What Are the Behavioral and Other Non-Drug Treatments    for Insomnia?  

Prevention of sleeplessness is very much dependent upon the patient's ability to relax and learn the art of sleeping well. It is best to try non-drug methods for insomnia first. 

Sleep Hygiene.  

The term sleep hygiene is used to describe a holistic approach to sleeping that encompasses many behaviors. Everyone should practice good sleep hygiene to prevent or relieve insomnia, or simply to safeguard sleep, making it more restful and pleasurable (see Table, Sleep Hygiene). 

1. Establish a regular time for going to bed and getting up in the morning and stick to it even on weekends and during vacations. 

2. Use the bed for sleep and sexual relations only, not for reading, watching television, or working; excessive time in bed seems to fragment sleep. 

3. Avoid naps, especially in the evening. 

4. 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. 

5. Take a hot bath about an hour and a half before bedtime. The body temperature then begins dropping rapidly, which may help sleep after that time. (Taking a bath shortly before bed increases alertness.) 

6. Do something relaxing in the half-hour before bedtime. Reading, meditation, and a leisurely walk are all appropriate activities. 

7. Keep the bedroom relatively cool and well ventilated.

8. Do not look at the clock. Obsessing over time will just make it more difficult to sleep. 

9. A light snack before bedtime can help sleep, but a large meal may have the opposite effect. 

10. Avoid fluids just before bedtime so that sleep is not disturbed by the need to urinate. 

11. Avoid caffeine in the hours before sleep. 

12. Quitting smoking not only brings many health benefits to any smoker, it eliminates the effects of nicotine that contribute to sleep loss. 

13. Patients who cannot sleep after 15 or 20 minutes should get up and go into another room, read or do a quiet activity using dim lighting until they are sleepy again. (Don't watch television, which emits too bright a light.) 

14. One study showed that sleeping alone is more restful than sleeping with another person. If a person with insomnia is distracted by a sleeping bed partner, moving to the couch for a couple of nights might be useful. 

Cognitive-Behavioral Techniques

Cognitive-behavioral techniques are helpful for retraining healthy sleep patterns. Such techniques combine sleep hygiene (see Table), relaxation techniques, and changing the habits and thought patterns that might cause wakefulness. Combinations may work best. A 1993 study reported that after only ten weeks, people with insomnia who used sleep restriction therapy, sleep hygiene, and relaxation techniques achieved a 75% reduction in the time taken to fall asleep (an average of 19 minutes). Such behavioral methods are also effective in elderly patients and, in fact, work better than drugs in this population as well as other age groups. If treating underlying problems and establishing proper sleep hygiene do not relieve sleeplessness, the patient may need to experiment with different behavioral approaches.

Sleep Restriction Therapy.

Sleep restriction therapy is one systematic behavioral method for achieving sleep. After keeping a sleep diary for two weeks, the patient calculates a sleep efficiency number by dividing actual average nightly sleep time by time in bed. (For example, if a patient sleeps five hours out of seven hours in bed, the sleep efficiency percentage is about 71%.) The patient's goal is to be sleeping 85% of the time in bed. To reach this, the patient begins by going to bed fifteen minutes later the first week; if 85% isn't reached by the end of the week, another fifteen minutes is cut from bedtime. The patient must limit time in bed even when tired. Once efficiency reaches 90% or more, the time allowed in bed is increased by 15 minutes per week. Other parts of the program include eating light meals and scheduling dinner four to five hours before bedtime, spending a half hour in the sun each day, and exercising. Sleeping pills should be stopped. People using this treatment have reported lasting improvements after just eight weeks. In one study comparing those who used sleep restriction therapy and those who used relaxation techniques, the improvement for sleep restriction subjects was approximately twice that of those who used relaxation methods alone. 

Relaxation Therapies and Methods. Relaxation may be beneficial for breaking the cycle of self-perpetuating insomnia occurring in some people; the less they sleep the more anxious they become about losing sleep, and the anxiety then keeps them awake. Sometimes a fear of sleeplessness dates back to childhood when parents used various threats to force their children into sleep for which they may not have been ready. Many methods are available, including muscle relaxation techniques, meditation, biofeedback, hypnosis, massage therapy, acupuncture, and guided imagery. No studies have proven one technique to be more effective than others. Infusing the air with the scent of lavender, which has been shown to have a sedative effect in animals, was, in one study, as effective as tranquilizers in helping elderly patients achieve a complete night's sleep. Self-help groups and relaxation practitioners are now found in many towns and cities. 

Exercise

Exercise may be one of the best ways to achieve healthy sleep. A recent study found that people with minor sleep disturbances improved after four months of brisk walking 30 minutes four times a week. Another recent study also reported that sleep improved in a group of elderly people who exercised regularly. 

Light Therapy

The circadian rhythm is greatly influenced by darkness and light rather than time of day. Bright light can discourage drowsiness, and darkness can cause sleepiness, day or night. Light therapy has proven effective for delayed sleep-phase syndrome and for sleep problems due to jet lag. Exposure to powerful artificial lamps (over 2000 lux) in the morning and avoidance of bright light in the evening usually results in earlier bedtimes. Studies have also shown that shift workers can adjust well by working in bright light at night and sleeping in a completely darkened room and wearing dark glasses during the day. (One study indicated that even moderate light was effective with this method.) People whose working conditions use ordinary light at night and who sleep in an insufficiently darkened bedroom during the day experience more fatigue.

Psychotherapy

Many people are reluctant to consult with a psychologist or psychiatrist, yet insomnia is commonly caused by emotional disorders that can be successfully treated. In a study of chronic insomniacs who were referred to therapists, only one-third followed through with appointments, but of those who did, about three-fourths benefited from psychotherapy.