Can't Sleep? Why Insomnia Treatment Starts With CBT-I, Not a Pill

"Can you give me something to help me sleep?" It is one of the most common requests a psychiatrist hears, and it is completely understandable. Poor sleep makes everything harder. But for chronic insomnia, the first-line treatment is not a pill. It is a specific, structured therapy called cognitive behavioral therapy for insomnia, or CBT-I.

What Counts as Chronic Insomnia

Chronic insomnia means trouble falling asleep, staying asleep or waking too early at least three nights a week for at least three months, with effects during the day, even when you have enough time set aside for sleep. Most people with it have tried the usual advice already, and it has not been enough.

First, Look for What Is Driving It

Insomnia often has a cause worth treating directly:

• Sleep apnea: snoring, gasping or daytime sleepiness despite a full night in bed.

• Restless legs: an urge to move the legs in the evening.

• Depression and anxiety: both commonly disrupt sleep, and poor sleep worsens both.

• Substances: alcohol, caffeine and cannabis all affect sleep quality. See our posts on alcohol and cannabis.

• Medications: stimulants, some antidepressants and steroids can all interfere.

• Medical causes: pain, reflux and perimenopausal hot flashes are common culprits.

We cover the wider picture in sleep disorders and mental health.

What CBT-I Is

CBT-I is a short, structured treatment, usually four to eight sessions. It retrains the body and mind to sleep, rather than sedating them.

• Sleep restriction: temporarily limiting time in bed to match the sleep you are actually getting, so sleep becomes deeper and more consolidated. Time in bed is then gradually extended.

• Stimulus control: using the bed only for sleep, and getting up if you are lying awake, so the bed stops being a place of frustration.

• A consistent wake time: the same time every day, including weekends.

• Cognitive work: addressing the worry about sleep that keeps the brain alert at night.

The first couple of weeks can feel harder, because sleep restriction makes you sleepier before it makes you sleep better. After that, most people improve, and unlike medication, the benefits tend to last after treatment ends. CBT-I is available with a trained therapist, in groups and through structured digital programs.

What the Guidelines Say

In April 2026 the American Academy of Sleep Medicine updated its guidance on insomnia treatment. CBT-I remains the most effective first-line treatment. When medication is used, the guideline favors CBT-I plus medication over medication alone, found no single drug that is clearly best, and advises using the shortest effective duration.

Where Medication Fits

Medication can help in the short term, alongside CBT-I, or when CBT-I is not available. Each option has trade-offs:

• Orexin receptor antagonists (suvorexant, lemborexant, daridorexant) block a brain signal that promotes wakefulness. They can cause next-day drowsiness.

• Z-drugs (zolpidem, eszopiclone) work well for many people but carry an FDA boxed warning about complex sleep behaviors such as sleepwalking and sleep-driving.

• Benzodiazepines carry risks of dependence, memory problems and falls, and are generally avoided for long-term sleep, especially in older adults.

• Low-dose doxepin can help with staying asleep.

• Trazodone is widely prescribed, but the evidence for insomnia on its own is thinner than its popularity suggests. It can make more sense when depression is also present.

• Over-the-counter options: sleep aids containing diphenhydramine or doxylamine cause next-day grogginess and are not recommended for older adults. Melatonin is more useful for timing problems such as jet lag than for chronic insomnia, and the actual dose in supplements varies widely.

Common Questions

Is it safe to take a sleeping pill every night? It depends on the medication and the person. Most guidance favors the shortest effective course. If you have been taking one for a long time, do not stop suddenly. Some cause rebound insomnia or withdrawal, so make a plan with your prescriber.

How long does CBT-I take to work? Many people notice improvement within a few weeks, with the full benefit by six to eight weeks.

I have had insomnia for years. Will CBT-I still work? Yes. It is effective for long-standing insomnia, including in people who also have depression or anxiety.

Worth a Conversation

If sleep has been a struggle for months, it deserves a real plan rather than a nightly workaround. SANA Psychiatry provides psychiatric evaluation and medication management for adults in Missouri, Illinois and Florida, in person and by video. You can schedule an appointment online.

Written by Sindhura Saini, board-certified psychiatrist (American Board of Psychiatry and Neurology). Last reviewed October 2026. This article is for education and is not a substitute for an individual medical evaluation. Do not stop or change a medication without talking with your prescriber.