Chronic insomnia — trouble falling or staying asleep at least three nights a week for three months, with daytime consequences — affects about 10 percent of adults. The treatment landscape is confusing because the loudest options (supplements, sleep aids) are not the ones sleep medicine actually recommends first.
FIRST-LINE: CBT-I. Cognitive behavioral therapy for insomnia is the recommended initial treatment in every major guideline — American College of Physicians, American Academy of Sleep Medicine, and European equivalents. It outperforms sleeping pills in long-term trials and its benefits persist after treatment ends. Pills do not.
WHAT CBT-I ACTUALLY IS. Six to eight structured sessions covering sleep restriction (temporarily limiting time in bed to rebuild sleep pressure), stimulus control (bed is for sleep only — no lying awake, no phones), cognitive work on catastrophic sleep thoughts, and relaxation training. It is available in person, by telehealth, and through validated digital programs, which perform nearly as well as face-to-face therapy.
SLEEP RESTRICTION SOUNDS BACKWARD. It works anyway. Spending nine hours in bed to get six hours of sleep trains your brain that bed is a place to be awake. Temporarily matching time-in-bed to actual sleep time — then expanding as sleep consolidates — rebuilds the association. The first two weeks are rough; the results at week six are why it is first-line.
WHERE MEDICATION FITS. Sleep medications have a legitimate role: short-term crises, jet lag, and bridging while CBT-I takes effect. Guidelines recommend the shortest effective course because tolerance and dependence develop, and most pills lose measurable effect within weeks of nightly use. If you have been on a nightly sleep aid for months, that is a conversation to have with your prescriber — never stop abruptly on your own.
MELATONIN, HONESTLY. Melatonin helps with circadian timing problems — jet lag, delayed sleep phase, shift adjustment — far more than with classic insomnia. For insomnia itself its effect is small. Timing matters more than dose: taken at the right time relative to your body's clock, low doses work; taken at the wrong time, it does little.
WHAT DOESN'T HOLD UP. Antihistamine sleep aids (diphenhydramine and relatives) lose effectiveness within days as tolerance builds, and regular use in older adults is linked to cognitive risks. Most herbal remedies have weak or inconsistent trial data. Alcohol fragments sleep architecture and reliably worsens the second half of the night — it is a sedative, not a sleep aid.
THE ENVIRONMENT STILL MATTERS. CBT-I is the engine, but sleep hygiene is the chassis: a cool room around 65 to 68°F, complete darkness, and a mattress that is not actively uncomfortable. No therapy overcomes a bedroom that fights you, and a supportive mattress removes one real source of night-time arousal — pain and discomfort.
RULE OUT THE IMITATORS. Restless legs syndrome, sleep apnea, and circadian disorders all masquerade as insomnia and need different treatment. If you snore, gasp, kick, or your legs feel creepy-crawly at bedtime, mention it — treating the underlying condition often resolves the 'insomnia' outright.
BOTTOM LINE. If insomnia has lasted three months, ask about CBT-I before anything else — digital programs count. Use medication short-term if you need it, fix the bedroom environment in parallel, and screen for apnea and restless legs. That sequence matches the evidence.