Sleep is one of those things that most of us only notice when it goes wrong — and when it does, the effect on every other area of life is immediate and cumulative. Concentration falters. Mood deteriorates. Physical health is affected. Decisions get worse. And yet in clinical practice, insomnia is often handled with a prescription for zopiclone or zolpidem and a follow-up in two weeks — an approach that addresses the symptom while creating a new problem.
I want to give you a better picture.
Why we sleep badly — the main categories
Primary insomnia (psychophysiological insomnia): The most common type. Often starts with a stressful period — a bereavement, job loss, illness — but persists long after the trigger has resolved. The bed itself becomes associated with wakefulness and anxiety. A vicious cycle: worry about sleep → hyperarousal → poor sleep → more worry about sleep.
Sleep hygiene problems: Irregular sleep schedules, excessive screen use before bed, caffeine too late in the day, alcohol (which disrupts sleep architecture despite helping you fall asleep), bedroom environment that is too warm, light, or noisy.
Mental health related: Anxiety and depression are major causes of poor sleep. Anxiety causes difficulty falling asleep (racing thoughts). Depression often causes early morning waking. Treating the underlying condition improves sleep.
Medical causes: Obstructive sleep apnoea (OSA), restless legs syndrome, chronic pain, nocturia (frequent night-time urination), hyperthyroidism, sleep disruption from medications.
Shift work and circadian disruption: The circadian rhythm is powerful and deeply disrupted by irregular shift patterns. Particularly relevant for healthcare workers, security staff, and others who work nights — a group that includes a significant proportion of African diaspora workers in the UK.
Case study: Josephine's three-year insomnia
Josephine, 47, a community nurse from Zimbabwe based in Bristol, came to see me after three years of poor sleep. She was on her second course of zopiclone — the first had been for two months, then she had stopped, then restarted when the insomnia returned worse than before.
Her pattern was: lying awake for 1–2 hours after going to bed, mind racing, then waking at 3am unable to return to sleep. She was exhausted at work. She had tried herbal supplements, a white noise machine, and a weighted blanket. Nothing had fixed it.
Her sleep started deteriorating when her mother died in 2021. But the grief had passed — she was not depressed, her life was good. And yet the sleep had never recovered.
This is classic psychophysiological insomnia. The trigger (bereavement) had gone, but the pattern had been learned. Her brain had associated bed with wakefulness. The zopiclone was overriding this association chemically but not changing it.
I referred her for Cognitive Behavioural Therapy for Insomnia (CBT-I). Eight sessions. Twelve weeks later she reported sleeping within 20 minutes of going to bed and waking once, briefly, before returning to sleep.
"It felt counterintuitive," she told me. "They told me to sleep less at first. I couldn't believe that was the advice. But it worked."
CBT-I — the treatment that actually fixes insomnia
CBT-I is the first-line recommended treatment for chronic insomnia according to NICE, the American College of Physicians, and virtually every major sleep medicine body worldwide. It outperforms sleeping pills in head-to-head studies, and its effects are durable — benefits persist after the therapy ends, unlike medication which stops working when you stop taking it.
CBT-I consists of several components:
Sleep restriction therapy: Counterintuitive but highly effective. You are given a prescribed sleep window — initially shorter than you might want — to build up sleep pressure and consolidate fragmented sleep. Over time the window is extended as sleep efficiency improves.
Stimulus control: Retraining your brain to associate bed with sleep rather than wakefulness. This means getting out of bed if you are awake for more than 20 minutes, only using bed for sleep and sex, and maintaining a consistent wake time regardless of how badly you slept.
Cognitive restructuring: Identifying and challenging the thoughts that maintain insomnia — "I need 8 hours or I can't function," "I'll never sleep properly again," "If I don't sleep tonight I'll be useless tomorrow." These thoughts are catastrophic and self-fulfilling.
Relaxation techniques: Progressive muscle relaxation, breathing exercises, imagery rehearsal.
Sleep hygiene education: As a component of CBT-I, not as a standalone treatment (sleep hygiene alone rarely fixes established insomnia).
How to access CBT-I in the UK:
- NHS Talking Therapies (formerly IAPT) — self-refer at talkingtherapies.nhs.uk — some areas now offer CBT-I specifically
- Sleepio — a digital CBT-I programme, NHS-funded in some areas, evidence-based
- Private therapists trained in CBT-I
The sleeping pill problem
I am not opposed to sleeping medication — it has a role, particularly in the short term during a crisis or as a bridge while CBT-I takes effect. But I am honest about its limitations:
Z-drugs (zopiclone, zolpidem): The most commonly prescribed. Effective for helping people fall asleep but problematic for several reasons:
- Tolerance develops within weeks — you need more for the same effect
- Dependency is common — the rebound insomnia when you stop is often worse than the original problem
- Side effects include daytime sedation, memory impairment, and increased fall risk in older people
- Not recommended for longer than 2–4 weeks
Antihistamines (promethazine, diphenhydramine): Available over the counter. Cause drowsiness but tolerance develops rapidly — often ineffective after a few nights of use.
Low-dose antidepressants (mirtazapine, amitriptyline): Used off-label for insomnia. Less dependency risk than Z-drugs. Useful where insomnia co-exists with depression or anxiety.
Melatonin: Has modest evidence for circadian-related sleep problems (jet lag, shift work, delayed sleep phase) and some evidence for older adults (over 55). Limited evidence for general insomnia.
What actually helps — the evidence-based list
Strong evidence:
- CBT-I (first-line treatment)
- Consistent wake time (even on weekends — the single most impactful sleep hygiene measure)
- Treating underlying anxiety or depression
- Treating sleep apnoea if present (ask your GP about a sleep study if you snore heavily or your partner witnesses you stop breathing)
Modest evidence:
- Reducing caffeine after midday
- Exercise (improves sleep quality — but not within 2–3 hours of bed for most people)
- Keeping the bedroom cool (18–19°C is often cited as optimal)
- Melatonin for circadian disorders
Limited evidence despite popularity:
- Weighted blankets — some people find them helpful, trial evidence is modest
- Herbal supplements (valerian, lavender, chamomile) — small or poorly conducted trials
- White noise — helpful for some, particularly in noisy environments, but not a cure for insomnia
Sources: NICE Clinical Guideline CG159 — Sleep Problems (2015, updated 2021); Trauer JM et al, Annals of Internal Medicine 2015 (CBT-I meta-analysis); Riemann D et al, Journal of Sleep Research 2017 (European Insomnia Guidelines); Qaseem A et al, Annals of Internal Medicine 2016 (American College of Physicians guidelines).