December 13, 2016
A recent research letter, published by JAMA, reported that one out of six American adults take at least one psychiatric medication. As a clinical psychologist I understand the benefits of non-medical treatments for psychiatric illness, but that doesn’t mean I don’t appreciate appropriate use of psychiatric meds. In fact, I refer a significant number of my patients to their primary care providers or to psychiatrists for medications, and I often make suggestions to the prescribing professionals about which medication I believe would work best for the referred patient. Nearly every time I do this, however, I have a long discussion with my patient about what it means to be on a psychiatric medication, and what it doesn’t mean. I almost always say something like, “several of your friends and several of your coworkers are on [psychiatric] meds… but they just haven’t told you,” in an effort to communicate how prevalent they are. This letter drives that point home really nicely.
But what I really like about the letter is that it also talks about how some medications are not be prescribed appropriately. Two classes of drugs that are most frequently mis-prescribed are benzodiazapines (e.g., Ativan, Xanax) and sedative/hypnotics (e.g., Ambien), which are supposed to be used short-term, not for months or years at a time.
March 17, 2016
There are several topics that seem to come up with patient after patient and I find myself making the same suggestions over and over again. One of these topics is sleep hygiene.
Simply stated, sleep hygiene is a way to describe your behaviors and habits related to sleep. There are several types of insomnia including delayed sleep onset, middle insomnia or frequent awakenings, and early morning awakenings. Though improving sleep hygiene can help with all three of these subtypes, change will be most dramatic with delayed onset or trouble falling asleep when you want to.
Sleep hygiene is all about rules, behavior change and “stimulus control.” Though I am rarely directive with my patients, when it comes to sleep hygiene I explain a set of rules they should follow if they want to be able to fall asleep quicker. Here they are:
- Use your bed for sleep and sex only. Don’t read, do work , play on your phone or watch TV in bed. This is all about stimulus control: you want your body to react to the stimulus of being in bed by getting tired and falling asleep. If you like to read before bedtime, sit in a chair next to your bed or, even better, do so in another room.
- Set rigid bedtimes and wake-times. Be reasonable and calculate out the number of hours of sleep you do best with. Note: more is not always better; most people tend to function best with approximately 7-8 hours of good quality sleep per night. Set these times and stick with them, even on weekends, at least in the beginning of your sleep hygiene training.
- Set a rigid pre-bedtime routine. For example, before you fall asleep you probably want to wash your face and brush your teeth. Some people like to take out the next day’s outfit the night before. Make time to include saying your goodnights to your loved ones, engaging in prayer, doing your evening reading or whatever. After you’ve listed all your pre-bedtime activities, write them out in the order you want to do them each night, estimate the start time prior to when you want to fall asleep and then stick with this rigid schedule. Again, this is all about stimulus control.
- This one is tough: If you’re not asleep within about 20 minutes or so, get out of bed and do something boring. Don’t read a good novel, watch an engaging movie or pay your bills. Instead do something mundane and boring like reading the user manual for your refrigerator. When you’re eyes get tired, get back in bed and start over. Once again, we’re focused on stimulus control: you are trying to get your body used to only sleeping (or having sex) when in bed.
- If you have tons of thoughts that run through your head as you’re trying to get to sleep, have a notepad and pen (and maybe a small flashlight) next to your bed. Roll over, write down those important thoughts and then let them go; you no longer have to try to remember them because they’re written down.
- Some people find that over-the-counter Melatonin is helpful if they take it about 30 minutes or so before bedtime. Unlike some other medications, Melatonin is not habit-forming.
- Taking a very hot soaking bath immediately before getting into bed (i.e., the last pre-bedtime activity) can help “jumpstart” the process of falling asleep. The theory behind this is that a very hot bath will raise your core body temperature a bit. Then, when you get out of the bath and into bed, your core temperature will drop, and this is the jumpstart because when you fall asleep your core body temperature automatically drops a little.
- No screens before bedtime. Recent research has demonstrated that the frequency of light emitted from televisions, laptops and handheld devices are neurologically stimulating and can make it much harder to relax and fall asleep.
- Start exercising on a regular basis, but try to do so earlier in the day. Don’t do any strenuous activity within a couple hours of bedtime.
- Eliminate caffeine from your diet. If you can’t do that, start to cut back by drinking half caffeinated and half decaffeinated drinks. No caffeine at all after lunch time.
- Don’t have a big dinner and don’t snack after dinner. Eat your bigger meals earlier in the day.
- Learn to do relaxation training. Now, the point of relaxation training is not generally to get you to sleep, but it surely doesn’t hurt. Most people find that progressive muscle relaxation and guided imagery are the best when they’re trying to fall asleep.
- Instead of having the television or music on when you’re trying to get to sleep, turn off those stimulating sounds and muffle out distracting sounds with a white noise machine or a regular fan. The “wooshing” sound of the fan masks other sounds and is not stimulating like music or the news.
- No naps. Though for some people naps can be quite rejuvenating, they alter your sleep-wake cycle and can delay sleep onset significantly. Cut naps out of your routine.
- Remember that your sleeping difficulties didn’t just start over night; you’ve probably been dealing with them for quite some time. Even if you follow every tip on this list it’ll still probably take a little while before you’re able to get to sleep quickly. With consistent efforts however, you should be able to improve your sleep within a few weeks or sooner.
- Speak with a psychologist, physician or other healthcare professional if you have questions or additional concerns.
August 20, 2013
I just read a brief little piece at CBSNews about a study that demonstrated the benefits of camping as an intervention to improve sleep. The article offers several possible reasons why going camping may help insomniacs sleep better, but ultimately the main reason is what I and many other psychologists “prescribe” to their patients: improved sleep hygiene. In other words modifying the behaviors associated with your sleep habits to eliminate unhealthy behaviors and improve healthy sleep behaviors. The reason that camping helps is that if you go camping for real (i.e., no electronics), then you naturally go to sleep shortly after it gets dark and you wake when the sun rises. (Campers also tend to get more exercise during the day than couch potatoes, and that surely is a good way to combat insomnia too.)
When I discuss sleep disturbance and improving sleep hygiene with my patients, I focus on a few key issues:
- Set a reasonable bedtime and waketime… and stick to it even on weekends.
- Space out your rigid bedtime and waketime so you have the opportunity to sleep about 7-9 hours.
- Set and maintain a pre-bedtime routine… and stick to it.
- As part of your pre-bedtime routine, you might want to include a very hot soaking bath to raise your core body temperature; this should be the last thing you do before hitting the sack.
- Use the bedroom or at least the bed itself only for sex and sleep. No reading, watching tv, etc.
- No napping during the day.
- No caffeinated beverages past lunch time. You might even consider eliminating all caffeinated beverages.
- Exercise early in the day, but not right before bedtime.
- If you tend to have “racing thoughts” when your head hits the pillow, have paper and pencil on your bedside table to jot down thoughts so you don’t have to actively keep them in your head to remember.
- If (and when) you have trouble falling asleep, give yourself about 15 minutes; if you’re not asleep, get out of bed and do something really boring (but not emotionally stressful like paying bills), like reading an old text book or something for 15 minutes or until your eyes get tired. Get back in bed and try for another 15 minutes. If you’re still not asleep after 15 minutes get out of bed and repeat the boring task, and repeat this cycle until you eventually fall asleep. You will eventually fall asleep, though for the first few nights it might take quite a while. You’ll be tire the next day, but that’s ok… remember, no napping as that will make things difficult the next night.
You see, your body wants to sleep, but your unhealthy sleep hygiene often gets in the way. If you improve your sleep related routines, you give your body the opportunity to reset its sleep-wake cycle.
November 19, 2012
When feeling tired a lot of folks reach for coffee, caffeinated soda or, increasingly these days, heavily-caffeinated energy drinks. There has been a slew of reports recently alleging significant health problems associated with energy drinks.
The New York Times , Bloomberg News , The Los Angeles Times , The Deseret (UT) News, MedPage Today , The Boston Globe and WebMD have all run articles that warn of the possible link between energy drinks and serious health issues including death. Of particular importance, the “manufacturers don’t properly disclose how much caffeine is actually contained in each product.” Some drinks that were tested “contained levels of caffeine at least 20 percent higher than what the label reports, 11 didn’t specify caffeine levels at all, and some even over-reported the amount of caffeine contained in the beverage.” This is significant because if someone consumes one of the over-reported beverages and think they can tolerate two or three drinks, then consumes beverages that had 1/5th more caffeine than listed (times two or three), it is easy to overdose.
If you’re feeling tired, get more sleep, don’t drink alcohol or caffeine before bed, exercise earlier in the day, improve your sleep hygiene, etc. If this doesn’t help consult with your psychologist and/or primary care physician.