Babies, grief and nights that need a doctor

The method is simple. Some situations aren't, and I should be plain about them.

When the night really does require you. Sometimes there's a baby, a sick child, a parent who calls out, or a job that puts you on call. You can't avoid being awake, and nobody should tell you to rest with pleasant imagery while a baby cries. What you can do is keep the two things separate. Deal with the baby. When the baby is settled and you're back in bed, the night routine applies. Parents of small children often find that the feed takes twenty minutes and the night shift that follows takes ninety. You can't do much about the twenty minutes, but the ninety can change.

Shift workers. If you work nights, your "three in the morning" may fall at two in the afternoon. The principle still holds. Don't work on problems in the hours set aside for sleep, and do the handover before them. The body clock evidence in chapter 4 is a reason to be especially wary of big decisions made in the last hours of a night shift.

Grief and crisis. After a bereavement, a break-up, a diagnosis or a job loss, broken nights are close to universal, and the mind will go where it goes. I wouldn't ask anyone in the first weeks of grief to label their thoughts and go to a childhood house. The parts of this book that still help are the gentler ones. Don't look at the clock, and don't reach any verdicts before breakfast. Get up and sit somewhere else if bed has become unbearable. If the broken nights go on for many weeks, tell your GP.

When the same stepless item comes every night. Chapter 12 mentioned worries with nothing on the right-hand side, such as your health, your worth, or something dreadful happening to the children. If one of these fills your nights and the handover doesn't touch it, it may be anxiety that's running by day as well. That responds to treatment. In England you can refer yourself to NHS talking therapies without seeing a GP first.

When it's insomnia. If you've had trouble sleeping for months, or it's affecting your days so that you're finding it hard to cope, the NHS advice is to see a GP. The treatment with the best evidence is a form of cognitive behavioural therapy designed for insomnia. James Trauer and colleagues pooled 20 controlled trials with 1,162 participants. After treatment, people fell asleep about 19 minutes faster and spent about 26 minutes less awake during the night, and the gains seemed to last. The treatment includes some of what's in this book, such as getting up when you can't sleep. It also includes things that aren't here, such as a structured programme for the hours you spend in bed, which works best with guidance. The NHS says a GP may offer it face to face or as an online programme. It also says that sleeping pills are now rarely prescribed for insomnia, and then only for short periods.

Physical causes. I listed these in the preface and they bear repeating. Loud snoring with pauses in breathing, gasping or choking in your sleep, and heavy daytime tiredness are the main symptoms of sleep apnoea, and the NHS advice is to see a GP. The NHS lists night sweats among the symptoms of the menopause and perimenopause, and a GP can discuss treatment for those. Pain that wakes you, or a bladder that gets you up several times a night, is worth raising with a doctor too. A waking that has a physical cause needs the cause treated. The handover and the night routine will still help with what your mind does once you're awake.

Alcohol. A drink in the evening can help you drop off, and it tends to wake you later. Irshaad Ebrahim and colleagues reviewed the studies on healthy sleepers. Alcohol shortened the time to fall asleep and deepened the first half of the night, and it disrupted the second half. If your wakings cluster on evenings when you've had a few drinks, that's a likely reason. Caffeine late in the day can do the same. The NHS suggests avoiding alcohol, tea and coffee for at least six hours before bed.

If the night thoughts are dark. The research in chapter 4 has a serious side. The hours after midnight are when low mood is lowest and self-control weakest. For someone already struggling, thoughts of being a burden or of ending things can be at their most persuasive then. If that happens to you, please treat it as the most important verdict of all to distrust. Get up, turn on a light, and contact someone. In England you can call NHS 111 at any hour, or 999 if you're in immediate danger. You don't need to wait until morning, and you don't need to be certain that it's serious. Tell your GP in the daytime as well.

Bad weeks. There'll be a stretch when it all comes back. There'll be a deadline or a family worry, and you'll skip the handover for a week and find yourself doing sums at four. It happens to everyone who tries to change a long habit, and it doesn't undo what you've learned. The response is small. Do the handover tomorrow evening and turn the clock back to the wall. The night shift had years of practice, and it will take a while for the new routine to become as automatic as the old one was.