The insomnia epidemic
Approximately 30% of adults experience insomnia symptoms, and 10% have chronic insomnia disorder — insomnia occurring at least 3 nights per week for at least 3 months, causing significant daytime impairment. Insomnia is not just an inconvenience. Chronic insomnia is associated with depression, anxiety, cardiovascular disease, impaired immune function, and accidents.
Types of insomnia
Sleep onset insomnia involves difficulty falling asleep. Sleep maintenance insomnia involves waking during the night and difficulty returning to sleep. Early morning awakening involves waking before the desired time and being unable to return to sleep. Non-restorative sleep involves feeling unrefreshed despite adequate hours in bed. Most people with insomnia experience more than one type.
CBT-I: the evidence-based first-line treatment
Cognitive Behavioral Therapy for Insomnia (CBT-I) is the first-line treatment for chronic insomnia — more effective than sleeping medications and with lasting benefits. Unlike medication, CBT-I addresses the underlying causes of insomnia rather than just the symptoms.
CBT-I includes several components: sleep restriction (initially reducing time in bed to build sleep pressure), stimulus control (rebuilding the mental association between bed and sleep), cognitive therapy (addressing unhelpful beliefs about sleep), and sleep hygiene education. A typical course involves 6-8 sessions.
Most people with chronic insomnia are spending too long in bed — trying to "catch up" on sleep. This actually worsens insomnia by weakening sleep drive and fragmenting sleep. Sleep restriction, while counterintuitive, is one of the most powerful components of CBT-I.
Sleeping medications
FDA-approved medications including eszopiclone, zolpidem, and suvorexant provide short-term relief but are not recommended as long-term treatment for chronic insomnia. Benzodiazepines have significant dependence and cognitive side effects with long-term use. Melatonin has limited evidence for sleep onset but is safer for short-term use. Sedating antidepressants (trazodone, mirtazapine) are commonly prescribed off-label.
When insomnia is a symptom
Insomnia frequently co-occurs with depression, anxiety, PTSD, chronic pain, and other conditions. Treating the underlying condition often improves sleep, but insomnia also frequently persists and requires direct treatment even after the primary condition is addressed. If you have both insomnia and another mental health condition, both deserve direct attention.