When You Can’t Sleep: How to Treat Insomnia

You lie awake at night staring at the ceiling. You feel like you’re cursed, but you’re not alone. Estimates suggest between 1 in 10 and 1 in 3 people suffer from some degree of insomnia, which is having trouble with either falling asleep, staying asleep during the night, or waking up earlier than you intend to in the morning (or a combination of the above). (1)

There are many reasons why you might be struggling to fall asleep or stay asleep throughout the night, ranging from stressful life events, like getting fired from a job, to health issues. (2) What’s more, those periods of short-term insomnia that last just a few days or a week (acute insomnia), can turn into longer-term insomnia, which is known as chronic insomnia, meaning that your sleep troubles last beyond the initial stressor.

What’s important to know is whether you’ve been having sleep trouble for just a few weeks or if it’s been for as long as you can remember, you can (and should!) get help. Lifestyle changes, therapies, and other treatments do exist to retrain your mind and body to get the sleep you need to stay not only happy but healthy, too.

Here are some of the treatment options your doctor or a sleep specialist might recommend if you have insomnia.

For a mild case of insomnia that’s only been a problem for a few days or weeks, doctors will first likely recommend making a few lifestyle changes to promote better sleep. Rita Aouad, MD, a psychiatrist and former assistant professor of sleep medicine at The Ohio State University Wexner Medical Center in Columbus, says she always starts with tweaking a person’s sleep hygiene, the daily habits and routines you follow that affect sleep.

Good sleep hygiene — practices that promote healthy sleep — includes:

• Sticking to a Sleep Schedule This means going to bed and waking up around the same time no matter if it’s Wednesday or Sunday.
• Avoiding Anything That Could Mess With Your Ability to Fall Asleep This means substance as caffeine and tobacco, for instance, that can stay in your system for eight hours. And don’t rely on a nightcap, either. “Some people think alcohol can help with sleep onset, but it actually fragments your sleep,” Dr. Aouad says.
• Not Exercising Too Late in the Day Ideally, you’ll hit the gym more than three hours before bedtime, Aouad says, otherwise the activity can stimulate your body and make it tougher to fall asleep.
• Limiting Daytime Naps to No More Than 30 Minutes Aouad suggests this.
• Turning Off Electronics At Least One Hour Before Bedtime
• Reserving the Bed Solely for Sleep and Sex
• Creating a Sleep-Promoting Environment That’s Quiet, Dark, and Cool

And if you’re doing all that and still have trouble sleeping, keep a few tips in mind, such as don’t lie in bed for hours if you can’t sleep. “If it’s been 20 minutes and you’re frustrated you’re not asleep and you’re thinking, ‘Why am I not asleep yet?’ or ‘I need to do this, this, and this tomorrow’ — that’s counterproductive,” Aouad says.

You can start to work yourself up and associate the bed with not sleeping, making it tougher to fall asleep like you want to do. “Leave the bedroom and do something boring,” she says, such as washing the dishes or folding laundry until you start to feel tired.

Or, if it’s an anxious mind that’s keeping you up, try scheduling worry time for tomorrow. “The worries tend to come out at night when there are fewer distractions and you’re not busy with tasks,” Aouad says. By writing the worries down on paper and setting aside time to address them the following day, you’re more likely to be able to let them go and get some rest. “The goal is to control your worries and not have your worries control you,” Aouad says.

If improving sleep hygiene and other lifestyle changes alone don’t help with your sleep, the next step is cognitive behavioral therapy to improve sleep and reverse chronic insomnia. Aouad says it’s a better option than medication.

“Medication will help you as long as it’s in your system, so that’s a day or two,” she says. While there are some appropriate uses for prescription sleep aids (if they are used correctly), they can come with extremely dangerous side effects, and they tend to be highly addictive. (3) “The benefits of cognitive behavioral therapy, a specific type of counseling to help with the anxiety around sleep that comes with chronic insomnia, have been shown to far outlast medication,” Aouad explains.

According to a 2012 study, cognitive behavioral therapy is better at improving sleep efficiency than common drugs, and led to an extra 30 to 60 minutes in sleep time when the two treatment strategies were compared. (4)

Cognitive behavioral therapy focuses on teaching techniques to help you relax, control your breathing and mood, slow down your racing mind, and get to sleep. “Really, the basis of it is providing education, talking about sleep drive and teaching people things like stimulus control and avoiding anything stimulating around bedtime,” Aouad says. Think of it as reteaching your body how to sleep.

The therapy also involves sleep restriction. (5) “Some people have this misunderstanding that if I can’t sleep, then I should spend more time in bed to try to get myself to sleep,” Aouad says. “Actually you should really only be in bed for the time that you’re sleeping.” The idea is by cutting down on the amount of time you spend lying in bed awake, you’ll be more tired and more likely to fall asleep quickly next time.

A 2015 study found just one session of cognitive behavioral therapy plus a self-help pamphlet effectively treated about half of the cases of acute insomnia. (6)

Aouad suggests seeking a therapist who has experience providing cognitive behavioral therapy for insomnia — the American Board of Sleep Medicine has a helpful list published on its website. (7) Usually it’s offered as a series of in-person sessions over the course of four to six weeks, though there are some online programs that could be helpful for people living in remote areas or for those without insurance, Aouad says.

Before turning to medication, your doctor should rule out other possible health issues. Insomnia oftentimes is a side effect of an underlying issue, such as depression or an anxiety disorder, in which case an antidepressant could be more beneficial than a sleep aid. If there’s something else going on, that issue should be addressed versus putting a Band-Aid on the problem with sleep medication, Aouad says.

“If you try sleep hygiene and cognitive behavioral therapy for insomnia, and you’re not seeing the benefit, I would say see a specialist so they can rule out any other possible medical or mental health issues that could be contributing to the insomnia and help direct you to treatment,” Aouad says.

In these cases, over-the-counter or prescription sleep medication can be helpful if used for a short period of time, as you simultaneously establish a healthier sleep routine — by improving your sleep hygiene and forming habits that allow you to get the sleep you need. The ideal scenario is that once you do get into a better sleep routine, you can stop taking the medication, but continue to sleep well.

If medication is prescribed, take it for as little time as necessary since it can be habit forming, Aouad says — three months at maximum. And be sure to discuss the medication’s purpose and side effects with your doctor.

For example, some medicines may help you fall asleep but leave you dealing with grogginess in the morning. Others can cause complications, such as sleepwalking or sleep-driving. And some drugs have been found to increase mortality risk, regardless of pre-existing conditions, according to research. (8) Your doctor should also discuss any previous, existing, or potential mental health problems with you before prescribing a sleep aid, as some can heighten the risk of depression and suicide, noted a 2017 study. (9)

Types of prescription sleep aids include:

• Benzodiazepines
• Nonbenzodiazepines hypnotics
• Selective gamma-aminobutyric acid medication
• Dual orexin receptor antagonists
• Histamine antagonists
• Antidepressants
• Melatonin receptor agonists
• Barbiturates
• Antipsychotics

Melatonin, a supplement that promotes sleep, can also be helpful, though it’s better at treating circadian rhythm issues (such as jetlag) than insomnia. (10) It’s not meant for nightly use, but Aouad says it’s worth a try in the short term because it’s sold over the counter and is generally harmless.

“The recommended dose is the smallest dose that’s effective to help you sleep,” she says. ”I would say 10 milligrams (mg) is the max, but most people should use 1 to 3 mg.” She says to take it about an hour before bed and recommends consulting your doctor first if you’re pregnant, breastfeeding, or plan to become pregnant.

Ideally, you’d take the supplement for about four or five days to get your circadian rhythm realigned to your new bedtime, but if you’ve been taking it for a month and still having trouble, it’s time to visit a doctor. At this point, it’s not about being prescribed a stronger medication as much as it’s about figuring out the underlying issue, Aouad says.

Absolutely. It may not be easy though, as curing insomnia often means improving your sleep hygiene and establishing habits that are more conducive to good sleep. And habits, especially routines you follow every day, can be tough to break.

But it is possible. And according to Aouad, each small step you take to establish better sleep is an important one.

“I think people underestimate how much making small changes to their habits can be beneficial,” Aouad says. “Even though those habits can be hard to change, gradually changing them over time can really improve someone’s sleep.”