The American Academy of Sleep Medicine (AASM) recommends a number of behavioral methods and prescription medications as the main treatments for insomnia. According to the AASM, these treatment options can improve both quality and quantity of sleep for people with insomnia.
Doctors agree that behavioral therapies should be the first-line treatment for insomnia. For children in particular, medications should rarely be used as initial treatment.
Sleep Hygiene Tips
Proper sleep hygiene should accompany any behavioral method. The term sleep hygiene is used to describe simple behaviors that may help everyone improve their sleep. These include:
- Establish a regular time for going to bed and getting up in the morning. Stick to this schedule even on weekends and during vacations.
- Use the bed for sleep and sexual relations only, not for reading, watching television, or working. Excessive time in bed disrupts sleep.
- Avoid naps, especially in the evening.
- Exercise before dinner. A low point in energy occurs a few hours after exercise; sleep will then come more easily. Exercising close to bedtime, however, may increase alertness.
- Take a hot bath about 1.5 - 2 hours before bedtime. This alters the body's core temperature rhythm and helps people fall asleep more easily and more continuously. (Taking a bath shortly before bed increases alertness.)
- Do something relaxing in the 30 minutes before bedtime. Reading, meditation, and a leisurely walk are all appropriate activities.
- Keep the bedroom relatively cool and well ventilated.
- Do not look at the clock. Obsessing over time will just make it more difficult to sleep.
- Eat light meals, and schedule dinner 4 - 5 hours before bedtime. A light snack before bedtime can help sleep, but a large meal may have the opposite effect.
- Spend at least a half hour in daylight every day. The best time is early in the day.
- Avoid fluids just before bedtime so that sleep is not disturbed by the need to urinate.
- Avoid caffeine in the hours before sleep.
- If still awake after 15 - 20 minutes, go into another room, read or do a quiet activity using dim lighting until feeling very sleepy. (Don't watch television or use bright lights.)
- If distracted by a sleeping bed partner, moving to the couch or a spare bed for a couple of nights might be helpful.
- If a specific worry is keeping one awake, thinking of the problem in terms of images rather than in words may allow a person to fall asleep more quickly and to wake up with less anxiety.
Prevention of sleeplessness depends upon the patient's ability to learn how to relax and sleep well. A number of behavioral methods can help achieve these goals. Behavioral techniques can actually cure chronic insomnia in many cases, and studies report that they help nearly all patients with primary chronic insomnia. The benefits of psychological and behavioral therapy in managing insomnia are long lasting.
Although medications can help people with insomnia to sleep, they cannot cure the condition. In addition, behavioral methods act faster. Behavioral methods work for all age groups, including children and elderly patients.
Behavioral methods include:
- Stimulus control
- Cognitive behavioral therapy
- Relaxation training and biofeedback
- Sleep restriction
All behavioral approaches have the same basic goals:
- To reduce the time it takes to go to sleep to below 30 minutes
- To reduce wake-up periods during the night
Studies report that 70 - 80% of patients who are treated with non-drug methods experience improved sleep. Furthermore, 75% of those who have been taking drugs are able to stop or reduce their use.
Stimulus Control. Stimulus control is considered the standard treatment for primary chronic insomnia and may be helpful for some patients with secondary insomnia as well. The primary goal of stimulus control is to regain the idea that the bed is for sleeping. It involves the following:
- Go to bed only when ready to sleep or for sex.
- If unable to sleep within 15 - 20 minutes, get up and go into another room. (People who find it physically difficult to get out of bed should sit up and do something relatively arousing, like reading a book.)
- Maintain a regular wake-up time no matter how few hours you actually sleep.
- Avoid naps.
Cognitive-Behavioral Therapy. Cognitive behavioral therapy (CBT) is a form of therapy that emphasizes observing and changing negative thoughts about sleep such as, "I'll never fall asleep." It uses actions intended to change behavior. The goal is to change or correct misconceptions about the ability to fall and stay asleep. Emphasis is on reinforcing the need for 7 - 8 hours of sleep each night and addressing the anxiety that patients with insomnia often develop around sleep. Several studies have shown it to work as well or better than drugs. According to several studies, adding medication to CBT does not provide additional benefit.
Relaxation Training and Biofeedback. Relaxation training includes breathing and guided imagery techniques. Progressive muscle relaxation is another technique for inducing sleep that works well for many people. It takes about 10 minutes to perform:
- Focus on one specific muscle group at a time. Most people start with the muscles in one foot. Inhale and tense the foot muscles for about 8 seconds. (Do this gently. It is not intended to cause severe pain or muscle contractions.)
- Relax the foot, and let it become loose and limp. Stay relaxed for 15 seconds, then repeat with the other foot.
- Move up to the next muscle group and repeat the sequence, doing one side of the body at a time. Move progressively from each foot and leg up through the abdomen and chest, to each hand and arm, then to the neck, shoulders, and face.
Biofeedback may be combined with relaxation techniques. Biofeedback involves being monitored with an electroencephalogram (EEG), a device that measures brain waves. Patients are given feedback to recognize certain states of tension or sleep stages so that they can either avoid or repeat them voluntarily.
Paradoxical Intention and Sleep Restriction Therapies. Paradoxical intention is a type of cognitive technique that aims to conquer anxiety about insomnia by forcing the patient to stay awake. Not trying to fall asleep may help relieve performance anxiety associated with sleep.
Sleep restriction therapy is similar to paradoxical intention. It involves limiting the time spent in bed to the number of hours that are typically actually spent asleep. Eventually the sleep loss helps some people fall asleep faster and spend more time asleep. As sleep improves, the hours spent in bed are increased.
In general, the following considerations are important regarding the use of medications for the treatment of insomnia:
- Underlying mental health problems, such as anxiety or depression, should be addressed first.
- Behavioral or psychologic techniques can actually correct insomnia, while prolonged use of sleeping pills can only produce temporary improvement.
- Non-benzodiazepine sedative hypnotics may be better tolerated than benzodiazepines and have less risk of dependency. These medicines, however, may be associated with potentially severe allergic reactions, such as anaphylaxis and facial swelling (angioedema). These drugs may also cause hazardous or strange behaviors, such as driving, making phone calls, or eating while asleep. If you need to take one of these prescription drugs, start with as low a dose as possible.
- For adults over age 60 years, studies suggest that the risks of sedative hypnotics may far outweigh their benefits. Sleep medications increase the risks for falls, depression, and memory loss in older patients. Elderly patients should generally start sleep medications at lower doses than younger patients.
- As a general rule, do not take either prescription nor non-prescription sleeping pills on consecutive days or for more than 2 - 4 days a week.
- If insomnia is still a problem after stopping the drug and continuing with good sleep hygiene, this pattern can be repeated again, but for only up to 4 weeks.
- Medication should be withdrawn gradually, and the patient should be aware of the possibility of rebound insomnia after stopping medication.
- Alcohol intensifies the side effects of all sleeping medication and should be avoided.
- If chronic insomnia is a companion to depression or anxiety, treating these problems first may be the best approach.