Help for long-running sleep problems

You may have tried the usual sleep advice and still lie awake most nights. If trouble getting to sleep or staying asleep has gone on for months and is affecting your days, it has a name. The NHS describes insomnia as regularly having problems sleeping, and calls it long-term insomnia once it has lasted three months or more. It also has a treatment with good evidence behind it.

Why it keeps going

Whatever started the bad nights, much of the research is about what keeps them going. In one well-cited account (Harvey, 2002), worry about sleep, and about how you'll cope tomorrow, keeps the body's alerting systems running at bedtime. That state makes you watch closely for signs that sleep isn't coming, and the watching makes the night seem worse than it is, which feeds more worry. Trying hard to push the thoughts away can add to it.

Two other things often join in. The bed becomes associated with lying awake, so getting into it cues alertness rather than sleep. And going to bed earlier or staying in bed later to catch up spreads the same amount of sleep over more hours, which dilutes sleep pressure, the drive to sleep that builds the longer you're awake, and makes nights lighter and more broken.

What CBT-I involves

Cognitive behavioural therapy for insomnia (CBT-I) works on each of those loops, usually as a short course of sessions with a sleep diary kept throughout. Stimulus control rebuilds the link between bed and sleep: go to bed only when sleepy, get up if you can't sleep, and keep the same getting-up time. Sleep restriction shrinks the time in bed to roughly the time you're actually sleeping, so pressure builds and sleep consolidates, then widens it again as sleep improves. The cognitive part looks at the worries and beliefs about sleep that keep the alerting systems switched on.

Sleep restriction needs a professional alongside you. Kyle and colleagues (2014) measured sleep in the laboratory in 16 people with insomnia during four weeks of it. During treatment their measured sleep fell by over an hour a night, and they were sleepier and slower to react during the day. By three months their alertness was back to where it started, and their insomnia had improved. It was small and had no comparison group, but it shows why time in bed is set with a clinician, and why driving needs care in the first weeks.

How good the evidence is

Furukawa and colleagues (2024) pooled 241 trials in more than 31,000 adults with chronic insomnia to estimate what each part of CBT-I contributes to recovery. The cognitive work, mindfulness and acceptance approaches, sleep restriction and stimulus control each added to the chance of recovery. Sleep-hygiene education added nothing measurable, and therapy delivered in person by a therapist did best. The authors caution that the parts might interact in ways their method couldn't detect.

The American College of Physicians recommends CBT-I as the first treatment for all adults with chronic insomnia (Qaseem et al., 2016), and the American Academy of Sleep Medicine strongly recommends it too (Edinger et al., 2021). The same guideline suggests clinicians don't use sleep hygiene, general advice on habits such as caffeine and alcohol, as the only treatment: on its own it did less well than the alternatives, and only two low-quality trials showed a meaningful benefit. That's graded a conditional recommendation, and the guideline says common-sense parts of the advice can still help inside a fuller programme.

Getting it through the NHS

Across 11 trials and 1,460 people, CBT-I delivered over the internet improved insomnia, and its effects were comparable to face-to-face treatment, with more personal clinical support going with bigger effects (Zachariae et al., 2016). In 2022, NICE recommended Sleepio, a six-week online CBT-I programme, for use in primary care for people who would otherwise be offered sleep-hygiene advice or sleeping pills, with a medical assessment first for anyone at higher risk of another sleep condition, such as during pregnancy. The NHS says a GP may offer CBT face to face or through an online self-help programme, and that sleeping pills are now rarely prescribed, and then usually only for days or a few weeks.

See your GP if changing your sleep habits hasn't helped, you've had trouble sleeping for months, or it's affecting your daily life in a way that makes it hard to cope. They can check for other causes and tell you what's offered locally.

Where your Sleep Map fits

Your Sleep Map plan is sleep coaching. Some of its steps borrow from CBT-I, but it isn't a substitute for treatment. If your diary points to long-running insomnia, we'll suggest you see your GP, and the diary is worth taking with you.