Almost one-third of seniors in Canada take a sleeping pill. However, these aren’t always the best option (even in younger people). Sleeping pills can be problematic, and can sometimes even make the situation worse. As a general rule, people should usually try non-drug options first. These non-drug options are safer and often work much better than sleeping pills when looking at the treatment of chronic insomnia.
What is insomnia?
There are different diagnostic criteria for insomnia. In general, it’s usually diagnosed when all 4 of the following are present:
- Difficulty falling asleep; difficulty staying asleep; or waking up too early
- Occurring despite adequate time/opportunity to sleep
- Causing impairment in daily activities (e.g. excessive tiredness, memory problems, irritability, errors at work, car accidents, etc.)
- Not explained by another sleep disorder, medical condition, or medication (e.g. sleep apnea)
If these 4 have been present at least 3 days per week for at least 3 months, this would be considered chronic insomnia.
The problem with sleeping pills
Many won’t realize, but sleeping pills should generally only be used for a short time (a couple weeks). Non-drug measures are usually preferred over sleeping pills when it comes to the chronic management of insomnia.
A gradual tolerance can develop with many sleeping pills (prescription and over-the-counter) where they don’t work as well and you need to keep increasing the dose. On top of this, if you try to stop taking a sleeping pill it can often be very difficult. This is because of a dependence that can develop with chronic use.
When it comes to side effects, sleeping pills can make you drowsy when you wake up (i.e. a “hangover”), can negatively impact memory, and can increase the risk of things like car accidents or bone fractures from falls in the elderly. So, they are not without risks.
For those keeping score, this means sleeping pills are 1) unlikely to be good for long term use (due to gradual tolerance); 2) even when they don’t work, if you’ve been taking them for a while, you will have a hard time stopping them; and 3) are associated with many risks.
What is cognitive behavioural therapy for insomnia (CBT-I)?
The most highly recommended non-drug option is multicomponent cognitive behavioral therapy for insomnia (abbreviated CBT-I). As the name kind of gives away, CBT-I has many different aspects involved to tackle insomnia from different angles.
At a quick glance, the components of CBT-I include:
- Stimulus control: this is essentially trying to stop habits that will sabotage your chances of sleeping (e.g. don’t lay in bed frustrated all night; get out of bed if you can’t sleep. If you stay in bed frustrated, you are essentially conditioning yourself to be frustrated anytime you lay in bed).
- Sleep hygiene: these can include things that you can control a bit easier, such as: limiting caffeine later in the day, reducing screen time around bedtime, limiting naps, etc.. On its own, sleep hygiene is usually not enough; but when combined with other interventions it can be very helpful
- Relaxation: This can include things like meditation, yoga, breathing exercises, mindfulness, etc.
- Sleep restriction therapy: This is where things can sometimes be a bit challenging at first. You are trying to be as efficient as possible when laying in bed to sleep; so, if you only tend to fall asleep by 2am, you start going to bed at 2am. Then you will slowly increase by gradually going to bed 30 minutes earlier. At first you may actually end up sleeping less, but I see this almost like resetting your biological clock. *NOTE: sleep restriction therapy may not be for everyone*
- Cognitive Restructuring: An endless loop can start forming where you can’t sleep, so you get frustrated; but then you can’t sleep because you’re frustrated; and then you get more anxious and frustrated….and the cycle continues. This part is to try to break out of this endless loop. Methods can include mental distraction techniques, meditation/mindfulness exercises, playing white noise, etc.
- Education: another main goal is educating people on what to expect, along with the rationale for all of the aspects of CBT-I
How well does it work?
As I already stated, CBT-I is probably the best available option to treat insomnia. Many studies have shown that CBT-I can help improve: sleep efficiency, sleep quality, number of awakenings, and time to fall asleep. Since it’s a limited duration treatment, it has also been shown to be cost-effective.
How fast does it work?
CBT-I is usually a program of up to 6 sessions (sometimes a bit more). It’s important to note that the effects are usually not instantaneous.
However, one bonus is that studies suggest that the benefits of CBT-I can continue beyond the end of the program and are also sustainable long-term.
Useful resources
I’ll start off by saying that the best resource that I’ve found that clearly explains CBT-I is the free resource called MySleepwell.ca. This non-profit project was developed at Dalhousie University. I really like the way that they explain each aspect of CBT-I, and they also recommend helpful resources.
One thing to note is that CBT-I is likely to be more effective if it’s done under the guidance of a trained therapist. However, not all therapists are able to offer this service; so you may not have local options in your area.
We’ve learned a lot of things during the COVID-19 pandemic, and one of these is that we can do a lot more virtually than we once thought possible. Evidence suggests that there is no significant difference in outcomes of CBT-I given in-person or by telehealth/virtually. I am a big believer in the future of virtual care for things like mental health (that usually won’t require a physical exam).
Other resources
White Noise
White noise was mentioned earlier as a way to help with distraction.
– There are many free apps available for smartphones that will play white noise. I have the free White Noise Generator on my phone.
– If you are looking for an actual white noise machine, we have this one at home (we actually have 2 of them). It offers different types of sounds, has ability to be plugged in or run on batteries, and is reasonably priced:
Meditation/mindfulness
There are many apps that offer this; some paid and some free. I personally have used the Smiling Mind app. This free app is made in Australia; and I have so far been very impressed by it. I have not felt a need to use any paid app instead of this one.
Books
| Title and Author | Comments / Availability |
|---|---|
| Sink Into Sleep: A Step-by-Step Guide for Reversing Insomnia by Judith R. Davidson | This book is for patients It offers a step-by-step overview of CBT-I; which can be followed by the reader. Could be an option for those who don’t want to start with one-on-one therapy sessions. (Also recommended by MySleepwell) Get it on: Kobo | Kindle | Amazon (physical book) |
| Cognitive Behavioral Treatment of Insomnia: A Session-by-Session Guide by Michael L. Perlis, Carla Jungquist, Michael T. Smith, Donn Posner | This book is for providers For those who want to learn the process of offering CBT-I (warning, it’s not cheap; but comes very highly rated) Get it on: Kindle | Amazon (physical book) |
Conclusion
Non-drug (or “drug-free”) CBT-I is very likely to be more effective long term, works better than drugs in some people, is cost-effective, and also is associated with a long-term benefit. There are many options available, ranging from free information based resources to one-on-one therapy sessions with licensed professionals. Virtual options are now emerging that offer even more accessible therapy for those who suffer from insomnia.
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