A recent Spectator Health headline made two claims about insomnia. First, that insomnia was hell. It is indeed an absolutely terrible experience, as the article itself explained. Some say it is like a form of torture.
But the second claim, that there are no good treatments for insomnia, was a shocking untruth. I want to say this as loudly and clearly as possible: insomnia is treatable.
I sense many people reading this may be surprised. It is time, then, to let the genie out of the bottle. Effective treatment for insomnia shouldn’t be a well-kept secret. First, though, the experience itself…
Why insomnia is hell
If you are a good sleeper, consider what it must be like to have a difficulty getting to sleep or staying asleep, on the majority of nights, for months and months, or more commonly in clinical practice, for year upon year. Insomnia can be absolutely relentless.
However, the problems don’t stop there. Four out of five long-term poor sleepers suffer from low mood. Indeed you are twice as likely to become clinically depressed if you have persistent insomnia than if you are a good sleeper. Poor sleep quality has also been linked to irritability, to greater conflict and to poorer relationships satisfaction; and, in the workplace, people with insomnia report concentration problems, fatigue, and difficulties performing at their best.
So let’s make no mistake: insomnia is really a 24-hour problem, and world medical authorities who publish diagnostic classifications now call it ‘insomnia disorder’.
Why effective treatment seems to be kept a secret
There are several reasons but let me focus on two main ones.
1) NHS England doesn’t take insomnia (or even sleep) very seriously — at least not yet. Imagine if they didn’t take nutrition or exercise seriously?
I hope this will change. A report by the Royal Society for Public Health, which I helped to produce, called for a Government minister to have sleep health on their agenda. I look forward to a response.
2) GPs and other health care staff don’t know what to do about insomnia, and they struggle to offer anything effective. We seem to have a ‘pills, potions or pamphlets’ culture when it comes to poor sleep — and none of these is very effective.
Some sleeping pills have an evidence base, but only for short-term use in insomnia that isn’t persistent. Unfortunately 12 million prescriptions annually means that they are given to many, many people, helping some for sure, but the majority don’t benefit, or don’t even want pills in the first place.
How about potions? Suffice to say there is zero research evidence for any sleep remedy you buy in the chemist. The fact that people resort to these is quite scandalous.
By pamphlets I mean the (well-intended) ‘sleep hygiene’ tips. There is nothing wrong with cutting down on caffeine if you drink too much coffee, or keeping your room dark at night, but these are not treatments for insomnia disorder. Likewise, advising people not to worry if they don’t sleep or encouraging them to get their sleep into a seven-days-a-week pattern is no more therapeutic than saying to someone who is depressed to try to think more positively. Sounds kind of trite, don’t you think?
So what does work for insomnia?
The most effective treatment for insomnia is cognitive behavioural therapy (CBT), and its benefits are long-lasting. Research for the past 20 years has consistently demonstrated that CBT is as effective as medication, even in the short-term, and is considerably more effective than medication for people with persistent insomnia, who are the majority (1, 2, 3).
Indeed, UK clinical guidelines from as far back as 2004 concluded that CBT really should be the first thing that a GP offers, not medication. It is not a list of simplistic sleep dos and don’ts, but a proper psychological therapy that helps people sort out their problems with their sleep schedule and their racing mind. CBT for insomnia works in the same way as does CBT for any other problem (like anxiety disorder or depression) — it helps you to understand triggers and maintaining factors for poor sleep, to learn skills in managing your sleep, to test and implement changes to improve your sleep, and to sleep normally again without trying.
So why do many people not know about CBT?
Well, traditionally CBT requires face-to-face therapy time with a clinical psychologist or trained therapist, and few NHS services even provide this for insomnia. They should, because it works, and I’m delighted that the Royal Society of Public Health report calls for insomnia to be properly screened by GPs and treated with CBT in the NHS.
To be honest this should already be happening, but there is a challenge of scalability. Insomnia is a huge problem — millions of people every year, millions and millions of prescriptions. How can alternatives really become available?
There is hope on the horizon, however. It has arrived in the form of digital CBT, delivered via web or smartphone, using highly personalised help driven by algorithms. Sleepio, which I launched in 2010, is one such digital CBT programme, and has received positive results when subjected to a randomised control trial.
Colin A Espie is professor of sleep medicine at the University of Oxford. If you would like to participate in his research programme on insomnia please email email@example.com or visit this page.
 Wilson, SJ, Nutt DJ, Alford C, et al. British Association for Psychopharmacology consensus statement on evidence-based treatment of insomnia, parasomnias and circadian rhythm disorders. J Psychopharmacol 2010;24:1577-600.