I was elated. How often does a first-year medical student get to perform a real behavioral intervention? Doctors are often criticized for trying to fix every problem with a pill; I was going to break the mold!

My joy deflated soon after we returned to see the patient together. My supervisor learned the same facts. But after weighing the different options, he decided that prescribing a sedative would be a more effective choice.

I wasn’t happy. Why couldn’t we try a behavioral strategy first? Were we just going to prescribe meds for every patient with blood pressure and cholesterol problems too? What was going on?

In the years since that experience, I’ve learned a thing or two about sleep. And my faith in behavioral interventions for insomnia has been confirmed time and time again. But I’ve also learned something that my attending physician intuitively sensed: that sleep hygiene education on its own is not an effective treatment for insomnia.

Because although sleep hygiene recommendations might seem reasonable, there are at least four big problems that prevent sleep hygiene from having a massive impact.

1. There is little scientific evidence that sleep hygiene education alone actually helps people with insomnia.

You read that correctly. Sleep hygiene education probably isn’t enough to reverse insomnia.** In fact, when scientists design experiments to test a new treatment for insomnia, they often give sleep hygiene interventions to the control group. It’s handy if you want a sugar pill, but is that really what you want?

Now don’t get me wrong—there is some data to suggest that certain sleep hygiene changes can improve sleep in people with very mild sleep problems. But these results have not been consistently found in people with insomnia. I suspect that the small benefits from improved sleep hygiene just aren’t enough to matter when you are really suffering. (Plus, many people with insomnia have already tried most things on this list. These aren’t exactly revolutionary suggestions.)

2. Sleep hygiene recommendations don’t tell you which behaviors make the biggest difference.

When implemented appropriately, some sleep hygiene principles are actually pretty good advice. But how do you know where to start?

For example, I’m still waiting to meet someone who suffered from insomnia for decades until they stopped going to bed hungry. That’s something people usually figure out on their own.

In contrast, “Use your bed only for sleep and sex” is the half-hearted brother of stimulus control therapy: a scientifically valid treatment for insomnia. Likewise, the recommendation to “Only sleep until you feel rested” is the basis for sleep restriction, a therapy proven to rapidly demolish insomnia. But each of these treatments require a specific, systematic approach. Vague principles hidden in a long list simply aren’t enough to make a difference.