Insomnia
Chronic Insomnia
Trouble falling asleep, staying asleep or waking too early at least three nights a week for three months or more, with daytime effects. CBT-I is the first-line treatment.
Overview
Chronic insomnia means difficulty falling asleep, staying asleep or waking too early, despite having enough time and a suitable place to sleep, at least three nights a week for at least three months. It also affects how you feel and function during the day, through fatigue, low mood, irritability or poor concentration.
Insomnia often begins with a stressful event, illness or schedule change. It becomes chronic when habits and worries that develop in response, such as spending longer in bed, napping, clock-watching or dreading bedtime, keep the problem going long after the trigger has passed.
Cognitive behavioral therapy for insomnia (CBT-I) is recommended as the first-line treatment by the American College of Physicians and the American Academy of Sleep Medicine. It is effective, its benefits tend to last after treatment ends, and it is available in person, by telehealth and through digital programmes. Medication can help some people in the short term or alongside CBT-I.
The American Academy of Sleep Medicine reports that chronic insomnia disorder affects about 10% of adults.
Common symptoms
- Difficulty falling asleep
- Waking during the night and struggling to get back to sleep
- Waking too early and being unable to fall back asleep
- Feeling unrefreshed after sleep
- Daytime fatigue, low energy or sleepiness
- Irritability, anxiety or low mood
- Trouble concentrating or remembering
- Worrying about sleep and dreading bedtime
Causes and risk factors
- Ongoing stress, anxiety or depression
- Irregular sleep schedules, long naps or spending too long in bed
- Chronic pain or medical conditions such as reflux, asthma or an overactive thyroid
- Other sleep disorders such as sleep apnea or restless legs syndrome
- Caffeine, nicotine or alcohol, especially later in the day
- Some medications, including certain antidepressants, steroids and decongestants
- Menopause and hormonal changes
- Older age and female sex
How it is diagnosed
Insomnia is diagnosed clinically through a detailed history, not a sleep study. Your clinician asks about your sleep pattern, routines, mood, health and medicines, and often asks you to keep a sleep diary for one to two weeks. Questionnaires such as the Insomnia Severity Index help measure how much it affects you.
The diagnosis of chronic insomnia disorder requires symptoms at least three nights a week for at least three months, with daytime impairment, despite adequate opportunity to sleep. A sleep study is used only if another condition, such as sleep apnea or a movement disorder, is suspected.
Treatment options
Cognitive behavioral therapy for insomnia (CBT-I)
A structured programme, usually 4 to 8 sessions, that changes the habits and thoughts that keep insomnia going. It is the recommended first-line treatment.
Sleep restriction therapy
A component of CBT-I that temporarily limits time in bed to match actual sleep, building stronger sleep drive.
Stimulus control
Using the bed only for sleep and sex, and getting up if you cannot sleep, to rebuild the link between bed and sleep.
Digital CBT-I
App or online programmes based on CBT-I are an option when in-person therapy is not available.
Orexin receptor antagonists
Prescription medicines such as suvorexant, lemborexant and daridorexant block a wake-promoting brain signal.
Other prescription sleep medicines
Options include zolpidem, eszopiclone and zaleplon, low-dose doxepin, and ramelteon. Choice depends on the type of insomnia and your health, and some carry risks such as next-day impairment and complex sleep behaviors.
Treating contributing conditions
Addressing pain, depression, anxiety, reflux or sleep apnea can improve sleep.
What you can do yourself
- Keep the same wake-up time every day, including weekends
- Go to bed only when you feel sleepy, not just tired
- If you cannot sleep after about 20 minutes, get up and do something calm in dim light, then return when sleepy
- Avoid caffeine after early afternoon and limit alcohol
- Avoid long or late naps
- Keep the bedroom dark, quiet and cool
- Build a wind-down routine and put screens and work away before bed
- Avoid checking the clock during the night
When to see a doctor
- Poor sleep has lasted more than a few weeks and affects your day
- You snore, gasp or stop breathing in your sleep
- You have an urge to move your legs at night
- You feel low, hopeless or anxious much of the time
- You rely on alcohol or over-the-counter sleep aids to sleep
Frequently asked questions
What is CBT-I and does it work?
CBT-I is a short, structured therapy that targets the behaviours and thoughts that maintain insomnia, using techniques like sleep restriction, stimulus control and cognitive restructuring. It is the first-line treatment in major guidelines and helps most people who complete it. Its benefits usually last after therapy ends, unlike medication.
Why do I keep waking up at 3 or 4 a.m.?
Night waking is normal, but in insomnia it is followed by alertness and worry that keep you awake. Stress, alcohol, depression, sleep apnea, reflux, needing to urinate and going to bed too early can all contribute. A sleep diary helps identify patterns to discuss with a clinician.
Are over-the-counter sleep aids a good long-term solution?
Most over-the-counter sleep aids contain sedating antihistamines, which can cause next-day grogginess, and AASM guidance does not recommend them for chronic insomnia. Older adults are particularly sensitive to their side effects. Talk with a clinician about safer, more effective options.
Does sleep hygiene alone cure insomnia?
Good sleep habits help, but sleep hygiene on its own is usually not enough for chronic insomnia. The more active parts of CBT-I, such as sleep restriction and stimulus control, are what produce lasting change.
Should I stay in bed longer to catch up on sleep?
It feels logical, but spending more time in bed awake often makes insomnia worse because it weakens the link between bed and sleep. CBT-I often does the opposite at first, temporarily shortening time in bed to consolidate sleep.
Sources
This page is general information, not a diagnosis or medical advice. Read our medical disclaimer.