Dr. Judith M. Allen (biography and disclosures)
What I did before
Prior to working at a Sleep Clinic, I regularly enquired about patients’ sleep in my psychiatric practice. I would ask how many hours they slept, and whether they had trouble falling asleep (initial insomnia), staying asleep (middle insomnia) or waking up too early and unable to return to sleep (terminal insomnia or early morning awakening). The timing in the night of the sleep difficulties can help in differentiating different psychiatric disorders from one another rand from primary insomnia. I also asked whether patients napped in the day. Then I would bombard them with a vast array of sedative hypnotics, sedating antidepressants, anticonulsants, or in a fit of desperation, antipsychotics. Alas, the sleep complaints, often perplexing, persisted. I had failed to ask the most important question when assessing insomnia concerns in patients with or without a primary psychiatric disorder: How long do you spend in bed?
What changed my practice
Asking that simple question revealed that many patients with insomnia complaints spend inordinate amounts of time in bed (TIB to us “sleep people”). Working at a sleep clinic, I also learned that generally we are all poor estimators of sleep, usually underestimating our total sleep time (TST). When patients develop insomnia, they commonly resort to increasing their TIB, which only increases sleep fragmentation. Then they lie down and nap in the day, also increasing sleep fragmentation at night. The treatment is not to add increasing dosages and combinations of sedating medications. Even patients with primary psychiatric disorders that have a biologic basis for secondary insomnia and adopt poor sleep habits can benefit from behavioural interventions for improving sleep.
What I do now
So now when I assess patients with insomnia complaints, both at the sleep clinic, and in my psychiatric practice, they complete a sleep diary documenting both TIB and estimated TST. TIB should approximate TST to produce good sleep efficiency (SE). Therefore if patients “guess” they sleep only 6 hours at night, but have taken to spending upwards of 9-12 hours in bed (often with napping!), they are instructed to decrease the TIB to match the estimated TST (ie 6 hours in bed) for 3 weeks (and no lying down or napping in the day!). This usually improves the SE, and they report sleeping most of their allotted TIB. Then they can gradually increase the TIB by 15 minutes a night per week as long as good SE is maintained. This way the patients discover what their individual optimal TIB will be that allows them to fall asleep and stay asleep throughout the night. If the SE does not improve after the 3 week intervention, especially in the absences of a primary psychiatric disorder, a referral to a Sleep Disorder Programme is in order.
So before resorting to sedative hypnotic, antidepressant and/or antipsychotic polypharmacy for complaints of insomnia, don’t forget to ask: How long do you spend in bed? You may be astounded by the answers and your ability to intervene, without the immediate use of medications.
Recommended reading:
“Say Goodnight to Insomnia” by Gregg Jacobs, Publisher: Owl Books
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useful and non medication and directs care back to patient; What they can do for themselves
Sounds like an excersize only highly motivated patients would pursue and ultimately do they feel any better i.e. less fatigued as a result ?
sounds like a grreat and simple question to help direct rational treatment.
I think its a great question to ask, though often forget to ask it. Sure it takes some patient motivation but by the time patients speak to us about this they may be fairly desperate as this has a huge impact on their life, and therefore motivated to try something. When we see the havoc that sedatives/hypnotics and other meds used for sleep wreak on people’s lives (though addiction or simple side effects), anything that decreases our use of such medications can only be welcomed.
What if a pt does not take naps during the day? Does it apply also to young working people? Would it be appropriate in this case to advice against going to bed at night if they do not feel sleepy?
Confirms practice
Good starting point. I was told also that the one important thing for insomniacs is to get them to wake up at exactly the same time every day!
Fascinating. Makes sense. I do not remember ever asking about TIB or estimating Sleep efficiency. Thank you.
On a related topic I have an increasing cohort of thankful people with improved cognitive function[STM] having persuaded them to discontinue using zopiclone on a regular basis.
This made me think about modifying my approach to insomnia but I do think patient acceptance and compliance of this strategy would be middling to poor. Patients are often quite desperate due to chronic poor sleep leading to impaired performance at work/ irritability affeting interpersonal relationships etc. Perhaps combining this approach with the short term use of a hypnotic would improve patient compliance and reassure them that you appreciate the impact of this problem in their life.
Helpful tip. I see so many people with iatrogenic insomnia due to chronic use of sedative/hypnotics such as benzodiazepines, ethanol and zopiclone it is refreshing to get useful non pharmacological techniques.
I think this one question is useful from a number of standpoints. Most importantly to me, it gives me an indication of how disrupted this person’s day to day life is; and as an ER doc, boiling it down to one question appeals immensely.
a helpful approach to fairly common problem
A good question to ask that I had forgotten about. I will add this approach to my first line of questioning — before starting to throw antipsychotics at them…
sleep efficiency sounds like a good approach to insomnia. I will use it instead of prescribing so quickly.
I’m not a doctor, but recently started using FitBit, which is one of several fairly inexpensive ($99) tools for tracking your activity during the day – and sleep. It measures your TIB and SE automatically, and i’m quite amazed at how much more sleep I’m getting than I had thought! If patients struggle to do this on their own and with guessing SE, a device like FitBit (and there are others, such as Jawbone’s Up and more) would probably help them – and provide the doctor with actual data, as well. And it would probably cost less than drugs, right?
I read a study by an anthropologist about sleep. He pointed out that before artificial light, people lay in “bed” for the dark hours. They didn’t have a lot of choice, as it was dark. So for an average of 12 hours (seasonally averaged) people long ago just lay around for a long time each night, dozing on & off throughout the long night. This was probably what we evolved to do and so our present sleep problems may have to do with the fact that we don’t spend enough time in bed.
I am not sure whether this question has been answered by sleep researchers, but if it has, I’ve been unable to find the answer:
Does an increase in sleep efficiency lead to a subsequent increase in total sleep time?
Unless the answer is a clear “Yes”, there is no point in attaching significance to sleep efficiency. Most of us would agree that an arm is a more useful limb than a leg, but it doesn’t follow that it is good idea to cut off a leg in order to increase the proportion of limbs that are arms.
I average 5 hours sleep, and am in bed for 8 hours, with a sleep efficiency of 62.5%. I recently took part in a CBT course, which restricted my hours in bed to 5, as advocated above. My sleep efficiency rapidly rose to 80%, but after 5 weeks rose no higher. My total sleep time was thus reduced to 4 hours per night. Not surprisingly, I felt terrible, until abandoning the course and getting back to 5 hours per night. A rise in sleep efficiency is a loss, not a gain, if it is associated with a fall in total sleep time.