Sleep difficulty (both falling asleep and staying asleep) is a common symptom of anxiety and depression.  It can also significantly worsen anxiety and low mood.  For these reasons, improving sleep should always be one of the goals of your treatment.  With a consistent routine and modified behavior, sleep quality can improve over time.  Here are some helpful tips!

1) Establish a consistent bedtime and wake up time.  

The recommended number of hours of sleep are listed below by age.  Since wake-up times are usually set by either school or work, you may need to adjust your bedtime to achieve these goals.

If you have a very hard time waking up each morning or feel constantly drowsy throughout the day or find yourself falling asleep every chance you get (ex. in the car, while doing homework, etc) or feel excessively grumpy and/or hyper, you are NOT likely getting enough sleep during the night so you should adjust your bedtime accordingly. 

2) Do NOT significantly change your bedtime and wake-up time during weekends. 

While you may not need to be as strict with wake-up times on weekends and during school breaks, try to keep your bedtime and wake-up time within 1-2 hours window from your weekday schedule.  The weekend and short breaks (3-4 days) are just NOT long enough for your brain to adjust back and forth.  Wide inconsistency between the weekdays and weekends can worsen sleep problems.

3) Adjust for your sleep needs.

In some cases, especially with younger kids, a bedtime may be too early because you do not actually need as much sleep and are not tired.  Then, of course, you will not be able to fall asleep quickly.  Different children of the same age can need different amounts of sleep. Guidelines do not fit every person.  Knowing this, it is often effective to temporarily push back the bedtime to way past when you would normally go to bed, waiting until you are truly super sleepy. If you try this trick, keep the same wake-up time.  Otherwise, you will end up with a sleep schedule that is just shifted over and not actually much different.  Then slowly pull the bedtime earlier and earlier to a reasonable but not-too-early hour, taking advantage of the natural sleepiness that will occur due to the early wake up time.  Your body will eventually learn that sleep is a good solution for sleepiness!  However, do NOT ignore signs that you are not getting enough night time sleep (as described above) and if you do detect them, it means your body DOES need more sleep than you think!  Keep pulling the bedtime forward until you no longer see/feel these signs!

 4) Avoid naps.

Occasional naps can be pleasant but be wary of developing a habit of regular naps.  This can disturb your sleep schedule and trap you into a vicious cycle of trouble falling asleep, difficulty waking up in the morning, and feeling sleepier during the day.

 5) Start dimming the lights in your room about an hour before bedtime.  

This starts sending a signal to your brain to start winding down.  Doing this with a soothing activity (warm bath in a dimly lit bathroom, listening to calming music, or a sleep meditation) can be very effective in sending the right signal.

 6) Aim to turn off all screens (including phones) at least 1 hour prior to bedtime.   

This is a tough one for everyone, especially for teens who have lots of activities and homework!  We understand that this may not always be possible if you need to use your computer to do your homework but do try to get off as soon as you are done with your work or leave non-screen related work towards the end of the night.  While watching a show on your phone or browsing the internet may seem like a physically relaxing activity, it is a very stimulating activity for your brain.  People who use their screens right up to their bedtime generally have a harder time falling asleep and/or staying asleep.  

7) Remove and charge your electronics (phones, laptops, iPads) outside of the bedroom or at least place on Sleep or Do Not Disturb mode for the night.

It is a good habit for everyone to learn to "unplug” for the night and remove all temptation from the bedroom.  In the very least, put screens physically across the room, as far away from the bed as possible. 

 8) Do NOT keep TVs or gaming systems in bedrooms.

The temptation to switch on the TV or a “quick” round of gaming is just too much for anyone!  Get the temptation out of the bedroom!

 9) Only use your bed for sleep and reading before bed.

People often use their beds to do schoolwork, watch their favorite shows, text their friends, or even eat.  Reserving the bed only for sleeping will set your brain up with an expectation of sleep whenever you physically get into bed.

 10) Consider a mattress upgrade!

Foam cloud mattresses or foam mattress covers can create a more comfortable, “sinking in” sensation which can help relax the body.

 11) Create the right environment

Making it cool enough in the room to require a thick blanket/comforter or multiple blankets is a nice trick. The weight of the blankets provides a “nest” and a secure feeling but a cool temperature in the room will be needed to make sure it is not too hot under the blankets/comforter.  Weighted blankets are also available that creates a similar sensation.  Most people find it easier to sleep in a cooler environment than a hot one (65-68 degrees is ideal for most).  

12) If you are having difficulty falling asleep, try the following:

• Exercise at least 30 minutes daily (to tire out your body)
• Avoid naps.
• Avoid eating immediately before bed (within 1 hour of bedtime)
• Avoid or at least limit caffeine to no more than one beverage at most and do not drink any caffeinated drinks after 2 pm.
• Engage in a quiet, relaxing activity the hour before bedtime – reading a book (not on a screen), drawing, journaling, listening to calm music, warm bath or shower, aromatherapy, doing a sleep meditation (Check out the Mindfulness Techniques Tips), focused breathing, body scan stretches.
• Turn off all lights especially any overhead light at the designated bedtime. 
• Keep the bedroom on the cooler side, between 60-68 degrees.
• Try a white noise machine or app.  Keep in mind that continuous noise like a fan or white noise works better than intermittent noise (like ocean waves).  
• Many people have trouble falling asleep because they are anxious. They worry about the things going on in their life. Oftentimes, these worries are exaggerated by a tired brain.  A solution that works well in such cases is to read your favorite fantasy book (Harry Potter, Chronicles of Narnia – yes, it is okay to revisit these oldies!) before bed. This gets the brain focusing on something completely unrelated to reality and your day-to-day worries. If your brain is focused on a story unrelated to you, it will not focus on your troubles.  It is then easier to flip the switch into sleep mode. If you are old enough to read, read a fantasy novel with a bedside lamp on, and when you become too sleepy to focus, turn off the lamp and try to fall asleep. A parent can also read to you for the same effect if you are not yet able to read or you prefer to be read to. Audiobooks can be another option. 

13) If you are still having difficulty falling asleep, get out of bed.

Ironically spending hours tossing and turning awake in your bed can cause your brain to start associating lying in bed with NOT sleeping. To avoid this from happening, physically get out of bed if you are not able to fall asleep within 30 minutes of getting into bed. Turn on a bedside or desk lamp (NOT the overhead light).  Sit at your desk or on the floor next to the bed and try reading from a book or a magazine. When you start to feel drowsy, try getting back into bed. At first, you may need to repeat this back and forth several times before actually falling asleep but it will eventually become shorter with time. Do NOT reach for your phone, turn on the TV, or eat when you are out of bed.  

14) If you continue to consistently have difficulty falling asleep, consider a trial of sleep aid medication for a short period of time.  

• Melatonin may be helpful in people with sleeping problems but more studies are still needed to understand how to use it in the safest way in children and adolescents. 
• It may be helpful to use melatonin for a short time to help you establish a healthier sleep schedule.  Try over the counter melatonin about 2 hours before bedtime for 2-3 days.  Start with the lowest dose available (1 mg).
• Look on the label for a logo that shows the product is certified by a third-party such as Consumer Lab, NSF International, UL and U.S. Pharmacopeia. This means the group has tested the product to make sure it has the ingredients listed and is not contaminated. The Food and Drug Administration (FDA) does not test melatonin or other dietary supplements.
• Keep melatonin out of young children's reach. Calls to Poison Control Centers for melatonin ingestion in young children have been increasing. 
• Long term use of melatonin is not recommended or helpful as it starts to lose its effectiveness with continued use.  Research suggests that using melatonin daily can drive down your own natural melatonin levels so using it periodically (a few days with at least a week in between) is more effective than using it daily. We also do not yet know all the long-term side effects prolonged use can pose for children and adolescents.
• Other sleep medications are available. Please speak to your doctor about the options available for your age. 

15) If you are having difficulty staying asleep and get up frequently throughout the night and have trouble falling back asleep, try the following:

• Resist the temptation check the time or reach for your phone when you wake up.
• Keep the lights off in your room. 
• Try focusing on your breathing – inhale through your nose for 5 seconds, hold your breath for 5 seconds, exhale through your mouth for 5 seconds, and be still for 5 seconds.  Try 5 cycles of this “box” breathing in a row.  
• Place your hand on your stomach and count the rise and fall of your stomach as you breathe.
• Try visualization or repetition to get your mind off of the “I can't fall asleep” thoughts and onto something else.  Imagine yourself doing your favorite activity or at your favorite location with your favorite person, reciting the lyrics of your favorite song, lines of poems, speeches you have memorized in the past for school, etc.  
• If your mind is getting crowded with worries, write them down in journal or pad of paper near bed.  Committing your worries and anxiety to paper can help declutter your mind.  Be sure to use a dim setting on a lamp, a nightlight, or a reading light and avoid turning on the overhead lights. 

 16) If you are still having difficulty falling back asleep, get out of bed.  

• Turn on the bedside or desk lamp (NOT the overhead light).  Sit at your desk or on the floor next to the bed and try reading.  When you start to feel drowsy, try getting back in bed.  
• Sometimes reverse psychology works – trying too hard to fall back asleep can lead to the opposite happening so try telling yourself “I need to stay awake” and you may find that your body finds it hard to stay awake!