What is the treatment for insomnia?

Summary

Insomnia can be short-term (lasting days or weeks, and up to three months), or long-term (lasting longer than three months).

Treatment for insomnia includes:

• Good sleep hygiene, such as:
• Using the bedroom only for sleep and sex.
• Getting up at the same time each day.
• Avoiding large meals, smoking, and alcohol within two hours of bed.
• Avoiding caffeine within six hours of bed, and ideally avoiding it from noon onwards.
• Exercising regularly during the day, but avoiding exercise late in the evening.
• Avoiding screen use within two hours of going to bed.
• Sleep-focused cognitive behaviour therapy (CBT-I).
• This involves various different cognitive (thought pattern) and behavioural strategies to treat insomnia.
• Treating anything that is making the insomnia worse, like stress, mental or physical health conditions, and medication side-effects.
• Sleep medications (sleeping tablets). However, these have lots of side-effects and harms. They are best avoided or for short-term use only.

If you think you have insomnia, find out what to do here.

In this series of articles centred around insomnia, you can read about insomnia symptoms, insomnia causes, and insomnia treatments - all written by one of our expert GPs.

The rest of this feature will take an in-depth look at treatments for insomnia, as at Patient, we know our readers sometimes want to have a deep dive into certain topics.

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Treatments for insomnia

Short-term insomnia usually gets better once the immediate cause - for example, a stressful event - has subsided. Sleep hygiene is often all that is needed.

Sleep hygiene is also important in treating chronic insomnia, but other treatment might be needed as well.

Treatments for insomnia include:

Sleep hygiene

Sleep hygiene describes a series of lifestyle changes that promote healthy sleep patterns and good sleeping habits.

See 'Self-help tips' below for details about what you can do to improve your sleep hygiene.

Sleep-focused cognitive behavioural therapy

Sleep-focused cognitive behavioural therapy, or cognitive behavioural therapy for insomnia (CBT-I), is a treatment that explores and changes the links between how we think, behave, and sleep.

There is good evidence that CBT-I is an effective treatment for insomnia, and it's recommended as the first-line treatment for people with chronic insomnia and troublesome short-term insomnia.

CBT-I can be delivered individually or in groups. It can be done in-person, over the phone, online, or via an app. It's usually delivered over four to six sessions. It has long-lasting beneficial effects on insomnia, even after the sessions finish.

CBT-I works on:

• Cognition - allowing you to recognise and change beliefs and thoughts that stop you from sleeping.
• Behaviour - helping you to develop good sleep habits and stop unhelpful behaviours.

Techniques used in CBT-I include:

• Stimulus control. Many people with insomnia learn to associate the bedroom with being awake. Stimulus control aims to reshape this association, so that the bedroom becomes a place for restful sleep instead. For example, people are advised to get out of bed if they've not been able to get to sleep after 10 minutes, go elsewhere, and only return to bed when they feel tired. This helps to avoid the association between being in bed and feeling wide awake.
• Sleep restriction. People with insomnia often spend a lot of time awake in bed. Sleep restriction limits the time you spend in bed - for example, if someone sleeps for 4 hours but spends 8 hours in bed, on a sleep restriction programme they might be told to spend only 4 hours and 30 minutes in bed, and gradually increase this as they spend more time in bed asleep. Again, this aims to develop links in the brain between being in bed and falling asleep - not being awake.
• Cognitive restructuring. This aims to identify and challenge harmful thoughts and beliefs that are making insomnia worse. For example, feeling anxious about sleep makes it harder to get to sleep. Anxieties about sleep can be driven by inaccurate or unhelpful thought patterns, which cognitive restructuring can help to tackle.
• Relaxation therapy. Various different techniques for relaxation can help to soothe anxious or tense thoughts that prevent you from sleeping.

Treating other causes of insomnia

If there are other causes of insomnia, such as medical conditions or medication side-effects, treating those can help with insomnia.

For example, taking insomnia-causing medications in the morning, rather than the evening, can reduce the effect they have on sleep.

Treating depression and anxiety can help insomnia, if they are causing sleeping difficulties.

Sleep medications

Various different medications are available as sleeping aids or sleeping tablets.

Sleeping tablets only treat the symptoms of insomnia, and not the causes.

Sleeping tablets should only be used for severe insomnia symptoms, and, even then, for a short amount of time only. They have side-effects that can cause significant harm.

Types of sleep medications include:

• Sedating (drowsiness-inducing) antihistamines, for example Nytol, Phenergan or Sominex.
• Most of these can be bought over-the-counter without prescription.
• They are relatively safe but tend to stop working if you use them for several nights in a row.
• Sometimes they cause a hangover effect, making you drowsy the next day.
• They should only be used for a maximum of one to two weeks.
• Z drugs, for example zopiclone and zolpidem.
• These are prescription-only.
• They can help you get to sleep quicker (by around 15 minutes) and stay asleep longer (by around 30-45 minutes).
• They have many side-effects, including:
• Confusion, drowsiness, and falls - especially in older people.
• Addiction and dependence on them to sleep.
• Long-term use of Z drugs is linked to several serious health problems, including:
• An increased risk of dementia.
• An increased risk of dying earlier.
• Z drugs should therefore generally be avoided. They should only be used for severe insomnia, and only for a short time - less than four weeks, and ideally less than two weeks.
• Melatonin.
• This is prescription-only in the UK, although in other countries, for example the USA, it can be bought as a supplement.
• In the UK, it's only licensed by the manufacturer for short-term use in people 55 or older, but is also used off-license in younger adults and children.
• Melatonin seems to be relatively safe in the short-term - up to several months.
• The safety of long-term melatonin is unclear.

Self-help tips

There are many things that you can do to improve your sleep hygiene. These include:

Create a restful sleeping environment

Make your bedroom a comfortable, relaxing place that promotes healthy sleep. That could include:

• Having a comfortable mattress, pillows, sheets, and bedding.
• Keeping the temperature at the right level. Many people like to keep the bedroom cool, but the bed warm - for example, sleeping with the window open and a thick duvet.
• Removing noises. If you can't do that, consider using earplugs or a source of white noise, like a fan, to block them out.
• Removing screens from the bedroom. Keep phones, TVs, tablets, laptops and computers in another room.
• Making the bedroom as dark as possible, such as with blackout curtains. Some people, though, find it easier to sleep with a night-light.

Stick to a schedule

Your body clock needs a regular routine. Try the following:

• Wake up at the same time each day, even if you didn't sleep well.
• Work out what time you need to go to bed, based on your wake-up time. Ensure that you build time into your schedule so that you can go to bed on time.
• Avoid napping during the day if you can, as it can make it harder to sleep through the night.
• Avoid doing stressful or difficult tasks in the evening, like studying or working. Try to leave at least an hour and a half between finishing these and going to bed.
• Leave at least 3 to 4 hours between eating and going to bed.

Associate the bedroom with sleep

The brain can easily learn to associate being in bed with being awake - leading to people suddenly feeling awake and unable to sleep as soon as they get into bed.

Re-training the brain to feel sleepy when in bed can help:

• Use the bedroom for sleep and sex only. Don't work or read in bed.
• If you've gone to bed and can't get to sleep after 15 minutes, get up and go to another room. Do something relaxing, and only go back to bed when you feel sleepy again. Lying in bed wide awake can make things worse.

Create a bedtime routine

Having a relaxing pre-bed routine can help your brain wind down and get ready to sleep. You might want to do some, or all, of the following as part of your evening routine:

• Take a relaxing bath or shower.
• Change into your sleepwear.
• Meditate.
• Do a relaxation exercise.
• Read a book.
• Listen to a podcast or radio show.
• Do some gentle stretches.

Avoid screen time

Bright lights, especially blue-tinted lights from computers, laptops, tablets and phones, confuse the brain into thinking it's daytime. Avoid bright lights and screens for at least an hour before going to bed.

Exercise - during the day

Exercise is good for sleep, and has lots of other health benefits as well. Exercise is best done in the morning, afternoon, or early evening. Exercising too close to bedtime - within an hour or two - can stimulate your mind and body too much, making it hard to sleep.

Cut down on caffeine, tobacco, alcohol, and other drugs

Caffeine is a stimulant that makes us feel more awake. Avoid drinking caffeine - for example tea, coffee, energy drinks, soft drinks - within 6 hours of going to bed. Some people are particularly sensitive and might want to cut out any caffeine from noon onwards.

Nicotine, such as in cigarettes and vapes, is also a stimulant. Avoid smoking or vaping within 4 hours of going to bed. It's best to stop smoking completely.

Drinking alcohol before going to bed does help you get to sleep quicker, but greatly disrupts sleep patterns in the second half of the night, meaning that sleep is overall worse. Avoid using alcohol as a way to get to sleep, and avoid drinking alcohol within four hours of bed.

Other drugs, such as cannabis, cocaine, and ecstasy (MDMA), can negatively affect sleep, and should also be avoided for healthy sleep.

Treatments that aren't recommended

Things that generally aren't recommended for insomnia include:

• Long-term use of sleeping tablets, due to the potential harms.
• Benzodiazepines - for example, temazepam.
• Antidepressants that cause drowsiness as a side-effect - for example, amitriptyline, mirtazapine - unless they're being used to treat depression as well.
• Antipsychotics - for example, quetiapine - although treating psychosis can improve insomnia.
• Chloral hydrate.
• Clomethiazole.
• Barbiturates.
• Herbal remedies, such as valerian root.

Complications of insomnia

Insomnia, especially chronic insomnia, can lead to other problems, such as:

• Reduced performance at school, university, or work.
• Accidents, due to daytime sleepiness or impaired reaction times.
• Mental health problems, like depression and anxiety.
• Thoughts of suicide. Click here if you, or someone you know, is having thoughts of suicide.
• An increased risk of other medical conditions, like heart disease and high blood pressure.