Chronic insomnia disorder, or insomnia, affects about 10 percent of the population. It’s characterized by difficulty falling asleep, staying asleep, and/or going back to sleep after waking up in the early morning. This happens at least three nights a week for a minimum of 3 months.
Medication is typically thought of as the sole or most effective treatment for chronic insomnia. And it can help. Medication is convenient, fast acting, and widely available. However, psychotherapy—particularly cognitive behavioral therapy for insomnia (CBT-I)—is actually the first-line treatment.
Again, cognitive behavioral therapy for insomnia (CBT-I) is the preferred treatment for chronic insomnia disorder. CBT-I is a safe, evidence-based treatment that’s been endorsed as a first-line intervention by various organizations, including the American Academy of Sleep Medicine, American College of Physicians, British Association for Psychopharmacology, and the European Sleep Research Society.
CBT-I is an active therapy that aims to alter thinking patterns and behaviors that prevent individuals from sleeping well. As the British Association for Psychopharmacology noted, CBT-I “employs a package of interventions designed to encourage ‘poor sleepers’ to think and behave like ‘good sleepers.’” These interventions include:
- Challenging and changing cognitive distortions and misconceptions around sleep and its negative daytime consequences. For example: “I can’t sleep without medication”; “I need to stay in bed when I can’t sleep”; “Not getting at least 6 hours of sleep is horrible for my health, and there is no way I can function at work tomorrow.”
- Associating bed with sleep instead of wakefulness (called stimulus control). Individuals are instructed to only use their bed for sleep and sex—not to read, watch TV, eat, or worry. Individuals also work on going to bed when they’re sleepy and getting out of bed when they can’t sleep.
- Restricting the time spent in bed (called sleep restriction) and waking up at the same time every day, regardless of how much sleep you got the night before. Individuals then gradually increase the time spent in bed by 15 to 30 minutes (as long as their middle-of-the-night wake-ups are minimal).
- Setting healthy habits around sleep, such as cutting down on caffeine (and other substances); not going to bed hungry; and creating a quiet, dark, comfortable environment.
- Practicing relaxation techniques, such as progressive muscle relaxation and deep breathing.
- Preventing a relapse, which includes identifying high-risk situations and implementing specific strategies.
CBT-I is highly individual. You and your therapist will identify the specific obstacles that impair your sleep. They tailor treatment according to those obstacles along with other factors, such as your age and any co-occurring disorders. For instance, taking naps typically isn’t recommended, but doing so can be beneficial for the elderly. Also, sleep restriction isn’t appropriate for individuals with bipolar disorder or seizure disorder.
CBT-I is available in individual, self-help, and group-based formats. It can take some time to improve your sleep, along with effort and hard work. However, that also means that any changes and improvements you make will be meaningful and long lasting.
If you’re unable to find a practitioner who specializes in CBT-I or currently can’t afford therapy, consider a self-help program. For example, psychologist Gregg D. Jacobs, one of the principal developers of CBT-I, created these products.
Medication may be helpful in managing short-term insomnia, such as during a particularly difficult, stressful time. However, psychotherapy is typically more effective, has very little risk, and has shown long-term effects.
According to the American College of Physicians, “As indicated on FDA labeling, pharmacologic treatments for insomnia are intended for short-term use, and patients should be discouraged from using these drugs for extended periods. Because few studies evaluated the use of the medications for more than 4 weeks, long term adverse effects are unknown.”
Still, the American Academy of Sleep Medicine (AASM) noted that some individuals might not have access to CBT-I, want to participate in it, or respond to it. This is why, according to the organization, “pharmacotherapy, alone or in combination with CBT-I, must continue to be considered a part of the therapeutic armamentarium, as it currently is for perhaps 25% of the population.”
They also noted that some studies have shown that long-term treatment with newer non-benzodiazepine hypnotics “can be safe and effective under properly controlled conditions.”
But long-term use should be reserved for individuals who can’t access CBT-I, haven’t benefited from it, and have had long-term gains with medication. Also, regular follow-up visits are vital to ensure the medication is still working (and there aren’t any adverse effects).
When prescribing sleep medication, your doctor should consider various important factors, such as your symptom pattern; treatment goals; past responses to treatment; any co-occurring conditions; any interactions with medication you’re currently taking; and side effects.
Benzodiazepines and Non-Benzodiazepines
Medications prescribed to treat insomnia include benzodiazepines and non-benzodiazepines hypnotics (also known as Z-drugs). Benzodiazepines act on GABA receptors in the brain, which modulate activity in major areas associated with the sleep-wake cycle. GABA is an inhibitory neurotransmitter, which means that its role is to suppress brain activity.
Benzodiazepines are classified according to their length of action: long, moderate, or short. A shorter half-life means the drug will take effect quickly but also leave the system faster.
In their treatment guidelines, the AASM recommends the intermediate-acting benzodiazepine temazepam (Restoril) for treating both sleep-onset insomnia and sleep-maintenance insomnia. They recommend triazolam (Halcion), a short-acting benzodiazepine, for sleep-onset insomnia.
Non-benzodiazepine hypnotics also act on the GABA receptors but with some differences as to how, where, and for how long. These include: eszopiclone (Lunesta), zaleplon (Sonata), and zolpidem (Ambien).
Ambien is the most widely prescribed hypnotic medication in America. It’s recommended by the AASM for treating both sleep-onset and sleep-maintenance insomnia. Lunesta is also recommended for both. Sonata is recommended for sleep-onset insomnia.
Both benzodiazepines and non-benzodiazepines have potential for abuse and addiction. They also can have negative effects on next-day functioning. For instance, individuals might experience a “hangover-like” effect marked by grogginess and/or impairments in memory.
Suppressed respiration and interactions with other drugs also raise safety concerns. Complex tasks, such as driving, might be impaired, which is a particular concern for the elderly. In fact, benzodiazepines and non-benzodiazepines may not be appropriate for older individuals.
In April 2019, the U.S. Food and Drug Administration (FDA) added a boxed warning to Lunesta, Sonata, and Ambien after reports of serious injuries and deaths from various complex sleep behaviors—such as sleep walking and sleep driving—that occurred after individuals took these medications. According to the FDA website:
“Serious injuries and death from complex sleep behaviors have occurred in patients with and without a history of such behaviors, even at the lowest recommended doses, and the behaviors can occur after just one dose. These behaviors can occur after taking these medicines with or without alcohol or other central nervous system depressants that may be sedating such as tranquilizers, opioids, and anti-anxiety medicines.”
In addition, the FDA issued a contraindication—their strongest warning—that individuals who’ve previously had an episode of complex sleep behavior should not use any of these medications.
Similarly, it’s critical to stop taking an insomnia drug if you’ve experienced an episode of complex sleep behavior while on it.
You can read more about the warning at FDA’s website.
Doctors may prescribe antidepressants for individuals with insomnia related to depression and for individuals with short-term primary insomnia who have a history of depression. For instance, guidelines from the AASM recommend doxepin (Silenor), a tricyclic antidepressant, for treating sleep maintenance in insomnia. According to the British Association for Psychopharmacology, doxepin appears to reduce waking up in the latter half of the night. It can cause dizziness and nausea.
Trazodone (Desyrel), a serotonin antagonist and reuptake inhibitor, is the second most prescribed medication in the U.S. However, research on trazodone’s efficacy is scarce and the AASM advises against prescribing this medication. In addition to causing dizziness and nausea, trazodone may cause abnormally low blood pressure and heart-rhythm disorders.
Other Sleep Medication
The American Academy of Sleep Medicine (AASM) also recommends ramelteon (Rozerem), a melatonin receptor agonist, for treating trouble falling asleep. Side effects include dizziness, nausea, fatigue, and headaches.
The AASM recommends suvorexant (Belsomra), a selective dual orexin receptor antagonist, for treating trouble staying asleep. Belsomra also can trigger headaches, dizziness, and sleepiness.
When you’re ready to stop taking sleep medication, you’ll likely need to do so gradually. This typically means taking a lower dose of the medication and decreasing how often you take it—a process that can take a few weeks or months. Also, after stopping your medication, rebound insomnia may occur for a few days or up to a week. Engaging in CBT-I can help tremendously with tapering off sleep medication.
The AASM advises against prescribing the antihistamine diphenhydramine (Benadryl), valerian, tryptophan, or melatonin for sleep because of scarce research on safety and efficacy.
Check out insomnia books. There are a number of helpful books you can work through to improve your sleep. Here are several examples: The 4-Week Insomnia Workbook; Say Good Night to Insomnia; End the Insomnia Struggle; The Insomnia Workbook; and The Women’s Guide to Overcoming Insomnia.
Never mix sleeping pills with alcohol. Alcohol and prescription or over-the-counter sleeping pills can be a dangerous, even lethal, combination. For example, consuming both can boost their sedating effects, which can decelerate your breathing. If you add an opioid, you can stop breathing altogether. (Of course, the same goes for mixing drugs with sleeping pills.)
Establish a soothing bedtime routine. The goal of a bedtime routine is to prime your body for sleep. For instance, if you take a hot shower every night, your body starts associating that shower with sleep time. It helps to set aside 30 minutes to an hour for your routine. Fill that time with activities that genuinely relax you, which might include meditating, reading scripture, journaling about what you’re grateful for, and stretching your body. (If you have kids, these nine tips can help you create a bedtime routine for you amid the chaos.)
Make your bedroom into a sanctuary. Make your bedroom as relaxing and sleep promoting as possible. Declutter. Use your favorite essential oils. Turn down the air conditioner. Have soft, clean sheets. Keep it dark and quiet.
Exercise. Research suggests that exercise can help to foster sleep, reduce anxiety, and boost mood. The key is to find what physical activities resonate with you. Consider experimenting with different kinds of activities—from walking to dancing to practicing yoga to playing sports.
Practice relaxation techniques. Use deep breathing to help you relax. Listen to guided meditations. Practice progressive muscle relaxation. Thankfully, there are many healthy tools and techniques that can help you to cultivate calm.
Reduce worry. Worry can easily keep you up at night. What can help is to spend 10 to 20 minutes earlier in the day writing down your worries and how you’re going to address them. If a worry thought pops up before bed, remind yourself that you’ve resolved it or you’re working toward resolving it.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Carr, T. (2018, December 12). The problem with sleeping pills. Consumer Reports. Retrieved from https://www.consumerreports.org/drugs/the-problem-with-sleeping-pills.
Cognitive behavioral therapy for insomnia. Stanford Health Care. Retrieved from https://stanfordhealthcare.org/medical-treatments/c/cognitive-behavioral-therapy-insomnia.html.
DeAngelis, T. (2016, October). Behavioral therapy works best for insomnia. Monitor on Psychology, 47, 9, 18. Retrieved from https://www.apa.org/monitor/2016/10/insomnia.
Qaseem A., Kansagara D., Forciea M.A., Cooke, M., Denberg, T.D. (2016). Management of chronic insomnia disorder in adults: A clinical practice guideline from the American College of Physicians. Annals of Internal Medicine, 165, 2, 125-133. DOI: 10.7326/M15-2175.
Riemann D., Baglioni C., Bassetti C., Bjorvatn, B., Groselj, L.D., Ellis, J.G…Spiegelhalder, K. (2017). European guideline for the diagnosis and treatment of insomnia. Journal of Sleep Research, 26, 675-700. DOI: https://doi.org/10.1111/jsr.12594.
Runko, V. Cognitive behavioral therapy for insomnia (CBT-I). Anxiety and Depression Association of America. Retrieved from https://adaa.org/sites/default/files/Runko_177.pdf
Sateia MJ. Buysse DJ, Krystal AD. Clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults: an American Academy of Sleep Medicine clinical practice guideline. (2017). Journal of Clinical Sleep Medicine, 13, 2, 307–349. DOI: 10.5664/jcsm.6470.
Wilson, S., Anderson, K., Baldwin, D., Dijk, D.J., Espie, A., Espie, C., …Sharpley, A. (2019). British Association for Psychopharmacology consensus statement on evidence-based treatment of insomnia, parasomnias and circadian rhythm disorders: An update. Journal of Psychopharmacology, 33, 8, 923-947. DOI: 10.1177/0269881119855343.