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.
“Say Goodnight to Insomnia” by Gregg Jacobs, Publisher: Owl Books