If you have long-term insomnia (3 or more nights a week for 3 months or longer), start with cognitive behavioral therapy for insomnia, and don't go straight to taking sleeping pills long term

Cost

Go to a hospital's sleep clinic, psychiatry or psychology department; you pay registration and treatment fees. Online self-help courses are much cheaper. One course usually takes 6 to 8 weeks, and you keep a sleep diary every day. What you can start on your own is stimulus control: go to bed only when you are sleepy, and get up if you lie there unable to sleep. Use the bed only for sleeping and sex, get up at the same time every day, and don't nap during the day. The hard part is the sleep restriction step: for the first few weeks you cut your time in bed short, and you will be sleepier during the day.

What you get

The National Health Commission's (国家卫健委) 2020 clinical standard sets out the diagnostic points for insomnia disorder following the international classification. One, difficulty falling asleep, or waking easily or too early after falling asleep. Two, feeling tired and sleepy during the day, with daily functioning affected. Three, these problems occur at least 3 times a week for at least 3 months. Less than 3 months is called short-term insomnia disorder. The standard makes cognitive behavioral therapy for insomnia the first-line treatment. It has 5 parts: sleep restriction, stimulus control, cognitive therapy, relaxation training and sleep hygiene, and a course usually runs 6 to 8 weeks. The standard says its short-term effect is comparable to medication, and in the long run it is better than medication. The standard also states that sleeping pills are generally taken for no more than 4 weeks in a row, and if they are to be continued, they are assessed once a month. The American College of Physicians' (美国医师协会) 2016 guideline strongly recommends that all adults with chronic insomnia start with this treatment. If it alone does not work, then discuss with the doctor whether to add a medicine for a short time. One analysis pooled 20 randomized controlled trials with 1162 people (a meta-analysis). After treatment, the time to fall asleep was 19.03 minutes shorter (95% CI 14.12–23.93, the plausible range). The time awake after falling asleep was 26.00 minutes less (15.48–36.52). The share of time in bed actually spent asleep (sleep efficiency) was 9.91% higher (8.09%–11.73%). Total sleep time was only 7.61 minutes longer, which is not statistically significant (−0.51 to 15.74). None of the studies reported adverse effects. Another analysis pooled 30 randomized controlled trials to see how long the effect lasts. Compared with people who had no treatment, the improvement in insomnia severity got smaller over time. At 3 months g = 0.64, at 6 months 0.40, and at 12 months 0.25. The effect gradually weakens, but the authors consider it still clinically meaningful within a year. Done online, one analysis pooled 11 randomized controlled trials with 1460 people. All sleep measures improved, with effect size g from 0.21 to 1.09. The authors say this is comparable to doing it in person, and the longer the course and the more follow-up from a person, the greater the effect. In another online randomized trial of 1711 people, in which the control group received only sleep hygiene materials, people who used digital treatment had a large improvement in sleep-related quality of life and small improvements in daytime physical and mental state. Now sleeping pills. One analysis pooled 24 randomized controlled trials with 2417 insomnia patients over 60. Every trial had people take the pills for at least 5 nights in a row. Compared with placebo, people on the pills slept 25.2 minutes more in total and woke 0.63 fewer times a night. For every 13 people who took them, 1 had better sleep quality. For every 6 people who took them, 1 had a side effect (NNH 6, 4.7 to 7.1). Side effects involving memory and thinking were 4.78 times those of placebo (OR 4.78, 1.47–15.47). Daytime fatigue was 3.82 times (OR 3.82, 1.88–7.80).

Notes

The five stimulus control rules in the cost field come from the American Academy of Sleep Medicine's 2021 guideline. Sleep restriction means first cutting your time in bed down to the time you actually sleep, then slowly adding it back according to your sleep efficiency. The guideline says it makes you sleepier during the day, so people who drive or operate machinery should use it with care. People with a tendency to mania, uncontrolled epilepsy, or unusual daytime sleepiness to begin with should also be careful, and it is best done with a doctor following up. Sleep education alone, covering routine, diet and environment, does not work on its own, and the guideline does not recommend it. A few nights of poor sleep are not insomnia disorder. In that case first fix your wake-up time; see §3.2 (get up at the same time every day). Then see §3.4 (no caffeine after 2 p.m.) and §3.8 (no glowing screens in the hour before bed). If you snore, stop breathing in your sleep or are very sleepy during the day, the standard requires ruling out sleep apnea first. For how to check, see §3.27 (sleep apnea). If your mood is low and you also sleep badly, see §3.18 (the first things to do when your mood is low). Sleeping pills are prescription drugs, and that analysis looked only at people over 60 taking them short term. The benefit is rated medium: the time saved falling asleep and the time awake in the night add up to about 45 minutes a night, which over a week is a matter of hours. Total sleep time barely changed. The 20-trial analysis excluded insomnia patients who also had other illnesses. Which department to go to in China is the author's experience (grade C) and differs by hospital; before registering, ask whether they offer this treatment. The person who benefits is mainly you. Don't expect melatonin to cure long-term insomnia; see §6.34 (taking melatonin to cure long-term insomnia).

Evidence grade

A : Specific numbers from meta-analyses, large cohorts or randomized trials; for law and policy, the statute or official text.

Sources

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Translated from the Chinese original. Original book, section 3, tip 26. Content may be out of date and rules differ by place. When you actually deal with an agency, a doctor or a court, follow what local officials, doctors and lawyers tell you. Disclaimer