The Sleep Whisperer is a new series of columns offering insights and advice about sleep health. It is not a substitute for seeking professional medical care.
A quick consult about sleep hygiene with “Dr. Google” yields an eclectic range of do’s and don’ts dictating how people should get their zzz’s. The advice ranges from drinking warm milk before bedtime to ensuring the bedroom temperature is 18.3°C. But can any of that really cure insomnia?
Sleep experts like myself are increasingly concerned. “Sleep hygiene has become a catch-all for everything, including advice for which there is no scientific evidence,” said Dr. Penny Corkum, a psychologist and professor at Dalhousie University.
The term sleep hygiene was popularized in the 1970s by psychologist Dr. Peter Hauri, who created a new sleep-disorders treatment that involved a set of rules such as eating a light snack before bedtime and keeping bedroom light levels low. Despite subsequent research, which showed such practices do not cure chronic insomnia, the concept of sleep hygiene stuck around in the popular consciousness.
Today, the consensus among sleep experts is that sleep hygiene on its own is insufficient to treat chronic insomnia in adults – defined as difficulty falling or staying asleep for at least three nights a week over a period of at least three months. Although education about healthy sleep practices can be effective for children and teens, its effects in adults are so minimal that most research on insomnia uses “sleep hygiene therapy” as a placebo comparator.
Nevertheless, many people with chronic insomnia get obsessed with sleep hygiene rules, clinging to them in an attempt to control their sleep. This often fuels the perception that slumber cannot happen unless all conditions are absolutely perfect (e.g. “I am running out of milk for my nightcap, for sure I won’t be able to sleep”). “The sleep-hygiene mindset can get people to develop all-or-nothing approaches to sleep,” said Dr. Elizabeth Keys, a registered nurse and professor at the University of British Columbia.
Put simply, breaching sleep-hygiene rules is rarely the root cause of sleep disorders. Chronic insomnia does not develop because one fails to eat a light snack before bedtime or forgets to adjust the thermostat. Rather, it typically stems from how we react to a bad night (which everyone faces from time to time). If sleep difficulties take the centre stage of our worries, we gradually start to believe that our sleep system is broken. Some people then put in place strategies aimed at getting more sleep, such as going to bed earlier, staying in bed later, and napping.
The problem is that these strategies can worsen sleep quality and expand the amount of time we spend frustrated and anxious about sleep while in bed. Our brain gradually associates the bedroom with these feelings and being awake; eventually, just entering the bedroom can trigger sleep anxiety, which makes it harder to doze off. Our fear of being unable to sleep becomes a self-fulfilling prophecy that perpetuates insomnia over time and pushes us to “try harder” to sleep. These changes in sleep-related thoughts and behaviours are what converts the occasional bad night, a perfectly normal phenomenon, into chronic insomnia disorder.
So what does work? Cognitive-behavioural therapy for insomnia (CBT-I) is recommended as the first-line treatment. It notably involves progressive personalized changes in sleep schedules to strengthen our sleep drive. This is combined with techniques to break down associations between the bedroom environment and the dread of a sleepless night it can provoke. Ultimately, CBT-I targets the specific factors leading to persisting sleep issues.
Although CBT-I has been shown to be effective in addressing the root causes of chronic insomnia, many people – including doctors – seem to focus on sleep hygiene instead.
“People can go for like 10 years without getting effective treatment for insomnia,” said Dr. Colleen Carney, a psychologist and professor at Toronto Metropolitan University. Rather than being offered CBT-I, Dr Carney said, people are often told to work on their sleep hygiene – such as avoiding sleeping in a noisy, brightly lit environment. “I do find it a little insulting. They’re not sleeping under those conditions – their sleep hygiene is typically pristine.”
A recent study in the Canadian Journal of Medicine indicates that 98% of primary care providers treating patients with insomnia review sleep hygiene with them first; only 58% discuss CBT-I with their patients. Initiatives like Health Quality Ontario’s new care standards for chronic insomnia, which stresses that CBT-I should come first, will hopefully better support health care practitioners and guide patients to seek appropriate care.
The bottom line: If you have been struggling to fall asleep or stay asleep for at least three nights per week over at least three months, you may have chronic insomnia – consider speaking to your health care provider and asking for a CBT-I referral. The Canadian Sleep Research Consortium has compiled a list of providers who offer this treatment.
If you do not have chronic insomnia and simply want to optimize your sleep, these healthy sleep practices (not to be confused with strict sleep hygiene rules) could help:
1. Avoid extreme sleep yo-yos
Keep a regular sleep schedule whenever possible. Regular bedtimes and wake-up times have been associated with better sleep, a stronger biological clock, and healthier mind and body.
2. Transition from active days to restful nights
Be active during the day to build a strong sleep drive and secure some time for winding down before bedtime. Doing pleasant calm activities will get you in a good headspace for sleep.
3. Don’t sleep-shame …
When you have a bad night, don’t dwell on it – let it go. People who move on after a poor night’s rest do better than those who focus on it and try to lock in rigid sleep hygiene rules.
Dr. Rébecca Robillard, PhD, is a clinical neuropsychologist and Associate Professor at the School of Psychology at the University of Ottawa. She also leads clinical sleep research at The Royal. Dr. Robillard’s main area of work focuses on interactions between mental health, the sleeping brain and the sleeping heart. She co-chairs the Canadian Sleep Research Consortium, a national hub of sleep scientists and clinicians.
