Sleep hygiene is not the cause and not cure for chronic insomnia

What is sleep hygiene?

Sleep hygiene is not another way of saying “sleep habits”- it is a treatment that was developed by Hauri (1977) but that had not been tested people with insomnia before it’s publication.

In brief, this involved a set of rules based on what was known about sleep from research in people without any sleep issues.

Subsequent research showed that such practices do not cure chronic insomnia. In fact, the effects of sleep hygiene in adults are so minimal that most research on insomnia uses “sleep-hygiene therapy” as a placebo comparator. Indeed, several randomized controlled trials for insomnia treatments (e.g., Carney et al., 2017; Jarnefelt et al., 2020) use Sleep Hygiene content based on Hauri (1977) as a behavioural sham control group.

Sleep Hygiene (Hauri, 1977)

  1. Reduce use of caffeine, and limit last consumption to early afternoon

  2. Reduce/eliminate use of nicotine

  3. Engage in daily exercise, but not too close to bedtime

  4. Try a bedtime snack (e.g., milk or peanut butter)

  5. Avoid middle of the night eating

  6. Reduce/eliminate alcohol and other substances

  7. Do not sleep in a noisy, lit, or an uncomfortable temperature

What is the current consensus about sleep hygiene?

In the Clinical Guidelines for Insomnia Disorder, the American Academy of Sleep Medicine (Edinger et al., 2021) specifically recommend against using sleep hygiene  as a standalone treatment for insomnia (i.e., handing out a Sleep Hygiene pamphlet to patients complaining of sleep).  Just like the USA and European Insomnia Guidelines, the Canadian consensus recommendations for the management of chronic insomnia state that sleep hygiene on its own is insufficient to treat insomnia disorder. In Canada, this has recently been formalized in the new health care standards for chronic insomnia by Health Quality Ontario.

So what should I make of all the information on the web which claim to refer to sleep hygiene?

Despite the scientific evidence showing it’s ineffectiveness, the concept of “sleep hygiene” spread beyond evidence-based healthcare practice. A review of websites shows poor fidelity to Hauri’s (1977)  treatment (Moss, Lachowski & Carney (2013). For example, some websites add partial elements of Cognitive Behavioural Therapy for Insomnia (CBT-I), like items tapping on Stimulus Control (e.g., no naps). However, extracting isolated elements of an integrated therapy without sufficient rationale and support may lead to poor outcomes. Importantly, this may create the impression that CBT-I does not work, thereby deterring people from seeking appropriate treatment. Sometimes, these websites also add completely new recommendations that are not always advised for people with insomnia (e.g., keep a regular bedtime). There are even increasing concerns among sleep experts that the spread of this type of information may even create harm in people with chronic insomnia

Could sleep hygiene still help at least attenuate at least some of the factors linked to insomnia in adults?

NO. Here are a few reasons why:

  • Poor sleep hygiene rules is rarely what causes insomnia. Chronic insomnia does not arise because we forget to eat a light snack before bed or neglect to adjust the thermostat. Enforcing these habits generally does little to improve the problem. Instead, insomnia often develops from how we respond to the occasional bad night’s sleep—a normal experience for everyone. When sleep difficulties become a central source of worry, we may start to believe our sleep system is “broken.” In an effort to fix it, many people adopt strategies like going to bed earlier, sleeping in longer, or napping during the day. Ironically, these behaviors are key factors that sustain chronic insomnia.

  • Sleep hygiene increases sleep effort, which can lead to chronic insomnia. Many people with insomnia use sleep hygiene in attempt to control their sleep. They can become overly focused on the strict application of these rules – fueling the false belief that sleep can only be achieved under perfect conditions. This mindset can turn into a rigid, all-or-nothing approach: “If I don’t have milk for my bedtime ritual, I’ll never sleep.” Such beliefs reinforce unhelpful expectations and reduce flexibility around sleep.

  • Most people with insomnia already have excellent sleep hygiene. After months – or sometimes even years--  of poor sleep, it is common for people with insomnia to have tried every tip they could find; reading about sleep hygiene, experimenting with routines, and following online advice. Yet, despite their best efforts to implement sleep hygiene practices, their insomnia is likely to persist because this is not the right treatment for them.

  • Ineffective treatments erodes hope. When people are repeatedly told to rely on strategies that do not work, they may feel discouraged, disheartened, and less likely to seek the approaches that truly help.

So what does work?

Cognitive-behavioural therapy for insomnia (CBT-I) is recommended as the first-line treatment for insomnia disorder. It notably involves progressive personalized changes in sleep schedules to strengthen our sleep drive. This is combined with techniques to break down associations between the bedroom environment and the dread of a sleepless night it can provoke. Ultimately, CBT-I targets the specific factors leading to persisting insomnia.

Help spread the word

A recent study in the Canadian Journal of Medicine indicates that 98% of primary care providers treating patients with insomnia review sleep hygiene with them first; only 58% discuss CBT-I with their patients. Health care practitioners need to be better supported to provide evidence-based sleep care. You can help by spreading the word to your colleagues.