Treating insomnia

Transient and intermittent insomnias may resolve on their own if they’re the result of a temporary disruption in your sleep schedule. 

However, if the insomnia is caused by a particularly stressful situation or pain from some physical condition, or if daily efficiency and quality of life are seriously impaired by sleeplessness, your doctor may prescribe short-acting sleeping pills. 

If you’re taking sleeping pills, you should be closely monitored to evaluate the drug's effectiveness and side effects. It’s also important to take the lowest dose necessary to relieve your symptoms.

Prescribed sleeping medications can be useful in some cases of insomnia.

When used properly, it can also be the quickest form of treatment. However, these medicines should be used as a temporary solution only. After a few weeks, they may lose their effectiveness, making some people raise the dosage. There’s also a risk of physical addiction to these medications, as well as injury from falls when getting up at night to use the bathroom (this is especially true for older people.)

Over-the-counter medications often complicate insomnia. They may help you fall asleep, but sleep quality is usually poor. Long-term use often worsens insomnia and makes it more difficult to treat. Use these medications only if your doctor recommends them.

Supplemental melatonin has recently undergone regulatory intervention, and is now only available by prescription for the treatment of insomnia. Melatonin is a hormone produced by the pineal gland in the brain. Small amounts in supplement form may help regulate the sleep cycle in people with circadian rhythm disorders and chronic insomnia. It’s particularly useful in the elderly. 

Important note: Never combine sleep-inducing drugs with even a small amount of alcohol. Alcohol is a sedative that can compound the drug’s effects.

Behavioural therapy
The gold-standard, evidence-based treatment for insomnia uncomplicated by a medical or psychiatric condition is cognitive behavioural therapy for insomnia (CBT-I).

CBT-I utilises the following techniques and interventions to help you restore your normal (physiological) sleep:

• Sleep hygiene (good sleep habits)
• Relaxation therapy
• Stimulus control
• Sleep restriction
• Cognitive therapy (addressing negative automatic thoughts)
• Behavioural adjustments 

Behavioural techniques can be as effective as sleeping pills and have no side effects. The goal is to help you "learn" healthy sleeping habits.

Examples of behaviour therapy include:

• Relaxation therapy. This aims to relax the mind and muscles by focusing on the repetition of a word, sound or muscular activity (tensing and releasing muscles while lying in bed), without actively excluding other thoughts or feelings. The aim is to relax passively by accepting each thought or emotion as it arises.
• Restriction of sleep. This involves allowing a few hours of sleep during the night and gradually increasing the time until you reach a normal night's sleep.
• Reconditioning aims to alter how you associate your bed and bedtime with sleep. You avoid using the bed for anything but sleep and intimacy, go to bed only when sleepy, and leave the bedroom if you can't sleep. You also learn to avoid naps, and to sleep at the same time each day.

Herbal remedies
The following remedies may help with sleep:

• Camomile: This is a calming, relaxing tea.
• Kava-kava: This Pacific-island root may help alleviate anxiety and encourage restful sleep. However, habitual use of high doses has been associated with serious side effects such as muscle weakness and a skin rash. Use with caution, in low doses and intermittently.
• Valerian: This herbal tranquilliser helps to relax muscles.

Important note: Always tell your doctor when you’re using alternative therapies as they may interact with your prescription drugs. They also often have side effects of their own.

Home treatment and prevention
Many sleep problems can be overcome by simple measures (also known as good sleep hygiene):

• Cut down on late-night snacks and late-evening heavy dinners. Some experts recommend that you shouldn’t eat at least three hours before bedtime. Protein promotes alertness and carbohydrates make you calm and drowsy, so eat a light, high-protein, low-carbohydrate lunch. This will decrease early-afternoon drowsiness, and make an afternoon nap less tempting. Conversely, a high-carbohydrate, low-protein supper should help encourage sleepiness closer to bedtime.
• Exercise. Even moderate exercise helps to control stress while releasing natural stimulants, decreasing the need for external stimulants such as caffeine. An exercise routine should help regulate your sleep cycle and make you feel sleepier in the late evening. However, avoid exercising vigorously too close to bedtime.
• Don't use your bedroom, even less your bed, as a place for activities other than sleep and intimacy. Get into bed when you’re ready to sleep and leave it when you wake, to avoid sending your body conflicting cues about sleep and waking life. 
• If you wake up in the middle of the night and can't fall asleep within half an hour, get up and rest, or read in a comfortable chair until you become sleepy.
• Establish a bedtime ritual of cues for going to sleep. These could include having a bath or drinking a glass of warm milk (milk contains an amino acid that’s converted into a sleep-enhancing compound in the brain). Many people feel relaxed after sex. 
• Cut down on daytime napping if it starts to affect your regular sleep patterns. Avoid napping within seven or eight hours of bedtime.
• Avoid alcohol in the late evening.
• Relaxation techniques may also be useful.

If your insomnia persists, keep a diary of your sleep history. This may be helpful later in diagnosing an underlying cause.

When to call a doctor
The majority of people with insomnia symptoms usually have short-term situational insomnia that resolves by itself. 

However, if your insomnia has been present for more than a couple of weeks and isn’t improving despite you establishing good sleep hygiene practices and/or you’re developing daytime fatigue, irritability and poor concentration, it’s time to get your doctor involved.

Read more:
Diagnosis of insomnia

Reviewed by Dr Irshaad Ebrahim, specialist neuropsychiatrist in sleep disorders at The London Sleep Centre and The Constantia Sleep Centre. FRCPsych. April 2018.