Pitched at London GPs, Dr Hugh Selsick from the Insomnia Clinic at the Royal London Hospital for Integrated Medicine/UCLH gives top tips for doctors on how to assess an insomniac patient in a 10-minute consultation.
2. How We Treat Insomnia
30
minute assessment.
Possibly blood tests and overnight sleep
studies.
Five 60 – 90 minute group sessions of
Cognitive Behaviour Therapy for Insomnia.
One or two 30 minute follow up sessions.
If on medication will then have ongoing
monitoring sessions.
3. Don’t:
Waste
time on sleep hygiene. Sleep
hygiene has been shown not to work and
is often used as the control when testing
insomnia treatments.
Assume that the insomnia is simply a sign
of depression. Insomnia frequently causes
depression, is a common residual
symptom when depression lift and
predisposes the patient to relapse.
4. Minute 1
Take
their insomnia seriously.
Insomnia has a similar impact on quality of
life to depression and congestive heart
failure (Katz, 2002).
Insomnia leads to increased health
resource utilization (Hatoum, 1998).
5. Minute 2
Reassure them that,
despite being a serious
illness, insomnia will not kill
them.
People with insomnia don’t
die any younger that
people without insomnia.
Remind them that the
scare stories they read in
the papers are often overextrapolations from limited
data and even then they
are almost always talking
about sleep deprivation.
6. Minute 3
Discard the myth of the 8 hour sleep.
The average sleep time in adults in the
Western world is about 7.5 hours.
But there is variation either side of that mean.
Naturally short sleepers are at risk of
developing insomnia when they try to strive
for the 8 hour ideal and fail.
Explain that the right amount of sleep for
them at the moment is the amount that
makes them feel alert most of the day most
days.
7. Minute 4
Don’t tell them to go to bed at the same time
every night. This often makes insomnia worse.
Tell them to get up at the same time every
morning, seven days a week, whether they
have slept well or slept badly, whatever time
they went to bed.
This way they start accumulating tiredness at
the same time each day and will gradually
come to feel sleepy around the same time
each day.
8. Minute 5
Discourage
napping.
If fatigue is the fuel that drives sleep, then
every nap is like stealing some of that
sleep fuel from the night.
It is better to push through the sleepy
periods during the day and save that
fatigue for the night.
Once their sleep improves it will be easier
to avoid napping.
9. Minute 6
Tell
them never to go to bed until they are
sleepy.
If they go to bed when they are not
sleepy they will just lie in bed waiting to
get sleepy. This will reinforce their belief
that their sleep is “broken”.
If they go to bed when sleepy they have
a better chance of falling asleep quickly
and staying asleep.
10. Minute 7
Tell them to spend less time in bed, not more.
They should set an earliest bedtime and
should not go to bed until they have reached
that bedtime and they are sleepy.
Each week the earliest bedtime is moved 20
minutes later.
When they are falling asleep within 20 minutes
and sleeping fairly solidly through the night
they can reverse the process and start
moving their earliest bedtime 20 minutes
earlier each week.
11. Minute 8
Things Allowed in the
Bedroom
Sleep
Sex
Getting dressed and
undressed.
Things Not Allowed in the Bedroom
TV/Radio
Computer
Talking on phone
Texting
Exercise
Ironing
Studying
Paying bills
Reading!!
Meditating
Arguing
Etc, etc, etc
12. Minute 9
If they go to bed, or wake up in the middle of
the night, and they are not asleep within
about 20 minutes, they should get up, get out
of the bedroom, and do something relaxing
and enjoyable e.g. watch TV, read, listen to a
podcast.
When they are sleepy they can go back to
bed.
If they aren’t asleep within another 20
minutes, repeat above.
13. Minute 10
Explain that these techniques work, but they
work slowly.
They will not sleep better straight away and,
in fact, may sleep worse initially.
But the payoff for the reduced sleep in the
short term is better sleep in the long term.
Teach them the mantra: I am not doing this
tonight to sleep better tonight. I may actually
sleep worse tonight. I am doing this to sleep
better in a month.
14. A Final Word
Do
not dismiss the possibility of using
medication out of hand.
Hypnotics carry certain risks.
So does insomnia.
Therefore, the risks and benefits of
medication should be weighed up in
each individual case, with the patient’s
input, before deciding whether to
prescribe or not prescribe hypnotics.
