For long-term insomnia (more than three nights a week, lasting more than three months), try cognitive behavioral therapy for insomnia first; do not start with long-term sleeping pills

After this treatment, falling asleep is about 19 minutes faster on average, and time awake in the night drops about 26 minutes. Effects slowly weaken, but they are still there at 12 months. Online self-help courses work about as well as in-person. Sleeping pills help people over 60 only a little: for every 6 who take them, 1 gets a side effect; for every 13, only 1 sleeps better.

Cost

Doing it at a hospital sleep clinic, psychiatry, or psychology costs registration and treatment fees. Online self-help courses cost much less. A course is usually 6 to 8 weeks; you keep a sleep diary every day. Stimulus control you can start yourself: go to bed only when sleepy; if you cannot sleep, get up. Use the bed only for sleep and sex, get up at the same time every day, and do not nap by day. The hard step is sleep restriction: for the first few weeks you shorten time in bed, so you are sleepier by day.

Benefit

The National Health Commission’s 2020 clinical norms, following the international classification, list the diagnostic points for insomnia disorder. One is trouble falling asleep, easy waking after sleep, or early waking. Two is daytime fatigue, sleepiness, and impaired function. Three is these at least 3 times a week for at least 3 months. Under 3 months is called short-term insomnia disorder. The norms set cognitive behavioral therapy for insomnia as first-line. It includes sleep restriction, stimulus control, cognitive therapy, relaxation training, and sleep hygiene — 5 parts — usually one cycle of 6 to 8 weeks. The norms say short-term effects match medication, and long-term outlook is better than medication. They also state sleeping pills generally should not continue past 4 weeks; if continued, reassess monthly. The American College of Physicians 2016 guideline strongly recommends: for adults with chronic insomnia, start with this therapy. If it alone is not enough, then discuss short-term medication with a doctor. One analysis pooled 20 randomized controlled trials and 1162 people (meta-analysis). After treatment, time to fall asleep shortened by 19.03 minutes (95% CI 14.12–23.93). Time awake after falling asleep fell by 26.00 minutes (15.48–36.52). The share of time in bed actually asleep (sleep efficiency) rose by 9.91% (8.09%–11.73%). Total sleep time rose only 7.61 minutes, not statistically significant (−0.51 to 15.74). No study reported adverse outcomes. Another analysis pooled 30 randomized controlled trials on how long effects last. Versus no treatment, improvement in insomnia severity shrank over time. At 3 months g = 0.64, at 6 months 0.40, at 12 months 0.25. Effects weaken gradually, but the authors still see clinical meaning within a year. For online delivery, one analysis pooled 11 randomized controlled trials and 1460 people. All sleep measures improved, effect sizes g from 0.21 to 1.09. The authors say this matches in-person effects; longer courses and more follow-up give larger effects. Another online randomized trial of 1711 people gave the control group only sleep-hygiene materials. Those on digital therapy had large gains in sleep-related quality of life and small gains in daytime physical and mental state. Then sleeping pills. One analysis pooled 24 randomized controlled trials and 2417 people with insomnia aged 60 and over. Each trial used at least 5 nights in a row. Versus placebo, people on pills slept 25.2 minutes more total and woke 0.63 fewer times at night. For every 13 who took pills, 1 had better sleep quality. For every 6 who took pills, 1 had a side effect (NNH 6, 4.7 to 7.1). Memory and thinking side effects were 4.78 times placebo (OR 4.78, 1.47–15.47). Daytime fatigue was 3.82 times (OR 3.82, 1.88–7.80).

Notes

The five stimulus-control points in the Cost line come from the American Academy of Sleep Medicine 2021 guideline. Sleep restriction first shortens time in bed to how long you actually sleep, then adds time back by sleep efficiency. The guideline says it makes you sleepier by day; people who drive or operate machines should use caution. People with manic tendency, uncontrolled epilepsy, or already severe daytime sleepiness should also use caution, preferably with a clinician following. Sleep hygiene alone — schedule, diet, environment talk — does not work as sole treatment; the guideline does not recommend it. A few bad nights are not insomnia disorder. Then first fix wake-up time; see item 2 of this section (fixed wake-up time). Also see item 4 (no caffeine after 2 p.m.) and item 8 (no glowing screens one hour before bed). For loud snoring, breathing pauses in sleep, or heavy daytime sleepiness, the norms require ruling out sleep apnea first. How to check is in item 27 of this section (sleep apnea). Low mood plus poor sleep is in item 18 of this section (first moves when mood is low). Sleeping pills are prescription drugs; that analysis only looked at people 60 and over on short courses. Benefit set to medium: faster sleep onset plus less night waking add up to about 45 minutes a night, hours over a week. Total sleep length barely changed. The 20-trial paper excluded people with insomnia plus other diseases. Which department to use in China is author experience (grade C); hospitals differ — ask before registering whether they offer this therapy. The main beneficiary is you. Do not expect melatonin to cure long-term insomnia; see Section 6, Item 34 (curing long-term insomnia with melatonin).

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