What can I do about my insomnia?

What to Do About Your Insomnia

Start Cognitive Behavioral Therapy for Insomnia (CBT-I) immediately—this is the single most effective treatment with durable benefits that persist long after treatment ends, unlike medications which lose effectiveness when stopped. 1, 2

Why CBT-I Must Be Your First Step

The American College of Physicians issues a strong recommendation that all patients with chronic insomnia receive CBT-I as initial treatment, and the American Academy of Sleep Medicine designates it as the standard of care. 2 This isn't just a suggestion—CBT-I produces clinically meaningful improvements sustained for up to 2 years, while pharmacotherapy shows degradation of benefit after discontinuation. 2

The Core Components You Need to Implement

Sleep Restriction Therapy (most critical for your situation):

• Track your actual sleep time using a sleep log for 1-2 weeks 3, 4
• Limit your time in bed to match only your actual sleep duration—if you're sleeping 4 hours, only allow yourself 4 hours in bed 3, 4
• This consolidates sleep by enhancing sleep drive and is specifically effective for sleep maintenance problems 3

Stimulus Control Therapy:

• Go to bed only when genuinely sleepy, not just tired 3, 4
• If you cannot fall asleep within 20 minutes, get out of bed and return only when sleepy 3, 4
• Use your bed only for sleep and sex—no phone, TV, computer, eating, or "clock watching" 1, 3
• Maintain a consistent wake time every day regardless of how much you slept 3, 4

Cognitive Therapy:

• Address distorted beliefs about sleep, such as catastrophizing about consequences of poor sleep 1, 4
• Challenge the "trying hard" to fall asleep mentality, which creates a vicious cycle of arousal and frustration 1

Relaxation Training:

• Practice progressive muscle relaxation or other relaxation techniques 4

How to Access CBT-I

In-person, therapist-led programs are most beneficial and typically require 4-8 sessions over 6 weeks. 2 Digital CBT-I is an effective and scalable alternative when in-person therapy is unavailable. 2

When to Consider Medication (Only After CBT-I)

If CBT-I alone is insufficient after 2-4 weeks, consider adding pharmacological therapy while continuing CBT-I. 3, 4 The American Academy of Sleep Medicine and Annals of Internal Medicine recommend considering pharmacological options only after behavioral interventions have been unsuccessful. 3

First-line medication options:

• Short-intermediate acting benzodiazepine receptor agonists: zolpidem, eszopiclone, zaleplon, or temazepam 3, 4
• Ramelteon for patients preferring non-DEA-scheduled drugs or those with substance use history 4

Second-line options if first-line fails:

• Sedating antidepressants: trazodone, doxepin (low-dose), amitriptyline, or mirtazapine 3, 4

Critical Mistakes to Avoid

Do not use over-the-counter antihistamines (like diphenhydramine or doxylamine)—they cause anticholinergic effects, daytime sedation, and lack efficacy for chronic insomnia. 3, 4

Do not rely on melatonin—it has insufficient evidence to determine efficacy for chronic insomnia. 2

Do not start with medications—this violates guideline recommendations and deprives you of more effective, durable therapy. 2

Do not practice "sleep hygiene" alone—while avoiding caffeine after noon, limiting alcohol, and keeping your bedroom dark and cool are helpful, sleep hygiene education lacks efficacy as a single intervention. 3, 2

What Else to Evaluate

Before assuming primary insomnia, screen for underlying causes: 3

• Sleep apnea or restless legs syndrome
• Medication side effects (SSRIs, stimulants, decongestants can all cause insomnia) 1
• Medical conditions causing pain or nocturia 3
• Psychiatric conditions (depression, anxiety) 1
• Substance use (caffeine, alcohol, nicotine) 1

Your Treatment Timeline

Weeks 1-2: Begin CBT-I with sleep restriction and stimulus control, document sleep patterns using sleep logs. 3

Weeks 3-4: Continue CBT-I, add relaxation techniques if insufficient improvement. 3

Weeks 5-8: If still insufficient after 6-8 weeks of CBT-I, consider short-term pharmacological therapy while continuing behavioral interventions. 3

Ongoing: Reassess every few weeks initially to evaluate effectiveness, and attempt medication tapering after 4-8 weeks when sleep consolidates. 3, 4