What can I do to address my insomnia?

Immediate Management of Your Current Sleeplessness

Get out of bed now and engage in a quiet, relaxing activity in dim lighting until you feel drowsy, then return to bed—this is the most evidence-based immediate action you can take tonight. 1

What to Do Right Now (Tonight)

Since you've been awake in bed for over 7 hours (7:30pm to 2:45am), you need to break the negative association between your bed and wakefulness:

• Leave your bed immediately and go to another room with dim lighting 1
• Engage in a calming, non-stimulating activity such as reading something boring, listening to quiet music, or gentle stretching—avoid screens, bright lights, and anything mentally engaging 1
• Return to bed only when you feel genuinely drowsy, not just tired 1
• Avoid clock-watching—turn clocks away from view, as monitoring time increases anxiety about sleep 1
• If sleep doesn't come within approximately 20 minutes after returning to bed, repeat this process 1

Long-Term Solution: Cognitive Behavioral Therapy for Insomnia (CBT-I)

CBT-I should be your first-line treatment for chronic insomnia, as it produces sustained improvements for up to 2 years, unlike medications which lose effectiveness after discontinuation. 2, 3

Core Components of CBT-I You Should Pursue:

• Stimulus Control Therapy (Standard recommendation): Use your bed only for sleep and sex; maintain a consistent sleep-wake schedule; avoid daytime naps; leave bed if not asleep within ~20 minutes 1

• Sleep Restriction/Compression Therapy (Standard recommendation): Keep a sleep log for 1-2 weeks to determine your actual total sleep time (TST), then limit time in bed to match only your TST (minimum 5 hours), gradually increasing by 15-20 minutes weekly as sleep efficiency improves above 85% 1

• Cognitive Restructuring: Address unhelpful beliefs like "I can't function without 8 hours," "I need medication to sleep," or "My life is ruined if I don't sleep tonight" 1

• Relaxation Training: Progressive muscle relaxation involves systematically tensing and releasing muscle groups to reduce physical arousal 1

How to Access CBT-I:

• In-person therapy with a trained therapist is most effective, typically requiring 4-8 sessions over 6 weeks 2
• Digital CBT-I programs are effective alternatives when in-person therapy is unavailable and provide scalable access 2

When Medications Might Be Considered

Pharmacotherapy should only be considered after attempting CBT-I or when CBT-I is unavailable, using shared decision-making with your healthcare provider. 2, 3

If medications are eventually needed:

• For sleep onset difficulty: Short-acting agents like zaleplon, zolpidem, or ramelteon (especially if you have substance use history, as it's non-DEA scheduled) 1, 4, 5
• For sleep maintenance difficulty: Longer-acting options like eszopiclone, temazepam, or low-dose doxepin (3-6mg) 1, 3, 4
• Medications should be short-term only and always combined with behavioral interventions 2, 6

Critical Behaviors to Avoid Tonight and Going Forward

• Don't stay in bed awake—this creates a learned association between your bed and wakefulness 1
• Don't use alcohol as a sleep aid—it fragments sleep and worsens insomnia 1, 6
• Don't consume caffeine after 4:00 PM 1, 7
• Don't nap during the day, as this reduces sleep drive at night 1
• Don't exercise, eat heavily, or engage in stimulating activities late in the evening 1
• Don't rely on sleep hygiene education alone—it's insufficient without behavioral interventions like stimulus control and sleep restriction 1, 2, 3

Red Flags Requiring Medical Evaluation

If your insomnia persists beyond 7-10 days despite these interventions, you need evaluation for:

• Underlying psychiatric disorders (depression, anxiety)—insomnia is bidirectional with mental health conditions 1, 8
• Medical conditions (chronic pain, thyroid disorders, sleep apnea, restless legs syndrome) 1, 3
• Medications disrupting sleep (SSRIs, stimulants, decongestants, corticosteroids, beta-blockers) 1, 3

The failure of insomnia to improve after 7-10 days of appropriate behavioral treatment indicates the need for comprehensive medical evaluation. 1, 4, 5