Short answer: cognitive behavioral therapy for insomnia (CBT-I) is the recommended first treatment for long-term insomnia because its benefits last after treatment ends. Sleep medications can help in the short term or alongside CBT-I, but many are not meant for nightly long-term use.
What CBT-I involves
- Sleep restriction: temporarily limiting time in bed to build stronger sleep drive
- Stimulus control: using the bed only for sleep and getting up when awake
- Consistent wake time: every day, including weekends
- Cognitive work: calming the worry about not sleeping
- Wind-down routine: dim light, no screens in bed
Most people improve in four to eight sessions. Digital CBT-I programs are another option.
When medication may help
Medication can be useful during a crisis, while starting CBT-I, or when insomnia is tied to depression, anxiety or another condition. A psychiatrist will consider your other medications, alcohol use, fall risk and the chance of dependence. Some antidepressants that help sleep are chosen when depression is also present.
Check for other causes
Snoring with daytime sleepiness may mean sleep apnea. Restless legs, chronic pain, reflux, caffeine, alcohol and some medications also disrupt sleep. Treating the cause often fixes the insomnia.
Why sleep restriction works
It sounds backward to spend less time in bed when you cannot sleep. But lying awake for hours teaches the brain that bed is a place for wakefulness and worry. By temporarily limiting time in bed to the hours you actually sleep, sleep becomes deeper and more consolidated. Time in bed is then gradually extended. The first week can be tiring, so it is best done with guidance.
Insomnia and mental health conditions
Insomnia often accompanies depression, anxiety, PTSD and bipolar disorder. In bipolar disorder, reduced sleep can be an early sign of mania and needs prompt attention. Treating insomnia directly, rather than assuming it will resolve when mood improves, leads to better outcomes for many conditions.
Building a sleep-friendly evening
- Stop caffeine by early afternoon
- Dim lights and put screens away an hour before bed
- Keep the bedroom cool, dark and quiet
- Write tomorrow’s to-do list earlier in the evening so it is not in your head at bedtime
Frequently asked questions
Is melatonin a good option?
Low-dose melatonin can help with timing problems such as jet lag or delayed sleep phase. It is less helpful for typical insomnia.
Can insomnia cause depression?
Chronic insomnia raises the risk of depression and anxiety, and treating insomnia can improve mood.
Read about sleep and mental health or schedule a psychiatric evaluation with Psych Boston. Request an appointment.
Related reading: Specific Phobias: Flying, Needles, Driving and More · Returning to Work After a Mental Health Leave
This article is general information, not medical advice. If you are in crisis, call or text 988 or call 911. Psych Boston is an outpatient psychiatry practice at 35 Bedford St #17, Lexington, MA781-218-9550).