Insomnia Protocol (CBT-I First)

Chronic insomnia affects about 10 to 30% of adults: trouble falling asleep, staying asleep, or waking too early at least 3 nights a week for at least 3 months. It is linked with fatigue, poor focus, low mood, and higher risk of depression, high blood pressure, diabetes and weight gain. How it becomes chronic: a trigger (stress, illness) leads to worry about sleep, then to habits that backfire (lying in bed awake, napping, caffeine, alcohol), and the insomnia sticks. CBT-I breaks that cycle. CBT-I: the most effective long-term treatment for chronic insomnia. Most people improve, and the benefits last after treatment ends, while sleep medications tend to work only while you take them. Its parts are sleep restriction (limits time in bed to build sleep drive), stimulus control (bed is for sleep, which breaks the link between bed and lying awake) and cognitive work on catastrophic thoughts ("I need 8 hours or I can't function" becomes "I can function on less sleep, and worrying makes it worse"). It takes 6 to 8 sessions with a therapist or a digital program. Sleep restriction: if you sleep 5 hours but spend 8 in bed (62.5% efficiency), allow about 5.5 hours in bed. Once efficiency is over 85%, widen the window by 15 to 30 minutes at a time. It works well but takes discipline, and the first week or two can be tiring. It is not safe without a clinician for people with seizure disorders or bipolar disorder, or for shift workers and drivers. Melatonin: it times sleep rather than sedating. Low doses (0.5 to 3 mg) work for many people; higher doses can cause next-day grogginess. Best for body clock problems (jet lag, shift work, delayed sleep phase), taken 30 to 60 minutes before the time you want to sleep. Glycine: 3 g before bed improved sleep quality in small studies, possibly by helping lower core body temperature. Inexpensive and generally safe. Magnesium: glycinate form, 200 to 350 mg at night, is calming. Sleep hygiene: not enough on its own for chronic insomnia (that needs CBT-I), but it is the foundation: steady schedule, dark and cool room, no screens late, no caffeine after 2 pm, little or no alcohol. Medications: a later step for chronic insomnia. Benzodiazepines and Z-drugs can cause tolerance, dependence, next-day impairment, rebound insomnia and falls in older adults. Other prescription options exist, such as low-dose doxepin (FDA-approved for insomnia), trazodone (off-label) and orexin receptor blockers. A licensed clinician decides whether any fits and the dose, and your prescriber makes any change to a sleep medication you take now. Sleep apnea: get checked if you snore, feel tired in the day, or someone has seen you stop breathing in your sleep. It is common, often undiagnosed, raises the risk of high blood pressure, heart disease and stroke, and can cause insomnia. CPAP is the usual treatment. Catastrophic thinking: "I need 8 hours or I'll be exhausted" can become self-fulfilling. CBT-I reframes it: "I can function on less sleep, worrying makes it worse, and I'll get the sleep I need." Chronic insomnia often improves a lot with CBT-I, and the gains tend to last. Invest in CBT-I, practice sleep hygiene, use supplements as a bridge, and work on underlying causes with your clinician. Sleep is a foundation of health.