CBT-I is the first-line insomnia treatment, and almost nobody is offered it

Every major guideline names cognitive behavioural therapy for insomnia as the first-line treatment for chronic insomnia, ahead of medication. Most people with chronic insomnia have never heard of it.

It works, the effects persist after treatment ends — which is not true of sleeping pills — and it is available in digital form for a fraction of the cost of therapy. It is also genuinely uncomfortable for the first fortnight, which is why people quit.

What insomnia actually is

Chronic insomnia is difficulty falling or staying asleep, at least three nights a week for at least three months, with daytime consequences.

The important insight behind CBT-I is that whatever started your insomnia — a bereavement, a baby, a stressful year, a hormonal shift — is usually no longer what is maintaining it. What maintains it is the set of entirely reasonable things people do in response to sleeping badly:

• Going to bed earlier to catch up
• Staying in bed longer in the morning
• Napping
• Lying in bed awake, trying
• Anxiously monitoring sleep and predicting disaster

Each of these makes it worse, and each is exactly what you would do.

The two components that do the work

Sleep restriction — better named sleep consolidation, because "restriction" makes it sound punitive.

You track how long you actually sleep, and you then limit time in bed to approximately that amount. If you are in bed nine hours and sleeping six, your window becomes about six and a quarter hours, with a fixed wake time. You do not go to bed until that window opens, however tired you are.

This raises sleep pressure and compresses fragmented sleep into a solid block. As efficiency improves — typically once you are sleeping more than about 85 to 90 percent of your time in bed — the window widens by 15 minutes at a time.

The first week is hard. You will be more tired. That is the mechanism working, not a sign it is failing. This is where most people quit, and it is the single reason CBT-I has a reputation for being difficult.

Stimulus control. The bed is for sleep and sex only. No working, scrolling, worrying or watching. If you are awake for more than about 20 minutes, get up and go elsewhere until sleepy. Same wake time every day, weekends included.

The point is to rebuild the association between bed and sleep, which chronic insomnia has replaced with an association between bed and frustration. The 3am wake-up covers how that association forms.

The rest of it

Cognitive work targets the beliefs that keep arousal high: "I need eight hours", "tomorrow will be ruined", "I've lost the ability to sleep". These are not trivial. Catastrophic sleep beliefs raise pre-sleep arousal, which is a direct physiological obstacle.

Relaxation training for the people whose problem is a body that will not settle.

Sleep hygiene — the caffeine, light and temperature advice everyone has heard — is included, and it is the least effective component on its own. This matters: being told to try sleep hygiene is not being offered CBT-I, and sleep hygiene alone has poor evidence as a standalone treatment.

How to get it

Digital CBT-I programmes have good trial evidence, particularly those with some therapist contact. Several are available directly, and in some health systems by referral. In-person or group CBT-I exists but waiting lists are typically long.

A course runs six to eight weeks. Improvement usually begins in weeks two to three, after the harder opening stretch.

What about sleeping pills

Z-drugs and benzodiazepines work acutely. Tolerance develops, they alter sleep architecture, they carry fall and cognitive risks, and stopping produces rebound insomnia that feels like proof you needed them. Guidelines restrict them to short-term use.

Melatonin is not a sedative — it is a circadian timing signal. It helps with delayed sleep phase and jet lag more than with classic middle-of-the-night insomnia, and it is more effective in low doses taken several hours before bed than in the large doses commonly sold.

Where it does not apply

CBT-I treats insomnia. It does not treat sleep apnoea, restless legs, or insomnia driven by an untreated physical cause.

Before starting, it is worth excluding: sleep apnoea, which is under-diagnosed in women; iron deficiency, which causes restless legs — low ferritin and low mood; thyroid disease; and perimenopausal vasomotor symptoms, where treating the night sweats often resolves the insomnia — perimenopause can start in your late thirties.

It also works less well if you are fighting a cyclical pattern without knowing it. If your sleep collapses predictably in the luteal phase, that is worth accounting for rather than treating as random failure — sleep in the luteal phase.

The sleep diary is the treatment, not the paperwork

CBT-I runs on a daily sleep diary. The window is set from it, the widening decisions are made from it, and the evidence that contradicts catastrophic beliefs comes from it — most people discover they sleep considerably more than they believe.

Keeping that diary reliably for six weeks is the practical obstacle. Naked makes it a few seconds a day, logged alongside your cycle, mood, alcohol and everything else, so you can also see which of those actually moves your sleep.

The people who complete CBT-I do very well. The people who do not, mostly stopped in week two.