Chronic insomnia: why therapy, not a tablet, comes first

01

What counts as chronic insomnia

Insomnia means trouble falling asleep, staying asleep, or waking too early, even though you had the time and a reasonable place to sleep. It shows up in the day too, as tiredness, poor concentration or irritability.

Doctors call it chronic when it happens at least three nights a week and has lasted at least three months. These are the thresholds in the international classification of sleep disorders (ICSD-3), and the psychiatric manual DSM-5 is broadly aligned with them. The American Academy of Sleep Medicine estimates that about 10 per cent of people have chronic insomnia.

02

Why insomnia keeps itself going

Insomnia often starts with a trigger, such as illness, a bereavement, money worries or shift work. What keeps it going months later is usually different: the habits and worries that grow up around sleep.

It’s natural to try to make up for lost sleep. You go to bed earlier, lie in longer, nap in the afternoon, or lie in bed hoping sleep will come. Together these mean more hours in bed and less of that time asleep.

Over time the brain learns a new link: bed means being awake and frustrated. Researchers call this a learned association between the bedroom and wakefulness. Add clock-watching and worry about tomorrow, and you get the vicious circle the European insomnia guideline describes, where anxiety about sleep and extra time in bed feed each other.

03

What CBT-I actually involves

CBT-I tackles those habits and thoughts directly. A course typically runs four to eight sessions, one-to-one or in a group, and it can be delivered in person or through a digital programme. You keep a simple sleep diary throughout so progress is visible.

• Sleep scheduling (sleep restriction): for a while, your time in bed is trimmed to roughly the time you are actually sleeping, as shown by your diary, though usually not below about five hours. This builds sleep pressure, so sleep becomes less broken. As it improves, the window is widened step by step, always with your therapist’s guidance.
• Stimulus control: a set of rules that rebuilds the link between bed and sleep. Go to bed only when sleepy, get up if you haven’t fallen asleep after about 15–20 minutes, use the bed only for sleep, get up at the same time every day including weekends, and avoid daytime naps.
• Cognitive work: questioning thoughts like “If I don’t sleep tonight, tomorrow is ruined”, setting realistic expectations, and letting go of the effort to force sleep.
• Relaxation: progressive muscle relaxation and slow breathing to calm the body before bed.
• Sleep hygiene: advice on caffeine, alcohol, screens and a dark, quiet bedroom. On its own it isn’t an effective treatment for chronic insomnia.

04

Why the guidelines put therapy first

Three major guidelines agree. In 2016 the American College of Physicians strongly recommended CBT-I as the initial treatment for all adults with chronic insomnia. In 2021 the American Academy of Sleep Medicine gave it a strong recommendation and advised against sleep hygiene alone. In 2023 the European Sleep Research Society named CBT-I the first-line treatment for adults of any age, at its top grade.

Sleeping tablets have a role, but a limited one. The American College of Physicians suggests considering them, after discussion with your doctor, if CBT-I alone hasn’t helped enough. The European guideline advises that most sleep medicines be used short-term, generally for about four weeks or less, with longer use decided case by case. The NHS warns that sleeping pills can have serious side effects and lead to dependence, and they can work less well over time.

If you already take a sleeping tablet, don’t stop it suddenly on your own, as some cause withdrawal symptoms such as agitation or anxiety. Your doctor can plan a gradual reduction if that is right for you.

05

When poor sleep needs a medical check

Poor sleep can point to another condition needing its own treatment. See a doctor if:

• someone notices loud snoring, gasping, choking or pauses in your breathing at night, or you wake with headaches and feel very tired by day. These can be signs of obstructive sleep apnoea. The European guideline notes that 30 to 40 per cent of people with insomnia may also have it, and recommends screening for it.
• you get an uncomfortable urge to move your legs when resting at night, which may be restless legs syndrome.
• your mood is low, you have lost interest in things, or you worry constantly. Depression and anxiety are closely linked with insomnia and need proper assessment, though CBT-I still helps sleep when depression is present.
• pain, another illness or a new medicine seems to be keeping you awake.

06

A few things to try tonight

• Choose a fixed wake-up time and keep to it tomorrow, even after a poor night.
• Go to bed when you feel sleepy, not simply because the clock says it’s time.
• If you have been awake for what feels like 15–20 minutes, get up, go to a dim room and do something calm until sleepy.
• Skip tea, coffee, alcohol and smoking for about six hours before bed. That includes the evening cup of chai.
• Wind down for an hour, keep screens out of bed, and keep the room dark and quiet.
• Earlier in the evening, jot down tomorrow’s worries so they sit on paper, not in your head at midnight.

If sleep hasn’t improved after a few weeks, or the trouble has lasted months, see a doctor, ideally one who offers CBT-I. Long-standing insomnia is treatable, and you don’t have to simply put up with it.