Chapter 3
Good Sleep Habits and Attitudes

The 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.[36]

First, remember that most people do not need 8 hours of sleep per night.  That old idea just is not so.  In our studies in San Diego, the average adult is actually asleep only between 6 and 6.5 hours a night.  National polls give similar results.  Moreover, in the recent Cancer Prevention Study II results, people who said they slept 6.5 to 7.5 hours lived a bit longer than people who slept 8 hours or more.  The shorter sleepers lived longer!  Even people who said that they slept as little as 3.5 hours lived longer than those who slept 8 hours or more!  In a group of women over age 65 who volunteered for the Women’s Health Initiative, wrist recording indicated that they actually slept about an hour less than they thought they slept. According to the recordings, those who slept 5.0-6.5 hours had the lowest mortality.[37] If you feel you sleep 5 to 7 hours a night and feel rested, there is no evidence that you have to sleep any more as far as life expectancy is concerned.  Incidentally, 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 about insomnia!

· People who said that they slept as little as 3.5 hours lived longer than those who slept 8 hours or more.

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

Short sleep is associated with good health as well as long life.  Studies show that in the range that most Americans sleep (which is 6, 7, or 8 hours or so), there are few discernable differences between people.  This may surprise you, but people who sleep 6 hours seem to be at least as happy as people who sleep 8 hours.  Moreover, people who sleep 6 hours get just as much work done and are just as rich as people who sleep 8 hours.  There may be some tendency for people with the shortest sleep times (5 or 6 hours) to be outgoing and energetic, whereas people with the longest sleep times (9 or 10 hours) seem to be more introverted, imaginative, or perhaps a bit depressed.  Notice the surprise!  People who sleep less are less depressed!

Indeed, hospital studies of depressed patients show something very surprising.  When depressed patients are kept awake all night (or at least for the second half of the night, e.g., after 2 AM), they actually feel less depressed the following day.  The sleep loss actually helps 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 at 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.  Evidently, although it is true that people who are getting depressed have poor sleep, 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 which restricts sleep improves the mood of patients with insomnia. Less time in bed can lessen depression.

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

People may actually 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 awaken while in bed.  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 develops in falling asleep and the more the person awakens 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.  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 sleepy you will be the next evening.  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 will restore the habit of falling asleep quickly after going to bed, and the more you improve the habit of sleeping soundly.  Some doctors would recommend that you should not spend more time in bed than you actually sleep.  If you think you only sleep 5 hours a night, spend only 5 hours in bed until you are sleeping all 5 hours.  Then you can try increasing time-in-bed about 15 min., e.g., to 5 hours and 15 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 only 85%, that is the longest bed time which you should allow yourself.

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 maintain 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.  Many of the patients I talk to 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, as 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 there is no reason 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 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 6 hours of bedtime.  Alcohol is sometimes a cause of sleep trouble, because although it relaxes 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 benefit is minimal.  Probably it is being outdoors in daylight, which is often where people exercise, which is helpful.  We have found that people who are outdoors more have fewer sleep problems.  For more information about this, see my online ebook, Brighten Your Life.

Controlled scientific studies show that adopting good sleep habits and attitudes is extremely effective in solving long-term sleep problems.  It is more effective than sleeping pills.[38]

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 treatment.  For a chronic problem, I do not advise that you ask a doctor for sleeping pills.  It is the wrong approach.

For help with insomnia by changing habits and attitudes, try Cognitive-Behavioral Therapy or CBT. If you can’t find a CBT therapist in your community, there are several helpful commercial web sites which cost less than a single therapist visit, e.g., CBTforInsomnia.com.[39] Two other CBT web sites are B-Med Interactive[40] and the University of Virginia’s Sleep Healthy Using the Internet (SHUTi) program[41], but I have no experience with either of them.
 
CBT is better than sleeping pills and safer.

Endnotes for Chapter 3

36. 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. [return]

37. 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]

38. Morin, CM et al.  Behavioral and pharmacological therapies for late-life insomnia. A randomized controlled trial.  JAMA. 1999;281:991-999). [return]

39. A description of the CBTforInsomnia.com 5-week “Conquering Insomnia” program can be found at www.cbtforinsomnia.com/About/treatment.htmlLink to a website outside this eBook. [return]

40. A description of the B-Med “Sleep Elementals” program (described as the company’s “initial program offering”) can be found at www.bmedi.comLink to a website outside this eBook. [return]

41. SHUTi (Sleep Healthy Using The Internet) is described at its University of Virginia website as “an interactive, web-based training program designed to help people who have problems with sleep.” shuti.bht.virginia.eduLink to a website outside this eBook [return]