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Teralyn Sell, PhD, MS, NCC, LPC, shares 5 foods that can help improve your patients' sleep. They are:

holds a doctorate in psychology and is the founder of Pro Recovery Rx, a supplement line dedicated to supporting brain health for individuals in addiction recovery. She also teaches a class called NeuroHealth Coach, which helps professionals integrate brain health into their daily lives.

These 5 foods can help improve quantity and quality of sleep. 

5 Foods to Improve Sleep

. Many patients with psychiatric disorders will tell us that sleep needs to be addressed,” said Colin A. Espie, PhD, Professor of Sleep Medicine in the Nuffield Department of Clinical Neurosciences at University of Oxford, Clinical Director of the Oxford Online Programme in Sleep Medicine, and Cofounder and Chief Scientist of Big Health.

 Associate Editorial Director, Heidi Anne Duerr, MPH, teamed up with Espie to discuss sleep issues and mental health in the session, “How Big Health Are Tackling Wider Mental Health Issues by Addressing Sleep.” Together, they looked at the prevalence of mental health and insomnia across multiple populations.

“Research has shown that it really is important to address both sleep and psychiatric disorders. If sleep is not addressed in patients with depression or 

, then it could very well exacerbate their psychiatric condition and vice versa,” Duerr shared.

Psychopharmacological options are very important to treat sleep disorders, the pair discussed, but so is 

 (CBT) that is associated with addressing sleep issues.

“CBT is not a treatment, but a family of treatments,” said Espie. “It contains bits that deal with the racing mind, the cognitive element of CBT, and addresses our approach to sleep.”

“In the headlines and in the news, we hear that there are shortages of mental health care professionals who can treat patients, including offering CBT to help patients,” continued Duerr.

The potential solution to such shortages? 

 (DTx) may be poised to step in, so long as they are utilized by empathetic doctors who are ready to be there for their patients. According to Espie, mental health treatment must be given the same respect and be held accountable as any other health care, and DTx are no exception.

“We must give them [our patients] treatments that work,” said Espie. He believes DTx must (1) work correctly, and (2) be provided only after they are validated via randomized, placebo controlled trials.

“Digital therapeutics need to be skillfully made, they cannot just be translations,” said Espie. “We need evidence-based treatments that are sophisticated enough to really help people to implement things in their life that make a difference.”

Something investigators should be aware of, Espie noted, is potential placebo effects of DTx. Just as with regular medications, DTx will not be regarded as effective treatments unless they produce benefit beyond placebo.

From the discussion, it is clear that DTx have the potential to improve patient care—and increase the number of patients receiving care. With more evidence-based research, the availability is likely to increase in the near future.

Digital therapeutics may be poised to step up as the next CBT. 

Need Your Sleep: DTx for Treating Comorbid Insomnia and Psychiatric Disorders

The average patient with bipolar disorder (BD) spends half their life struggling with mood symptoms and the other half struggling with sleep.

 Insomnia persists in 70% of patients even when their mood is stable, and these sleep problems put them at risk for more episodes of mania and depression (

 Some clinicians are liberal with hypnotics, while others prefer the lower abuse potential of sedating antidepressants like trazodone. Both these approaches have problems. Fortunately, there are also new therapies that improve mood and sleep by entraining the circadian rhythm (

 or z-hypnotic (eg, eszopiclone, zaleplon, zolpidem) could halt the progression of insomnia into mania, but the idea has never been adequately tested. These GABAergic hypnotics lack controlled trials in BD, and the few observational studies paint a mixed picture. A chart review of 278 z-hypnotic trials in adolescents with BD concluded that the drugs improved 

 in 40% to 60% of patients and did not lead to abuse with long-term use.

 On the other hand, reports document 30 cases of high doses of zolpidem and regular doses of alprazolam and triazolam inducing mania.

In contrast, clonazepam and lorazepam appear safer, with small controlled trials suggesting that these agents do not worsen, and may improve, manic symptoms (the 

 were not used as hypnotics in these trials).

 However, over the long term, benzodiazepines carry risks of tolerance and dependence, and long-term use may worsen cognition and mood in BD, according to nonrandomized studies that attempted to control for the confounding tendency to prescribe benzodiazepines in more severe cases.

 in BD is to choose mood stabilizers with sedative effects. Many antipsychotics are sedating, but some have more meaningful benefits in sleep quality; these include quetiapine in particular, and possibly lumateperone, olanzapine, 

Lithium is rarely sedating, but it does have positive effects on the circadian system, such as dampening the phase-advance (“night owl”) tendency that is associated with poorer health and greater risk of depression.

Sedating antidepressants are more problematic, particularly in bipolar I disorder, in which the risk of manic induction is high. Most, including trazodone and 

, are associated with case reports of triggering mania. In a retrospective study, patients with BD who used sedating antidepressants for sleep were significantly more likely to develop mania and episode acceleration than those who took traditional hypnotics.

Melatonin agonists have captured the interest of investigators because of their potential to realign the circadian system, which is often disrupted in BD. Pure melatonin failed to improve sleep, 

, or rapid cycling in 2 small controlled trials,

 but the melatonin agonist ramelteon has intriguing results from 3 industry-sponsored, randomized, placebo-controlled trials in BD. Although ramelteon failed to improve sleep or mania, it did prevent depression in patients who struggled with insomnia.

The first study tested ramelteon in 21 patients with acute mania and found a reduction in depressive symptoms but no benefit in mania or sleep.

 Next, ramelteon was tested in 83 patients with BD who had active 

 but stable mood. For 6 months, they took either placebo or a nightly dose of ramelteon 8 mg. As in the first trial, ramelteon did little to improve sleep (there was only a nonsignificant trend), but it did lower the risk of depression, more than doubling the time to a new episode from 84 to 188 days (P = .02).

 A larger study attempted to replicate that finding, but the results were negative across all outcomes.

One explanation for these intriguing results is that the positive trials enrolled patients with active insomnia, while the negative trial did not, suggesting that ramelteon might have preferential effects in patients with disturbed circadian rhythms. But then why didn’t the drug improve their sleep? These studies relied on subjective measures of sleep, and ramelteon has a poor track record on subjective outcomes. In primary insomnia, it improved subjective sleep onset by only 4 minutes over placebo and objective sleep onset by 9 minutes. 

 showed the reverse pattern, improving subjective onset by 14 minutes but objective onset by only 4 minutes (placebo, by the way, is no dud, and improved sleep onset by 8 to 20 minutes).

One thing to take away from this is the importance of setting realistic expectations when starting patients on ramelteon. This hypnotic is not like the others: It is relatively nonsedating and has no anxiolytic, amnestic, or rewarding effects. On the one hand, those qualities improve on its safety, but they are unlikely to endear it to patients with BD, who often want a hypnotic to quiet the anxious, racing thoughts that rev up as they try to fall asleep. Ramelteon will do none of that, but nor will it cause patients to fall, overuse their medication, or engage in complex sleep behaviors like cooking or driving in the middle of the night. One positive aspect that most patients appreciate is the lack of tolerance and withdrawal with ramelteon. Rather than wearing off, ramelteon’s sleep benefits built up over weeks to months in some studies.

While ramelteon is a melatonin agonist, dark therapy is a behavioral treatment that enhances endogenous melatonin by keeping patients in a pitch-dark room overnight. Dark therapy was developed by Thomas Wehr, MD, who speculated that evening darkness might improve sleep and mania in the same way that morning light improves 

 and circadian rhythms. In the 1990s, he recruited normal participants with mild sleep problems to the National Institute of Mental Health, where they stayed in a pitch-dark room overnight from 6:00 pm to 8:00 am. After a few weeks of this dark therapy, their sleep improved.

 Next, he turned his attention to BD, and found that the same protocol stabilized refractory rapid cycling.

Further studies supported Wehr’s observation, but it was not until the discovery of blue light–blocking glasses that dark therapy became practical for everyday use. In theory, the physiologic changes associated with total darkness might be achieved by 

, because the receptor that regulates melatonin secretion—melanopsin—responds only to the blue spectrum. The hope in that theory is that patients might be able to practice dark therapy while still being able to see in the evening.

Psychiatrist James Phelps, MD, first tested that hope in private practice, and his results were later confirmed in a randomized, placebo-controlled trial in Norway. For the entire evening from 6:00 pm to 8:00 am, patients hospitalized with acute mania wore blue light–blocking glasses or, if sleeping or trying to sleep, stayed in a pitch-dark room without the glasses. Within a week, their 

 improved with a large effect size (1.86) compared with a placebo group that wore gray glasses.

The dark therapy protocol can be gradually relaxed after recovery, allowing patients to put the glasses on a few hours before bed to prevent future episodes. That relaxed protocol also improves the sleep, according to 3 randomized controlled trials in primary insomnia. Wearing blue light–blockers 1.5 to 3 hours before bed helped patients fall asleep earlier and stay asleep longer, and improved sleep quality as well as mood and 

 However, blue light blockers do not have a strong sedative effect. In line with their circadian mechanism, they improve the regularity of sleep more than they improve subjective measures of insomnia.

A critical step in dark therapy is finding glasses that filter close to 100% of blue light. Lenses that were tested in clinical trials include Uvex Skyper S1933X, Uvex Ultra-spec 2000 ($10 to $15) and, for more comfort at a higher price, glasses at lowbluelights.com ($50). More information on the nuts and bolts of dark therapy is available in the Psych Pearls podcasts from August and October 2021.

Cognitive behavioral therapy for insomnia (CBT-i) is thought to work by stabilizing the circadian system, making it a natural fit for mood disorders. In unipolar depression, CBT-i improves mood and sleep, but the therapy is often avoided in BD because it requires patients to limit their time in bed, raising concerns that this sleep deprivation could trigger mania. In 2015, Allison Harvey, PhD, and colleagues at the University of California – Berkeley modified the CBT-i protocol to include a built-in safety valve for BD (CBT-iBD). The newer therapy limits bed restriction to no fewer than 6.5 hours.

CBT-iBD also includes techniques to address common circadian rhythm abnormalities in BD, such sleep inertia (a prolonged sense of grogginess in the morning) and nocturnal hyperactivity. To counter these sleep-disrupting tendencies, patients develop a wake-up routine encompassing bright light and energizing activity, and an evening wind-down routine in which the lights are dimmed and 

To test the therapy, Harvey recruited 58 patients with stable BD but active insomnia and randomized them to CBT-iBD or a psychoeducational therapy. At the end of the 8-week therapy, patients in the CBT-iBD group were sleeping better compared with controls, but more profound changes came later. After 6 months, those who learned CBT-iBD had an 8-fold reduction in mood problems, spending an average of 3.3 days in a mood episode vs 25.5 days for controls.

Later, Bryony Sheaves, DClinPsy, BSc, CPsychol, and colleagues adapted CBT-iBD for patients with schizophrenia, major depression, and BD in an inpatient crisis unit. The 2-week program improved sleep and well-being, and it hastened discharge by 8.5 days compared to treatment as usual.

It can be difficult to find therapists who practice CBT-insomnia, but the core program is available through a prescription app (Somryst) or a free, VA-sponsored app (CBT-i Coach). These programs can be adjusted for BD with the modifications described above.

Dark therapy and CBT-i are safe in the young and old, and a few tips can help adapt these treatments for different ages. Adolescents often have severe night-owl tendencies, which can be corrected by having the patient wake up 15 to 30 minutes earlier each day and wearing blue light–blockers in the early evening (eg, 5:00 pm to 8:00 pm). Napping is common in older adults but is discouraged in the CBT-i protocol. One compromise is to have the patient eliminate naps during the therapy, and then gradually add them back in once regular sleep is restored. Then they can continue the naps as long as they do not cause a relapse into insomnia. Finally, for patients of all ages who are afraid of the dark, there are nightlights that emit zero blue light (at lowbluelights.com and Amazon).

Although no hypnotics are FDA approved in children and adolescents, lithium and several antipsychotics (eg, quetiapine) are approved for them. In the elderly, the risks of falls and cognitive impairment have placed most hypnotics on the “inappropriate” list of the Beers criteria, although ramelteon is well studied in older adults and approved by the Beers.

Treating insomnia in BD is both an art and a science, requiring practitioners to balance the patient’s goal of rapid sedation with the more therapeutic approach of retraining the circadian rhythm. Circadian therapies like ramelteon, dark therapy, and CBT-insomnia have a slow build, but they promise more lasting and substantial benefits for mood and sleep than fast-acting hypnotics.

is the Mood Disorders Section Editor for 

, Editor in Chief of The Carlat Psychiatry Report, and director of the Mood Treatment Center. The author does not accept honoraria from pharmaceutical companies but receives royalties from PESI for The Depression and Bipolar Workbook and from W.W. Norton & Co for

 Bipolar, Not So Much: Understanding Your Mood Swings and Depression.

1. Judd LL, Schettler PJ, Akiskal HS, et al. 

Long-term symptomatic status of bipolar I vs bipolar II disorders.

2. Harvey AG, Soehner AM, Kaplan KA, et al

. Treating insomnia improves mood state, sleep, and functioning in bipolar disorder: a pilot randomized controlled trial.

3. Schaffer CB, Schaffer LC, Miller AR, et al. 

Efficacy and safety of nonbenzodiazepine hypnotics for chronic insomnia in patients with bipolar disorder.

4. Sabe M, Kashef H, Gironi C, Sentissi O. 

Zolpidem stimulant effect: induced mania case report and systematic review of cases.

Prog Neuropsychopharmacol Biol Psychiatry.

A case of alprazolam, but not lorazepam, inducing manic symptoms.

6. Singh J, Skrzypcak B, Yasaei R, Mangat N. 

Triazolam-induced mania in a patient with bipolar I disorder following a dental procedure.

Clonazepam and lorazepam in acute mania: a Bayesian meta-analysis.

8. Cañada Y, Sabater A, Sierra P, et al. 

The effect of concomitant benzodiazepine use on neurocognition in stable, long-term patients with bipolar disorder.

9. Perlis RH, Ostacher MJ, Miklowitz DJ, et al. 

Benzodiazepine use and risk of recurrence in bipolar disorder: a STEP-BD report.

The effect of second-generation antipsychotic drugs on sleep parameters in patients with unipolar or bipolar disorder

11. Xu N, Shinohara K, Saunders KEA, et al. 

Effect of lithium on circadian rhythm in bipolar disorder: a systematic review and meta-analysis.

12. Saiz-Ruiz J, Cebollada A, Ibañez A. 

Sleep disorders in bipolar depression: hypnotics vs sedative antidepressants.

13. Quested DJ, Gibson JC, Sharpley AL, et al. 

Melatonin in acute mania investigation (MIAMI-UK). A randomized controlled trial of add-on melatonin in bipolar disorder.

14. McElroy SL, Winstanley EL, Martens B, et al. 

A randomized, placebo-controlled study of adjunctive ramelteon in ambulatory bipolar I disorder with manic symptoms and sleep disturbance.

15. Norris ER, Burke K, Correll JR, et al. 

A double-blind, randomized, placebo-controlled trial of adjunctive ramelteon for the treatment of insomnia and mood stability in patients with euthymic bipolar disorder.

16. Mahableshwarkar AR, Calabrese JR, Macek TA, et al. 

Efficacy and safety of sublingual ramelteon as an adjunctive therapy in the maintenance treatment of bipolar I disorder in adults: a phase 3, randomized controlled trial.

A review of ramelteon in the treatment of sleep disorders.

19. Barbato G, Barker C, Bender C, et al. 

Extended sleep in humans in 14 hour nights (LD 10:14): relationship between REM density and spontaneous awakening.

20. Wehr TA, Turner EH, Shimada JM, et al. 

Treatment of rapidly cycling bipolar patient by using extended bed rest and darkness to stabilize the timing and duration of sleep.

21. Henriksen TE, Skrede S, Fasmer OB, et al. 

Blue-blocking glasses as additive treatment for mania: a randomized placebo-controlled trial.

Amber lenses to block blue light and improve sleep: a randomized trial.

23. Shechter A, Kim EW, St-Onge MP, Westwood AJ. 

Blocking nocturnal blue light for insomnia: a randomized controlled trial.

24. Zimmerman ME, Kim MB, Hale C, et al. 

Neuropsychological function response to nocturnal blue light blockage in individuals with symptoms of insomnia: a pilot randomized controlled study.

25. Aiken C, Newsome K. Blue light blockers: a behavior therapy for mania. 

. October 7, 2021. Accessed December 23, 2021. 

https://www.psychiatrictimes.com/view/blue-light-blockers-behavior-therapy-for-mania

26. Janků K, Šmotek M, Fárková E, Kopřivová J. 

Block the light and sleep well: evening blue light filtration as a part of cognitive behavioral therapy for insomnia

Interventions for sleep disturbance in bipolar disorder.

The average patient with bipolar disorder struggles with sleep disorders. Here's how you can help. 

New Directions for Insomnia and Bipolar Disorder

There is increased recognition of sex differences in the epidemiology and phenomenology of 

. For example, compared to males, females have a slightly lower incidence of the disorder, a later age of onset, and more depressive symptoms.

 Such sex differences may be mediated, in part, due to neuroprotective effects of estrogen.

 By contrast, findings regarding sex differences in cognition in schizophrenia are inconsistent.

 Insomnia is also common in the clinical course of schizophrenia.

 In the general population, insomnia is associated with greater cognitive impairment, but its association (and potential sexual dimorphic effect) in schizophrenia is less clear.

“Ms Smith” is a 50-year-old Caucasian female with a 20+ year history of schizoaffective disorder, bipolar type, and a remote history of a cerebellar hemorrhagic stroke. She has been on a stable dose of antipsychotic medication for the past 10 years, prior to which a clozapine trial was discontinued due to tolerability and adverse effects. She chronically sleeps 3 to 5 hours per night, with both initial and terminal 

. She has chronic auditory hallucinations, thought insertion, and persecutory beliefs. She also has chronic cognitive impairment, thought to be in part due to not only her chronic psychotic illness, but also a sequela of the past cerebellar infarct. She graduated with a 2-year technical degree after high school. She has completed different forms of the Digit Symbol Coding test at multiple outpatient psychiatric clinic visits over the years, with a mean (SD) score of 31±4. A trial of adjunctive 

 for residual positive symptoms of psychosis was discontinued due to exacerbation of cognitive impairment.

Zhu and colleagues investigated sex differences in insomnia and 

 in a large sample of Chinese patients with chronic schizophrenia.

 They recruited 718 patients (480 males and 238 females) with chronic schizophrenia from 2 psychiatric hospitals and 397 healthy controls (169 males and 228 females) without a personal or family history of psychiatric or neurological disease. Inclusion criteria for patients were age 17 to 70, Chinese Han ethnicity, DSM-IV diagnosis of schizophrenia, and stable antipsychotic dose for > 6 months. Patients were excluded if they had a history of neurological disease, severe medical comorbidity, head injury, pregnancy or lactation, or history of drug or 

Insomnia was assessed as both a categorical (yes/no) and a continuous measure with the Insomnia Severity Index (ISI). Symptoms were rated using the Positive and Negative Syndrome Scale (PANSS). Cognition was evaluated with the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). The authors used 2 x 2 ANOVA (insomnia x sex) and Spearman correlation coefficients to investigate sex differences in clinical variables in patients with and without 

The mean subject age was 46. There was a significantly increased prevalence of (categorical) insomnia in females versus males with schizophrenia (25.6% versus 18.3%, OR=1.54). Females with schizophrenia also had significantly higher PANSS total and subscale scores. Males with schizophrenia had higher (better) RBANS total, visuospatial/constructional, and language scores than females. In both males and females with 

, patients with (categorical) insomnia had higher PANSS scores than those without insomnia. By contrast, there was no difference in RBANS scores in males with versus without insomnia. However, females with insomnia had lower RBANS total and subscale scores. As a continuous measure, ISI scores were significantly, negatively correlated with RBANS total scores, language, attention, and delayed memory scores in males (ρ=-0.14 - -0.12 for each). By contrast, ISI scores were significantly negatively correlated with RBANS total scores (ρ=-0.18) and immediate memory (ρ=-0.19) scores in females.

The authors concluded that females with schizophrenia had an increased prevalence of insomnia and greater 

 than males. They also found sex differences in correlations between insomnia and cognition in these patients. Study strengths included the large cumulative sample size. Study limitations included the cross-sectional study design and the nonstandardized antipsychotic (and other) medications in the study sample. Future studies should consider associations between insomnia and cognition using a longitudinal design and also in first-episode and antipsychotic-free patients with schizophrenia.

Findings support evidence for sex differences in insomnia and cognition in patients with schizophrenia. Given associations with more severe symptoms and greater cognitive impairment, insomnia represents an important potential treatment target in this patient population.

is professor in the Department of Psychiatry and Health Behavior, Augusta University, Augusta, Georgia. He is on the Editorial Board and serves as the schizophrenia section chief for 

The author reports that he receives research support from Augusta University, the National Institute of Mental Health, and the Stanley Medical Research Institute.

Sex and gender differences in schizophrenic psychoses.

Gender differences in schizophrenia and first-episode psychosis: a comprehensive literature review.

Oestrogens, prolactin, hypothalamic-pituitary-gonadal axis, and schizophrenic psychoses.

Prevalence of insomnia and clinical and quality of life correlates in Chinese patients with schizophrenia treated in primary care. 

Sex difference in association between insomnia and cognitive impairment in patients with chronic schizophrenia.

Thinking about sex and sleep in schizophrenia: Researchers performed a large cross-sectional study of sex differences in insomnia and cognition in chronic schizophrenia.

Sex Differences in Insomnia and Cognition in Schizophrenia

Recently, investigators conducted a narrative literature review of affective disorders and sleep difficulties in children and young people, seeking to understand the relationship between sleep and both depression and bipolar disorder.

Monica Comsa, FRACP, Child and Adolescent Mental Health Service, Cumbria Northumberland, Tyne and Wear NHS Foundation Trust, UK, and colleagues found that parasomnias, narcolepsy, and sleep-related movement disorders are associated with depression in children and adolescents. Additionally, children and adolescents with depression can present with a number of sleep difficulties, which are also associated with several other issues, such as higher depression severity, greater fatigue, suicidal ideation, physical complaints, pain, and decreased concentration. 

On the other hand, insomnia, obstructive sleep apnea, and circadian rhythm disorders are associated with both depression and bipolar disorder in children and adolescents. Sleep difficulties can occur before, during, and after an episode of depression or bipolar disorder.

“Sleep disturbances among adolescents with bipolar disorder can affect the severity of depressive and manic symptoms, are a poor prognostic indicator, and have been associated with social and academic impairment,” said Comsa and colleagues.

These sleep difficulties may be the result of medication. According to the investigators, antidepressants and antipsychotics can directly affect sleep architecture, and clinicians should be cognizant of this problem when prescribing and might instead consider nonpharmacological interventions. These interventions for sleep problems might minimize the risk of relapse in affective disorders.

Investigators suggested a multi-modal approach to target both the affective and specific sleep disorders is the ideal treatment plan: “Psychoeducation, consistent sleep-wake schedules and tailored interventions for addressing sleep problems should play an important role in the prevention and treatment of mental health difficulties, at any age. Concomitantly addressing sleep problems can lead to an increased remission rate of depression.”

More research is required to understand the impact of combined interventions on clinical outcomes, concluded investigators.

“Of most importance is the impact of specific treatment for sleep disorders on the long-term outcome of affective disorders. Clinicians need to know if better nights reliably lead to better days.”

1. Comsa M, Anderson KN, Sharma A, et al. 

The relationship between sleep and depression and bipolar disorder in children and young people.

Sleep, depression, and bipolar disorder: what's the connection? 

Sleepy Link: Sleep, Depression, & Bipolar Disorder in Children and Adolescents

Research shows that a combination of sleep knowledge and education about sleep can have a substantial impact on a person’s sleep habits. An often underrecognized fact is that healthy sleep habits are not intuitive, and attitudes about sleep vary widely. Inconsistent sleep schedules, sacrificing sleep, poorly timed naps, and use of electronics before sleep are all common habits among individuals of all ages, including those with and without sleep disorders. These habits can lead to consequences like behavioral and emotional issues, even among individuals who do not fit the criteria for a psychiatric diagnosis.

For example, a study assessing parental practices among parents whose children were enrolled in an early child education program showed that 81% of the parents surveyed believed that their children had healthy sleep habits, yet 50% and 33% of the children had unhealthy bedtime practices and insufficient sleep that were not recognized as such by their parents.

 These habits may lead to lifelong sleep problems if parents and children are not provided with the correct information about the importance of sleep and instructed about safe and effective ways to improve sleep quality and quantity.

Older adults often have sleep practices that can be detrimental to emotional and health as well. A large study that included 2312 participants aged 65 and older showed a high prevalence of insufficient sleep that was found to be associated with a sedentary lifestyle and an overall lack of physical activity.

Sleep knowledge and attitudes include several different components. One study conducted at the Department of Psychological Science at the University of North Carolina at Charlotte defined 3 separate components of sleep attitudes:

1) A cognitive component includes a person’s beliefs about the importance and necessity of adequate sleep.

2) An emotional component involves having a positive evaluation of the necessity of sleep.

3) A behavioral component involves taking action to make time for sleep in a person’s schedule.

The study found that participants who reported positive attitudes about sleep also experienced longer sleep duration, better sleep quality, and better sleep hygiene.

 Of these 3 interrelated components, it is the behavioral that has the most definitive impact, as it is a necessary factor in actually achieving adequate sleep. However, most individuals would not take the steps to incorporate the behavioral component in the absence of the cognitive and emotional components, so they are all key factors.

Another study used objective measures tracked by a Fitbit Flex accelerometer for 7 days to assess sleep among a group of 218 college students. Interestingly, while the study also showed that sleep attitudes were directly associated with longer sleep duration and better sleep quality, the researchers found that greater sleep knowledge did not correlate with these outcomes.

 These results suggest that a fundamental comprehension about the benefits of sleep and a baseline knowledge of the effective ways to attain good sleep are not enough to impact a person’s daily sleep habits and sleep outcomes. It appears that the attitudes a person has about sleep play a far greater role than pure knowledge when it comes to influencing behavior.

Of course, a positive attitude about sleep must be paired with accurate knowledge, as even the most well-intentioned patient can potentially attempt to use methods for sleep that are not beneficial. These can include drinking alcohol before bed, which many believe promotes healthy sleep, but can reduce the quality of a person’s sleep. For individuals who do not have sleep problems, interventions to improve sleep can include a variety of strategies, including stress management, relaxation, stimulus control, sleep hygiene, and exercise.

It is not uncommon for people to underestimate the importance of sleep and its impact on health. For instance, workaholism and competitive sleep deprivation are common among highly productive individuals—even health professionals. The outcomes can lead to interpersonal relationship difficulties, and in some instances, may lead to a referral for a psychiatric or psychological evaluation.

Physicians can help promote accurate sleep knowledge and healthy sleep attitudes for patients. Cognitive and behavioral interventions have been shown to have a positive impact on sleep,

 and these interventions can have lasting effects once patients experience an improved quality of life with less daytime fatigue, improved mood, and better productivity after adopting them.

; clinical assistant professor, Case Western Reserve University School of Medicine, Division of Medical Education; and editor in chief emeritus of 

Sleep health literacy in head start families and staff: exploratory study of knowledge, motivation, and competencies to promote healthy sleep

2. Ortolá R, García-Esquinas E, Cabanas-Sánchez V, et al. 

Association of physical activity, sedentary behavior, and sleep with unhealthy aging: consistent results for device-measured and self-reported behaviors using isotemporal substitution models

Association of sleep attitudes with sleep hygiene, duration, and quality: a survey exploration of the moderating effect of age, gender, race, and perceived socioeconomic status

Direct and indirect associations of sleep knowledge and attitudes with objective and subjective sleep duration and quality via sleep hygiene

5. Murawski B, Wade L, Plotnikoff RC, et al. 

A systematic review and meta-analysis of cognitive and behavioral interventions to improve sleep health in adults without sleep disorders

How can knowledge—and positive attitudes—about sleep improve quality of life for patients?

Sleep Attitudes Influence Sleep More than Knowledge

Borderline personality disorder has many clinical features, including relatively unrecognized sleep disturbances. Generally, sleep problems are not considered a primary characteristic of this condition, but research is beginning to identify specific patterns of sleep disruptions that are associated with the disorder.

 is characterized by substantial emotional instability, relationship strains, behavioral problems, and difficulties with self-image. It is disruptive for the person who has the disorder, as well as for other individuals in their lives. There is no effective or recommended pharmacological treatment for this chronic disorder. The clinical management, which consists of behavioral and cognitive therapies, is challenging.

 differ from the criteria for diagnosis of bipolar disorder, there are some similarities, and it can be difficult at times to differentiate the 2 conditions.

 Bipolar disorder is a psychiatric disorder characterized by fluctuations in mood and energy levels, often with features of 

 and depression. Borderline personality disorder and bipolar disorder can both profoundly interfere with an affected patient’s quality of life, and they both often cause mood instability, hopelessness, and other overlapping symptoms. Unlike borderline personality disorder, 

 is often treated with prescription medication, along with counseling and behavioral therapy. A 

 of either of these disorders can delay proper referral to a psychiatrist or behavioral specialist and delay the timely implementation of appropriate therapy.

Several studies have shown that patients who have borderline personality disorder experience substantial variability in their sleep times from night to night when compared with the general population. These trends have been documented by clinical history and questionaries, and objectively with actigraphy and polysomnogram studies.

 is a disruptive condition that causes fluctuations in sleep rhythms, with phase delay and misaligned rest-activity pattens. Patients who have circadian rhythm sleep disturbance can experience irregular sleep patterns, with inconsistency and unpredictability from day to day. This causes a lack of adequate sleep, as well as low energy and concentration during the day. This sleep disturbance has been associated with borderline personality disorder.

Furthermore, the severity of certain symptoms of borderline personality disorder has been shown to correlate with certain actigraphy patterns that demonstrate daytime and nighttime abnormalities that are consistent with circadian sleep disturbance. In one study, patients who carried a diagnosis of borderline personality disorder and who had high levels of impulsivity and mood instability showed substantial phase delayed daytime activity patterns, low inter daily stability, weak amplitude, and greater fragmentation of rest activity states over a study duration of 28 days.

 These patterns were not noted in the study participants who had a diagnosis of 

 or in the controls. Another study showed that patients with borderline personality disorder had delayed phase of nighttime rest patterns, delayed daytime activity onset, as well as delayed temperature phase, while controls and patients who had bipolar disorder did not exhibit these features.

While there appears to be a correlation between the severity of symptoms of borderline personality disorder and circadian rhythm dysfunction, the clinical implications have not been established, nor has any specific cause-and-effect relationship. Whether the emotional and behavioral aspects of borderline personality disorder affect circadian rhythm regulation, or the circadian rhythm dysregulation affects symptoms of borderline personality disorder is not clear. The distinct differences in circadian rhythm disturbance patterns between patients with borderline personality disorder and patients with bipolar disorder that has been replicated in several studies is interesting, especially given the similarities between the 2 conditions.

Circadian rhythm disturbance is objectively quantifiable, but difficult to treat, and these observations do not clearly provide direction for the treatment of borderline personality disorder. However, awareness and treatment of sleep disturbances are important aspects of patient management. Screening tests, including interviews and actigraphy, can identify 

 that patients might not have otherwise reported if they did not know those problems were abnormal. Patients who would benefit from appropriate therapy for their sleep disorder may experience an improved quality of life if treatment is implemented. Furthermore, the diagnostic signs can potentially provide an adjunct in the diagnostic process for patients when borderline personality disorder is considered in the differential diagnosis. Because borderline personality disorder lacks objective criteria, it is possible that some patients may feel empowered, heard, and understood when they are made aware of an objective feature of their condition. This may potentially improve compliance with treatment for some patients.

Self-report screening instruments differentiate bipolar disorder and borderline personality disorder.

Sleep disturbances in borderline personality disorder are relatively unrecognized. 

Sleep Disorders

5 Foods to Improve Sleep

Need Your Sleep: DTx for Treating Comorbid Insomnia and Psychiatric Disorders

New Directions for Insomnia and Bipolar Disorder

Sex Differences in Insomnia and Cognition in Schizophrenia

Sleepy Link: Sleep, Depression, & Bipolar Disorder in Children and Adolescents

Sleep Attitudes Influence Sleep More than Knowledge

Sleep Patterns in Borderline Personality Disorder

Daridorexant: Improvement on Measures of Sleep Onset and Sleep Maintenance

Research Shows dCBT May Help Prevent Postpartum Depression

Is Insomnia a Predictor of Mental Illness?