Sleep, stress & energy
Insomnia & sleep
Lying awake again? The first treatment usually recommended isn't a pill.
Insomnia is common and often keeps itself going through worry and habit. The first treatment usually recommended for long-term insomnia is a 6- to 8-week therapy called CBT-I, and two of its steps can start tonight.
In 30 seconds
The short answer
Insomnia means trouble falling asleep, staying asleep or getting good-quality sleep, even when you have the time to sleep.1 Short spells often follow stress or a change in routine.2 When it happens 3 or more nights a week for more than 3 months, it is called chronic.3 For long-term insomnia, the first treatment usually recommended is CBT-I, a 6- to 8-week therapy.16
- It is common, and often has a cause. Most chronic insomnia is a symptom or side effect of something else: a condition, a medicine, caffeine or alcohol.5
- Worry keeps it going. Worrying about sleep and watching the clock can make insomnia worse.7
- The first treatment is a therapy. CBT-I is usually recommended first for long-term insomnia and can be very effective.16
- Pills are short-term at most. Sleep medicines carry risks and should not be used long term.35
Why insomnia hangs on
How insomnia can keep itself going
An illustration of a common pattern, based on the NHLBI description of causes and of stimulus control. It is not a diagnosis.
A trigger
Stress or a change in routine disturbs sleep for a few nights.2
Worry about sleep
Clock-watching and worrying about sleep make it worse.7
Bed becomes a place to be awake
Lying awake teaches you to link bed with being awake. Stimulus control reverses this.20
Daytime catch-up
Long naps, caffeine and screens late in the day push sleep further away.8
How much sleep is enough?
Sleep needs change with age. These are general recommendations, not targets to worry about on any single night.
Recommended hours of sleep a day, by age
General recommendations, not results measured in you, and not a description of a ProperHealth or Clarkson service.
The first treatment: CBT-I
| Part | What it does | What it asks of you |
|---|---|---|
| Cognitive therapy | Helps you feel less nervous about not being able to sleep.18 | Noticing and questioning worried thoughts about sleep. |
| Relaxation training | Teaches you how to relax and fall asleep faster.18 | Practicing a relaxation method, often at bedtime. |
| Sleep education | Helps you learn good sleep habits.18 | A regular schedule, and caffeine and screens moved earlier.2325 |
| Sleep restriction | Sets a specific amount of time in bed; with time, sleep improves.19 | Keeping to the time in bed your therapist sets. |
| Stimulus control | Links being in bed with being asleep.20 | Bed only when sleepy; out of bed if you can't sleep.20 |
CBT-I usually takes 6 to 8 weeks and can be done in person, by phone or online.1617
Two parts you can start tonight
- Same time every day. Go to sleep and wake up around the same time, weekends included.23 Keep any difference to about an hour.24
- Get up if you can't sleep. After about 20 minutes, get up and do something relaxing.22 Go back to bed when sleepy.20
- Relaxation on its own has only a small amount of low-quality evidence. It works best as one part of CBT-I.21
When it is not just insomnia
Most chronic insomnia is a symptom of something else.5 Your provider will look for it.
- Some medicines disrupt sleep, including some cold and allergy products and some prescriptions for other conditions.29
- Caffeine's effects can last up to 8 hours.25 Alcohol makes sleep lighter, so you wake more.26
- Loud snoring or waking up gasping can point to sleep apnea.14 Untreated sleep apnea can lead to serious problems.39
- Blood tests can check for thyroid and other problems; a sleep study looks for other sleep disorders.1415
- A 1- to 2-week sleep diary before your visit helps your provider see the pattern.13
From the Dr. Majid Ali archive
A historical perspective
“Bedtime technology for me? No, thank you.”— Dr. Majid Ali, 2014-12-26Sleep runs through Dr. Ali's writing, usually beside his stress and breathing material. He treated sleep as a restorative process to protect, and in 2014 wrote a short piece rejecting technology in the bedroom.
That instinct is consistent with current guidance, which advises keeping screens out of the hour before bed.28 His wider view, that daytime habits show up in the night's sleep, also matches today's list of risk factors.8
Where ProperHealth stops. Some of his sleep records sit beside remedy protocols and oxidant-therapy material, and he framed sleep within his own healing models. Only his behavioral observations are presented here. Nothing here recommends a remedy for insomnia, and nothing here is a reason to change a prescribed medicine.
What to do next
Set one wake-up time for every day
Weekends included, with no more than about an hour's difference.24 This is part of good sleep habits.
Get up after about 20 minutes awake
Do something relaxing, then go back to bed when sleepy.22
Move caffeine and screens earlier
Caffeine can last up to 8 hours.25 Make the hour before bed quiet time.28
Keep a sleep diary for 1 to 2 weeks
Bedtimes, wake times, naps, caffeine, alcohol and exercise.13 Take it to your appointment.
Ask about CBT-I by name
It is usually the first treatment recommended for long-term insomnia, and it can be done online.1617
Sleep aids, supplements and safety
A pharmacist can review what you take for sleep, spot medicines that may be keeping you awake, and help you prepare questions for your prescriber. A pharmacist does not diagnose insomnia or sleep apnea, and does not start or stop sleep medicines.
- Over-the-counter sleep aids usually contain antihistamines. They can make you sleepy but can be unsafe for some people.30 Diphenhydramine generally should not be used in older adults, and alcohol adds to its drowsiness.31
- Prescription sleep medicines may help in the short term but carry risks and should not be used long term.35 Rare side effects include walking, eating or driving while asleep.34
- Melatonin has not been proven to treat insomnia.32 It may help with jet lag or shift work, but guidelines recommend against it for chronic insomnia.33
- Herbal products. Kava has been linked to serious liver injury; valerian's value is not demonstrated.36 The FDA does not review supplements before they are sold.38
- Tell your providers about anything you take for sleep, including supplements.37 Some prescriptions for other conditions can cause insomnia.29
Compared
Conventional and integrative care, compared
Why CBT-I comes before pills, what sleep medicines and over-the-counter aids cost, what causes insomnia, and where melatonin, kava and valerian stand.
What conventional treatment does
- Cognitive behavioral therapy for insomnia (CBT-I) is a 6- to 8-week plan to fall asleep faster and stay asleep longer; it is usually the first treatment recommended for long-term insomnia and can be very effective.16 It includes cognitive therapy, relaxation training and sleep education,18 sleep restriction19 and stimulus control,20 given by a doctor, nurse or therapist, in person, by telephone or online.17 Multicomponent CBT-I remains the most strongly recommended treatment.21
- Some prescription sleep medicines are for short-term use.34
Limits and adverse effects
- Rare side effects of prescription sleep medicines include doing things while asleep, such as walking, eating or driving; benzodiazepines can be habit-forming and are for only a few weeks.34 Sleep medicines may help in the short term but carry risks, should not be used long term, and some lose their effect over time.35
- Over-the-counter sleep aids often contain antihistamines; they can make you sleepy but can be unsafe for some people,30 and diphenhydramine generally should not be used in older adults except for serious allergic reactions.31 Some medicines disrupt sleep, including some cold and allergy products, and some prescriptions for other conditions raise the risk of insomnia.29
What contributes to the condition
- Most chronic insomnia is secondary — a symptom or side effect of a medical condition, a medicine or another sleep disorder; caffeine, tobacco and alcohol can also cause it.5 Stress and worry raise the risk, and worrying about whether you will sleep makes it worse.7 Long daytime naps, too little activity, caffeine, nicotine or alcohol, and screens close to bedtime raise the risk.8
- Chronic insomnia raises the risk of high blood pressure, coronary heart disease, diabetes and cancer.4 It affects women more often than men, and older adults are more likely to have it.6
Integrative and naturopathic approaches, by evidence
Evidence levels: EstablishedEmergingHypothesisNot supported
- Established
Go to sleep and wake around the same time each day,23 within about an hour on weekends.24 Caffeine's effects can last up to 8 hours;25 alcohol makes falling asleep easier but sleep lighter;26 get regular activity in the daytime, at least 5 to 6 hours before bed,27 and keep the hour before bed quiet, away from bright screens.28 If you cannot fall asleep for 20 minutes, get up and do something relaxing.22
- Emerging
Melatonin may help sleep problems from shift work or jet lag, but two clinical guidelines (2017 and 2019) recommended against it for chronic insomnia,33 and research has not proven it effective; side effects can include daytime sleepiness, headaches, upset stomach and worsening depression.32 Relaxation techniques on their own have only a small amount of low-quality evidence.21
- Not supported
Kava has been linked to liver injury that is sometimes serious or even fatal, and valerian's value for insomnia has not been demonstrated.36 The FDA does not review dietary supplements for safety and effectiveness before they are sold.38
Loud snoring with pauses in breathing, or waking up gasping, is not insomnia — ask for a sleep assessment;43 and tell your providers about any complementary approach you use.37
When to get help now
Each warning sign cites the official guidance behind it. The wording still needs pharmacist sign-off.
- Thoughts of harming yourself, or feeling you would be better off gone — call or text 988 (Suicide & Crisis Lifeline, US) now. If you are in immediate danger, call 911.40
- Falling asleep while driving, at work or mid-conversation — do not drive while drowsy, and talk to your provider.4142
- Loud snoring with pauses in breathing, or waking up gasping or choking — ask for a sleep assessment.43
- Sleepwalking, eating or driving while asleep on a sleep medicine — do not take the next dose until you have spoken to your prescriber.4445
- Confusion or a fall in an older adult using a sleep aid — tell the doctor right away.4647
- Insomnia with low mood, loss of interest or hopelessness — book an appointment; this is treatable.4849