Behavioural therapies

Sleep hygiene

Initially, review of sleep behaviours and sleep hygiene advice with recommendations to adhere strictly to the principles of sleep hygiene will provide the clinician with an indication of the patient’s motivation to change the behaviours that are perpetuating the insomnia1.

Whilst there may be insufficient evidence to assess the effectiveness of sleep hygiene as a single intervention61 its use is widely supported by expert opinion in current literature and guidelines1416235284. Sleep hygiene routines aim to make people more aware of behavioural, environmental and temporal factors that may be detrimental or beneficial to their sleep1 and includes:

  • Establish fixed times for going to bed and waking up (try to avoid sleeping in after a poor night’s sleep).
  • Try to relax before going to bed.
  • Maintain a comfortable sleeping environment (not too hot, cold, noisy or bright).
  • Avoid napping during the day.
  • Avoid caffeine after lunch and alcohol within 6 hours of bedtime.
  • Avoid nicotine close to bedtime or during the night.
  • Engage in moderate physical activity but avoid heavy exercise within 3 hours of bedtime.
  • Avoid consuming excessive liquids or a heavy evening meal before bedtime.
  • Avoid watching/checking the clock.

Sleep consolidation (sleep restriction therapy)

Some insomnia patients may spend excessive time in bed trying to attain more sleep. Sleep consolidation is accomplished by compressing the total time in bed to match the total sleep need of the patient179.

Establishing sleep consolidation:

  • Devise a ‘sleep prescription’ with the patient: a fixed bedtime and wake time.
  • Determine the average total sleep time.
  • Prescribe the time in bed to current total sleep time plus 30 minutes.
  • The minimum sleep time should be no less than 5 hours.
  • Set a consistent wake time (firmly fixed 7 days/week).
  • The bedtime is determined by counting backwards from the fixed wake time.
  • For the first 2–4 weeks these times should remain consistent. The clinician should monitor the patient’s adherence with sleep logs.
  • Advise the patient that napping will reduce the depth and restorative quality of sleep the following night.
  • Once the patient is sleeping for >85–90% of the time spent in bed for 2 consecutive weeks, the amount of time spent in bed is slowly increased by 15–30 minute every week1. If sleep efficiency of 90% is maintained, then therapy is successful.

The average total sleep time for most people is between 6 and 8 hours per night154.

  • Advise patients that the goal of treatment is to improve the continuity and restorative quality of sleep, not to make them ‘8-hour sleepers’. More often than not the total sleep time will be less than 8 hours per night.
  • Advise patients that they may suffer from daytime sleepiness in the initiation phase of compressing their sleep schedule1.

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