A Safer Way to Tame Insomnia

One night in July 2022, a month after his first bout of COVID-19, Dan Elton woke up around 2:00 a.m. and couldn’t get back to sleep. Having gone to bed just four hours earlier, he felt far from rested, but at 6:00 a.m., he surrendered and went to make coffee.

Elton, then 34, knew that sleep disruptions are a common after-effect of COVID, but he hoped his bad night had been a fluke. It wasn’t. Over the following weeks, the pre-dawn awakenings continued. On top of lingering fatigue from the illness itself, the shortage of shuteye left him barely able to function. He took a medical leave from his job as a data scientist and rarely left his apartment in Bethesda, Maryland. “I was on the couch most of the day,” he recalls.

Elton’s miseries bore the hallmarks of insomnia, a condition characterized, according to the National Institutes of Health, by difficulty “falling asleep, staying asleep, or getting good quality sleep.” For a person to be clinically diagnosed with the disorder, however, several other criteria must be met: The problem needs to occur at least three nights a week for at least one month, even under ideal sleeping circumstances, and it must negatively affect the patient’s work, social life, or other activities. About one-third of U.S. adults report trouble initiating or maintaining slumber, but only 6% to 10% have symptoms severe enough to qualify as clinical insomnia.

Elton had been treated for the disorder once before, but this bout was far worse. On the advice of his insurance company, he turned to a telehealth psychiatrist.

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After a brief consultation, the online doctor prescribed trazodone, an antidepressant often used “off-label” to treat insomnia. Though Elton had previously found the medication helpful, it had no effect this time around. Next, he tried lorazepam (marketed as Ativan), in the class of sedative drugs known as benzodiazepines. It, too, did nothing.

Desperate for relief, Elton set out on a therapeutic quest: He would try every kind of mainstream insomnia remedy available, until he found one with an ideal balance of efficacy, safety, and tolerability. Ultimately, he sampled a dozen different medications — some for a few nights, others for several weeks, still others for months on end. To help fellow sufferers, he later posted about his experiences on social media.

The popular sleep medication zolpidem (Ambien) was highly effective, Elton found, but made it hard to perform complex mental tasks the next morning. Over-the-counter sleep aids containing diphenhydramine or doxylamine, both antihistamines, left him even groggier. Another sedating antidepressant, mirtazapine, worked well until a sleep-disrupting side effect kicked in: restless legs syndrome, which persisted after he stopped taking the pills. Gabapentin helped relieve that symptom, while controlling his insomnia as well; he needed ever-increasing doses, however, and they sometimes messed with his memory and concentration. Lemborexant (Dayvigo), a new type of drug called an orexin antagonist, brought excellent sleep, but also left him slightly fuzzy-headed in the morning. And he worried about more serious health impacts if he needed to take it, or any other sleep med, indefinitely.

Elton experimented with dietary supplements as well — magnesium, L-theanine, apigenin, valerian, and lemon balm. Some made it easier to drift off again after waking in the middle of the night, but none significantly lengthened his sleeping time. He tried cannabis-derived substances, too: CBD was useless; THC made his insomnia worse.

Then Elton tried a radically different approach: cognitive behavior therapy for insomnia, or CBT-I. After nearly a year of searching, he’d found his Holy Grail: an effective treatment with no side effects whatsoever. “It’s not easy,” he says. “It takes weeks to see the benefits. But it really works.”

CBT-I: Widely Recommended, Vastly Under-Prescribed

Expert consensus affirms Elton’s experience. CBT-I is recommended as the first-line treatment for insomnia by the American Academy of Sleep Medicine (AASM), the American College of Physicians (ACP), and other clinicians’ groups. The method, which addresses behaviors and thought patterns that perpetuate patients’ sleep problems, was introduced in 1993 by Canadian psychologist Charles Morin, Ph.D. Since then, numerous studies have shown that it’s as effective as medications in the short term, and more so over the long haul. Up to 80 percent of people who use it see improvements.

CBT-I doesn’t always eliminate the need for sleep meds. Some patients need a brief course of pills before they feel ready to face the therapy’s challenges, which initially include spending less time in bed to improve sleep efficiency. Other individuals may have an underlying condition (ranging from chronic pain to bipolar disorder) that requires pharmaceutical sleep aids over longer periods. In such cases, this technique can help patients shorten their time on the drugs or minimize their dosage.

Yet most patients aren’t offered CBT-I when they’re diagnosed. One reason, says Michael Grandner, Ph.D., director of the Sleep and Health Research Program at the University of Arizona, is that most doctors have little training in sleep medicine. “They don’t know what they don’t know,” he says. Another obstacle is the scarcity of therapists who provide CBT-I: Only a few hundred nationwide are credentialed in the technique. And even when patients can access it, many are reluctant to make the commitment.

“Lots of people would rather just take a pill,” notes Elton, drawing on his longtime involvement in Reddit forums about sleep disorders.

“Lots of people would rather just take a pill.”

For occasional insomnia symptoms, that preference may not be problematic. But when reliance on sleep meds continues for months or years, the risk-benefit analysis becomes more complex.

To understand how CBT-I could change those calculations, it may help to travel a bit farther down the rabbit hole that Elton plumbed.

The Problems With Pills

For patients diagnosed with insomnia disorder, several types of medication are commonly used, most of which are not typically recommended for prolonged consumption. (The ACP suggests a limit of four to five weeks on all sleep meds.) In some cases, this is because the risk of harmful side effects rises with continued use; in others, it’s because the safety of long-term use has not yet been established.

Nonetheless, some patients continue pharmacotherapy for decades.

The most commonly available OTC sleep aids, diphenhydramine and doxylamine, work by blocking histamine, a chemical messenger that helps regulate body functions ranging from inflammation to alertness. Because these antihistamines are anticholinergic drugs, which block certain kinds of activity in your parasympathetic nervous system, they can have carryover effects that include mental fogginess and physical clumsiness, increasing the risk of falls and other accidents — especially in older adults, whose brains and bodies process medications differently. Users often develop tolerance to anticholinergics’ sleep-inducing effects, requiring higher doses to achieve the same results. Studies also show an association between prolonged use and heightened risk of Alzheimer’s and other dementias.

Trazodone, the medication that launched Elton’s pharmaceutical journey, is not approved by the Food and Drug Administration (FDA) as a sleep aid, but it’s often prescribed “off-label” for that purpose. Although it creates a slight sensation of drowsiness, studies show the antidepressant to be no more effective than placebo at promoting slumber. But it’s popular with both patients and physicians, Dr. Grandner says, precisely because of the placebo effect. “Most people with insomnia have a natural ability to sleep,” he explains. “If you say, ‘I’m giving you something that’s going to help, and they feel it working, they can often relax and fall asleep.” The picture is not entirely sunny, however: potential side effects include cardiac arrhythmias, sudden drops in blood pressure, and suicidal thoughts.

Benzodiazepines, such as lorazepam and temazepam, work by enhancing the effects of the neurotransmitter GABA, which inhibits activity in the central nervous system. “When you boost GABA, you slow down,” says Dr. Grandner. These drugs share many of the downsides of anticholinergics, including daytime carryover effects that make them particularly hazardous to older people. Benzos also alter the structure and pattern of sleep stages in potentially harmful ways. Users often develop physical dependence, experiencing withdrawal symptoms if they try to quit or reduce dosage. Perhaps not coincidentally, long-term consumption is associated with increased risk of dementia and higher overall mortality

Nonbenzodiazepines, or “Z drugs,” such as zolpidem, zaleplon, and eszopiclone, debuted in the 1990s as an alternative to benzodiazepines; they, too, target GABA, but in a different way. Although their safety profile is somewhat more benign, they can similarly hamper mental and physical nimbleness. Studies show that these drugs can cause temporary short-term memory loss and anterograde amnesia (difficulty in absorbing new information). Their potential side effects include such bizarre behaviors as sleep eating, sleep driving, and sleep sex. Although few studies of long-term use have been completed, research suggests that it may also raise dementia risk.

Orexin antagonists, such as lemborexant (Dayvigo), are the newest class of insomnia drugs. Introduced in the past decade, they target a different neurotransmitter: orexin, which helps maintain wakefulness, among other functions. Instead of broadly suppressing neural transmissions, they block the activity of a molecule that prevents sleep. “These drugs just open the door and let you walk through,” Dr. Grandner explains. For this reason, orexin antagonists seem to be significantly safer than previous sleep meds. Emerging evidence suggests that they may even help prevent dementia in patients with poor sleep (itself a risk factor), though it’s too soon to say for sure.

Still, side effects can include narcolepsy-like symptoms such as daytime sleepiness or sleep paralysis (inability to move while falling asleep or waking up). A recent study has also raised theoretical concerns that the drugs could negatively affect reproductive and sexual health. Although such impacts have not been observed clinically, some experts warn that they could arise with wider use over extended periods.

Supplements and Cannabinoids: Uncertain Benefits, Potential Risks

Supplements may seem like a gentler, more natural way to treat insomnia — and in a way, they are. Some contain substances that have been used for centuries to promote slumber, such as valerian, lemon balm, kava, ashwagandha, or tart cherry juice. Others are based on chemicals that play key roles in the physiology of sleep, such as magnesium or melatonin. Studies suggest that many of these compounds can ease mild or transient insomnia symptoms. However, none have been shown to be effective at controlling full-blown insomnia disorder.

“I’m not going to tell people to stay away from supplements if they feel it has utility for them,” says Alon Avidan, M.D., director of the sleep disorders center at the University of California, Los Angeles. “The problem is that there’s a placebo effect that lasts about two weeks. After that, these things often stop working.”

“I’m not going to tell people to stay away from supplements if they feel it has utility for them. The problem is that there’s a placebo effect that lasts about two weeks. After that, these things often stop working.”

But some “natural” sleep aids can cause troublesome side effects. Kava and ashwagandha, for example, have been associated with liver damage in rare cases. And many common supplements can have harmful interactions with other medications, such as sedatives, antidepressants, or antihistamines. Patients should always check with a doctor before using such products.

Cannabinoids come with a different set of problems. THC, the main psychoactive substance in cannabis, “can have profound effects on sleep in some people, but there are notable downsides,” says Dr. Grandner. Potential side effects include anxiety, depression, physical dependency, and an increased risk of psychosis. What’s more, prolonged use of THC can impair sleep quality. For CBD, the hazards are milder, but the evidence of efficacy is murkier. Some studies suggest it can help control insomnia; others show little benefit. The effects seem to vary from individual to individual.

How CBT-I Breaks the Cycle of Insomnia

That’s why CBT-I is thought to be the ideal “third way.” The technique avoids the risks posed by medications and other soporific substances. Instead of tinkering with the neurochemical mechanisms of insomnia, it focuses on the cognitive and behavioral factors that keep a patient’s sleep-wake patterns out of whack. “I think of myself less like a psychologist and more like a dietitian or physical therapist,” says Sara Nowakowski, Ph.D., a CBT-I specialist at Baylor College of Medicine. “I analyze what you’re doing and come up with a tailored program to reset your sleep.”

The method is built around the so-called 3-P model, which posits that three primary factors contribute to the development of chronic insomnia: predisposing factors (traits or conditions that make a person vulnerable to insomnia); precipitating factors (situations, such as illnesses or stressful life events, that trigger the disorder’s onset); and perpetuating factors (behaviors and ways of thinking that keep it rolling along).

CBT-I centers on the third P, seeking to replace cognitive and behavioral habits that perpetuate insomnia with habits that foster healthy sleep. Treatment is typically delivered over the course of six to eight weekly or biweekly sessions. The technique is built around two core components: Sleep Restriction Therapy (SRT) and Stimulus Control Therapy (SCT). It also incorporates two other important components: sleep hygiene and cognitive therapy.

SRT is based on the idea that people can be trained to sleep through the night by matching their opportunity to sleep with their ability to sleep. The goal is for the patient to sleep more efficiently, with as little time as possible spent tossing and turning.

“If it’s taking you two or three hours to fall asleep, and your anxiety is rising the whole time, that makes things worse,” says Ritu Goel, M.D., a sleep specialist in Long Beach, California, and a member of MedShadow’s Health and Medical Advisory Panel. “We try to find out how much sleep an individual really needs and match their time in bed to that.”

To start the process, the therapist determines the patient’s average sleep duration over a week or two, using data from a daily journal or wearable devices, or both. The person is then restricted to spending only that much time between the sheets. Going forward, the patient’s prescribed time in bed (PTIB) is adjusted based on how much the individual actually sleeps. If patients spend less than 85% of their time in bed sleeping, their PTIB is reduced by 15 minutes the following week. If they spend more than 90% of their time sleeping, their PTIB is increased by 15 minutes. (These changes are made by altering bedtimes; getting-up time remains constant.) As sleepiness builds up from multiple nights of restriction, patients tend to drift off faster and stay asleep until the alarm goes off. Within a few weeks, as their sleep efficiency improves and their PTIB reaches seven or eight hours, most wake up rested and refreshed.

SCT arises from the behavioral principle that humans (and other animals) come to associate locations with the activities frequently performed there. For good sleepers, the thinking goes, bed is a place associated with slumber. For those with insomnia, however, that piece of furniture becomes associated with activities like watching TV, scrolling on phones, and lying awake struggling to sleep. To undo such conditioning, SCT provides patients with a list of rules. For example: Get into bed only when sleepy. Avoid using the bed for anything besides sleep or sex. Get out of bed if you don’t fall asleep within 15 or 20 minutes and do something relaxing (reading an undramatic book can help, though screens should be shunned). Return only when sleepy.

Sleep hygiene consists of basic lifestyle practices to promote healthy slumber (avoid caffeine and alcohol before bed, get regular exercise, etc.) that you’ve likely heard before but may not always follow. And cognitive therapy is a treatment designed to identify and modify patterns of thought that help perpetuate a patient’s insomnia or contribute to pre-sleep arousal — including worrying about their sleep. “Nobody ever got to sleep faster by trying harder,” Dr. Grandner says. “CBT-I gets you out of your own way.”

“Nobody ever got to sleep faster by trying harder. CBT-I gets you out of your own way.”

CBT-I can also be combined with other practices in a synergistic way. Dr. Goel often suggests patients pair the technique with their favorite form of meditation, or with their preferred supplements. And like other CBT-I specialists, she recommends the method as a complement to sleep medications, if those are clinically indicated. “Pharmaceuticals have their place,” she says. “It’s not either/or.”

Besides helping patients overcome their current insomnia symptoms, the technique provides skills that they can use whenever sleep challenges arise in future. “We have a saying that CBT-I is not about tonight — it’s about tomorrow night,” says Dr. Nowakowski. “You’re building for better sleep long-term.”

Reducing Dependence on Sleep Meds

Although obtaining in-person therapy with a CBT-I specialist can be challenging, especially outside of major metropolitan areas, many providers offer telehealth visits. And if the wait for an appointment is too long, or you don’t feel the need for personalized attention, numerous books and apps are available to guide you through the process.

Dan Elton has engaged with CBT-I from all those angles, beginning with several sessions in May 2023 with a psychologist who specialized in the technique. By that summer, he was able to get a good night’s sleep without meds for the first time since his post-COVID insomnia struck a year earlier.

That’s not the end of the story, however. A few months ago, Elton’s restless legs syndrome returned, disrupting his sleep and forcing him to go back on gabapentin and lemborexant, the orexin antagonist. But this time, he was able to use less medication from the start, and he’s now down to a quarter-tablet of lemborexant per night. Along with the cognitive and behavioral tools he learned in therapy, he’s experimenting with reishi mushrooms, a traditional Chinese remedy used to treat both involuntary limb movements and insomnia symptoms.  “It’s fun to try new things,” he says. “And once in a great while, they actually work.”

CBT-I hasn’t solved all of Elton’s sleep problems, but it has improved them — and his life — considerably. He recently moved to Boston for a job with an AI-related nonprofit, and he’s excited about the future. “I’m about 80 percent recovered, and my health and energy are continuing to get better. Given all I went through, I’d say I’m doing pretty well.”