What Do Doctors Want You to Understand?

About 30% of people in the U.S. report insomnia symptoms.¹ But only about 10% to 15% of adults have the long-term condition doctors call chronic insomnia disorder.² Our guide to evidence-based sleep hygiene habits covers the habits that keep most people sleeping well. This guide is for when sleep has stopped working.

Here is the pattern doctors see most often. Something stressful happens: a new job, an illness, a loss, money trouble.³ ⁴ Sleep gets worse. So you do what feels sensible. You go to bed earlier. You stay in bed longer, hoping to catch up. You nap. You start to dread bedtime.

Then the stress passes, but the insomnia stays. The coping habits have become the problem.³ Lying awake in bed night after night teaches your brain that bed is a place for being awake.³ Worry about sleep keeps your mind on alert.⁴ The original cause is gone, but the pattern runs on its own.

This is why doctors think about insomnia in two layers. What started it matters. But what keeps it going matters more, because that is what treatment can change.

When Does Poor Sleep Become Insomnia?

Insomnia means trouble falling asleep, staying asleep, or waking too early, even when you have a chance to sleep.⁵ Doctors call it chronic when it happens at least three nights a week for three months or longer.¹ ⁵

The key is what happens during the day. Insomnia is a problem when it leaves you tired, foggy, irritable, or struggling at work or at home.³ Someone who sleeps six hours and feels fine is different from someone who sleeps six hours and cannot function.

Some things raise the chance of insomnia:⁴

• Stress and worry, including worry about sleep itself

• Getting older

• Being a woman, especially during pregnancy or menopause

• Shift work, night work, or frequent travel across time zones

• Caffeine, nicotine, or alcohol, especially late in the day

• Long daytime naps and too little physical activity

Insomnia also often comes with other health problems. These include sleep apnea, restless legs syndrome (an urge to move your legs at night), depression, and pain.¹ ³ Our guide to how anxiety affects your body explains how worry can show up as poor sleep.

WHAT YOUR DOCTOR IS LOOKING FOR

Your doctor wants to know whether this is insomnia on its own, or insomnia plus something else. They will ask how often it happens and how it affects your days, and review your medicines, caffeine, and alcohol.⁵ They may ask you to keep a sleep diary for one to two weeks.⁵ They also listen for clues to other sleep problems. Loud snoring, gasping at night, or heavy daytime sleepiness can point to sleep apnea, which needs its own test.³ ⁵ A coming guide on the signs of sleep apnea covers those clues. A blood test can check for thyroid problems.⁵ If depression or pain is part of the picture, a good plan treats both. Insomnia is not just a side effect of the other condition.³

What Actually Helps?

CBT-I comes first. The VA/DoD guideline strongly recommends CBT-I for long-term insomnia.³ The American Academy of Sleep Medicine also favors CBT-I. It suggests adding CBT-I for people who take sleep medicine, and suggests CBT-I alone over adding medicine to it.² It usually runs six to eight weeks.⁶ It targets the habits and thoughts that keep insomnia going:³ ⁶

• Sleep restriction. You limit your time in bed to about the time you actually sleep. This builds up your natural sleep drive. You then slowly add time back.

• Stimulus control. You use the bed for sleep, not for TV, phones, or lying awake.³ ⁸ If you cannot fall asleep, you get out of bed and do something calm until you feel sleepy.⁶ ⁸ You wake up at the same time every day.

• Changing unhelpful thoughts. You learn to calm a racing mind and let go of beliefs that make sleep harder.

• Relaxation. Slow breathing or a calming routine before bed.

CBT-I can be done one-on-one, in groups, by phone or video, or through some online programs.⁸

Why start there? In a 2024 review of many studies, about 41% of people who started with CBT-I were in remission months later, meaning their insomnia had resolved. That compared with about 28% of those who started with medicine alone.⁷ People were also less likely to drop out of CBT-I.⁷ Adding medicine to CBT-I did not clearly help more than CBT-I alone.² ⁷

Sleep hygiene is not enough on its own. Guidelines advise against using them as the only treatment for chronic insomnia.² ³

Medicine has a place, but a limited one. Sleep medicines can help some people in the short term. Doctors generally discourage using them for more than three months.¹ Over-the-counter sleep aids can be unsafe for some people, so ask your doctor or pharmacist first.⁶

What Does This Mean for You?

If it has been a few weeks, protect your wake time. Get up at the same time every day, even after a bad night. Do not lie in bed for hours trying to sleep.¹ ³ Avoid long naps, especially late in the day.⁴ ⁶

If it has been three months, ask about CBT-I. Tell your doctor how often it happens and how it affects your days. Ask whether CBT-I is available in person, by video, or online.

Be cautious with quick fixes. Research has not shown melatonin to be an effective insomnia treatment.⁶ A coming guide on melatonin, magnesium, and other sleep aids will look at the evidence.