WITHSome lucky people sleep in bed, close their eyes and pass out within five minutes. Others stare at the ceiling for an hour, check their watch, try to find a new angle on the ceiling, and then toss and turn, every night, week after week.

Insomnia affects 10% – 15% of the US populationand it's usually caused by a variety of biological and behavioral factors, says Dr. Sairam Parthasarathy, director of the University of Arizona Health Sciences Center for Sleep, Circadian Rhythm, and Neuroscience. Women, people who work nights, and older adults are among those most at risk. It often runs in families, and experts have recently concluded that COVID-19 may cause new insomnia.

While we all experience sleepless nights from time to time, usually due to stress or lifestyle changes, chronic insomnia occurs three or more nights a week, lasts more than three months, and can’t be fully explained by a health problem. “For those in the ‘very severe’ category, it can be debilitating and incapacitating,” Parthasarathy says. “We see people who are paralyzed by it, and then there are those who are frustrated by it for years” — and when they retire or have more free time, they finally decide to do something about it.

There's a good reason to work on beating insomnia: It's a sleep disorder. related to increased risk of hypertension, diabetes, obesity, depression, heart attack and stroke. And it can make you miserable.

Fortunately, resetting your sleep patterns can help most people overcome insomnia, and cognitive behavioral therapy for insomnia, or CBT-I, is a proven way to do it. But it takes time, and it’s not always an easy process.

New sleep schedule

CBT-I is a kind of “brain retraining program,” says Dr. Jing Wang, clinical director of the Mount Sinai Integrative Sleep Center and an assistant professor at the Icahn School of Medicine at Mount Sinai. Over weekly sessions for about four to eight weeks, you’ll work with a sleep doctor or psychiatrist to target the behaviors and habits that perpetuate your insomnia.

One of the cornerstones of treatment is sleep restriction therapy, which helps rewire and create new habits about what happens when you’re in bed. Patients typically keep a sleep diary, tracking what time they go to bed, when they wake up, and how many hours they actually sleep, Parthasarathy says. Doctors then use that information to create a timeline. Imagine, for example, someone goes to bed at 8 p.m. and gets up at 6 a.m., but only actually sleeps for six of those hours. The rest of the time? They lie there in agony, stressed out because they’re still awake, or they rummage through the refrigerator and then fire up their laptop to at least make that sleepless time productive.

In sleep restriction therapy, Parthasarathy would work backward from this hypothetical patient’s wake-up time (6 a.m.), since that’s probably non-negotiable due to work. Then he’d ask the person to go to bed at midnight — with the idea that they’d fall asleep right away and get the same six hours of sleep before getting up at 6 a.m. Other patients would have different bedtimes, depending on how many hours they currently sleep a night and what time they need to get up. (Doctors never set a schedule that puts someone below 5.5 hours of sleep a night, though.)

No matter how tired a person feels by midnight — or whatever bedtime they’ve been assigned — they’re not allowed to climb into bed. “We’re trying to consolidate the sleep period and eliminate the time when sleep isn’t actually happening in a person’s bed,” he says. “By forcing them to go longer without sleep, their brain starts to crave sleep. So when they go to bed at 12, they’re not tossing and turning for an hour. They’re asleep within five or 10 minutes.”

After a week, Parthasarathy assesses how well his patients are sleeping. While sleep diaries aren’t always 100 percent accurate, he’s found that patients are generally good at estimating how long it took them to fall asleep and how long they were awake during the night, especially since many are clock-watching. If a person’s sleep efficiency was above 90 percent each night—meaning they slept more than 90 percent of the time they were in bed—he’ll loosen the sleep window by 15 minutes so they can go to bed a little earlier. He’ll continue to adjust the sleep window by 15 minutes each week until a person’s sleep efficiency drops to 85 to 90 percent. “If it gets below 85 percent, that means a lot of them are lying in bed, and we don’t want that,” he says. Over time, patients’ sleep schedules adjust to their ideal bedtime, and by then their bodies have learned that once they get into bed, it’s time to go to sleep. “There is subconscious programming going on in our brains,” Parthasarathy says.

Although CBT-I is considered safe and effective For most people, sleep deprivation can be debilitating; as Parthasarathy acknowledges, people with insomnia often find things get worse before they get better. That’s why he advises people with conditions like epilepsy or bipolar disorder to avoid CBT-I — lack of sleep can be a trigger. It’s not always the right choice for people in jobs that require alertness, such as public transportation drivers.

Overall, even if you continue CBT-I, it’s important to be safe in the hours before you’re allowed to go to bed. “People will feel sleepier for the first week or two of sleep restriction,” says Parthasarathy. “Some of them are like, ‘Why am I doing this to myself?’” In addition to avoiding risky behaviors like driving, experts recommend filling the hours before you’re allowed to go to bed with relaxing activities, perhaps journaling, taking a bath, or meditating.

Set yourself up for success

Improving sleep hygiene is an essential part of CBT-I, Wang says. That includes adopting new habits around screens: Wang recommends turning off phones, computers, and even the TV at least one to two hours before bed. Part of the problem with screens, she says, is the light they produce: It suppresses melatonina hormone that helps you prepare for sleep.

The content on your screens can also be problematic. People have heightened reactions to watching the news, for example, Wang notes — while some stay up late to keep up with what’s happening in politics or the world, the scenes they see can upset them to the point that they can’t fall asleep. Watching a horror movie before bed can have a similar effect.

In addition to keeping your bedroom as dark as possible, consider ditching your alarm clock. “Cover it or take it out of the bedroom,” Wang advises. “That process of looking at the time is energizing. You’re doing a mental check: ‘Okay, it’s midnight, I have to get up in five hours.’ That kind of stress is definitely No encourage sleep.

Wang also encourages patients to ditch their sleep trackers — or at least look at them less often. She’s found that some people become fixated on combing through the data, obsessing over every little change in their sleep patterns. “There’s always variability from night to night,” she says. “So I would strongly encourage anyone who finds looking at this data very anxiety-provoking and stressful to not check it.”

Changing lifestyle and habits

What you eat and drink before bed can play a role in how well you sleep. Doctors generally recommend not eating right before bed — late meals related to more frequent awakenings at night. And it's a good idea to cut out caffeine by 12 p.m., says Dr. Emerson Wickwire, chief of sleep medicine at the University of Maryland Medical Center.

Be careful with your alcohol consumption, too. “Alcohol worsens everything about sleep,” says Wickwire, “with one exception: it makes you fall asleep faster.” After that, everything changes. Alcohol is a muscle relaxant, meaning it relaxes the muscles in your upper airway, which can cause symptoms of obstructive sleep apnea even in people who haven’t been diagnosed with the condition. “The second reason alcohol can worsen sleep is because it changes the distribution of sleep stages throughout the evening, or what’s called sleep architecture, and that can negatively impact brain function,” he says. You may find that after drinking, your sleep is more fragmented, you wake up more often, and you have trouble falling asleep. falling asleep again.

People who habitually nap during the day also need to make adjustments while on CBT-I. Your sleep drive is affected by how long you’ve been awake and how active you’ve been, says Wickwire. While napping is fine for people who don’t have insomnia, it can hinder your progress during CBT-I because it means you won’t be as tired when it’s time to go to bed. For example, if you wake up at 7 a.m., you’ve been awake for 16 hours by 11 p.m., meaning your body should be craving sleep. “But if you take a nap at 6 p.m., by 11 p.m. you’ve only been awake for four or five hours,” he says, which could doom you to a night of tossing and turning.

The role of drugs

Clinical practice guidelines of the American Academy of Sleep Medicine consistently recommend CBT-I as a first-line treatment for chronic insomnia. “There are a lot of studies comparing the results of behavioral therapy with medication,” Wickwire says. “And in general, CBT is equally effective in the short term, and the results are better maintained over time.” Research suggests that CBT-I results in fewer side effects than drug treatment, reduces the likelihood of relapse, and improves sleep in the long term.

“No pill will teach your body to sleep,” Wickwire says. “At the same time, that doesn’t mean all sleep aids are bad.” Patients should talk to their doctor; sometimes, as in particularly severe cases, it makes sense to combine CBT-I with prescription sleep aids.

Over-the-counter sleep supplements are a different story. It’s important not to rely on products like ZzzQuil, Benadryl, melatonin gummies, or Advil PM, Wang says. “If you’re sick and need to take one, that’s fine.” But with melatonin especially, “There are many variations and opportunities for misuse or unintended adverse effects. We strongly discourage self-medication for insomnia.”

Light at the end of the tunnel

People with insomnia often begin to notice improvements in their sleep within a couple of weeks. The speed at which people respond varies, Wang says; some may need six to 12 weeks before they notice a significant difference.

Wang likes to remind patients, who often feel stressed and exhausted, that change is possible. “It’s often very slow. We don’t expect all these problems to go away tomorrow,” she says. “It’s about small steps and consistency — and encouraging people who feel like it’s too hard, that yes, it may get worse before it gets better.” But if you keep at it, she adds, long, peaceful nights of sleep will be more than just a slumber.

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