Some lucky sleepers climb into bed, close their eyes, and are out cold within five minutes. Others stare at the ceiling for an hour, check the clock, try to find a fresh angle of the ceiling to observe, and then toss, turn, and repeat, every night, week after week.
Insomnia affects 10% to 15% of the U.S. population, and it’s usually caused by a variety of biological and behavioral factors, says Dr. Sairam Parthasarathy, director of the University of Arizona Health Sciences Center for Sleep, Circadian and Neuroscience Research. Women, people who work nights, and seniors are among those most at risk. It often runs in families, and recently, experts concluded that COVID-19 can trigger new insomnia.
While everyone will experience the occasional sleepless night, usually brought on by stress or lifestyle changes, chronic insomnia occurs three or more nights a week, lasts more than three months, and can’t be fully explained by a health problem. “For those who are in the ‘very severe’ category, it can be debilitating and incapacitating,” Parthasarathy says. “We see people where it’s crippling, and then there are some where it’s been annoying them for years”—and when they retire or otherwise have more free time, they finally decide to do something about it.
There’s good reason to work on putting your insomnia to sleep: The sleep disorder is associated with an increased risk of hypertension, diabetes, obesity, depression, heart attack, and stroke. And it can make you miserable.
Fortunately, resetting your sleep schedule can help the majority of people recover from insomnia—and cognitive behavioral therapy for insomnia, or CBT-I, is a proven way of doing it. But it takes time, and it’s not always an easy process.
A new sleep schedule
CBT-I is like “a brain retraining program,” says Dr. Jing Wang, clinical director of the Mount Sinai Integrative Sleep Center and an associate professor at the Icahn School of Medicine at Mount Sinai. Over the course of weekly sessions for around four to eight weeks, you’ll work with a sleep doctor or psychiatrist to target the behaviors and habits perpetuating your insomnia.
One of the cornerstones of treatment is sleep restriction therapy, which helps reset and create new habits around what happens when you’re in bed. Patients generally keep a sleep diary tracking what time they get into bed, when they wake up, and how many hours they actually sleep, Parthasarathy says. Then, doctors use that information to create a temporary schedule. Imagine, for example, that someone goes to bed at 8 p.m. and gets up at 6 a.m., but they’re only actually asleep for six of those hours. The rest of the time? They’re lying there in agony, stressed over the fact that they’re still awake—or they’re rummaging through the fridge, and then turning their laptop on to at least make that sleepless time productive.
With sleep restriction therapy, Parthasarathy would work backward from that hypothetical patient’s wake time (6 a.m.), since it’s probably non-negotiable due to work. Then he would instruct the person to get into bed at midnight—with the idea that they’d fall right asleep and get the same six hours of sleep before getting up at 6 a.m. Other patients will have different get-into-bed times, based on how many hours they’re currently sleeping per night, and what time they need to get up. (Doctors never set a schedule that drops someone below 5.5 hours of sleep per night, however.)
No matter how tired a person feels leading up to midnight—or whatever other sleep time they’ve been assigned—they’re not allowed to climb into bed. “We’re trying to consolidate the sleep period, and take off the time where sleep is not actually happening in the person’s bed,” he says. “By making them go longer without sleep, their brain becomes thirsty for it. So when they go to bed at 12, they’re not tossing and turning for an hour. They fall asleep in 5 or 10 minutes.”
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After one week, Parthasarathy assesses how well his patients are sleeping. While sleep diaries aren’t always 100% accurate, he’s found that patients generally do a good job estimating how long it took them to fall asleep, and how much they were awake during the night, especially given that many watch the clock. If someone’s sleep efficiency was greater than 90% every night—meaning they slept for more than 90% of the time they were in bed—he’ll relax their sleeping window by 15 minutes, so they get to go to bed slightly earlier. He’ll continue adjusting the sleep window by 15-minute increments weekly until the person’s sleep efficacy drops to 85% to 90%. “If it falls below 85%, that means there’s a lot of them lying around in bed, and we don’t want that,” he says. With time, patients’ sleep schedules are adjusted to their ideal bedtime—and by then, their body has learned that as soon as they get into bed, it’s time to fall asleep. “There’s subliminal programming that happens in our brain,” Parthasarathy says.
Though CBT-I is considered safe and effective for most people, sleep restriction can be exhausting; as Parthasarathy acknowledges, things often get worse before they get better for people with insomnia. That’s why he advises people with conditions like a seizure disorder or bipolar disorder to avoid CBT-I—lack of sleep can be triggering. It’s not always the right choice for people in jobs that require vigilance, either, like public-transportation drivers.
In general, even if you proceed with CBT-I, it’s important to be safe in those hours before you’re allowed to get into bed. “The first week or two after starting sleep restriction, people will feel sleepier,” Parthasarathy says. “Some of them are like, ‘Why am I doing this to myself?’” In addition to avoiding risky behaviors like driving, experts recommend filling the hours before you’re allowed to get into bed with relaxing activities: maybe journaling, taking a bath, or meditating.
Setting yourself up for success
Improving sleep hygiene is an essential part of CBT-I, Wang says. That includes adopting new habits around screens: Wang recommends turning off phones, computers, and even the TV at least one to two hours before going to bed. Part of the problem with screens, she says, is the light they produce: It suppresses melatonin, the hormone that helps prepare you for sleep.
The content on your screens can also be problematic. People have heightened reactions to, for example, watching the news, Wang points out—while some stay up late to catch whatever’s going on in politics or around the world, the scenes they see playing out can upset them to the point that they’re unable to sleep. Watching a horror film before bed can have a similar effect.
In addition to keeping your bedroom as dark as possible, consider ditching your alarm clock. “Cover it, or take it out of the bedroom,” Wang advises. “That act of looking at the time is activating. You’re taking a mental check: ‘OK, it’s midnight, I need to be up in five hours.’” That kind of stress certainly does not encourage sleep.
Wang also urges patients to ditch the sleep trackers—or at least look at them less frequently. Some people get fixated on combing through data, she’s found, obsessing over every slight change in their sleep patterns. “There’s always night-to-night variability,” she says. “So for somebody for whom looking at that data is causing a lot of anxiety, and that’s getting them more worked up, I really encourage them not to check it.”
Adjusting lifestyle habits
What you eat and drink before going to bed can play a role in how soundly you sleep. Doctors generally recommend not eating right before bed—late meals are linked with more frequent wake-ups during the night. And it’s a good idea to cut off caffeine intake by 12 p.m., says Dr. Emerson Wickwire, section head of sleep medicine at the University of Maryland Medical Center.
Proceed carefully, too, with alcohol intake. “Alcohol makes everything about sleep worse,” Wickwire says, “with one exception—you’ll fall asleep faster.” After that, things take a turn. Alcohol is a muscle relaxant, which means it relaxes the muscles in the upper airway, potentially causing symptoms of obstructive sleep apnea, even in people who aren’t diagnosed with the condition. “The second reason that alcohol can impair sleep is that it changes the distribution of sleep stages across the evening, or what’s called sleep architecture, and that can negatively impact brain function,” he says. You might find that you experience more fragmented sleep after drinking, waking up frequently and having trouble falling back asleep.
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People with a napping habit also need to make adjustments while undergoing CBT-I. The sleep drive is influenced by how long you’ve been awake and how active you’ve been, Wickwire says. While napping is OK for people who don’t have insomnia, it can thwart progress during CBT-I, because it means someone won’t be as tired when it’s time to go to bed. For example, if you get up at 7 a.m., you’ve been awake for 16 hours by 11 p.m.—which means your body should be craving sleep. “But if you take a nap at 6 p.m., by 11 p.m. you’ve only been awake for four or five hours,” he says, which could sentence you to a night of tossing and turning.
A role for medication
Clinical practice guidelines from the American Academy of Sleep Medicine consistently recommend CBT-I as the first-line treatment for chronic insomnia. “There are multiple studies that have compared outcomes between behavioral treatments and medication treatments,” Wickwire says. “And in general, CBT is equally effective in the short term, with gains better maintained over time.” Research suggests that CBT-I leads to fewer side effects than medication, a lower chance of relapse, and a tendency for sleep to continue improving long into the future.
“No pill can teach your body how to sleep,” Wickwire says. “At the same time, that’s not to say that all sleep medications are bad.” Patients should talk to their provider; sometimes, like in especially severe cases, it makes sense to combine CBT-I with a prescription sleep medication.
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Over-the-counter sleep supplements are a different story. It’s important not to rely on products like ZzzQuil, Benadryl, melatonin gummies, or Advil PM, Wang says. “If you’re sick and need to take one, that’s fine.” But with melatonin especially, “There’s a lot of variability and potential for misuses, or inadvertently causing the reverse effect. We really discourage self-medicating for insomnia.”
Light at the end of the tunnel
People with insomnia often start to see improvement in how much sleep they’re getting within a couple weeks. Exactly how quickly people respond varies, Wang says; some might need six to 12 weeks before noticing a meaningful difference.
Wang likes to remind patients—who are often stressed and exhausted—that change is possible. “Oftentimes it’s very slow. We don’t expect that tomorrow, these issues will all go away,” she says. “It’s the little steps and consistency—and encouraging people who feel like this is too hard that, yes, it may get worse before it gets better.” But if you keep at it, she adds, long, peaceful nights of slumber will be more than a sweet dream.