Helping Patients Sleep: Practical, Non-Pharmacologic Insomnia Strategies

Insomnia and I are very well acquainted with one another. Like 10% of the population, I experienced chronic insomnia for years. And like nearly one-third of adults, I still experience insomnia from time to time. Through my own history, as well as years of research into the literature and undergoing cognitive behavioral therapy for insomnia (CBT-I), the gold standard for treatment of chronic insomnia, I have developed a helpful, informal approach to helping my patients with this condition.

Why It Matters

Insomnia is absolutely miserable, as captured in this famous scene from the movie “Fight Club.” It has tremendous impacts on quality of life and ability to function. It is associated with adverse health outcomes like anxiety, depression, metabolic disorders, cardiovascular disease, and an increased risk of motor vehicle accidents.

There are times when a patient needs to see a sleep specialist, such as if they have a sleep disorder like obstructive sleep apnea or periodic limb movement disorder. And there are times when a person’s insomnia may be due to other factors, like a side effect of a new medication, or an underlying medical condition, all of which need to be addressed first. But when a person has primary insomnia that is not obviously due to an underlying sleep disorder, primary care is the ideal place to turn for help. There is so much primary care clinicians can do to help patients with insomnia long before they may need medications or be able to access CBT-I.

The Two-Process Model of Sleep

The two-process model of sleep is fundamental to understanding the management of insomnia. In school and training, many of us learn about the first of these two processes: the circadian rhythm. This is a master clock for complex sleep/wake rhythms over a 24-hour period, regulated by the hypothalamus and significantly influenced by light exposure. We support our circadian rhythm’s impact on healthy sleep by going to bed and waking up at consistent times, getting plenty of light exposure in the morning, and reducing light exposure before bedtime.

The second process, the homeostatic sleep drive, may be less familiar to some of us. This is a type of sleep pressure or hunger that builds up throughout the day as our brains use up ATP. Interestingly, states of arousal can override both processes, so managing stress and agitation is vital for promoting better sleep.

A Three-Pronged Approach

Step 1: Take Care of Low-Hanging Fruit

When I care for a patient with insomnia, the first thing I try to do is eliminate any easy obstacles. An excellent sleep history can unearth many different barriers to high-quality sleep, such as excessive caffeine consumption, especially later in the day; alcohol use; a bedroom that is too bright, noisy, or hot; or a mattress that is over 10 years old and may be contributing to aches, pains, and discomfort while sleeping. If a patient is able to adjust their sleep environment to create a quiet, cool, dark space with a comfortable and supportive mattress and pillow, this alone can do wonders for their sleep quality and quantity.

While blue light exposure from devices such as phones and tablets is often cited as a deterrent to good sleep, a more important follow-up question is: how is the device being used? Doomscrolling through stressful, rage-baiting posts about the state of the world is very different from unwinding with a favorite crossword puzzle. Rather than focusing too much on blue light exposure in absolute terms, it can be useful to assess whether the activity is helpful or harmful to the person’s ability to fall and stay asleep.

Step 2: Gather Data

Have your patient record detailed information about their daily and nightly sleep habits for 2 weeks using a sleep inventory, such as the Stanford Sleep Diary or Sleep Disorders Inventory. These (and others like them) are detailed logs capturing dozens of data points about the person’s activities, medications, diet, relaxation strategies, and sleep and wake times each day and night. Even two weeks’ worth of this data can yield surprising insights for the patient and clinician alike, and can help guide next steps in a tailored, targeted way. It is also important to calculate the average number of hours of sleep per night at this step, to be used in the next step.

Step 3: Management (in Three Parts) — Attitude, Attitude, Attitude

The rule of 3’s continues as we dig into the non-pharmacological management of insomnia.

Reframe Their Beliefs About Sleep

First, throughout the entire process of working with our patients, we must constantly help them reframe unhelpful beliefs about sleep. When a person struggles with insomnia, their anxiety and dread of bedtime can become all-consuming. In their exhaustion and desperation, they may believe that they will never sleep again. We need to help them identify and expose dysfunctional beliefs and attitudes about sleep.

When I went through CBT-I, my sleep psychologist told me something that rocked my world: “Good sleepers know that a bad night of sleep is just that: one bad night of sleep. It’s a blip. And they have confidence that the next night will be better.” I thought, “Who ARE these people?” This type of confidence felt utterly foreign to me. We can help instill this confidence in our patients. They will get the sleep they need. Their bodies and minds will help them get appropriate rest.

Sleep Compression

The second pillar of management is sleep compression. The idea here is to increase the homeostatic sleep drive by inducing temporary sleep debt and increasing sleep efficiency. Remember when we calculated our patient’s average number of hours of sleep per night? Here is where that information comes in handy. If we take that number and add 30 to 60 minutes, we arrive at the total number of hours they should stay in bed. So if they currently get 5 hours of sleep per night, we create a schedule in which they’re in bed for 6 hours. This can mean going to bed at 11 p.m. and waking up at 5 a.m. every day, including weekends.

As my sleep psychologist told me, “This is short-term pain for long-term gain.” This short-term schedule, as punishing as it may sound, increases that sleep hunger and creates opportunities for consolidated, concentrated sleep. Once this is working and the person is sleeping more effectively during this period, we can gradually liberalize their time in bed by 15-minute increments, encouraging our patient to reassess how they’re feeling until they reach a sleep-and-wake schedule that works for them long-term.

This strategy of sleep compression is so effective that it is supported as a standalone treatment for chronic insomnia by the American Academy of Sleep Medicine. However, it is not recommended for everyone. People who operate heavy machinery, are predisposed to hypomania or mania, or have suboptimally controlled seizure disorders, are not good candidates for this short-term sleep restriction strategy.

Stimulus Control

Since states of activation can override both the circadian rhythm and homeostatic sleep drive, it is important to create a zen-like atmosphere surrounding sleep. If a person has been trying to fall asleep for 15 to 20 minutes or more, rather than staying in bed feeling frustrated and anxious about not sleeping, they should get out of bed and do something relaxing and enjoyable.

Personally, I was TRYING… SO… HARD… to engage in relaxation techniques such as mindfulness, deep breathing, and body scans that I counterintuitively amped myself up, unknowingly suppressing my homeostatic sleep drive and making it harder to fall asleep. This was an enormous light bulb moment for me. As my sleep psychologist said, “Stop thinking about sleep. Instead, ask yourself, ‘how can I enjoy this moment?’”

Some people may choose to read, color, or watch a relaxing rerun of a TV show. Many of my patients tell me that watching old episodes of “Friends” does the trick for them. For me personally, it was “Schitt’s Creek.” After 20 minutes of turning my concentration away from sleep and towards the Rose family, I was relaxed enough to finally drift off.

Sleep Tight!

Chronic insomnia can impact every part of our patients’ lives. We know that CBT-I is the guideline-recommended, gold standard of treatment, with minimal harms or downsides (especially compared to medications). In the meantime, there is so much primary care clinicians can do to help our patients suffering from chronic insomnia, much of which is rooted in CBT-I principles. The approach may take some time, but the benefits are durable, and the process can be repeated any time a person struggles with insomnia in the future.

To hear more about this topic, check out the Primary Care Review and Perspectives podcast conversation on “Neda’s Non-Pharm Approach to Insomnia.”