Insomnia: the drug-free treatment recommended as the first choice

Chronic insomnia, that is, difficulty falling or staying asleep at least three nights a week for at least three months, affects a considerable share of adults. It affects mood, concentration and quality of life. Many people seek help from sleeping pills, but these usually help for a short time and have side effects.

CBT-I

Cognitive behavioural therapy for insomnia (CBT-I) is a structured programme, usually of 4–8 sessions, that works on the habits and thoughts that keep insomnia going. In 2016 the American College of Physicians recommended CBT-I as the first treatment for adults with chronic insomnia, before medication.

What the evidence says

In 2015 James Trauer and colleagues combined 20 clinical trials with over 1,100 participants. CBT-I shortened the time to fall asleep by about 19 minutes on average, reduced time awake during the night by about 26 minutes and increased sleep efficiency, the share of time in bed spent asleep. The effects seemed to last for months after the end of therapy, unlike many medicines.

Sleep cannot be forced. But we can create the conditions for it to come by itself.

The main principles

• Stimulus control: the bed is used only for sleep. If you cannot fall asleep within about 20 minutes, get up, go to another room with dim light and return when you feel sleepy.
• Sleep restriction: for a while, time in bed is limited to close to the time you actually sleep, so that sleep becomes deeper and more continuous. This should be done with professional guidance.
• A regular schedule: get up at the same time every day, even at weekends.
• Working with thoughts: beliefs such as "if I don't sleep eight hours, tomorrow will be a disaster", which add to anxiety about sleep, are examined.
• Sleep hygiene: little caffeine after lunch, little alcohol, a dark and cool room.

Where to find help

CBT-I is offered by psychologists and sleep specialists, and in some countries also through evaluated digital programmes. Talk to your doctor, especially if insomnia comes with loud snoring, pauses in breathing during sleep, depression or chronic pain, which need separate assessment.