When sleep has been bad for six months

Short-term insomnia is normal and usually resolves. A bad fortnight after a bereavement, a move, a deadline — that is the system working.

What brings people here is the other kind: sleep that stopped being reliable eight months ago and has not come back, where the exhaustion has started changing how work and relationships go.

Why tablets are not the answer

Z-drugs and benzodiazepines genuinely work. For about two weeks. Tolerance develops quickly, the rebound insomnia on stopping is worse than the original problem, and in older adults the fall risk is substantial and well documented.

I prescribe them occasionally, for a few days, in a specific crisis. As a treatment for chronic insomnia they make things worse over any horizon longer than a month.

What does work

Cognitive behavioural therapy for insomnia — CBT-I — outperforms medication at six and twelve months in head-to-head trials. It is the recommended first line in every current guideline. It is also rarely offered, because it takes longer to explain than a prescription takes to write.

The core of it is counter-intuitive and the reason people abandon it without help:

Sleep restriction. If you are in bed nine hours and sleeping five, you spend four hours a night learning that bed is a place where you lie awake. The treatment shortens your time in bed to roughly your actual sleep time, which is brutal for about ten days and then works.

Stimulus control. Bed is for sleep. If you are awake twenty minutes, get up, go elsewhere, do something dull in dim light, return when sleepy.

A fixed wake time. Not a fixed bedtime — a fixed rising time, including weekends. This is the single lever with the most effect on the body clock.

The things that are not the problem

For most of the people I see, it is not caffeine, screens, or the mattress. Those get addressed first because they are easy, and the failure of a “sleep hygiene” checklist then convinces people nothing will work.

Sleep hygiene alone has repeatedly been shown to be an ineffective treatment for established insomnia. It is necessary and nowhere near sufficient.

If this has been going on for months, book a proper appointment. There is a real treatment and it is not a tablet.