Anxiety & Mood
Insomnia: why you can’t sleep and what actually helps
Why you can’t sleep, when insomnia becomes chronic, and what really helps: cognitive behavioural therapy for insomnia first, with medication only where needed.
Insomnia is difficulty falling asleep, staying asleep or waking too early, with tiredness or difficulties the next day. It is called chronic when it happens at least three nights a week for at least three months [1]. The first treatment for chronic insomnia is not a pill. It is a specific form of psychotherapy, cognitive behavioural therapy for insomnia. Sleeping pills have a place, mostly for a short time.
How common it is
The 2023 European guideline states that insomnia affects up to 10% of adults in Europe [1].
In a review of more than 50 general-population surveys, about one in three people had at least one symptom of insomnia. When only people with consequences during the day were counted, the figure was 9% to 15%. About 6% had a full diagnosis [4].
It is more common in women [4].
Put simply: one bad night is not a disorder. It becomes one when it persists and costs you your day.
Why can’t I sleep?
There is usually no single cause. Insomnia can start with something specific, such as a worry or a change. Then it can carry on by itself, through habits and thoughts we develop to “rescue” our sleep.
The vicious circle of worry. The European guideline describes a vicious circle: worrying in advance that you will not sleep, thoughts that keep turning at night, a body on alert, and sleep becomes even harder [1].
More time in bed. It is natural to go to bed earlier or stay in bed longer to “catch up” on sleep. The behavioural model of insomnia sees exactly this extension of time in bed as something that keeps insomnia going [1].
Caffeine. In a randomised study, a moderate dose of caffeine disturbed sleep even when it was taken six hours before bedtime [6].
Alcohol. It helps you fall asleep faster, but it disrupts sleep in the second half of the night [7].
Depression. Insomnia is consistently linked with depression and also works as a warning sign. In a meta-analysis of 21 studies, people with insomnia but without depression had about twice the risk of developing depression later [5].
Physical causes and other sleep disorders. An overactive thyroid, for example, can cause difficulty sleeping, nervousness and a fast heartbeat [8]. If sleep apnoea or leg movements during sleep are suspected, the European guideline recommends a sleep study (polysomnography) [1].
In an assessment I do not only ask “how many hours do you sleep”. I ask about mood, anxiety, coffee, alcohol and physical conditions. When a physical condition, such as the thyroid, contributes to the problem, we treat it first, because it can mimic and worsen psychological symptoms.
What helps: cognitive behavioural therapy for insomnia
The 2023 European guideline and the American College of Physicians (ACP) recommend cognitive behavioural therapy for insomnia as the first treatment for chronic insomnia in adults [1][2]. The European guideline recommends it at any age and when other conditions are present, either face to face or in digital form [1].
The therapy combines:
Restricting time in bed. You stay in bed for roughly as long as you actually sleep. This builds the “pressure” to sleep, and sleep becomes more continuous. Then the time is increased gradually.
Stimulus control. The bed is linked with sleep again: you get up when you cannot fall asleep, and you wake at the same time every day.
Cognitive techniques for the thoughts that keep the mind awake.
Relaxation and information about how sleep works.
In a meta-analysis of 20 randomised studies with 1,162 adults, the therapy reduced the time it took to fall asleep by 19 minutes and the time spent awake during the night by 26 minutes. Total sleep time increased slightly, by about 8 minutes, without a clear difference. The benefits appeared to last afterwards as well [3].
“Sleep hygiene” rules on their own are not enough. The European guideline states that sleep hygiene advice, without the other components, is not an evidence-based treatment for chronic insomnia [1]. Light and exercise may help as additions.
A good night’s sleep is built from the morning. A fixed wake-up time, a little activity early in the day and physical exercise as a release give the body a rhythm. We do not wait for sleep to “come”; we create the conditions for it to come.
What about sleeping pills?
The European guideline suggests medication when cognitive behavioural therapy does not help enough [1]:
Benzodiazepines, related drugs such as zolpidem, daridorexant and some sedating antidepressants are used for a short period, up to four weeks. Longer use is considered in some cases, weighing benefits and drawbacks.
Orexin receptor antagonists, such as daridorexant, can be given for up to three months, and in some cases longer.
Prolonged-release melatonin can be given for up to three months to people aged 55 and over.
Antihistamines, antipsychotics, immediate-release melatonin and herbal preparations are not recommended for insomnia.
The American College of Physicians recommends a shared decision between doctor and patient about whether to add medication, with a discussion of benefits, risks and cost [2].
When medication is needed, we agree it as a trial with a start and an end: how long it will last, how we will judge whether it helps and how we will stop it. The first effort is psychotherapeutic; medication comes as an alternative when that is not enough.
If you have ADHD
If your difficulty is mainly that you fall asleep very late and wake up with difficulty, and you have or suspect ADHD, read ADHD and sleep: why nights run late and mornings feel hard.
When to ask for help
Insomnia has lasted more than three months or leaves you very tired during the day.
You use alcohol or pills to fall asleep.
You snore loudly, you have been told you stop breathing in your sleep, or you feel an urge to move your legs in the evening.
Together with insomnia you have low mood, anxiety or loss of interest.
Safety: If you feel sleepy while driving, stop somewhere safe. If, together with insomnia, you have thoughts that life is not worth living or thoughts of harming yourself, ask for help immediately: 166 (ambulance, EKAV), 112, or the Suicide Prevention Line 1018.
How I can help
Book an assessment, at the practice in Trikala or online. See also the page on sleep disorders. Sessions can also take place by video; see how working with an online psychiatrist works, or book an appointment.
This article is educational and does not replace individual clinical assessment. Do not change or stop any treatment you are already taking without talking to your doctor.
Sources
Riemann D, et al. The European Insomnia Guideline: An update on the diagnosis and treatment of insomnia 2023. J Sleep Res. 2023. https://doi.org/10.1111/jsr.14035
Qaseem A, et al. Management of Chronic Insomnia Disorder in Adults: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2016. https://doi.org/10.7326/M15-2175
Trauer JM, et al. Cognitive Behavioral Therapy for Chronic Insomnia: A Systematic Review and Meta-analysis. Ann Intern Med. 2015. https://doi.org/10.7326/M14-2841
Ohayon MM. Epidemiology of insomnia: what we know and what we still need to learn. Sleep Med Rev. 2002. https://doi.org/10.1053/smrv.2002.0186
Baglioni C, et al. Insomnia as a predictor of depression: a meta-analytic evaluation of longitudinal epidemiological studies. J Affect Disord. 2011. https://doi.org/10.1016/j.jad.2011.01.011
Drake C, et al. Caffeine effects on sleep taken 0, 3, or 6 hours before going to bed. J Clin Sleep Med. 2013. https://doi.org/10.5664/jcsm.3170
Ebrahim IO, et al. Alcohol and sleep I: effects on normal sleep. Alcohol Clin Exp Res. 2013. https://doi.org/10.1111/acer.12006
NHS. Overactive thyroid (hyperthyroidism). Last reviewed 11 April 2023. https://www.nhs.uk/conditions/overactive-thyroid-hyperthyroidism/
