleep 29(11): 1398-1414.
Schutte-Rodin, S., Broch, L., Buysse, D., Dorsey, C. & Sateia, M. (2008). Clinical guideline for the evaluation and management of chronic insomnia in adults. Journal of Clinical Sleep Medicine 4(5): 487-504.
Taylor, D.J., Schmidt-Nowara, W., Jessop, C.A., & Ahearn, J. (2010). Sleep restriction therapy and hypnotic withdrawal versus sleep hygiene education in hypnotic using patients with insomnia. Journal of Clinical Sleep Medicine 6(2): 169-175.
Diana C. Dolan, Ph.D., CBSM is a clinical psychologist serving as an evidence-based psychotherapy trainer with the Center for Deployment Psychology at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.
SrA Pruitt slumps in the chair in her primary care provider’s exam room. She’s frustrated she hasn’t slept much in the past five months since her promotion and just wants a magic bullet to help her fall asleep faster and stay asleep longer. She clearly did not expect her provider to ask her to see me; she crosses her arms and says bitterly “…but I’ve already tried all those things that are supposed to make my sleep better.”
This complaint is probably the number one refrain I hear from patients referred to me, a behavioral health provider, someone who treats sleep issues from a cognitive and behavioral perspective. I can see the confusion-how would a behavioral health provider help? Isn’t sleep a medical or physical problem? And most importantly, why bother trying anything else when they have already tried all of the behavior changes that supposedly improve sleep, like earplugs, a new mattress, and tea before bed?
Ah, yes. Supposedly. If only someone with poor sleep would just change their sleep environment—making it quieter, darker, cooler, or more comfortable—or perhaps change their routine—avoid pre-bedtime bright lights, limit caffeine and alcohol, a warm bath—or even add in some stress management—journal, a glass of hot milk, lavender spray—shouldn’t their sleep improve? Wouldn’t these changes do the trick? These tips and strategies to promote good quality sleep are collectively known as sleep hygiene (see here for sleep hygiene specifics). I have had so many patients with chronic insomnia desperately try all of these strategies and more, including various herbal oils and diet changes and special pillows and white noise machines. Yet here they sit with me, struggling with difficulty falling or staying asleep.
Here’s the unfortunate truth: sleep hygiene does not work for chronic insomnia, or difficulties sleeping lasting three months or more. Yes, it can be helpful to improve sleep further in mostly normal sleepers. Yes, it can be helpful for those who would otherwise be able to sleep but have a poor sleep environment. Yes, it can be helpful for those experiencing a few bad nights, such as adjusting to stress and changes like a return from deployment or move. In some cases, implementing sleep hygiene early on can prevent long-term sleep difficulties. It just doesn’t work once chronic sleep difficulties set in.
The American Academy of Sleep Medicine (AASM) says in their Clinical Practice Guideline for Chronic Insomnia that “Although all patients with chronic insomnia should adhere to rules of good sleep hygiene, there is insufficient evidence to indicate that sleep hygiene alone is effective in the treatment of chronic insomnia. It should be used in combination with other therapies” (Schutte-Rodin et al, 2008).
For example, in one study, a comparison of a technique called sleep restriction in addition to sleep hygiene tips to sleep hygiene alone found that sleep hygiene alone did not normalize sleep efficiency, sleep onset latency, or early morning awakenings (Taylor et al, 2010). In contrast, sleep restriction was effective with moderate to large effect sizes, and those who had sleep restriction were able to largely eliminate medication use and maintained their improvements for a year. Even relaxation has been shown to be more helpful for sleep than sleep hygiene (Morin et al, 2006). In many studies, sleep hygiene is used as a control condition as opposed to an active condition; that is, researchers equate sleep hygiene with no or minimal treatment.
So, what’s the problem with sleep hygiene? Well, here are my thoughts:
- Given time pressures in busy medical and mental health clinics, often the only attention paid to sleep problems is to hand over a sleep hygiene pamphlet or perhaps have a brief discussion. One provider I spoke with said “But it’s so much easier to give patients a handout [than provide CBTI].” Sleep hygiene displaces interventions that are known to be effective.
- A worse cost may come when patients actually try these recommendations and inevitably fail. We may know because of the above research that of course these recommendations are unlikely to be successful, but the patient made a good faith effort and may now give up or even develop a sense of hopelessness about sleep. Sleep hygiene may prevent these patients from seeking further behavioral treatment or following up on a referral to a behavioral sleep medicine provider.
- If patients do present for behavioral treatment such as CBTI, hopelessness from sleep hygiene efforts may hinder adherence. If this happens, low adherence can translate into poor CBTI outcomes thus resulting in a self-fulfilling prophecy.
One of the biggest challenges to behavioral treatments for many conditions isn’t so much effectiveness-it’s getting patients to engage in treatment. Imagine what patients think if after a referral for yet another effort to improve their sleep ability they are told to try the same old-same old? Instead, acknowledging to patients presenting for chronic sleep problems that it’s not surprising sleep hygiene tips did not work for them may not only validate their experiences, but also increase buy-in and engagement in behavioral strategies that are effective.
Unfortunately, to make matters more confusing to patients and providers alike some sleep hygiene sheets include small elements of other techniques, such as guidelines from sleep restriction or stimulus control. Just keep in mind that even in that case, these pieces are not implemented in a systematic fashion during self-monitoring and in combination with other techniques as found in the evidence based treatment Cognitive Behavioral Therapy for Insomnia (CBT-I). CBTI, by the way, is recommended as the first line treatment for chronic insomnia not only by the AASM but also by the American College of Physicians (Qaseem et al, 2016). Some CBTI protocols do not even bother to include sleep hygiene at all. So it makes sense to bypass sleep hygiene altogether and go straight to CBTI for these patients.
I highly recommend all medical and mental health providers whose patients report chronic insomnia to go beyond providing a sleep hygiene handout, and consider referral to a provider trained in CBTI (Certified Behavioral Sleep Medicine) providers and Society of Behavioral Sleep Medicine members; for Service members and Veterans, Military Treatment Facilities and VAs often have trained providers on site) . Even better, consider seeking CBT-I training yourself! (CDP conveniently offers CBTI training in a two-day workshop with post-consultation available; check out our upcoming training events.) Sleep hygiene can be helpful in some cases, but in my opinion it shouldn’t be the only tool in the sleep toolbox.
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
References:
Qaseem, A., Kansagara, D., Forciea, M.A., Cooke, M., & Denberg, T.D. (2016). Management of chronic insomnia disorder in adults: a clinical practice guideline from the American College of Physicians. Annals of Internal Medicine 165(2): 125-133.
Morin, C.M., Bootzin, R.R., Buysse, D.J., Edinger, J.D., Espie, C.A., & Lichstein, K.L. (2006). Psychological and behavioral treatment of insomnia: update of the recent evidence (1998-2004). Sleep 29(11): 1398-1414.
Schutte-Rodin, S., Broch, L., Buysse, D., Dorsey, C. & Sateia, M. (2008). Clinical guideline for the evaluation and management of chronic insomnia in adults. Journal of Clinical Sleep Medicine 4(5): 487-504.
Taylor, D.J., Schmidt-Nowara, W., Jessop, C.A., & Ahearn, J. (2010). Sleep restriction therapy and hypnotic withdrawal versus sleep hygiene education in hypnotic using patients with insomnia. Journal of Clinical Sleep Medicine 6(2): 169-175.
Diana C. Dolan, Ph.D., CBSM is a clinical psychologist serving as an evidence-based psychotherapy trainer with the Center for Deployment Psychology at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.