How to sleep well

Written by Professor David Veale, Consultant Psychiatrist

This advice should be taken as a general guide. It is always best to consult a doctor or therapist about your individual needs if difficulties persist.

Sleep is your body’s superpower – it impacts your cognitive functions such as memory, learning and concentration, your ability to emotionally regulate and even how you are able to manage symptoms of anxiety and depression.

The good news is many studies have found that a good sleep routine can improve your mental health and help treat depression. The bad news is that 14% of Brits are living on dangerously low levels of sleep, under five hours per night.

But getting better sleep is possible. This article sets out the science behind sleep and the circadian rhythm, the issues when this internal body clock is dysregulated and how you can get a better night’s sleep.

The science of sleep: Daylight is your best friend

The most important component of good sleep is routine and exposure to daylight. Humans have an inner timekeeping system that guides us to sleep at night and be awake and alert in the daytime. This system is located in the brain and includes the master clock and a gland that secretes the hormone melatonin, to tell us when to fall and stay asleep. This system has a rhythm of approximately, but not exactly, 24-hours. In the absence of an external day-night cycle, it cycles on its own with a rhythm, of more or less 24 hours 12 minutes, depending on the individual. The brain triggers the release of melatonin to increase in the evening, helping make us sleepy, and decrease in the morning, helping us wake up.

If you were to live in constantly dark or dim surroundings, your sleep-wake cycle would drift later about 12 minutes a day (sometimes much more). But when you experience daylight or adequate indoor lighting, the sleep-wake cycle is surprisingly close to 24 hours. This adjustment is possible because we also have a system that secures a connection from the outer environment to our inner physiology. These outer signals serve as solar-cycle timekeepers, called zeitgebers (German for ‘time giver’). The daily light-dark cycle is by far the strongest zeitgeber, but daily cycles of social contact, food intake, and exercise can also cue the brain into synchrony, controlling its inherent drifting pattern.

Light therefore in the morning acts as a zeitgeber by stimulating specialised receptors in the retina of the eye that are very sensitive to light. In turn, these signals reach the brain’s timekeeping system, thereby entraining our rhythms and sleep to the external 24-hour solar cycle. This entrainment process works ingeniously, such that light in the period after waking up advances the sleep-wake rhythm to better match the external day, whereas light before sleep delays the sleep-wake rhythm, which can cause you to fall asleep later (this can feel like insomnia if you want to keep a normal bedtime).  If you have gotten out of sync after flying to a different time zone, these light cues will adjust your sleep pattern in a matter of days.

My body clock is dysregulated

Sleep can be disrupted by various factors and difficulty getting to or staying asleep is generally referred to as insomnia. Underlying problems including anxiety and depression can often be involved. Disrupted sleep can also cause your internal circadian rhythm to fall out of sync. This is referred to as ‘body clock problems’ and it can cause those experiencing it to wake during the night or too early in the morning. Common solutions, including sleeping during the day or lying in on the weekends, can make the problem worse by interfering with the production of melatonin – a hormone that regulates the body.

How to help yourself get a good night’s sleep

You will be pleased to know that in conjunction with focusing on these external light cues to signal to your body that it is time to sleep, there are ways you can help yourself get a better night’s sleep.

Implement a routine – and stick to it

• Going to bed: As a general rule, make sure your final meal of the day is light and get to bed by 10:30pm.
• Getting up: Get up at the same time every day, usually by 7:00-7:30am. Restrict lie-ins on weekends to an extra 30 minutes. Try to see sunlight as soon as you wake – either by opening the curtains or using bright light therapy if the sunshine is coming into your bedroom room. The best advice is to go for a walk or sit out outside for half an hour while you have breakfast to get the full benefit of daylight over indoor light (which is less bright). Avoid sleeping during the day. Napping can make it harder to sleep at night. If you must nap, restrict it to 15 minutes before 3:00pm.
• Winding down: Have a wind down routine to get yourself ready to sleep. Avoid stimulating yourself at least an hour before bed, i.e. don’t check your emails or social media. Try to keep phones, laptops and other electronic distractions away from the bed. Maybe have a hot shower or bath, as these can drop your core temperature, mimicking the drop your body naturally experiences before sleep. Keeping warm once in bed will also help you become drowsy. Some people are sensitive to the ‘blue light’ from TVs and mobile phones and it may helpful to use blue blocking (amber coloured) glasses or lighting in the evenings to encourage melatonin release. Block Blue Light have options for these glasses.
• During the night: If you are sharing the bed with someone who likes to be cold while you want more warmth, make the bed with two sheets or different duvets on top. Avoid watching the time or calculating how long it is taking you to get to sleep. Turn the clock away from you, and preferably have it out of reach.
• Setting the scene: Try to make sure your bedroom encourages rest. Look at your bedroom critically. It can be helpful to ask yourself the following. Is my bedroom:
  • Tidy? An untidy room can increase tension.
  • Too warm? Too cold? The optimum temperature for sleep is about 18°C.
  • Airless? Using a fan or opening a window can help alleviate feelings that a room is stuffy.
  • Comfortable? It may be time to consider a new mattress. The Sleep Charity offers useful advice.
  • Dark enough? Streetlights and other lighting can be intrusive. Consider blackout linings on the window or an eye mask.
  • Is the bedroom associated with other things like work?
• What if I already have a routine and feel sleepy too late? Your sleep may be ‘phase delayed’ if you are not feeling sleepy until after 1:00-2:00am or later. Wearing blue blocking (amber coloured) glasses from sunset may help you feel sleepy naturally before midnight. Here, you are trying to encourage your melatonin to be released by creating virtual darkness in your brain. This is best discussed with a therapist or doctor. Make sure you still get up by 7:00am and use Bright Light Therapy to switch off the melatonin.
• What if I feel sleepy too early? If you are falling asleep too early, your sleep may be ‘phase advanced’. This is less common than phase delay, though, and it may be that you are going to bed too early. Avoid going to bed before you feel sleepy. Try to catch that sleepy feeling as your trigger to go to bed. If you get up at a regular time, say 7:00am, you should be heading to bed 16 hours later (in this case 10:30-11:00pm). If you are truly going to sleep early (e.g. 7:00-8:00pm), your therapist may want to prescribe Bright Light Therapy in the early evening to help you suppress your melatonin release and encourage you to stay awake until 11:00pm. This is best discussed with your therapist or doctor.

Be caffeine-aware

Coffee, cola and energy drinks (e.g. Red Bull) all contain caffeine, which is a stimulant particularly good at keeping people awake. Caffeine can itself contribute to anxiety and irritability. Some people do not break down caffeine quickly and if you suspect you are one of them you should try to drink caffeine-free drinks after 2:00pm.

Avoid alcohol in the evening

Alcohol is a sedative that can help you get to sleep. However, if you use alcohol as a sedative, you may then experience a rebound (like withdrawal symptoms). It is also a diuretic and may make you want to go the toilet in the early hours of the morning. Of course, many people sleep when they have been drinking a lot but if you are depressed or anxious then avoid alcohol in the evenings because it will wake you during the night. If you drink alcohol, try to finish drinking by 8:00pm so there is at least two hours before bed.

Avoid smoking or illegal substances

Nicotine and other substances can contribute to difficulties sleeping as they are stimulants. If you’re going to smoke or take other substances, don’t do so in the evenings.

Tackle excessive sleepiness

Excessive sleepiness, tiredness and loss of energy are very common in depression and anxiety. Sleeping too much is another form of avoidance of people or activities. The only way to solve this is to stick to your sleep routine and activity schedule. Ensure you get up by 7:00-7:30am.

If you are on medication, you may want to discuss with your doctor whether it may be contributing to excessive tiredness. Some antidepressants are sedatives and others may be better at improving alertness.

There are occasionally medical causes of excessive sleepiness. Could you be suffering from obstructive sleep apnoea? This is a treatable condition; if left untreated, the tiredness may interfere with your performance at work, or with driving or operating machinery, and cause depression.

When sleep solutions are the problem

You may lay awake worrying that you’ll be too tired to cope the next day if you don’t sleep and trying desperately to make yourself go to sleep. Other common worries about sleep include ‘I’m making myself physically ill’, ‘I’m making my depression worse’ or ‘I’m going crazy’. No doubt not sleeping well is very unpleasant and worrying about it makes good sleep even harder to achieve.

An important point to focus on if you have a sleep problem is the way you think about sleep. The attitudes you have directly affect the way you feel about sleeping or your difficulties in sleeping, and the way you behave about sleep. Here are some examples of common unhelpful rules about sleep:

• I must have at least eight hours of sleep or I can’t function
• I can’t stand feeling tired
• Unless I sleep well I’ll never recover
• I must think of ways to get a good night’s sleep
• If I can’t sleep well I must rest in other ways
• Sleep’s a physical problem – there’s nothing I can do about it

Try to identify any such beliefs about sleep and unhelpful solutions to discuss with your doctor or therapist. The crucial thing to remember is that sleep is often sort of ‘upside down’; the more pressure you put on yourself and the more significance you give poor sleep the harder it is to sleep well. If you are ruminating (brooding) about your why you can’t sleep and if only you could get to sleep, the trick is to regard your thoughts about sleep as just thoughts, not fused with reality as facts. It is just your mind chattering away like a radio in the background. You don’t have to tune in to the radio and listen to it.

Medication for sleeping problems

Hypnotic drugs or ’sedatives’ are medicines prescribed by a doctor that help you get to sleep. They do not provide natural sleep, so users tend not to feel refreshed. Sleeping tablets should be prescribed only in the short term to help someone through a crisis. Persistent use can result in addiction and rebound insomnia when the drugs are stopped – that is, the insomnia gets worse in the short term.

Further help

If you have a persistent sleep problem, we recommend the materials by Professor Colin Espie which are developed from CBT for Insomnia. These include:

• Sleepio, available for free on the NHS
• Overcoming Insomnia by Colin Espie