Awake at 3 a.m.? Strategies to help you to get back to sleep

Sleep-maintenance insomnia is common in mid-life. Changing your thoughts and behaviors can help.

It's 3:00 in the morning—far too early to get up for the day. But you can't get back to sleep because your mind keeps rehashing past and future worries—and fretting that you're going to be exhausted all day long. Sound familiar? Known as sleep-maintenance insomnia, this common problem often crops up in mid-life.

In the wee hours of the morning, the last thing you want to do is take a sleeping pill, since you probably need to get up in a few hours. In fact, experts now recommend a special type of short-term therapy as the first-line treatment for insomnia instead of drugs. Called cognitive behavioral therapy for insomnia, or CBT-I, this therapy teaches people to change the unproductive thinking patterns and habits that get in the way of a good night's sleep. It's just as effective but safer than sleeping pills for both sleep-maintenance insomnia and trouble falling asleep at the start of the night (sleep-onset insomnia).

Rethinking your sleep habits

According to the Harvard Medical School Special Health Report Improving Sleep, edited by Dr. Lawrence Epstein, people with insomnia tend to become preoccupied with sleep and apprehensive about the consequences of poor sleep — a phenomenon dubbed "insomniaphobia" by Harvard sleep specialist Dr. John Winkelman. In CBT-I, a therapist helps you replace negative thoughts (such as "I'll be so tired, I'll have a terrible day at work tomorrow!") with more positive ones ("My job does not depend on how much sleep I get tonight"). Typically, you meet with the therapist once a week for an hour, for six to eight weeks. He or she also provides structure and support while you practice new thoughts and habits, and teaches you other successful sleep strategies. For example, you should:

• Make your bedroom a sleep sanctuary. Reserve it for sleep, intimacy, and restful activities such as meditation and reading for pleasure. Keep it cool, dark, and quiet. To block out noises, use a fan or other appliance that produces a steady "white noise." Make sure your mattress is comfortable.

• Set a regular sleep schedule. Try to go to bed and wake up at the same time every day, which helps synchronize your sleep-wake cycle.
• Limit awake-time in bed. If you don't get back to sleep within 20 minutes after waking up in the middle of the night, get out of bed and do something relaxing until you feel sleepy again.
• Stay away from stimulants. Avoid caffeinated beverages (coffee, many teas, chocolate, and some soft drinks) after 1 or 2 p.m.—or altogether, if you're especially caffeine-sensitive.
• Get regular exercise. Aerobic exercise such as walking, jogging, or swimming can help you fall asleep faster, get more deep sleep, and awaken less often during the night.

How to access CBT-I

Many health insurance plans cover CBT-I, which falls under mental health coverage. However, not many therapists are trained in this special type of talk therapy. Even in the medical mecca of Boston, only a handful of clinicians offer CBT-I. Also, some people fail to complete all the required sessions or to practice the techniques on their own.

Internet-based programs might help address both problems. Several small studies suggest that online CBT-I programs can help insomniacs sleep better. In one such program, called SHUTi (Sleep Healthy Using the Internet), participants were about half as likely to wake up after falling asleep compared with a control group.

Another study documented at least mild improvements in about 80% of people who completed weeks of online CBT-I, with 35% reporting that their sleep was "much improved" or "very much improved."

– By Julie Corliss
Executive Editor, Harvard Heart Letter