The consequences of sleep deprivation can be dangerous for emergency physicians, with a known increased risk for automobile crashes (Acad Emerg Med 2000;7:1171; Emerg Med Int 2018;2018:4501679; http://bit.ly/2DG4iXf), and for patients through medical errors. (Agency for Healthcare Research and Quality Patient Safety Network; http://bit.ly/2toJUVZ.) Balancing shiftwork with family life and everyday stress takes a toll. We've all been there: the pressure of having to get to sleep for the next shift, the requirement to be awake, alert, rested, and at the top of our game in six, five, four, or three hours.
Emergency physicians can suffer from chronic insomnia disorder, defined as symptoms at least three nights a week for three months (Chest 2014;146:1387) or shift work disorder (Chest 2017;151:1156). Both are well-described clinical entities with significant health consequences. Individuals with chronic symptoms are urged to seek a comprehensive general medical evaluation and help for sleep disorders. The optimal treatment for chronic insomnia is cognitive behavior therapy (CBT), which incorporates multimodal behavioral interventions over several weeks. (Ann Intern Med 2016;165:125; http://bit.ly/2DCEDys; J Sleep Res 2017;26:675; http://bit.ly/2DMuzmW; Indian J Psychiatry 2012;54:359; http://bit.ly/2DGFjmL; BMJ Open 2016;6:e010707; http://bit.ly/2DIOZNo.)
Limited scientific literature addresses short-term sleep problems or their one-night fixes. As with so many topics, the internet offers plenty of unsupported advice, such as the American Alliance for Healthy Sleep. (http://bit.ly/2DK1sAi.)
Prescription and over-the-counter drugs are the most common treatment for insomnia despite well-recognized risks of long-term use. (Psychiatry 2012;54:359; http://bit.ly/2DGFjmL.) A recent survey found that 56 percent of emergency physicians practicing in Canada's Calgary region said they used sleep aids. (Ann Emerg Med 2018. pii: S0196-0644(18)30626-7.) European and American guidelines for insomnia treatment suggest considering pharmacological therapy only when cognitive behavioral therapy alone is unsuccessful or unavailable. (Ann Intern Med 2016;165:125; http://bit.ly/2DCEDys; J Sleep Res 2017;26:675; http://bit.ly/2DMuzmW.)
Melatonin, a hormone that may be useful for specific circadian sleep disturbances (Endocr Rev 2018;39:990) is not recommended in practice guidelines for insomnia. (Ann Intern Med 2016;165:125; http://bit.ly/2DCEDys; J Sleep Res 2017;26:675; http://bit.ly/2DMuzmW; J Clin Sleep Med 2017;13:307; http://bit.ly/2Eb0pec.) Equivalence with placebo was found in 64 percent of randomized trials of insomnia drugs. (Sleep 2015;38:925; http://bit.ly/2SEOC0E.)
Therapeutic options for episodic sleep disturbances include techniques to control the sleep environment, decrease pre-sleep cognitive arousal by taming sleep-inhibiting thought content, and manipulate the underlying neurobiology of sleep.
Daily sleep hygiene (adopting specific healthy bedtime habits and environmental controls that limit distractions and promote healthy sleep) is an essential part of every insomnia treatment regimen. Formalized and extensively studied as stimulus control therapy, sleep hygiene is the most widely studied and endorsed single component behavioral insomnia treatment. (Pediatric Sleep Problems: A Clinician's Guide to Behavioral Interventions. Washington, D.C.: American Psychological Association; 2015; Sleep 2012;35:49; http://bit.ly/2EcfwnQ; Brain Sci 2017;7; http://bit.ly/2EcuL05.) Like exercise and a healthy diet, these practices promote general well-being and are advocated for all. (Indian J Psychiatry 2012;54:359; http://bit.ly/2DGFjmL.)
Sleep hacks are non-pharmacologic interventions that are considered low risk and worth a try when faced with an episode of sleeplessness. Scientific support varies, with few studies and limited sample sizes. Some one-night interventions are single cognitive components of established multimodal CBT regimens. (Sleep Med Rev 2018;42:19.) Unlike traditional insomnia therapy literature, which focuses on older adults, several of these interventions have been studied in adolescents and young adults.
Some regimens decrease sleep latency by reducing unwanted pre-sleep cognitive arousal, the intrusive and worrisome thoughts that prolong falling asleep. Mindfulness, meditation, and relaxation techniques are effective to varying degrees and are facilitated by readily available recordings. (Indian J Psychiatry 2012;54:359; http://bit.ly/2DGFjmL; J Sleep Res 2018;27:e12668.) Cognitive refocusing reduces arousing thoughts by focusing on engaging but non-arousing thoughts, like lyrics of a favorite song, a familiar story, or a film plot. (Behav Ther 2013;44:100.) There is some evidence that a brief session of constructive worry—recording worries and their possible solutions—off the bed and before planned sleep, decreases later pre-sleep arousal. (Sleep Med Rev 2018;42:19.)
Similarly, five minutes of bedtime writing about tasks to be completed in the next few days (a to-do list) reduce sleep latency. (J Exp Psychol Gen 2018;147:139; http://bit.ly/2tp2gGo.) Comparable reductions in sleep onset are produced by pre-sleep imagery distraction. Subjects in a study imagined a situation they found interesting and engaging but also pleasant and relaxing, most commonly holidays or a summer afternoon in the sun. (Behav Res Ther 2002;40:267.)
A third category of sleep hacks attempts to influence the underlying neural mechanisms of sleep. Most people are familiar with white noise, the pure version of which comprises all sound frequencies at equal intensity. Adding white noise to the sleep environment can improve sleep, mainly by masking other sounds. (Rev Lat Am Enfermagem 2017;25:e2926; http://bit.ly/2tnXWHh.) Pink noise (available via smartphone apps and YouTube videos) is a slightly different random noise, a correction of white noise in which each octave carries an equal amount of energy. (Ind Health 1993;31:35.) Pink noise is believed to act directly on the brain to improve sleep quality by synchronizing with and enhancing slow-wave neural activity. (Ind Health 1993;31:35; J Theor Biol 2012;306:68;Trends Neurosci 2018;41:470.)
These hacks offer a safe alternative and are worth a try. Your mileage may vary.
Dr. Frumkinserves as volunteer faculty in the emergency medicine residency at Naval Medical Center in Portsmouth, VA. The views expressed in this article are his own, and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government.Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.