Insomnia: a promising cure

by Halstead16th Nov 201816 comments

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I once saw a talk by Anders Sandberg in which he said the best cognitive enhancers are caffeine, modafinil and sleep. The former two have diminishing returns, but the latter does not. It's pretty clear that sleep is a major determinant of productivity and mood. I have noticed that a number of EAs suffer from insomnia and are searching for a viable cure, so I thought I would outline one that has worked incredibly well for me, and is well-supported by evidence. This is in the hope of substantially improving the productivity and mood of EAs, which I think is a very high value thing. This is a post about the best nootropic going (for insomniacs): CBT for insomnia, including sleep restriction.

Personal experience

I suffered from moderate to severe insomnia throughout my twenties, and had particularly severe insomnia for a couple of years before I turned 30. I was prescribed sleeping pills which don't work or have bad side-effects. I have learned that this is pretty typical treatment in the UK. During the nadir, I would struggle to get to sleep for two hours, then sleep for four hours, then wake up at 5am and be unable to get back to sleep, lying in bed until 9am. I tried various sleeping pills for this, including melatonin (way too much, it turns out), which helped a bit.

I then tried CBT-insomnia including sleep restriction using an online course (called Shut-i which now appears not to be available for some reason) and was cured after about 2 months and have been ever since. I now sleep upwards of 8 hours every night. This approach has been similarly successful for a friend suffering severe insomnia who tried various prescribed sleeping pills with little success.

Evidence for CBT for insomnia

Anecdotes aside, CBT for insomnia is well-supported by evidence. For example, see these two systematic reviews and this review by the American Academy of Sleep Medicine. NICE, the respected utilitarianish body that determines healthcare prioritisation in the UK says that:

  • There is good evidence that stimulus control therapy, relaxation therapy, and cognitive behavioural therapy (CBT) are effective in the treatment of long-term insomnia [Morgenthaler et al, 2006; Wilson et al, 2010].
  • There is moderate evidence that sleep restriction, paradoxical intention, and biofeedback are effective in the treatment of long-term insomnia [Morgenthaler et al, 2006].

Update: Luke Muehlhauser has questioned the strength of the evidence on CBT-I in a comment below. Note that he does still recommend CBT-I to people suffering insomnia, given the limited costs associated with CBT-I. I disagree with Luke's reading of the evidence, as I discuss in the comment.

Prevailing treatment for insomnia

In spite of the evidence, insomnia is very poorly treated, in the UK at least, with doctors often recommending sleeping pills that don't work and have bad side-effects. I know people who have tried these without success and were told that they had run out of options. Given that CBT for insomnia is recommended by NICE, this is a pretty crazy situation. Moreover, the treatment is non-pharmacological and doesn't require a trained therapist.

What does CBT for insomnia involve?

I recommend Overcoming Insomnia by Colin Espie for a good and short outline.

  • Sleep restriction. Personally, I found this the most effective aspect. People with insomnia tend to spend way too long in bed in the belief that this will increase their chance of sleep. This is the opposite of what you should do.
    • Stay in bed for at most as long as the total amount of sleep you ideally need. If you need 8 hours of sleep, spend at most 8hrs 30mins in bed, and no more.
    • Don't read or watch TV in bed, just sleep/have sex.
    • Insomnia sufferers should aim to more strictly restrict their time in bed. If you are sleeping five hours a night, you should aim to gradually limit the time you spent in bed, down from 7 hours to 5 hours. This reduces the psychological association between bed and lack of sleep, and so reduces the stress response you experience when in bed. Once you have broken the association, you can scale your time in bed back up. A full plan is outlined in the Espie book.
  • Sleep hygiene: outlined at this NHS link, and this NSF link.
  • Noting down and rationally dealing with worries, a la CBT, also mentioned in the NHS link.
  • Dimming the lights: A form of sleep hygiene that deserves a special mention. Many EAs wander round in orange goggles after 9pm, uncowed by social mores. This is a good thing - I suggest dimming the lights throughout your house, including the bathroom, about 2 hours before you go to bed.

NB. I am eternally grateful to Daria Belostotskaya for suggesting this solution to me.

15 comments, sorted by Highlighting new comments since Today at 11:53 PM
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Strong upvote for including a lot of evidence, but also enough details of one person's implementation that the advice will be easier to follow. If even a few people add a few hours of sleep over this, it will be worth the time it took to write. (And of course, as the first post on the new Forum about this topic, it can be a place for others to record their advice.)

Adding to your point about "dimming the lights":

  • The Twilight app on Android lets you set a time to dim your phone's screen automatically (it will also use warmer colors/emit less blue light, which just adjusting brightness won't).
  • f.lux does the same for desktop computers.
  • I highly recommend both of the above apps. If you don't have light filtering on your computer and phone, and you use them after sundown, taking ten minutes to install these will probably repay you many times over.
  • I don't use an iPhone, but those who do have several options.

Some people in the comments were recommending Why We Sleep.  People may be interested in this update by Alexey Guzey:

Matthew Walker's "Why We Sleep" Is Riddled with Scientific and Factual Errors

Here's an excerpt:
 

Any book of Why We Sleep’s length is bound to contain some factual errors. Therefore, to avoid potential concerns about cherry-picking the few inaccuracies scattered throughout, in this essay, I’m going to highlight the five most egregious scientific and factual errors Walker makes in Chapter 1 of the book. This chapter contains 10 pages and constitutes less than 4% of the book by the total word count.

[...]


No, two-thirds of adults in developed nations do not fail to obtain the recommended amount of sleep

Suppose that you recommend that adults sleep 7-9 hours per night.

  1. then, someone learns (a) that roughly 40% of people sleep less than 7 hours, roughly 25% sleep 7 hours, and roughly 35% sleep 8 hours or more, meaning that a bit over one-third of people sleep less than you recommend Linked data is for the US but it appears (a) that other developed countries have very similar sleep habits.
  2. then they look at your recommendation and say that you recommended an average of 8 hours of sleep per night.
  3. then they say that you recommended 8 hours of sleep per night
  4. then they say that two-thirds of people sleep less than the 8 hours you recommended

Would this be a fair representation of your position and of the data or would this be misleading?

This is literally what Walker does in his book. On page 3, in the very first paragraph of Chapter 1, Walker writes:

Two-thirds of adults throughout all developed nations fail to obtain the recommended eight hours of nightly sleep.

In the footnote to this sentence he writes:

The World Health Organization and the National Sleep Foundation both stipulate an average of eight hours of sleep per night for adults.

Here are the National Sleep Foundation’s sleep recommendations (a) announced in 2015:

Adults (26-64): Sleep range did not change and remains 7-9 hours

Here are the World Health Organization’s sleep recommendations:

The quote is empty because the WHO does not stipulate how much an adult should sleep anywhere. I don’t know where Walker got this information.


The rest of the post is written in a similarly exasperated and exhaustive nature, patiently taking down Walker's unfounded claims page by page. (Again, all of this is just in Chapter 1).

While I have not individually vetted the claims in Guzey's blog post, on face value it seems reasonably well-researched and careful, certainly more so than the book it was critiquing. There are also followups on the StatModelling blog by Andrew Gelman, a famous Bayesian statistician and blogger.

Note that Guzey's critique and the followups on Gelman's blog came out after this forum post and most of the associated comments were published, and it will be somewhat unfair to blame commentators for not being aware of the scientific and factual errors of an acclaimed/professed "sleep scientist."

I am currently listening to an awesome popular science book on sleep called Why We Sleep by Matthew Walker

I highly recommend this book which summarizes the current state of sleep research and its practical implications to most people since most are spending about a third of their time sleeping. If you care about your learning ability, social skills, recovery, creativity or memory, I think it is likely you will find this book valuable.

Yes I've heard good things about this book.

I also think that whether you are a lark or a night owl will determine whether you can succeed in certain jobs. I naturally get out of bed after 9am - this is recalcitrant in the face of extensive efforts to get up earlier. The evidence suggests that lark/owl is ~20-50% heritable, and that people are fairly evenly distributed across the lark/owl range. In a large sample:

"Approximately, 27% identified as definite morning types, 35% as moderate morning types, 28% as moderate evening types and 9% as definite evening types."

I don't think I or other hard owls could hack it in a finance job where I had to be in the office at 8am, and so get out of bed at 630am. I think owls probably thrive best in jobs that have flexible hours. I think 80k should potentially take this into account when giving job advice. (I owe this observation to Bastian Stern). According to the above study, owls have a 10% higher mortality risk than larks, which is plausibly due to working hours that aren't in line with people's natural circadian rhythms.

Agreed. In Why We Sleep, there is also discussion about the lark-night owl -spectrum. The author even suggests that currently society is actively discriminating against night owls because office hours 8-16 are assumed almost everywhere, and thus the population of night owls have poorer health and productivity than other groups.

CBT-I is also recommended in Why We Sleep (see my summary of the book).

Nitpick: "The former two have diminishing returns, but the latter does not." It definitely does - I think getting 12 or 13 hours sleep is actively worse for you than getting 9 hours.

Hey, yep I think there's more nuance there then I suggested. Still, as a rough rule, I find it best to sleep for as long as possible over the course of a week. Sleeping as long as possible for a day may not be optimal because then you may sleep less on the following day. But getting maximal total sleep over a week-long timeframe proves best for my mood and concentration.

I'm aware that some evidence shows a correlation between sleeping more than 8 hours and health problems, even controlling for confounders. My guess is that this link isn't causal because it's not clear what the mechanism is, and I think undiagnosed depression/other illnesses could be driving a lot of the association

I disagree about the strength of evidence for CBT-I effectiveness.

Hi,

I'm not sure I agree with some parts of your argument in that write-up. My main points of contention are:

1. The accuracy of self-reports. You have given low/negligible weight to all studies relying on self-report, but I don't think that is warranted. Firstly, lots of widely cited research on sleep medicine uses sleep diaries only or sleep diaries + objective measures to measure sleep. This suggests that even though it is widely recognised that sleep diaries are less accurate than objective measures, they are nevertheless considered to be important evidence by experts in the field. Most of the statements you cite in support of your stance (except Bauer and Blunden which I can't access) just say that sleep diaries are less accurate than objective measures, they don't say that sleep diary measures should be nearly completely ignored. You cite two studies showing that sleep diary measures and objective measures come apart, but one of these uses parents' reporting the sleep of their autistic children, which seems so different to self-reported sleep as to be completely irrelevant to the accuracy of the latter.

Secondly, your proposed test outlined in footnote 51 suggests you think there is a fairly strong correlation between self-reported measures and objective measures. You think there is a 70% chance that at least 35% of studies will have the sign of the effect on objective and subjective measures coming apart. So, am I right to infer that you think that in expectation up to 75.5% of studies will have the same sign on both measures, in which case the measures are fairly strongly correlated?

Thirdly, my a priori intuition is that self-reported sleep measures will be pretty accurate in that they will note the direction in which your sleep is moving quite well. I can tell when I have slept badly (what feels like 6 hours) and slept well (what feels like 8 hours). The actual numbers might be wrong, but I think the direction of travel would almost always be correct.

2. Long-term effects. I have higher confidence that the effects of CBT-I will persist into the longer-term, so I think the endline studies are better evidence of long-term effect that you. Indeed, this seems to be a view shared in various papers - the effects are more likely to persist than drugs. E.g. the NIH says "Moreover, there are indications that the beneficial effects of CBT, in contrast to those produced by medications, may last well beyond the termination of active treatment’’. I've read similar claims in various other studies. This chimes with my personal experience and with my prior. I can see why we would build up a tolerance to sleeping pills, which would limit long-term efficacy. But on the posited mechanism of CBT-I, the mechanism is breaking the psychological association between bed and lack of sleep, and making permanent changes to your sleep routine and environment. I don't see why this kind of effect would decay.

3. Deference to experts/epistemic modesty. NICE and the NIH both say that CBT-I is effective and recommend it as the first line of defence against chronic insomnia. A pan-European body of sleep researchers at major European universities also comes to the same conclusion. Until I see some leading sleep researchers who publicly disagree with these major scientific bodies, or agree with the arguments you make in your piece, I think it makes more sense to go with the scientific bodies.

I would also add - the American Academy of Sleep Medicine agrees that CBT-I should be the first line of defence against insomnia.

Pushing on the epistemic modesty point, if you didn't interview any experts when writing your brief, it seems overconfident to disagree with the scientific establishment. If you have a tentatively held conclusion and you've not engaged with other experts, I think the sensible thing to do is defer.

More generally, I think extensive interviews with experts should be part of all reviews of evidence on interventions

Interesting - I didn't look into the evidence that much and was happy to defer to NICE on it, which if what you say is correct (I haven't checked), may not have been right. As you say, sleep restriction+hygiene still seems worth trying even if, as you argue, the evidence isn't that strong, given that it has a plausible mechanism and is unlikely to do harm.

I will look deeper into the evidence and add an edit to the main text in the meantime

Thanks for sharing! Have been searching on Sleeping Restriction in particular and I guess i should be trying this method. I believe different methods work on different people. I personally think that reading a book (definitely not thriller or horror story), helps me with my sleep. In addition, nature sounds like raindrops, water stream or even thunder are really soothing as it calms my mind greatly. I have been using this Music for sleeping website for quite sometime. Not sure if it's helpful for those with sleeping issue like me.

Awesome post! I’ve tried CBT in combination with CBD and it has really worked for me. I have experienced mild sleeplessness for the last 5 years and I have tried a lot of different things to help me fall asleep faster, and stay asleep during the night. I tried Melatonin (made me wake-up a bit groggy), meditation before going to bed (helped a bit to calm down, but still woke up in the middle of the night) and a bunch of other habits, routines and supplements.

Something that has really helped me fall asleep faster, and stay asleep during the night (!!), is REST by goodness. It’s an oral spray, containing hemp-derived CBD, CBN (which some studies have shown to be a natural alternative to valium), Valerian Root, Chamomille, Reishi, L-theanine and peppermint extract. All-natural ingredients, which I love because I don’t like synthetic/pharmaceutical options for sleep, non-addictive and super effective. Would highly recommend it: www.goodness-cbd.com

I'm going to look into CBT-I.

I don't have chronic insomnia these days, but sometimes I sleep badly for a few days in a row. A few years ago I discovered Benadryl (diphenhydramine) and it works well for me. It helps me stay asleep, and it also helps me to fall asleep up to a couple of hours earlier than my sleep time when I need to wake up earlier. It's also a boon for overnight travel.

It's non-prescription, and possible side effects don't look too bad compared to other common non-prescription drugs. I don't think it's addictive or has withdrawal effects but it's not meant as more than a short-term solution.

As Derek mentioned before, Benadryl has a big anticholinergic effect and anticholinergic drugs have been linked to dementia, but I take solace in the fact that people who have allergies are allowed to take, as per the label, up to 4 doses daily of 50mg (presumably for as long as the allergy endures), and I only need one dose of 25-50mg to sleep soundly.

My GP and some friends recommended Sleepio, a CBT-based online programme for insomnia. It's not cheap, but if you participate in their research you get it for free, and anecdotally it seems most people who request that option are accepted eventually (I had to wait a couple months, I think). I'm not sure how it compares to other CBT programmes; the only evidence they cite for their specific programme is a pretty small RCT (N=164, divided into 3 treatment groups) that they conducted themselves.

When it comes to drug therapy, I'm a little surprised there isn't more attention given to mirtazapine (Remeron in the US), which is an anti-depressant that's also sedating. The effect size for depression compares favourably to most alternatives (e.g. Cipriani et al., 2018), and there is good evidence it improves sleep in a large proportion of users (e.g. Wichniak et al., 2017). In the UK at least, it's not supposed to be prescribed for insomnia alone, just comorbid insomnia and depression, and is considered a 'second-line' antidepressant after SSRIs, but I think it's used off-label for insomnia alone in some countries.

Aside from weight gain and withdrawal effects, the main concern is that it's mildly anti-cholinergic. Other drugs with a much stronger anti-cholinergic effect have recently been found to increase the risk of dementia in over-60s (e.g. Richardson et al., 2018), so there are theoretical grounds for suspecting it could cause non-clinical deficits in brain functioning of younger people. But chronic sleep deprivation and depression are also really bad for long- as well as short-term cognitive functioning, as are other drug therapies (e.g. diphenhydramine [Nytol/Benadryl] and other anti-histamines are much more strongly anti-cholinergic, and benzodiazepines/Z-drugs are bad for you in all kinds of ways). So if CBT etc doesn't work, it might be worth considering.