Treating Chronic Insomnia

Pills lose their effect when you stop them; cognitive behavioral therapy doesn't. The clinical guidelines flipped a decade ago: CBT-I is now the recommended first-line treatment for chronic insomnia, ahead of any drug.

Chronic insomnia (difficulty falling or staying asleep, ≥3 nights/week, ≥3 months) affects 10–15% of adults. The treatment landscape has shifted: CBT-I is now first-line, ahead of any medication. Pharmacotherapy is reserved for cases where CBT-I is inadequate or unavailable.

CBT-I: the first-line treatment

Cognitive Behavioral Therapy for Insomnia (CBT-I) outperforms hypnotic drugs in head-to-head trials, with effects that persist after treatment ends — unlike medications, which lose effect when discontinued.

The 2017 American Academy of Sleep Medicine guideline^[1] and subsequent updates^[2] recommend CBT-I as the first-line treatment for chronic insomnia, ahead of any pharmacotherapy.

CBT-I has five core components:

Stimulus control — bed only for sleep and sex; if not asleep within ~20 minutes, get out of bed. Re-associates the bed with sleep, not wakefulness.
Sleep restriction therapy — temporarily limit time in bed to consolidate sleep. Counterintuitive but the most powerful single component. Daytime napping is typically eliminated during this phase because it borrows from the homeostatic pressure that should be driving consolidated night-time sleep — see Daytime naps.
Cognitive restructuring — challenges catastrophic thinking about sleep ("If I don't sleep 8 hours, tomorrow will be ruined").
Sleep hygiene — the well-known basics. Modest effect alone; useful as a foundation.
Relaxation training — for sleep-anxiety subtype.

Access to CBT-I

The bottleneck has historically been access — too few trained clinicians. Validated digital CBT-I programs now make it available at scale:

Sleepio — UK NHS-endorsed.^[3]
Somryst — US FDA-cleared.^[4]
SHUTi — research-validated.^[5]

These have RCT support comparable to in-person CBT-I.

When pharmacotherapy is appropriate

The 2017 AASM guideline gave only weak (conditional) recommendations for any pharmacotherapy in chronic insomnia, reflecting modest efficacy and meaningful harms. Pharmacotherapy makes sense when:

CBT-I has been adequately tried and failed
Comorbid psychiatric or pain conditions are driving insomnia
Acute, time-limited situations (bereavement, hospitalization, severe transient stress)
Bridge therapy while CBT-I is being initiated

Specific medications, ranked by safety profile

Tier 1: Most favorable risk-benefit (where pharmacotherapy is needed)

Dual orexin receptor antagonists (DORAs): suvorexant, lemborexant, daridorexant^[6]

Newer class targeting wakefulness rather than imposing sedation.
A 2025 network meta-analysis of 8 RCTs (n=5,198) in Translational Psychiatry found all three significantly reduced sleep onset latency, increased total sleep time, and lowered ISI scores vs. placebo.^[7]
No evidence of dependence, tolerance, or rebound insomnia — major advantage over benzodiazepines and Z-drugs.
Adverse effects include somnolence, narcolepsy-like symptoms (sleep paralysis, hallucinations, ~3× placebo rate), modest residual sedation.^[8]
Now often preferred over Z-drugs when pharmacotherapy is needed for chronic insomnia.

Low-dose doxepin (3–6 mg)

Sedating antidepressant at sub-antidepressant doses.
Modest evidence for sleep maintenance.
Anticholinergic effects are dose-dependent and minimal at these low doses.

Tier 2: Use sparingly, time-limited

Z-drugs (zolpidem, zaleplon, eszopiclone)

Effective acutely but with substantial harms with chronic use.^[9]
Increased fall and fracture risk in older adults (observational).
Recommendations: limit to ≤4 weeks where possible.
Complex sleep behaviors (sleep-driving, sleep-eating) are real but rare.

Trazodone

Widely prescribed off-label for sleep, with limited efficacy data.
Meaningful next-day sedation.
Reasonable for patients with comorbid depression.

Tier 3: Avoid chronic use

Benzodiazepines (temazepam, triazolam, lorazepam, etc.)

Effective acutely but with substantial harms: falls, fractures (especially in older adults; OR ~1.4), cognitive impairment, dependence, withdrawal.
Not recommended for chronic use; on the Beers Criteria for inappropriate prescribing in older adults.
Withdrawal can be severe — taper slowly.

OTC antihistamines (diphenhydramine — Benadryl, ZzzQuil)

Not recommended chronically.
High anticholinergic burden, daytime sedation, cognitive effects.
Anticholinergic medications are associated with dementia in multiple cohorts (e.g., Gray et al., JAMA Intern Med 2015).
Avoid in adults over 50.

Special populations

Midlife women with vasomotor symptom-driven insomnia

Discuss menopausal hormone therapy (MHT) with your clinician — particularly if within 10 years of menopause and without contraindications.
CBT-I as first-line behavioral treatment.
Non-hormonal options: low-dose paroxetine, gabapentin, venlafaxine, fezolinetant.

Midlife men with low energy/libido

Get screened for OSA before pursuing testosterone replacement. OSA causes fatigue and low T; treating OSA often resolves both. See testosterone therapy for the broader framework — lifestyle correction first, who actually benefits from TRT, and why "optimization" toward 25-year-old levels carries a real cardiovascular cost.

Older adults

DORAs and low-dose doxepin preferred.
Avoid benzodiazepines, Z-drugs, and antihistamines where possible.
A 2025 simulation study in Sleep estimated that prescription sleep medication use in adults over 50 carries substantial cumulative risk of falls and cognitive impairment, underscoring the importance of CBT-I as first-line.^[10]

What about supplements?

Magnesium, melatonin, L-theanine, ashwagandha, glycine, valerian, CBD — covered in detail in the Sleep supplements page. Bottom line: most have modest evidence and are reasonable adjuncts, but none replace CBT-I for chronic insomnia.