Role of Sleep and Sleep Hygiene in Mental Health: Insights for Healthcare Professionals

It is no secret that mental health and sleep quality are deeply interconnected. But, in the realm of mental health, the importance of sleep and sleep hygiene is often underestimated. Poor sleep can exacerbate symptoms of anxiety, depression, and other mental health disorders – while good sleep can enhance mood, cognitive function, and overall wellbeing. Originally developed to treat mild to moderate insomnia, sleep hygiene is a concept now recognised as a cornerstone in helping to manage various mental health conditions¹. It encompasses both behavioural and environmental recommendations designed to promote healthy and restful sleep².

Understanding sleep and sleep Hygiene, and Its importance for our wellbeing

Good sleep hygiene encompasses a consistent sleep schedule, creating a sleep-friendly environment, establishing a pre-sleep routine, and limiting stimulants to promote consistent, uninterrupted sleep¹. Paying attention to sleep hygiene is one of the most straightforward ways to set oneself up to positively impact both sleep quality and quantity which, in turn, can significantly enhance mental and physical wellbeing²:

• Set a sleep schedule: maintaining a regular sleep schedule is vital. Having a fixed wake-up and bedtime normalises sleep as an essential part of the day, helping the brain and body get accustomed to a full sleep cycle.
• Follow a nightly routine: preparing for bed effectively can determine how easily one falls asleep. A consistent pre-bed routine signals the brain that it’s time to wind down. For example, dimming the lights and avoiding screens for 30-60 minutes before bed helps the production of melatonin.
• Cultivate healthy daily habits: Sunlight is a key driver of circadian rhythms and can encourage quality sleep, while regular exercise also not only makes it easier to sleep but also offers numerous health benefits. Secondly, avoiding nicotine and alcohol is crucial, as both disrupt the body’s ability to sleep. Lastly, restricting in-bed activities to sleep only helps build a mental link between bed and sleep.
• Optimise the Environment: setting a cool temperature, blocking out light with heavy curtains or an eye mask, and drowning out noise with earplugs or white noise machines ensures the ideal environment to help foster good quality sleep.

Good sleep hygiene significantly impacts overall health and daily functioning, and vice versa; a person’s physical health can affect their sleep quality, and chronic sleep deprivation can have consequences on overall wellbeing. Lack of sleep increases the risk of weight gain, dementia, heart attack, stroke, high blood pressure, and type 2 diabetes, among other conditions³ like Alzheimer’s disease⁴. It can also impair daily functioning, negatively impacting memory formation, emotion regulation, attention, and cognitive processing speed and abilities⁴, leading to increased risk of injury from car crashes and work accidents³. Additionally, inadequate sleep weakens the immune response, hindering vaccine efficiency, and can even increase the severity of allergic reactions⁴.

Various factors can influence sleep quality, including physical and mental health, upbringing, and temperament. Poor sleep hygiene, however, can often be one of the most significant contributing factors for a reduction in good quality sleep, as well as exacerbating existing sleep disorders⁵. So, improving sleep hygiene can alleviate some of these issues, though it may not on its own completely cure underlying sleep disorders³.

The science behind sleep and mental health

Understanding the intricate relationship between sleep and mental health is essential for healthcare professionals aiming to provide well rounded, whole person care. Sleep is not just a period of rest but a complex, biologically active process comprised of multiple stages and cycles that all play a vital role in maintaining mental and physical health.

The stages of sleep

Throughout sleep, the brain cycles through different stages, each with unique functions essential for our wellbeing. These stages are broadly classified into Rapid Eye Movement (REM) sleep and non-REM sleep⁶:

• Non-REM sleep: the sleep cycle begins with non-REM sleep, which is divided into four stages. The first stage is the transition between wakefulness and sleep. The second stage involves light sleep, where heart rate and breathing regulate, and body temperature drops. Stages three and four are deep sleep phases, crucial for physical and mental restoration. Though REM sleep was once considered the most critical phase for learning and memory, newer research suggests that non-REM sleep is equally, if not more, important for these processes.
• REM sleep: As the cycle progresses into REM sleep, the eyes move rapidly behind closed lids, and brain waves resemble wakefulness. During this phase, breathing rate increases, and the body experiences temporary paralysis as dreams occur. REM sleep is crucial for memory consolidation, emotional processing, and brain development, as well as helping activate the central nervous system to prepare the body to wake up⁷. The sleep cycle repeats throughout the night, with each cycle spending less time in deep sleep and more in REM sleep.

Biological mechanisms of sleep

Sleep deprivation can profoundly affect the brain and body. It disrupts neurotransmitter balance, stress hormones, and cognitive functions, leading to disruption to mental wellbeing.

• Neurotransmitter balance: REM sleep deprivation affects neuronal excitement; essential for assessing danger and processing reactions to threats⁸. A reduction of non-REM sleep can reduce the release of specific neurotransmitters, impairing the brain’s ability to refresh and restore sensitivity to various hormones⁹, leading to a reduction in cognition⁸.
• Stress hormones: sleep deprivation disrupts the connection between the amygdala and the medial prefrontal cortex; areas of the brain that are critical for emotional regulation^10-11. This disruption results in increased amygdala reactivity to negative stimuli, leading to inappropriate behavioural responses and impaired decision-making^11-12. Additionally, sleep deprivation and disorders activate the hypothalamic-pituitary-adrenal axis, causing neuroendocrine dysregulation and increasing the release of stress hormones like glucocorticoids¹³.
• Cognitive function: the brain requires sleep for synaptic plasticity and maintaining synapse strength. Cognitive abilities – including learning and formation of memories – are significantly impaired after even short-term sleep deprivation¹⁴.

Impact of poor sleep on mental health

The relationship between sleep and mental health is bidirectional, with mental health disorders affecting sleep and vice versa⁴. And so, sleep deprivation is highly comorbid with a huge variety of mental health disorders^15-18:

• Depression: approximately 75% of people with depression experience insomnia or hypersomnia. Poor sleep can exacerbate depressive symptoms, creating a negative feedback loop that worsens both conditions.
• Anxiety disorders: anxiety disorders are strongly associated with sleep problems. Hyperarousal from worry and fear contributes to insomnia, and poor sleep can trigger anxiety in those predisposed to it. PTSD sufferers also often experience nightmares and heightened alertness at night.
• Bipolar disorder: sleep patterns in bipolar disorder vary with emotional states. During manic episodes, reduced sleep is common, while depressive periods may involve excessive sleep. These disruptions can then lead to a triggering or worsening of mood episodes.
• Schizophrenia: insomnia and circadian rhythm disorders are prevalent in people with schizophrenia, often exacerbated by medications. Poor sleep and schizophrenia symptoms can mutually reinforce each other.
• ADHD: People with ADHD frequently struggle with sleep issues, including difficulty falling asleep, frequent awakenings, and excessive daytime sleepiness. Sleep problems can worsen ADHD symptoms like reduced attention span and behaviour issues.
• Autistic Spectrum Disorder (ASD): Children and adolescents with ASD often have persistent sleep problems, such as insomnia and sleep-disordered breathing, which can worsen symptoms and quality of life.

Assessing and improving sleep, and sleep hygiene in patients

Effective assessment and improvement of sleep hygiene are essential for mental health professionals aiming to enhance their patients’ overall mental – and physical – wellbeing. The below information provides a guide that begins to offer key strategies and tools for evaluating sleep patterns, alongside practical techniques for improving sleep hygiene.

Assessing sleep and sleep hygiene

• Sleep diaries: encourage patients to keep a sleep diary to track their sleep patterns over time. This simple tool is really effective in revealing sleep habits, bedtime routines, and potential disruptions, providing valuable insights into their sleep hygiene.
• Questionnaires: use standardised sleep assessment questionnaires, such as the Pittsburgh Sleep Quality Index (PSQI), to measure the quality and patterns of sleep in patients. These tools can help identify sleep disturbances and guide treatment planning.
• Wearable technology: recommend the use of wearable sleep trackers. These devices monitor various sleep parameters, such as duration, quality, heart rate, and movement, offering an objective assessment of sleep patterns. Data from these devices can help identify specific issues and track improvements over time.

Techniques to improve sleep hygiene and sleep quality

Cognitive-Behavioural Therapy for Insomnia (CBT-I): CBT-I is a structured, evidence-based approach to treating insomnia. It explores the connection between thoughts, behaviours, and sleep. A trained CBT-I provider helps patients identify and modify thoughts and behaviours that contribute to insomnia, promoting healthier sleep habits¹⁹.

Relaxation techniques: relaxation techniques can help reduce racing thoughts and tension, enhancing the body’s natural relaxation response¹⁹. Effective techniques include:

• Breathing exercises: slow, deep breathing can lower heart rate and reduce anxiety, promoting relaxation.
• Progressive Muscle Relaxation (PMR): alternating between tensing and relaxing different muscle groups, sequentially, can alleviate physical tension.
• Hypnosis: guided or self-hypnosis can facilitate relaxation and increase the speed of sleep onset.
• Meditation: focusing attention through meditation can reduce stress and anxiety, fostering increased relaxation.

Environmental adjustments: creating a sleep-conducive environment is crucial. Key adjustments can include things like maintaining a cool bedroom temperature, using heavy curtains or eye masks to block out light¹⁹, and earplugs or noise machines to drown out disruptive sounds².

Accessible technologies for monitoring sleep and enhancing sleep quality:

• Sleep trackers: these devices monitor sleep duration and quality, phases, as well as environmental factors²⁰. They have been growing in popularity over recent years²¹, and are now able to provide valuable feedback that can help improve sleep habits. Some trackers even offer personalised tips based on the data collected, helping patients optimise their sleep hygiene²⁰.
• Smart mattresses: these innovative solutions are designed with inbuilt sensors to track sleep and adjust temperature and firmness, smart mattresses can help to enhance sleep quality²². Some are beginning to be integrated with AI²³ to adapt to individual sleep positions and preferences.
• Lighting: light exposure significantly impacts sleep²⁴, as it is linked to our biological circadian rhythms. Innovative sleep lighting technologies, such as smart bulbs and automated window shades, can create a bedroom environment conducive to sleep by mimicking natural light patterns²⁰.
• Sleep environment devices: tools like sound conditioners, air purifiers, and climate control devices can improve the sleep environment²⁰. Sound conditioners, for example, can produce white or pink noise to mask disruptive sounds and help people fall asleep faster and stay asleep easier²⁵, while air purifiers can remove impurities and contaminants from the air, enhancing overall sleep soundness²⁰.

Integrating sleep hygiene into mental health care

The importance of sleep hygiene in mental health care cannot be overstated; the neurobiological morbidities that can occur from a reduction in sleep are profound. Sleep hygiene – encompassing both behavioural and environmental practices – is vital for improving sleep quality and, by extension, overall wellbeing. Promoting better sleep in therapy not only aids in the management of existing mental health conditions but also serves as a preventative measure against the development of future issues.

For more information on how to incorporate these sleep hygiene strategies for mental health professionals into your practice, and to access additional resources, visit Orchestrate Health’s website. If you have patients struggling with sleep and its impact on their mental health, we are here to support you with comprehensive care and expert guidance.

References

1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4400203/
2. https://www.sleepfoundation.org/sleep-hygiene
3. https://www.sleepfoundation.org/physical-health
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17. https://www.sleepfoundation.org/mental-health
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19. https://www.sleepfoundation.org/insomnia/treatment/cognitive-behavioral-therapy-insomnia
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