Insomnia after stress: why cognitive behavioural therapy is recommended first, not sleeping pills

Insomnia is a disorder in which a person has trouble falling asleep or sleeping without waking; some people have both problems. Daytime difficulties are added: fatigue, low mood or irritability, and problems with attention and concentration. To speak of “insomnia disorder”, these difficulties must occur at least several times a week over a period of 3 months. According to the guideline, up to 10% of adults in Europe have insomnia.

What the 2023 European Insomnia Guideline recommends

The guideline was developed by the European Sleep Research Society (ESRS) and the European Insomnia Network (EIN). The main points:

• The first-line treatment for chronic insomnia in adults of any age, including those with comorbid conditions, is cognitive behavioural therapy for insomnia (CBT-I); this is the strongest level of evidence (A). It can be delivered face to face (individually or in a group) or digitally, through a website or app of proven effectiveness, preferably with guidance from a professional.
• How it works: CBT-I works on thinking (the “racing mind”) and at the same time re-establishes a healthy sleep pattern.
• If CBT-I is not effective enough, the patient and doctor decide together whether to start medication.
• Duration of use: medication is generally recommended for no longer than 4 weeks, because tolerance develops within days to weeks; dose increases are not advised, as they may accelerate dependence. In some cases longer courses are possible after carefully weighing benefits and risks.

What the guideline does not recommend

Antihistamines, antipsychotics, fast-release melatonin, ramelteon and herbal remedies are not recommended for treating insomnia (level A). Light therapy and exercise may be a useful addition to CBT-I (level B).

A separate note for people who have lived through trauma

The insomnia guideline speaks about insomnia in general. If the sleep disturbance is linked to PTSD, see also the guideline of the US Departments of Veterans Affairs and Defense (VA/DoD, 2023): according to its summary, benzodiazepines are not recommended in PTSD, and prazosin is suggested for consideration specifically for nightmares, but not as a treatment for PTSD overall. So any sleeping pills in PTSD should be discussed with a doctor rather than decided on your own.

What to do in practice

• If poor sleep occurs several times a week for more than a few weeks and gets in the way during the day, see a family doctor or psychiatrist. The assessment uses a conversation about sleep and health, questionnaires and sleep diaries.
• Ask about CBT-I: a face-to-face or digital programme of proven effectiveness.
• Do not stop or change prescribed medication without a doctor.

Sources

• Riemann D. et al. The European Insomnia Guideline: An update on the diagnosis and treatment of insomnia 2023. J Sleep Res 2023;32(6):e14035
• VA/DoD guideline: Management of PTSD and Acute Stress Disorder (2023)

This material is for information only and does not replace consultation with a doctor or psychologist. Self-medication can be harmful to your health.