Can sleep restriction therapy really help my insomnia?

It very well could. If you have chronic insomnia, this approach may sound counterintuitive, even crazy, but it may help some people become better sleepers. Basically, sleep restriction therapy (SRT) involves reducing the number of hours you spend in your bed, which, in turn, makes you sleepier when you eventually do turn in for the night, so that you are more likely to fall asleep quicker. It also makes it more likely that you’ll sleep more deeply and stay asleep longer.

Another way to think about SRT is sleep efficiency therapy. Sleep efficiency is the percentage of time asleep while in bed. Normal is 85 to 95 percent. SRT is performed until 85 percent of the time in bed is spent asleep.

Many factors can affect how SRT is done, including what medications you are taking, what health issues you have, and your age. That’s why it’s best to see a sleep specialist for guidance.

You will be asked to keep a sleep diary for at least a couple of weeks, noting, for example, how long you spend in bed, how long it takes you to fall asleep, what time you wake up, and how much time you actually sleep. You will also list what disturbs your sleep—for example, using a cell phone in bed, drinking coffee near bedtime, or needing to get up to go to the bathroom in the middle of the night are common sleep disruptors.

To make you an efficient sleeper, SRT temporarily shortens your nightly time in bed, to no less than five hours a night, says Jana Cooke, M.D., a sleep specialist and member of our editorial board. If you have trouble falling asleep, you will go to bed later than your current bedtime. Alternatively, if you wake up in the middle of the night or earlier than your desired wake time, you will get up earlier in the morning than your usual time.

Here’s an example of how SRT could be implemented: If you normally get into bed at 11:00 pm and wake up at 7:00 am but don’t actually fall asleep until 1:00 am—that is, you normally get only six hours of sleep a night—then the sleep specialist would instruct you to get into bed at 1:00 am and set your alarm to wake up at 7:00 am. Over a short period of time, the sleep specialist would gradually adjust your schedule and increase your sleep time by having you go to sleep a little earlier or by having you wake up a little later. When doing SRT, once you get out of bed in the morning, you shouldn’t take naps or lie down until it’s bedtime.

For SRT to be effective for chronic insomnia, you must be committed to the technique. It’s not something you try for a few nights here and there. And going through it may not be easy, at least at first. It may be hard getting up with the alarm in the morning or staying up later at night than you usually would. You may experience daytime sleepiness and problems concentrating (but as noted above, no naps allowed).

Some people may not know what to do with the extra time they have to spend out of bed awake, including those who have depression or chronic pain. And it’s not for everyone: You shouldn’t do SRT if you drive or operate heavy equipment or if you have excessive daytime sleepiness, a poorly controlled seizure disorder, or bipolar disorder.

But does SRT—which has been used in clinical practice for more than 30 years—really work? Here’s a sampling of some studies from the past few years:

• A meta-analysis of eight randomized controlled trials published in Sleep Medicine Reviews in 2021 found that SRT improved the amount of uninterrupted sleep and severity of insomnia, compared to control groups, at least in the short term. The researchers noted that more studies are needed to determine the long-term effects of SRT.
• In a study in the journal Sleep in 2022, 56 people with insomnia were randomized for four weeks into either an SRT group or a control group (which went to bed at a regular time but didn’t reduce the hours in bed). The treatment group felt sleepier at night and reported less cognitive arousal.
• In a 2020 study by the same investigators as the study above, the participants were divided into the same two groups for four weeks, and insomnia was assessed over 12 weeks. At weeks 4 and 12, the SRT group had reductions in insomnia severity, improvements in continuous sleep (fewer interruptions), and at 12 weeks, a better quality of life related to sleep. According to the researchers, this was the first study to show that SRT was superior to just maintaining a regular bedtime.

In 2021, a Task Force commissioned by the American Academy of Sleep Medicine conditionally recommended SRT as a solo treatment for chronic insomnia. A conditional recommendation means that healthcare providers should use their best judgment along with patient preferences in making treatment decisions. Though the studies evaluated showed benefits of SRT for insomnia, the Task Force noted that they are few in number and the methodology was often poor.

While some experts use SRT as a stand-alone therapy, it is usually included as part of cognitive behavioral therapy for insomnia (CBT-I), which involves tackling the feelings of frustration and a negative mindset that often come with chronic sleep deprivation. The idea is to make bedtime not something to dread; it may even become something to look forward to. There are three aspects to CBT-I: education, behavior, and cognition. SRT represents one technique in the behavior domain and, according to Dr. Cooke, is generally considered the most effective one in CBT-I.

BOTTOM LINE: If you have chronic insomnia, discuss with your doctor whether sleep restriction therapy (with or without CBT-I) may be a good option for you. Your doctor can refer you to a sleep specialist or behavioral health expert for further evaluation and possible treatment.