Chapter 3
Good Sleep Habits and Attitudes: Cognitive-Behavioral Therapy of Insomnia (CBT-I)

The better alternative to sleeping pills is to develop good sleep habits and good sleep attitudes. Good sleep habits and attitude are the best approach for a long-term sleep problem, and they produce surprising improvement.[40] In this chapter, we start with presenting the thinking (cognitive reasoning) behind good attitudes and then the cognitive-behavioral therapy of insomnia.

First, remember that most people do not need eight hours of sleep per night. That old idea just is not so. People with financial connections to sleeping pill manufacturers are trying to preserve the eight hours belief that never had much evidence behind it. In our studies in San Diego, the average adult was recorded asleep only between 6.0 to 6.5 hours a night. National polls give similar results. Moreover, in the Cancer Prevention Study II study of over a million Americans, people who said they slept 6.5 to 7.5 hours lived a bit longer than people who slept eight hours or more. The shorter sleepers lived longer! Even some groups who said that they slept as little as 3.5 hours lived longer than similar groups who slept eight hours or more! In a group of women over age 65 who volunteered for the Women’s Health Initiative, wrist recording indicated that they slept about an hour less than they thought they had slept. According to those recordings, volunteers who slept 5.0 to 6.5 hours had the lowest mortality.[41] If you feel you sleep five to seven hours a night and feel rested, there is no evidence that you should try to sleep any more as far as life expectancy is concerned, and that is largely true of other health measures. For example, there is more heart disease among those who sleep more than eight hours. Incidentally, in some studies controlling for other illnesses, age, and so forth, people who said that they had insomnia lived a little longer than those who did not have insomnia!  Therefore, do not worry too much about insomnia!

· Some groups who said that they slept as little as 3.5 hours lived longer than groups who slept eight hours or more.

 · People who said that they had insomnia lived a little longer than those who did not have insomnia.

 · There were MORE DEATHS related to sleeping eight hours or more than there were related to sleeping less than 6.5 hours.

Short sleep is associated with good health as well as long life. Studies show that in the range that most Americans sleep (which is six to eight hours or so), there are few discernable differences between people. This may surprise you, but people who sleep six hours seem to be at least as happy as people who sleep eight hours. Moreover, people who sleep six hours get just as much work done and are just as rich as people who sleep eight hours. There may be some tendency for people with the shortest sleep times (five or six hours) to be outgoing and energetic, whereas people with the longest sleep times (nine or 10 hours) seem to be more introverted, imaginative, or perhaps a bit depressed, and they are more likely to be unemployed. Notice the surprise!  People who sleep less are often less depressed!

Indeed, hospital studies of depressed patients show something very remarkable. When depressed patients are kept awake all night (or at least for the second half of the night, e.g., after 2 a.m.), they describe feeling less depressed the following day. Being awake at night lifts a depressed mood. Moreover, after the wake therapy, taking a nap makes depressive symptoms recur. Wake therapy would be a very popular treatment for depression except for one problem:  people with depression who stay up all night do get sleepy, and after they sleep soundly the next night, the low mood relapses. In my ebook Brighten Your Life, I explain how this relapse can be avoided with bright light. It is true that people who are getting depressed may have poor sleep, but it is not proven that getting more sleep helps depression. It may be quite the opposite. In fact, it has now been proven that cognitive-behavioral therapy that restricts time in bed improves the mood of patients with insomnia. Less time in bed can sometimes lessen depression.

For these reasons, depressed people usually should not struggle to get more sleep, and should certainly avoid sleeping pills, which tend to cause depression.

Many people may improve their moods by getting up a bit earlier.

There is another factor. Spending too long in bed – as you might expect – causes people trouble with falling asleep and makes them more likely to wake up in the middle of the night. Sometimes, the frustration of lying in bed awake adds to the problem, and it builds on itself, getting worse and worse. The more time the person spends in bed trying to get more sleep, the more trouble can develop in falling asleep and the more the person may awaken in the night. Surprisingly, it seems that spending too long in bed might be a major cause of sleep trouble among both elderly and depressed people. One expert remarked that the false belief that people should sleep eight hours is one of the major causes of insomnia. Fortunately, there is an easy solution.

People who are spending a lot of time in bed lying awake should spend less time in bed. This means either going to bed later or getting up earlier. Getting up by a regular time seems to be important, so trouble falling asleep should not persuade you to sleep late. The less time you spend in bed, the more you will feel sleepy the next evening and the more easily you will fall asleep. Think about it. If you spend less time in bed, you will surely tend to fall asleep more easily and sleep more soundly in the future. Moreover, the less time you spend in bed, the more you are likely to restore the habit of falling asleep quickly after going to bed, and the more you improve the habit of sleeping soundly. Some doctors recommend that at the beginning of cognitive-behavioral therapy, you should avoid spending more time in bed than you currently think you sleep. For example, if you think you only sleep 5½ hours a night, spend only 5½ hours in bed until you are sleeping all 5½ hours. Then you can try increasing time-in-bed about 15 min., e.g., to 5 hours and 45 minutes. You can gradually increase your time in bed on a weekly basis until you are no longer sleepy enough to sleep at least 85% of your time in bed. Once you are sleeping no more than 85%, that is the longest bed time that you should allow yourself.

One warning: when you have first reduced your time in bed, you will feel more sleepy. Be cautious because that new sleepiness could cause problems with driving and other tasks. The sleepiness helps you sleep more soundly, but in the day, restriction of time in bed causes discomfort and minor risk before you learn to sleep more efficiently while in bed.

Most sleep experts also recommend that whatever bedtime you allow yourself, you should not go to bed if you do not feel sleepy. Moreover, if you awaken at night and no longer feel sleepy, get out of bed, and do not go back until you are sleepy again and expect to fall asleep. Even after being up during the night, you should get out of bed by your regular awakening time, because sleeping late tends to make the problem worse. Getting out of bed when you are not sleepy makes you sleepier the next night and helps retrain good sleep habits.

Almost all of us have stayed up entirely for a night or two, so we know that nothing terrible happens to us. I have talked to many patients who say that they have slept only a few hours a night for years, and yet they are somehow afraid that losing sleep will hurt them. Probably not. Remember that if anything, people who sleep a bit less than average tend to live longer and be less depressed. If you are willing to stay out of bed and amuse yourself somewhere else when you are not sleepy, soon you will stop worrying about sleep. If you lose a whole night’s sleep or part of a night, so what? It will not be so bad, so long as you do not worry about it. When you do go to bed (because you are finally sleepy), you will have restored your confidence that you are likely to fall asleep, so the long-term problem resolves.

If you do begin to worry about how a bad night of sleep will affect you the next day, remember that it is a very poor idea to take a sleeping pill. The sleeping pill is likely to make your performance worse the next day, and very unlikely to help.

Experts also advise that you avoid worrying in bed, watching TV (especially those scary late-night movies), reading scary mysteries, and doing other upsetting things besides sleep and sex in bed. The idea is not to make a habit of being worried or alerted in bed. If you are a person who worries, select a place to worry (such as a chair in another room), and sit down to worry there. When you are tired of worrying, then go to bed.

Good sleep habits also require avoiding coffee or anything else with caffeine within six hours of bedtime. Alcohol is sometimes a cause of sleep trouble, because although alcohol may relax us at first, it leads to insomnia as soon as the blood alcohol level falls. Drinking early in the evening may cause trouble falling asleep. Drinking at bedtime may cause midsleep awakenings and early awakening.

People say that exercise helps sleep, but I think the real exercise benefit is minimal. Probably it is being outdoors in daylight (often where people exercise) which is most helpful. We have found that people who spend more time in daylight have fewer sleep problems. For more information about this, see my online ebook, Brighten Your Life.

Adopting good sleep habits and attitudes is extremely effective in solving long-term sleep problems. It is more effective than sleeping pills.[42]

If good sleep habits and good attitudes do not solve your problem, there is a good chance that you are suffering from depression. You should consult your doctor. You can read more about treatment of depression in my online ebook, Brighten Your Life. You might also consult a sleep specialist at a sleep clinic. You might have a problem with your body clock (which I describe in Brighten Your Life) or another sleep disorder which could benefit from specific specialist treatment or self-treatment. For a chronic problem, I advise against asking a doctor for sleeping pills. It is the wrong approach.

For help with insomnia by changing habits and attitudes, try a program of Cognitive-Behavioral Therapy for insomnia, abbreviated CBT-I. A good therapist might be most helpful, but if you can’t find a CBT therapist in your community, you can get much of the same benefit from pamphlets, books, or the internet. A Smart Phone App called “CBT-I Coach” has been available free from Android (Google Play) and iOS (Apple Store) download sites. It was developed by U.S. experts with support from the Veterans Administration. There are also growing number of developed commercial internet web sites which may cost less than a single therapist visit, e.g.,[43] and SHUTi[44], but I have no recent experience with either of them. There are other CBT-I programs in the U.S. that I know less about and also good CBT-I web sites from the United Kingdom (e.g., and other parts of Europe. The Veterans Administration is making available on-line an increasing number of informational materials to help people get away from sleeping pills, besides the CBT-I Coach cell-phone app.

CBT-I helps more than sleeping pills and CBT-I is much safer. An exhaustive literature study sponsored by the U.S. government Agency for Healthcare Research and Quality (AHRQ) concluded that CBT-I produced much more definite sleep improvements than sleeping pills, and the CBT-I produced far less evidence of serious bad effects.[45] The AHRQ analysis found CBT-I to be better, even though the AHRQ methods had been biased in favor of sleeping pills because: 1) AHRQ only considered subjective patient evaluations (ignoring objective sleep recordings that are known to find less drug benefit), 2) AHRQ considered only published articles (known to be biased because drug companies tend to avoid publishing poor trial outcomes), and 3) AHRQ gave much more attention to possible benefits than important risks. In reporting even “low-strength evidence” for weak sleep benefits from hypnotics, the AHRQ report failed to mention that they had not confirmed any benefit from the recently-reduced recommended-low doses of drugs such as zolpidem, eszopiclone, and suvorexant.

Interpreting the AHRQ evidence, an American College of Physicians Guideline concluded that treatment of insomnia should begin with CBT-I, not with any sleeping pill. Considering the risks, the American College of Physicians expressed doubt that sleeping pills should ever be used even for short-term treatment.[46]

There have now been dozens of randomized trial comparisons of CBT-I versus sleeping pills, showing that in the long run, CBT-I is more helpful and safer than sleeping pills.

Endnotes for Chapter 3

40. Morin, CM. Insomnia: Psychological Assessment and Management. New York, Guilford, 1993.; Morin, CM et al. Nonpharmacologic treatment of chronic insomnia. Sleep. 1999;22:1134-1156.; Edinger, JD et al. Cognitive behavioral therapy for treatment of chronic primary insomnia. JAMA. 2001;285:1856-1864.Link to a website outside this eBook. [return]

41. Kripke, D. F., Langer, R. D., Elliott, J. A., Klauber, M. R., and Rex, K. M., Mortality related to actigraphic long and short sleep, Sleep Med. 12(1)Link to a website outside this eBook, 28-33. 2011. [return]

42. Morin, CM et al. Behavioral and pharmacological therapies for late-life insomnia. A randomized controlled trial. JAMA. 1999;281:991-999.Link to a website outside this eBook. [return]

43. A description of the 5-week “Conquering Insomnia” program can be found at www.cbtforinsomnia.comLink to a website outside this eBook. [return]

44. According to its website, SHUTi (Sleep Healthy Using The Internet) “was created to help you overcome sleep problems and insomnia symptoms using techniques and strategies modeled after Cognitive Behavioral Therapy.” www.myshuti.comLink to a website outside this eBook [return]

45. Brasure M, MacDonald R, Fuchs E, et al. Management of Insomnia Disorder [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2015 Dec. (Comparative Effectiveness Reviews, No. 159.) to a website outside this eBook [return]

46. Wilt, T. J., MacDonald, R., Brasure, M. , Olson, C. M., Carlyle, M., Fuchs, E., Khawaja, I. S., Diem, S., Koffel, E., Ouellette, J., Butler, M., and Kane, R. L., Pharmacologic Treatment of Insomnia Disorder: An Evidence Report for a Clinical Practice Guideline by the American College of Physicians. Ann Intern.Med 165(2), 103-112. 5-3-2016.Link to a website outside this eBook [return]