Sleep Science | Explainer
What Sleep Doctors Recommend Before Any Sleep Aid
The first treatment the major guidelines name for chronic insomnia is not a pill, a gummy or a tea. It is a short course of therapy most people have never been offered.
If you have trouble sleeping for months on end, you have probably been told about sleep hygiene, offered a pill or pointed to the supplement aisle.
What you may not have been told is that the major medical guidelines put something else first.
What the guidelines say
In 2016, the American College of Physicians recommended that all adults with chronic insomnia receive cognitive behavioural therapy for insomnia as the initial treatment. Medicines, it said, should be a second step, considered only if therapy alone does not work.
In 2021, the American Academy of Sleep Medicine gave CBT I a strong recommendation, its highest grade, for adults with chronic insomnia.
The academy's 2017 guideline on sleep medicines went the other way on melatonin. It suggested that clinicians not use melatonin to treat trouble falling asleep or staying asleep in adults with chronic insomnia.
What CBT I actually is
CBT I is a structured programme, usually spread over four to eight sessions, that targets the habits and thoughts that keep insomnia going. Most programmes combine:
- A sleep diary, to see what your nights really look like.
- Stimulus control: using the bed only for sleep, and getting up when you cannot sleep rather than lying there.
- Sleep restriction: matching your time in bed to the sleep you are actually getting, then widening it as sleep improves.
- Cognitive work on the worries about sleep that keep you awake.
- Relaxation and basic sleep habits.
Why it is not more common
Trained therapists are scarce, and a pill or a supplement is quicker to hand over than a course of therapy. The early weeks can also feel worse before they feel better, because sleep restriction makes you more tired at first.
How to start
Ask your doctor for a referral to a CBT I provider. Digital programmes have also been studied, and some are free: the US Department of Veterans Affairs offers the CBT i Coach app to anyone.
If your sleep problem comes with loud snoring, pauses in breathing or falling asleep during the day, see a doctor first, because those can be signs of a different sleep disorder.