Put your patients to sleep: Useful nondrug strategies for chronic insomnia
Sleep diaries and dispelling dysfunctional beliefs may be as effective as hypnotics.
Session 3 (Week 2). Review the sleep diary, and calculate the average time to sleep onset and sleep efficiency (divide total minutes of reported sleep by the total minutes spent in bed). Typical goals include an average onset of 10 to 20 minutes and an average efficiency of >90%.
Therapeutic intervention: If sleep efficiency falls below 80%, further restrict TIB by 15 minutes; if sleep efficiency is >90%, increase TIB by 15 minutes (no TIB change is needed with efficiencies between 80% and 90%). Identify dysfunctional beliefs about sleep, and provide strategies to interrupt cognitive overactivation—the pressured “talking to oneself” in hopes of falling asleep.
Session 4 (Week 3). Review the sleep diary, and calculate the average time to sleep onset and sleep efficiency. Increase or decrease TIB based on sleep efficiency as described above. Determine if the patient has dysfunctional beliefs regarding sleep.
Therapeutic intervention: Reframe the patient’s dysfunctional beliefs/concepts by comparing sleep diary entries with dysfunctional beliefs (Table 2). Remind patients about strategies to address cognitive overactivation, and have them practice daily to apply the appropriate reframe response from Table 2 that improves sleep. Review progressive muscular relaxation to address somatized tension and arousal, but instruct patients to practice relaxation only during the day at this point.
Table 2
Correcting patients’ dysfunctional sleep beliefs/concepts
| Belief/concept | Reframe responses |
|---|---|
| ‘I need 8 hours sleep per night’ | 1. Nightly sleep need varies among individuals from 5 to 9 hours, particularly with aging 2. Employed adults sleep 6.5 to 7 hours per workweek night 3. For the ‘average’ person, it takes <6 hours of sleep to reduce performance |
| ‘If I don’t sleep, I can’t _____ (work, socialize, take care of the kids, etc.) or ‘If I don’t sleep tonight, I won’t be able to ____’ | 1. Every day one-third of Americans sleep <6.5 hours and yet work, socialize, and live their lives 2. ‘You told me that on ____ you had a terrible night, yet you did ____ (that presentation, meeting, activity with family, etc.)’ |
| ‘If I don’t sleep, I feel _____’ | Explore situations where the person has felt tired, irritable, angry, anxious, etc. independent from lack of sleep |
| ‘If X happens, I won’t sleep’ | Explore situations where X or something like it happened, yet sleep occurred |
| ‘I don’t sleep at all’ | 1. Explore whether a bed partner reports the patient was sleeping or snoring when the person was convinced he or she was awake 2. Tell patients that if they remain in bed for >30 minutes, it is likely they slept, particularly if anxious or frustrated (older depressed patients may be an exception) 3. Teach patients that ‘don’t at all’ statements often represent an excessive focus on wakefulness, and that self-monitoring by sleep diary is helpful |
Session 5 (Week 4). Review the sleep diary. Adjust TIB as necessary. Emphasize the patient’s mastery of dysfunctional beliefs, and highlight progress on the sleep diary. Spend much of this session helping patients improve their relaxation practice and preparing them to bring it to bedtime.
Therapeutic intervention: Tell the patient to apply the relaxation training to bedtime and nocturnal awakenings.
Session 6 (Week 6). Review the sleep diary. Emphasize progress. Address any problem areas regarding dysfunctional beliefs, maladaptive behaviors, or relaxation methods.
Therapeutic intervention: Prepare patients to maintain sleep gains on their own.
Session 7 (Week 8). Review the sleep diary. Have patients identify areas of mastery. Discuss scenarios that might be expected to result in a temporary return of insomnia—such as difficulties with work or home life, stress of job change, or medical illness—and strategies they could apply to improve sleep. Such strategies might include a “safety net” of a sedative/hypnotic agent to use after ≥2 nights of poor sleep.
‘Booster’ session. Three months later, schedule a booster session to determine whether the patient has maintained mastery of improved sleep. Patients who are doing well often cancel this session because they are satisfied with their progress.
Related resource
- American Academy of Sleep Medicine. www.aasmnet.org.
Drug brand names
- Amitriptyline • Elavil, Endep
- Eszopiclone • Lunesta
- Mirtazapine • Remeron
- Quetiapine • Seroquel
- Sertraline • Zoloft
- Trazodone • Desyrel
- Zolpidem • Ambien
Disclosure
Dr. Becker receives research/grant support from sanofi-aventis and is a speaker for Sepracor Inc. and Takeda Pharmaceutical.
