Have you, like me, observed the following with regard to the psychological and behavioral treatment of insomnia?
1. Mental health clinicians do make sleep hygiene recommendations to their patients with insomnia but typically end up frustrated that patients are not strongly motivated to follow these recommendations.
2. Mental health clinicians know that cognitive behavioral therapy for insomnia (CBT-I) is a very effective and first-line treatment for chronic insomnia, or so they have heard. But many clinicians don’t clearly differentiate between sleep hygiene and CBT-I.
Sleep hygiene can be a minor part of CBT-I, but CBT-I involves much more. Did you know that authoritative clinical practice guidelines recommend that sleep hygiene as a stand-alone intervention should NOT be recommended to patients with insomnia (for example, Edinger et al., 2021)? We’ll discuss that separately on this website.
In this short article, I will make it clear:
1. What sleep hygiene and CBT-I consist of
2. Why they are very different interventions.
Let us not use the terms sleep hygiene and CBT-I interchangeably.
What is sleep hygiene?
Sleep hygiene is an intervention consisting of general education and recommendations about factors that tend to either promote or interfere with sleep, which can be divided into two broad categories, as described below (Edinger et al., 2021). The recommendations include the following (Robbins and Quan, 2024; Stepanski and Wyatt, 2003; Irish et al., 2015):
1. Environmental factors, for example,
- Light: Reduce evening light exposure; minimize evening exposure to bright screens of any kind; sleep in a dark room; maximize exposure to bright light in the morning
- Room temperature: Keep the room cool
- Noise: Use white noise or earplugs if needed
2. Lifestyle factors, for example,
- Schedule: Follow a regular sleep-wake schedule, including on weekends and during vacations
- Naps: Avoid naps or limit them to no more than 30 minutes
- Meals: Avoid heavy meals in the 3 hours before bedtime
- Exercise: Exercise regularly; moderate exercise in the evening is fine for most people, but most people should avoid vigorous exercise in the 1 to 2 hours before bedtime
- Caffeine: Avoid for a minimum of 6 hours (preferably more) before bedtime (Gardiner et al., 2023); ideally, avoid caffeine after lunchtime
- Alcohol: Avoid in the 3 hours before bedtime
- Nicotine: Avoid in the 3 hours before bedtime