Sleeping well

We spend about a third of our lives asleep. We don’t fully understand why, but we know that we need to sleep well to stay physically and emotionally healthy.

Sleep helps the body to repair itself and helps us to recover from physical and mental illness. It helps us to learn, concentrate and be productive. Whatever the reason, not getting enough good quality sleep can have a negative impact on your wellbeing.

We are often told that we are supposed to sleep for 8 hours a night. While it is true that the average amount of sleep that adults need is around 7 or 8 hours, this is just an average. That means there are many people who need more than 8 hours sleep and many people who need less. The amount of sleep you need also changes with age.

Here you can see the different recommended hours of sleep for different age groups. It is normal to need more or less sleep than this, but if you are getting far more or less sleep than the recommended hours, speak to your GP.

How do I know if I am getting enough sleep?

Judge your sleep by how you feel in the day rather than by the number of hours you sleep at night.

If you feel well, alert and rested for most of the day, and on most days, then you are getting enough sleep for you. This is regardless of how many hours you are sleeping.

Remember, nobody feels well, alert and rested all day, every day. Even good sleepers have times of day when they feel tired. We all have the odd bad day when it comes to our sleep, or even the odd bad week.

Sleep types

While you sleep, you pass through several types of sleep. There are the two main types:

Rapid Eye Movement (REM) sleep

This comes and goes throughout the night and makes up about one fifth of your sleep time. During REM sleep:

• your brain is very active
• your muscles are very relaxed
• your eyes move from side to side
• you dream.

Non-REM sleep

During non-REM sleep, your body secretes growth hormones into your blood stream, and your brain clears out waste products that have built up while you were awake. This helps your body to repair itself. Unlike REM sleep, in non-REM sleep:

• your brain is less active
• your muscles are less relaxed (though more relaxed than when you are awake).

There are 3 stages of non-REM sleep:

• Stage 1 – Very light sleep. This is halfway between wakefulness and sleep.
• Non-REM Stage 2 – Light sleep. You can wake up easily without feeling confused. Stage 2 is important for memory processing and mental function.
• Non-REM Stage 3 – Deep sleep. This is the most unconscious you will be in everyday life, although your brain is still working and you maintain some awareness of your environment. Stage 3 is important for memory processing, mental function, and the physical repair of the body.

Sleep cycles

While sleeping, you go through sleep cycles. In adults, these cycles last about 90 minutes each, so you will have several each night. Each cycle has several sleep stages that usually happen in the same order.

Here is an example cycle:

1. Non-REM stage 1 - This normally only happens as you fall asleep at the beginning of the night or after waking up and falling back to sleep during the night.
2. Non-REM stage 2
3. Non-REM stage 3
4. Non-REM stage 2
5. REM sleep.

Not every cycle is the same. The first couple of cycles have a lot of deep sleep and not much light sleep. The later cycles tend to have very little deep sleep and lots of light sleep.

We have included a diagram to show what the cycles in an example night’s sleep look like:

Most people wake up a few times during the night, and this is quite normal. As long as you don’t wake up for long, and you don’t feel tired in the day, then this is nothing to worry about.

Some people feel that they are hardly sleeping at all, even when other people can see that they are sleeping for at least some of the night. This is because the short periods that you wake for during the night can feel much longer than they really are.

The occasional night without sleep will make you feel tired the next day, but it won't affect your health.

However, after several sleepless nights, you will start to find that you:

• feel tired all the time
• fall asleep during the day
• find it difficult to concentrate or make decisions
• start to feel low and anxious – over time, poor sleep can be a factor in developing depression
• start to worry about not being able to sleep.

Sleeping poorly can be dangerous if you are driving or operating heavy machinery. Many people are killed each year when they fall asleep while driving.

There are shown to be links between poor sleep and being overweight, high blood pressure and diabetes.

There are three main causes of poor sleep. These are:

• insomnia
• sleep deprivation
• organic sleep disorders – these are sleep disorders that have a physical cause.

Insomnia is a condition where you can’t fall asleep or stay asleep for long enough, even though you have the opportunity to sleep.

If you have insomnia, you might feel tired during the day but are unlikely to feel like you might actually fall asleep. Some people describe it as feeling ‘tired but wired’. You might struggle to concentrate or remember things properly and may feel anxious or irritable.

Insomnia can have an impact on your physical health. However, on average, people with insomnia do not die any younger than people without it.

If you sleep less than other people you know, but feel fine in the day, then you do not have insomnia. You are simply someone who needs less sleep.

What causes insomnia?

There are lots of things that might mean you find it harder to sleep. Some of these are everyday problems such as:

• your bedroom being too noisy, hot or cold
• your bed being uncomfortable or too small
• not having a regular sleep routine
• your partner having a different pattern of sleep from you
• your partner snoring or being a restless sleeper
• not getting enough exercise
• eating too close to your bedtime, or going to bed hungry
• smoking cigarettes, or drinking alcohol or caffeine
• being unwell, in pain or having a high temperature.

Some problems that effect sleep are more serious, such as:

• Emotional problems – Think about what is happening in your life, and how this might be affecting your sleep. Perhaps you are having difficulties at work or in your relationships that are causing you anxiety or worry. If you feel you are finding it hard to stop thinking about your problems, or you are feeling very low or anxious, speak to your GP.
• Physical health problems – There are lots of different physical health problems that can make it harder for you to get good sleep. For example, if you have chronic pain this might keep you awake at night. Or if you have cancer, treatments for this might make it difficult for you to sleep. If you have a physical health condition, this could be linked to your bad sleep.
• Medications – Certain medications can make it harder for you to sleep, or cause you to have disturbed sleep. The same can be true if you are stopping a certain medication, such as antidepressants. Check with your doctor whether the medication you are taking could be causing you to have poor sleep.

Insomnia can be very unpleasant. However, it can be made worse by the way we think about it and respond to it. For example, you might start to sleep badly because you are stressed at work. You might then start to worry that you aren’t sleeping well. This, in turn, can make your sleep worse. That worry might continue to disturb your sleep even if you are no longer stressed by work.

Self-help for insomnia

Many people with insomnia go to bed far too early. This makes sense as, if you are not getting enough sleep, you might feel you need to spend more time in bed to give yourself more time to sleep. But this can make insomnia worse as it gives you more opportunities to be awake in your bed. Try the following method to get better sleep:

1. Decide the earliest bedtime that you are comfortable with. Do not go to bed until you have reached that earliest bedtime, and you are feeling sleepy. For example, you might choose a bedtime of 10pm.
2. Try delaying that earliest bedtime by 15 minutes each week. For example, 10.15, then 10.30 and so on. Aim to do this until you are falling asleep within about 20 minutes of going to bed and are not awake for more than about 20 minutes in the night.
3. At that point you can experiment with moving your earliest bedtime 15 minutes earlier each week to increase the amount of sleep you get.
4. If, when moving the bedtime earlier, you feel that your sleep is deteriorating, move it later again until it becomes more consistent.

There are lots of other self-help tips in the section further on in this resource called ‘What can I do to improve my sleep?’ which might be helpful if you have insomnia.

Treatments for insomnia

Psychological therapy

Cognitive behaviour therapy (CBT) helps you to learn more helpful ways of thinking and reacting in everyday situations. CBT for insomnia (or CBT-I) uses psychological and behavioural techniques to help you sleep. It is simple to learn, though some of the techniques take a bit of work. A few of the techniques are described briefly in the section on improving your sleep.

Medications

Some people use sleep medications every so often when they are struggling to sleep, and find this doesn’t cause them any problems. However, if you are using any kind of sleep medication regularly, speak to your GP. There might be other treatments or changes to your routine that could help you to sleep better.

In this section we will cover medications that are licenced to be used to help sleep. We will also look at unlicensed medications that are sometimes bought over the counter or online without a prescription.

Licensed medications

Z-drugs
Z-drugs are used to help with difficulty sleeping. You should be prescribed z-drugs for no longer than 4 weeks at a time, and you should take them for as short a period as possible.

Z-drugs should be used with caution in older people and are not recommended for people who are pregnant or breastfeeding. The main side-effects are an unpleasant taste in your mouth and feeling sleepy in the daytime.

Benzodiazepines
The benzodiazepines most used for sleep are diazepam, nitrazepam and temazepam.

Benzodiazepines can be addictive. You should be prescribed benzodiazepines for no longer than 4 weeks, and you should take them for as short a time as possible. They can cause confusion and unsteadiness, and this is more likely in elderly people.

Prolonged-release melatonin
Melatonin is a hormone that occurs naturally in the body and increases and decreases with your sleep. A synthetic version of melatonin can be used to improve sleep in people with insomnia.

If you are over the age of 55 and have persistent insomnia, you might be prescribed melatonin. People with neurodevelopmental conditions like ADHD and autism are also sometimes prescribed melatonin for sleep.

Melatonin shouldn’t be prescribed for more than 13 weeks. Side-effects include daytime drowsiness, headaches and feeling sick.

Some people buy melatonin online. This is dangerous because when you buy a drug online you can’t always tell what will be in it. Melatonin can also interact with a lot of different drugs, and cause unpleasant side-effects. It is important that melatonin is prescribed by a doctor and that you are supported in taking it.

Daridorexant
This is a relatively new drug that helps people to feel less awake by influencing a chemical in the brain that is responsible for regulating wakefulness and appetite. It is recommended for the treatment of more serious and long-lasting insomnia. Common side-effects of daridorexant include headaches, and feeling sleepy or tired in the morning. Daridorexant should be prescribed for as short a time as possible though it can be prescribed longer term if needed.

Unlicensed medications

Amitriptyline
Amitriptyline is an antidepressant that is sometimes prescribed in small doses to help sleep, but is not licenced for this use. It is dangerous in overdose and has side effects such as dizziness, confusion, constipation, dry mouth and drowsiness. It can be dangerous in people with heart problems.

Other antidepressants
Trazodone and mirtazapine are both antidepressants that can also help you to sleep. If you are depressed and having difficulty sleeping your doctor may prescribe you one of these.

Antipsychotics
Antipsychotics such as quetiapine can cause sedation which may improve sleep. However, they are not recommended as a treatment for insomnia. There is limited evidence that they are effective, and they can have adverse effects. Side-effects include weight gain, changes in metabolism and movement disorders.

Other medications

Below are medications that can be bought without a prescription, either online or over-the-counter. We recommend speaking to a doctor before using any drugs that have not prescribed by a doctor for the treatment of sleep problems. This is because they can interact with other medications, or because there might be a licensed treatment or therapy that would work better for you.

Antihistamines
Some antihistamines cause drowsiness, and because of this some people take these to help them sleep. These kinds of antihistamines can cause daytime drowsiness, dizziness and a dry mouth, and it is dangerous to take them and drive or operate machinery.  

Valerian
This is a herbal alternative medication, and is contained in over-the-counter herbal sleep medications. Some studies have shown that people report sleeping better having taken valerian.

It has side-effects like drowsiness, so it can be dangerous to drive or operate machinery. It can also interact with other drugs, so it is important that you speak to your doctor before taking it.

General information

If you are prescribed any sleeping medication, your prescriber should speak to you about how the medication works, any side-effects and how long you should take it for. If you have been taking medication for sleep regularly for longer than a few months, consider talking to your doctor about whether you still need it.

Sleep deprivation is when you lose out on sleep because you don’t have the opportunity to sleep. It can be caused by a lot of different things. For example, working at night or having a new baby.

We all experience sleep deprivation occasionally, and usually it is easy to adjust back to our normal sleep patterns. Sleep deprivation is much harder to cope with if it happens regularly. Shift workers, who work at night, or parents with a newborn baby, may lose a lot of sleep and find that they need to sleep at times when they would typically be awake.

A parent’s disturbed sleep usually ends as their child becomes more settled at night. Shift work, on the other hand, can go on for years. You may need to do it to earn a living, but it can lead to you:

• being more irritable
• finding it harder to make good decisions
• being more likely to have a heart attack or stroke
• being more likely to develop diabetes
• being at a greater risk of driving or workplace accidents.

Take a look at the section later on in this resource called ‘What can I do to improve my sleep?’ for information on getting better sleep, and guidance for people who work night shifts.

This is when you feel very sleepy in the daytime. This can happen all the time, or may come and go.

Hypersomnia can be caused by:

• not getting enough sleep at night
• other sleep disorders such as obstructive sleep apnoea
• some medications
• depression
• neurological disorders (including narcolepsy).

Hypersomnia is not the same as occasional sleepiness, which we all have from time to time. For example, most people feel a bit tired in the afternoon after they have eaten lunch. But it can become a problem if you feel sleepy most days and it affects your work, driving or social life.

Narcolepsy is a type of hypersomnia. With narcolepsy you can also have:

• frequent hallucinations
• episodes of paralysis on falling asleep or waking up
• sudden weakness in your muscles when you laugh, or feel a strong emotion. This is known as cataplexy.

Another type of hypersomnia is idiopathic hypersomnia. This is when people sleep for a very long time at night but still feel very sleepy during the day, and there is no other cause for the sleepiness such as obstructive sleep apnoea or narcolepsy.

Treatment for hypersomnia

The treatment for hypersomnia depends on what is causing it. If it is caused by another sleep disorder, neurological disorder or depression then treating these will normally improve the hypersomnia. If it is caused by medication, then your doctor might try changing your medication.

It is always a good idea to start by increasing the time you have for sleep at night, for example by going to bed earlier. This may resolve the problem. If this sort of thing doesn’t help, your doctor might prescribe you a medication to treat your sleepiness and increase your alertness. 

Snoring and obstructive sleep apnoea are two organic sleep disorders. These are sleep problems that have a physical cause, and can make you very sleepy in the day. In some cases, they can be dangerous if you drive or operate machinery.

Snoring

When we fall asleep, our muscles relax, including the ones that hold our airways open. When this happens, our upper airway can narrow slightly. Some of the parts of the airway, like the tongue and the back of the throat, become relaxed. When we breathe in, these parts of the airway can vibrate, causing snoring.

Obstructive sleep apnoea

Obstructive sleep apnoea (OSA) happens when the throat narrows too much during sleep. If your airway gets too narrow, it becomes hard or impossible to breathe. The level of oxygen in your blood drops and you have to wake up to open your airway. This can feel like choking or gasping. You usually only stay awake for a short time, then fall asleep again. You may not even be aware that you have woken up.

It is important to note that with OSA, when you are struggling to breathe in your sleep you will always wake up eventually and reopen your airway. But if left untreated OSA can lead to health problems such as high blood pressure, heart problems, diabetes or depression.

OSA can give you broken, poor-quality sleep, and leave you feeling sleepy in the day.

You are more likely to get sleep apnoea if you are older, overweight, a smoker or a heavy drinker.

How can I tell if I have obstructive sleep apnoea?

Below are some of the common symptoms of OSA. Most people won’t have all of these symptoms, but if you have any of these you should discuss them with your GP:

• Snoring.
• Other people telling you that you stop breathing in your sleep.
• Waking up choking, gasping for air or feeling panicky.
• Feeling sleepy in the day.
• Feeling like your sleep is broken or of poor quality.
• Going to the toilet several times a night.
• Waking up with a headache in the mornings.

This can be checked with a simple overnight sleep study, which can often be done at home.

How is obstructive sleep apnoea treated?

If you have OSA, you might be able to help yourself by cutting down on smoking and drinking, losing weight, and sleeping on your side rather than on your back. But if none of these things work, there are different treatments that can be helpful:

A mandibular advancement splint

A mandibular advancement splint can be helpful in mild OSA. This is a bit like a jaw guard that you put in your mouth at night. It pulls your lower jaw forward slightly and opens your airway.

Automatic Positive Airway Pressure (APAP) or Continuous Positive Airway Pressure (CPAP) machines

You might be offered an APAP or CPAP machine if you have moderate to severe OSA.

If you have an APAP or CPAP machine, when you go to bed you will put on a special mask. This is attached to a little machine by the bed that blows normal air from your room into the mask, so the air you breathe in is at a slightly higher pressure than the air in the room around you. This stops your airway from closing and making you choke.

APAP and CPAP machines are slightly different, and your doctor should help to explain how your machine works. You might also hear APAP described as ‘Autoset’ or ‘Autoadjusting’ Positive Airway Pressure.

If you have restless legs syndrome (RLS), you will get an uncomfortable, painful or burning feeling in your legs. Sometimes this will happen in other parts of your body. It will be worse at night, and when lying down or sitting still. You may be able to relieve this discomfort, for a short time, if you move or stretch the affected body part, or walk around.

You might be able to describe where you feel the discomfort but struggle to explain exactly what it feels like. RLS can make it very difficult to fall asleep, and can even wake you from sleep.

RLS can happen for no reason at all, but can also be caused by:

• low iron
• vitamin deficiencies
• pregnancy
• kidney problems
• back problems
• medications
• genetics (it can run in families)
• diabetes
• neurological problems
• some medications.

Usually, a sleep study is not needed to diagnose RLS, though your doctor may need to test your blood to check for the problems mentioned above.

How is restless legs syndrome treated?

There are many ways to treat RLS and treatment may involve a combination of different things, including:

• exercise
• warm baths in the evening
• massaging the affected body part
• iron or vitamin supplements
• medications, including those used in Parkinson’s disease, anticonvulsants and pain killers.

Most of us will have nightmares from time to time. These are vivid, detailed, frightening or upsetting dreams that wake us from sleep. We remember nightmares clearly when we wake up.

Nightmares can leave you feeling low, anxious or tired the next day. Nightmares happen more often in the morning, when we have most of our REM (dreaming) sleep.

Nightmares can become a problem if they happen too often and if they affect how you feel and function during the day. You can become afraid to sleep, and feel tired or low in mood in the daytime.

What causes nightmares?

Most nightmares don’t seem to happen for any particular reason, but they can be caused by sleep disorders such as OSA, mental health conditions and some medications.

They can also be caused by traumatic events and are one of the common symptoms of post-traumatic stress disorder (PTSD). In PTSD, you might start having nightmares after experiencing a traumatic event, though they might not start immediately. The theme of the nightmares is often closely related to the trauma you experienced.

In children, nightmares are common and can be a normal part of growing up. They will usually stop happening on their own, with time. But if they happen often, and a child becomes upset by them, they should be discussed with a doctor.

Why do we have dreams and nightmares?

One theory is that dreams allow us to practice dealing with negative events and emotions. Many dreams have negative themes such as anxiety, embarrassment, confusion or anger. It is also completely normal for dreams to be bizarre and nonsensical, and for them to include people from your past and present.

However, dreams are not usually frightening, whereas nightmares can be very scary, disturbing or involve a sense of loss, or significant danger to yourself or a loved one.

How are nightmares treated?

If there is a clear cause, like a particular medication or another sleep disorder, then changing the medication or treating the other disorder will often help the nightmares to go away. If your nightmares don’t have any clear cause, or are caused by PTSD, psychological therapies can be helpful.

Worrying about nightmares also seems to make them worse or keep them going. If you have regular nightmares, your anxiety about them can cause further nightmares. So, relaxing before you go to bed can help to reduce the nightmares. A simple and effective technique called progressive muscle relaxation can help. We look at this later on in this resource.

Sleep terrors and sleepwalking are two common ‘non-REM sleep parasomnias’. These are unwanted behaviours or experiences that occur during sleep. They usually happen during deep sleep, where you will wake up slightly and be in a half-awake, half-asleep state. During this state you can do things automatically, without any conscious control. Parasomnias are quite common in children but can occur in adults as well.

Sleep terrors

Sleep terrors can be quite dramatic, and scary for the people who see them happen.

If you have sleep terrors you will suddenly sit up in bed, screaming or crying, with your eyes wide open. You will look terrified but won’t answer when people try to talk to you or comfort you. You might also lash out at people, though you won’t realise you are doing it.

In most cases, after having sleep terrors you will fall back to sleep and have little or no memory of the event when you wake up in the morning. Sometimes you might be able to recall some of it. For example, you might see frightening things that are not actually there, such as seeing a shadowy figure in the room, spiders on the bed or the ceiling falling down.

Unlike nightmares, sleep terrors tend to occur in the first half of the night, usually in the first hour or two after falling asleep.

Sleepwalking

Sleepwalking is when you get out of bed and walk around in a half-awake, half-asleep state. You might also pick up or move objects, or even eat. You will usually go back to being fully asleep at the end of the episode and usually won’t remember anything about it the next morning. More rarely, people who sleepwalk can engage in dangerous behaviours such as cooking or driving.

What causes sleep terrors and sleepwalking?

Usually there is no serious physical or mental cause for sleep terrors and sleepwalking. However, they can run in families or be caused by other sleep disorders. These conditions can be made worse if you are sleep deprived, stressed or are drinking a lot of alcohol or caffeine.

How do I know if I have sleep terrors or sleepwalking?

You probably won’t know, unless someone else sees it happening or if you wake up while it’s happening. It is usually the person you sleep with who will first notice that you have sleep terrors or are sleepwalking.

How do you treat sleep terrors and sleepwalking?

If you are having sleep terrors or sleepwalking episodes, make sure that you are getting enough   sleep, avoid alcohol and cut down on caffeine. You can try some relaxation at bedtime using progressive muscle relaxation, which is described later on in this resource.

Most children will grow out of sleep terrors and sleepwalking without needing treatment. If sleepwalking and sleep terrors are starting to have a very negative effect on your life, there are some behavioural treatments that can be prescribed by a specialist.

Your doctor might want you to have a sleep study to see if you have any other sleep disorders, and occasionally you might be prescribed medications.

What should I do if someone is sleepwalking?

If you see someone sleepwalking, you should gently guide them back to bed, without trying to wake them up. It is wise to take simple precautions, such as locking windows that can be climbed out of, locking doors, removing any breakable items near the bed, or locking away sharp objects such as knives or tools. Setting up a motion-sensitive light in the bedroom may help wake the person up when they start to sleepwalk and may also make it less likely they will hurt themselves when walking around the room.

We all have an internal body clock that tells us when we should be awake and when we should be asleep. In circadian rhythm disorders, this clock is not well synchronised with the outside world. As a result, you may not be able to sleep or stay awake when you need to.

Delayed sleep wake phase disorder (DSWPD)

The most common circadian rhythm disorder is a delayed sleep wake phase disorder (DSWPD). This is where you can’t fall asleep until very late at night. If you could, you would sleep late into the morning or even the afternoon. In extreme cases you might be awake all night and sleep through the day. Unless your lifestyle allows you to go to bed late and wake up late, this can be a problem.

DSWPD can leave you feeling really tired in the mornings and then more awake as the day goes on. You will then feel most awake and full of energy late at night, when other people are ready to fall asleep.

How are circadian rhythm disorders different to insomnia?

Generally, people with circadian rhythm disorders will sleep well when allowed to sleep at their preferred time, unlike people with insomnia who may struggle to sleep at the right time and have poor quality sleep.

What causes circadian rhythm disorders?

Some circadian rhythm disorders have a clear cause. For example, jet lag is caused by traveling across times zones. When you do this, it can take time for your body clock to adjust to the new time zone. Shift work sleep disorder occurs in people who work shifts, particularly night shifts. This means they struggle to stay awake at night when their body expects to sleep and then struggle to sleep in the day when their body expects to be awake.

Other disorders, such as delayed sleep wake phase disorder, are not caused by external or lifestyle factors. They can run in families and so genetics plays a role.

How are circadian rhythm disorders treated?

Certain circadian rhythm disorders can be treated by a specialist, using carefully timed light and a carefully timed medication called melatonin.

Delayed sleep wake phase disorder is common in teenagers and most of them will grow out of it as they enter adulthood. In some cases, people with delayed sleep wake phase disorder might find it more effective to adjust their lifestyle. For example, by:

• choosing a job that allows them to work when they are naturally alert
• or starting classes later in the day. 

You should never drive if sleepy, whether you have a sleep disorder or not. You must stop driving straight away and inform the DVLA if you have:

• confirmed moderate or severe obstructive sleep apnoea, with excessive sleepiness
• narcolepsy or cataplexy, or both
• any other sleep condition that has caused excessive sleepiness for at least 3 months - including suspected or confirmed mild obstructive sleep apnoea

You must not drive until you’re free from excessive sleepiness or until your symptoms are under control and you’re strictly following any necessary treatment. Once the sleepiness has been treated, the DVLA will usually let you resume driving.

Have a regular sleeping and waking routine

Set an alarm for the same time every day, even on weekends. This helps to regulate your body clock. It will also mean that you start feeling sleepy at the same time every night, which can make your sleep more predictable.

Avoid napping if you have insomnia

When you nap in the day you use up some of your sleepiness, which can negatively impact your sleep at night. It can be hard to avoid napping when you are very sleepy, but you will notice that the sleepiness will pass after a while, and you will feel more awake again.

To avoid napping:

• Schedule activities for times of day when you usually feel like napping.
• Bright light, fresh air and physical activity are powerful ways of staying awake. Taking a walk around the block during the day will get you all three!
• Ask your friends or family to be on the lookout. If they see you falling asleep, they should wake you up.
• Sitting or lying down can make you feel especially tired. If you are working at a desk or watching TV on your sofa, try to stand up and move every few minutes.
• Chew gum. Many people find this an effective way to stay awake.
• If it is before 2pm, caffeine can help you to stay alert. Caffeine can take 20–30 minutes to start working. If you know there is a time of day when you are at risk of falling asleep, try having caffeine half an hour before that time.

Be careful how you use caffeine and alcohol

Caffeine can be helpful, but it also hangs around in your body long after you have consumed it, and can negatively affect your sleep. There are also fizzy drinks, and even mints, that contain a lot of caffeine. Stop drinking tea, coffee or anything else with caffeine in it by 2pm. If you want a hot drink in the evening, try something milky or herbal and caffeine-free.

You should also try not to drink a lot of alcohol. It may help you fall asleep, but you will probably wake up during the night. You can find out more about alcohol in our resource on alcohol, mental health and the brain.

Your sleep can also be negatively affected by smoking cigarettes, as nicotine is a stimulant. The same is true of using recreational drugs like cocaine.

Have a wind-down period before bed

It is normal for our minds to become very busy when we get into bed. For many of us it’s the first time all day that we can be alone with our thoughts. So it’s not surprising that our brains become very active when we get into bed and turn out the lights.

To stop this from happening, set aside 30 minutes to a couple of hours before you go to bed where you don’t work, study or do things that cause you to think a lot. Use this time to relax and wind down, and to finish processing your thoughts about what happened during the day. If possible, leave your phone outside your room before you go to bed.

You can also do something at the beginning of your wind-down time to signal to your mind that the day is over:

• Have a warm bath or shower – As well as being relaxing, and giving you time alone with your thoughts, baths and showers raise your body temperature. Doing this an hour or two before bed can improve your sleep.
• Do some of your pre-bed routine – This could be getting into your pyjamas, laying out your clothes for the next day, or checking the doors are locked. These are clear signals to your brain that your day is over.
• Write down your thoughts or worries – Many of us are kept awake at night worrying about things we forgot to do or need to do the following day. Getting these thoughts out of your head and onto paper helps you to let them go. You can then check this list in the morning.

Go to bed when you are sleepy

If you are having difficulty falling asleep or staying asleep, going to bed too early can actually make the problem worse. If you go to bed before you are sleepy you might lie awake for a long time waiting to fall asleep or wake up in the night or very early in the morning. It will also mean that you come to associate your bed with not sleeping. So only go to bed when you are feeling sleepy.

This may mean you go to bed later than you are used to, but with time it will improve the quality of your sleep.

Protect your space

As humans we form associations between places, emotions, and behaviours. When you walk into your favourite restaurant you start to feel hungry, because you know you’re about to eat great food. After a while, just thinking about that restaurant might make you hungry! When we go to bed, we want our brain and body to switch into sleep mode, so we need to associate our bed and bedroom with sleep. To do this:

• Only use the bedroom for sleep, getting dressed and intimacy – Don’t use it for work, study, relaxing or any other activities. Stay out of the bedroom during the day, and if you do need to do something in the bedroom, come straight out again when you’re finished.
• Don’t stay in bed if you are struggling to sleep – Lying awake in bed will strengthen the association between the bedroom and wakefulness. Instead, leave your bedroom and do something relaxing in another room. This could be reading, listening to a podcast or doing a puzzle. Only go back to bed when you feel sleepy.
• If you only have one room, for example, if you live in a university residence, hostel or bedsit, you can still use this technique. When you are working, watching TV or reading a book, avoid doing this on your bed. If your bed is your only furniture, take the bedding off in the day and put it back on when going to sleep. This will help you form an association between your bedding and sleep.

This technique can be very powerful, but it works slowly. It may take several weeks before you notice an improvement in your sleep, and you may sleep a bit worse before you sleep better. But, with time, the bed will become exclusively associated with sleep and the act of going to bed will automatically make you feel sleepy.

Relax when you get into bed

There are lots of different things you can do to relax when you are in bed. The simplest method to relax is Progressive Muscle Relaxation (PMR).

Progressive Muscle Relaxation

Progressive Muscle Relaxation can help you to fall asleep more easily. It’s a skill that will get stronger with practice, so try to do it every night, not just when you are struggling to sleep. This technique can be used when you first get into bed, if you wake up in the middle of the night, or both.

1. Lie down in bed on your back with your arms and legs uncrossed.
2. Close your eyes.
3. Move through your body, selecting a muscle or group of muscles. Tense that muscle or group of muscles for about 5 seconds.
4. After 5 seconds, stop tensing and wait 10–20 seconds before moving on to the next muscle. During that time, think about the muscle you’ve just tensed, noticing how it feels and enjoying the sense of relaxation.

The whole process should take 10–15 minutes, though you might fall asleep before the end. Don’t worry if your mind wanders or whether you are doing it exactly right.

Here is a suggested sequence for tensing your muscles:

1. Raise your eyebrows as high as you can.
2. Squeeze your eyes tight shut.
3. Press your lips together.
4. Pull your shoulders up towards your ears.
5. Pull your shoulders back as if trying to make them meet behind your back.
6. Tense your right bicep by bringing your right hand up to you right shoulder and squeezing. Do the same with your left bicep, bringing your left hand up to your left shoulder.
7. Make a fist with your right hand and squeeze as tight as possible. Do the same with your left hand.
8. Tense the big muscles at the front of your right thigh by making your leg as straight as possible, trying to push the back of your knee into the bed. Do the same with your left thigh.
9. Tense your right calf muscles by pointing the toes of your right foot down as if standing on tip toes. Do the same with your left foot. If your calves cramp when you tense them, you can do this for a shorter amount of time.

What if these tips don’t work?

If you try these tips and you still can't sleep, speak to your GP. You can talk over any problems that may be stopping you from sleeping well and they can check that your sleep problems are not due to a physical illness, prescribed medication, emotional problems or a sleep disorder.

Our internal body clock helps us to be awake in the day and asleep at night. Because of this it can be challenging when you have to work at night or work irregular hours. However, there are some things you can do to manage your sleep and your shifts.

Shift patterns

Where possible, try to work shifts that get progressively later.

Here is an example shift pattern to demonstrate how this could work:

Your body clock adjusts better to shifts that get later rather than earlier. This pattern ensures you have enough time to sleep between shifts.

Working nights

If you work nights, try doing these things:

• Try to nap for as long as possible in the afternoon ahead of your first night shift.
• If you are working a series of nights, ensure that you nap for as long as possible in the afternoons before each night shift.
• If you need to sleep when you get home from your night shift, that is fine as long as it doesn’t interfere with your ability to sleep in the afternoon. If a morning nap does make it hard to sleep in the afternoon, then avoid the morning nap.
• Nap during your night shift if there is a safe and appropriate opportunity to do so. However, if you need to be alert at short notice during the nights, e.g. if you are a doctor on call, then keep the naps to no more than 15 – 20 minutes. If you sleep for longer you may go into a deep sleep, and it will take longer for you to feel fully alert when you wake up.
• Once you have finished your run of night shifts, have a nap in the morning for between one and a half and three hours. Then go to bed early that night to give yourself the opportunity to catch up on the sleep you have lost.
• When working nights keep your mealtimes the same as when working days. Eat breakfast in the morning, lunch in the middle of the day and dinner in the evening. Don’t eat large meals during the night shift – stick to light snacks. This is because your body cannot process food at night as well as it can during the day.
• If you drive home from night shifts, be extra careful as there is an increased risk of falling asleep at the wheel. If you need to drive, consider taking your morning nap before leaving work. If possible, use public transport or speak to your employer about whether they can provide transport after night shifts. If you feel tired at the wheel, pull over straight away and have a nap in your car somewhere safe.

You should never drive if you feel sleepy. It is your legal responsibility to ensure that you are alert enough to drive safely before you get behind the wheel. If you feel sleepy when you are driving, stop the car as soon as it is safe to do so, park somewhere safe like a car park. Take a nap and do not resume driving until you feel completely alert.

The Sleep Apnoea Trust – A charity that supports sleep apnoea patients, their partners and their families.

Narcolepsy UK - Promotes the interests of people with narcolepsy and encourages better understanding of the illness.

Sleepful app
This free app provides people with insomnia with a programme that aims to improve their sleep. It was developed through a series of publicly funded research studies and clinical trials in the UK. 

Sleepio app – Sleepio is a self-help programme that treats insomnia using techniques from CBT. To access Sleepio you will need a referral from your GP.

Sleep disorder clinics. There are a number of Sleep Disorder Clinics, but referral to one of them should be made through your GP. Patients cannot refer themselves.

Bedtime meditation video, NHS – This is a 35-minute meditation video to be used before bed.

Useful reading

Reading Well Agency: Books on Prescription

Reading Well Books on Prescription helps you manage your well-being using self-help reading. The scheme is endorsed by health professionals, including the Royal College of Psychiatrists, and is supported by public libraries. Some books you might find helpful include:

• How to Beat Insomnia and Sleep Problems: A Brief, Evidence-based Self-help Treatment, Kirstie Anderson
• The Secret World Of Sleep: Tales of Nightmares and Neuroscience, by Guy Leschziner

This information was produced by the Royal College of Psychiatrists’ Public Engagement Editorial Board (PEEB). It reflects the best available evidence at the time of writing.

Expert author: Dr Hugh Selsick

Expert by experience: Victoria Bridgland

Full references available on request.