Five counterintuitive strategies to get better sleep

Real text from an old friend: “This is terrible, but sometimes when I ask myself ‘how does Sara get so much done?’ I hear Liv Tyler in Empire Records saying, ‘there are 24 useable hours in every day.’”

She then congratulated me on not abusing amphetamines and instead just having terrible, unrelenting insomnia. 

Sigh.

Consistent sleep has eluded me my whole life. Some of my earliest childhood memories are of watching the minutes tick by in giant red block numbers on my bedside clock radio. I exercise and use white noise and blackout shutters. I don’t snore or have any other signs of neurological or physical sleep issues. I’m not depressed. My anxiety is well-controlled. I keep the lights low at night and shower before bed.

And multiple times a week, I was sleeping less than 6 hours. I was very tired. Even after a good faith attempt at CBT-I, the most evidence based treatment we have for primary insomnia*, I still had weeks of rough nights. The sleep medications I tried worked temporarily, but they quickly became ineffective or made me groggy the next day. I was at a loss.

There are so many good articles on the basics of sleep hygiene, that I’m not going to waste your time on what you probably already know. Instead, let’s talk about five changes that seemed crazy to me before I tried them. Is my sleep perfect now? Of course not. But it is better, and, most importantly, I’m less stressed about it. 

1. I started drinking coffee

After a few rough patches with caffeine (sophomore year in college - when I lived in a house with a Diet Coke dispenser and got so dehydrated and underslept that I fainted - stands out as a prime example), I swore it off. I liked coffee, but I was convinced it would make my sleep worse. I’d nurse my herbal tea, watching my colleagues sip Americanos with naked jealousy, and tell myself it was the only way.

This year, after allowing myself a holiday latte and feeling INVINCIBLE, I decided to dig a little deeper into the research. Coffee has a mixed reputation when it comes to alertness and sleep. 90% of people in the United States use (an average of 200mg) caffeine, much of this from coffee. Caffeine has clearly and consistently shown its ability to improve physical and cognitive performance, and there have been recent articles on its possible connection to longevity. 

On the other hand, there is a “no duh” connection between caffeine use and wakefulness, and it can absolutely contribute to insomnia. However, other trappings of our modern life (artificial light, constant stimulation, etc) may potentiate caffeine’s tendency to keep us up. It may be less about the coffee itself, and more about how, when, and in what setting we use it. My conclusion: there’s a sweet spot of caffeine which ranges from zero to… who knows for each person which maximizes the positive and minimizes the negative effects on energy, focus, performance, and sleep.

The key for me was to be specific and intentional about my coffee use: One to two cups. First thing in the morning. I don’t change the amount or timing of my coffee as a reaction to sleepiness, even if I haven’t slept well the night before. Instead, I grit my teeth, roll my eyes, and remember the silver lining: I’m going to be very ready for bedtime. And while I may not get the euphoric buzz I once did (tolerance can happen with any “drug”), I do start my day with a bit of bounce and wind down naturally in the evening.

2. I use minimal melatonin

More melatonin, more sleep, right? Maybe not. I had tried melatonin in the past, every time a disappointment. It seemed like the worst of both worlds - it didn’t “knock me out” but I still woke up groggy and with a headache the next day. Turns out, I was using it all wrong.

The thing is, melatonin isn’t a sleep medication or a sedative. It’s a naturally occurring hormone that helps regulate our sleep cycle. Gently coaxing our internal system with low dose melatonin (the studies I read recommended 0.3mg - less than 1/10th of what’s found in a typical bottle from the supermarket) is more effective and causes fewer side effects than blasting our brains with supraphysiologic doses.

Timing is also important. If we really want to mimic our natural fluctuations, the move is to take it at least 1-2 hours before planning to hit the hay. Taking a high dose right before bed may make you feel sleepier at the moment your head hits the pillow, but it may also lead to grogginess, difficulty waking, and a confusing shift in schedule for your body, making it harder to fall asleep in the future.

The best way I’ve found to use melatonin is to work my circadian rhythm from all angles: get bright light exposure first thing in the morning (I walk my dog at sunrise, but light boxes can work great for dark climates, winter, and shift work), try to schedule less mentally taxing and/or more physical activities for the late afternoon, use a low dose of melatonin about 90 minutes before bedtime during periods of rough sleep, and keep a consistent sleep schedule. 

Hot tip: the lavender chamomile flavored gummy by Vicks is a delicious after dinner treat. 

3. I don’t try to go back to sleep

Much has been written about why it’s better to get out of bed rather than still “trying” to sleep after about 15-20 minutes. Ultimately, this advice boils down to a key CBT-Insomnia principle: beds should only be for bedtime activities, so our brain associates being in bed with sleep. Not with work. Not with watching TV shows or reading cookbooks (if you’re a weirdo, like me). Not with paying bills online or hashing out schedules with our spouse. Just sleep. 

That said, easier said than done, right? This is a pivot point in my list, because I’m better at doing something than not doing something. Adding coffee and tweaking melatonin were easy for me, and they came with the inherent cognitive reward of buying/acquiring things. Subtracting something from my default routine - particularly something that I’ve found comforting or assumed was helpful - is hard. 

When I’d wake up at 4am in the past, I’d think, poor Sara, just stay in bed and rest. Or, ugh, this is awful - watch more of that show, you deserve it. Hours would go by, and I rarely got more sleep. I’d drag myself out of bed in the morning, facing a demanding day and running on fumes. 

About a year ago, I started keeping insomnia lists for myself. Now, if I wake up in the middle of the night and don't immediately fall back asleep, I pull on a comfy robe, get out of bed, and start getting things done. My most recent mid-night pick: battling through journal articles for my psychiatry board certification renewal. 

If dry science writing doesn’t do it for you, consider meal prep, crosswords, yin yoga, or small housework or organization projects. Keep a written checklist on the refrigerator or your desk (not on your bedside table where it will stare at you judgmentally) for the added satisfaction of physically crossing things off once they’re complete. If you start feeling sleepy again, yay! Head back to bed! If not, well, look at all you got done. 

And when your planned wake up time finally rolls around? Celebrate with a delicious breakfast… and your normal morning routine. I used to be tempted to sneak back into bed for a “rest” after a bad night, but this has pretty much always backfired and prolonged my bad sleep by “resetting” my sleep clock. Going through the vicious tired => nap => insomnia => more tired => nap cycle just doesn’t work for me.

4. I let myself go to bed hungry

A glass of milk, a turkey sandwich, a midnight snack: we imagine these comforts warming our tummies and lulling us to sleep. And we’ve all noticed ourselves nodding off after a big meal from time to time. But is tanking up really a good strategy for sliding into sleep at night?

Nope. Not at all. 

Yes, turkey (as well as eggs, beans, and other protein sources) contains tryptophan, which releases a melatonin precursor, but it’s more the combination of overeating, carb-loading, and turkey that knocks us out during the holidays. Plus, the raging sleep debt from cleaning, cooking, shopping, decorating, wrapping presents, and wrangling kids, all while holding down day jobs (with very white knuckles… just me?).

In reality, our bodies do just fine sleeping when hungry. For most healthy people, the block is more mental than physical. Plus, we’re more likely to reach for sugary or processed foods at night, which can be a set up for delaying bedtime (sugar rush!) and disrupting sleep later in the night (reflux! indigestion! sugar crashes!). Though I haven’t found a smoking gun study, there is evidence that late night eating is associated with poor sleep.

Now, I try to stop eating after our 6pm dinner. If I want something sweet to wind down, I’ll try to reach for a low sugar, non alcoholic drink like tea with a little honey or a Ghia non-alcoholic cocktail (pricey, but delicious). It has definitely helped with nighttime stomach weirdness, and I do think it’s put a dent in my insomnia. 

Side note #1: I haven’t decreased the overall amount I eat in a day, just when I eat it. 

Side note #2: That this has been a really hard habit to break. It’s a work in progress.

Side note #3: I didn’t comment on alcoholic nightcaps, mostly because I’ve never been a big drinker, but rest assured (see what I did there?), the evidence is crystal clear that alcohol is a net negative on sleep.

5. I limit my wind down time

We psychiatrists harp on the benefits of a bedtime routine, but there can be too much of a good thing. As such, I’ll keep this one brief. 

Keeping a consistent evening routine is a hallmark of good sleep hygiene. It’s at the foundation of all sleep training (particularly relevant to my toddler-household), because it’s a well-documented way to cue the brain that it’s bedtime. However, there was a moment last year when I was still up at midnight because I just had to finish my journaling before I could get to the crossword that would precede my lavender pillow spray… 

I realized that my extensive (*cough* borderline obsessive) bedtime routine was turning into just another way to procrastinate going to bed. Not only did it waste time on low reward activities, but it rebounded me into awakeness, making my brain pump out stress chemicals. My wind down time was winding me up. 

Now, my routine usually takes 15 minutes and consists of hygiene/basic self care and a brief journal entry. I answer three prompts: [what are you] grateful for, [what will you be] mindful of, and [what are you] looking forward to? 

That’s it.

So where does that leave me?

For now, I’ve reached a detente with my sleep. It’s better, but I’ve accepted it will never be perfect, and it will probably get worse from time to time. When it’s bad, I no longer rail against the injustice of my overactive mind. I take a deep breath (or silent-scream into my dog’s fur), roll out of bed, cross some things off my list, and look forward to my morning cup of coffee.

* Insomnia is defined by the WHO as a problem initiating and/or maintaining sleep or nonrestorative sleep at least three times per week which is associated with daytime distress or impairment. Primary insomnia means that there is no clear medical or psychiatric cause of the sleep issues.