Approximately 1 in 3 American adults does not get enough sleep on a regular basis, and 10–15% meet the diagnostic criteria for chronic insomnia disorder. Insomnia is not simply "not enough sleep" — it is difficulty falling asleep, staying asleep, or waking too early despite adequate opportunity and circumstances for sleep, producing daytime impairment. It is both a symptom of other conditions and a disorder in its own right, with a specific evidence-based treatment that outperforms sleeping pills for long-term outcomes.
Acute vs. Chronic Insomnia
Acute insomnia (lasting days to weeks) is nearly universal and typically triggered by identifiable stressors — a new job, relationship problems, a health scare, jet lag. It resolves when the stressor resolves or the person adapts. Chronic insomnia (persisting ≥3 nights per week for ≥3 months) involves a self-perpetuating cycle that persists independently of the original trigger. The cycle is driven by hyperarousal (the brain becomes conditioned to be alert in the bedroom), catastrophic thinking about sleep ("if I don't sleep tonight I'll fail tomorrow"), and behaviours that seem helpful but perpetuate insomnia (going to bed too early, spending excessive time in bed, napping).
What Perpetuates Insomnia
- Spending too much time in bed: Creates a mismatch between sleep drive and time available, fragmenting and lightening sleep.
- Clock-watching: Reinforces arousal and anxiety in the bedroom.
- Irregular sleep schedules: Undermines circadian rhythm stability.
- Daytime napping: Reduces sleep pressure for the night.
- Hyperarousal: Racing thoughts, worry about sleep, and physiological arousal at bedtime.
Cognitive Behavioural Therapy for Insomnia (CBT-I)
CBT-I is the first-line treatment recommended by the American Academy of Sleep Medicine, the American College of Physicians, and the NHS — above medications. It achieves superior long-term outcomes to sleeping pills in every head-to-head trial, with benefits maintained at 12–24 month follow-up. CBT-I consists of several components delivered over 6–8 sessions:
- Sleep restriction: Temporarily limiting time in bed to match actual sleep time, building sleep pressure and consolidating fragmented sleep.
- Stimulus control: Reassociating the bed with sleep (not wakefulness) by using the bed only for sleep and sex, and getting out of bed if awake more than 20 minutes.
- Cognitive restructuring: Identifying and challenging unhelpful beliefs about sleep ("I need 8 hours or I can't function", "I've lost the ability to sleep").
- Sleep hygiene education: Optimising sleep environment and habits.
Digital CBT-I programs (Sleepio, Somryst) deliver equivalent efficacy to therapist-delivered treatment and are accessible without a referral.
Medications: Short-Term Role
Sleeping medications are appropriate for short-term (2–4 week) use in acute insomnia or as a bridge while initiating CBT-I. Melatonin receptor agonists (ramelteon) and orexin receptor antagonists (suvorexant, lemborexant) carry lower dependency risk than benzodiazepines and Z-drugs (zolpidem, zopiclone). Benzodiazepines and Z-drugs cause tolerance, withdrawal, rebound insomnia, and — in older adults — significantly increase fall and fracture risk. Low-dose doxepin is specifically approved for sleep-maintenance insomnia.
Sources
- Qaseem A, et al. ACP Clinical Practice Guideline: Management of Chronic Insomnia. Ann Intern Med. 2016.
- Riemann D, et al. European guideline for the diagnosis and treatment of insomnia. J Sleep Res. 2017.
- Morin CM, et al. Psychological and behavioral treatment of insomnia. Sleep. 2006.
- Mayo Clinic. Insomnia — Diagnosis and treatment. 2023.