Why Sleeping Pills Aren't the First Treatment for Chronic Insomnia, and What Is
For most adults with long-running insomnia, the evidence points away from medication as the starting move. Here is what comes first, and why so many Hyderabad clinics still get it wrong.
Medical disclaimer: This page is reviewed by Dr. Pradyut Waghray, MBBS MD FRCP (London) FCCP FAMS. It is for informational purposes only and does not replace a consultation with a sleep physician.
Last reviewed: 2026-05-11 by Dr. Pradyut Waghray
Reviewed by Dr. Pradyut Waghray, MBBS MD FRCP (London) FCCP FAMS, Founder of Respire Airway Clinics. Over 35 years treating sleep and respiratory medicine in Hyderabad.
“I lie awake for hours every night. I have tried everything. Nothing works.” This is the most common sentence we hear at our insomnia clinic. It is also usually wrong about one thing.
For chronic insomnia, the American Academy of Sleep Medicine and the American College of Physicians both recommend Cognitive Behavioural Therapy for Insomnia, known as CBT-I, as the first-line treatment. Medication comes second. And in a meaningful share of patients who arrive saying they cannot sleep, the actual cause is undiagnosed sleep apnea, especially in women over 35.
That second point is the one most people miss. We see it weekly.
What Insomnia Actually Is, and the Two Types Most People Do Not Know
Insomnia has two forms, and which one you have decides what works.
Clinically, insomnia is difficulty falling asleep, difficulty staying asleep, or waking too early and being unable to return to sleep. It becomes chronic insomnia when it happens at least three nights a week for at least three months, and it causes daytime impact: fatigue, mood change, concentration loss, or worry about sleep itself.
Primary Insomnia: the sleep system itself
Primary insomnia is when sleep is the problem, with no underlying medical or psychiatric cause. The arousal system is over-active at night, the body has learned to associate the bed with wakefulness, and worry about sleep makes the next night worse. CBT-I is built for this group.
Secondary Insomnia: caused by something else
Secondary insomnia is sleeplessness caused by another condition: obstructive sleep apnea, anxiety and depression, thyroid disorder, chronic pain, restless legs syndrome, certain medications, and perimenopause. Treating the sleep complaint without identifying the driver does not work.
A second useful split is by timing: sleep onset insomnia (cannot fall asleep) versus sleep maintenance insomnia (cannot stay asleep). Maintenance insomnia, particularly with 2am to 4am wakings, raises the question in the next section.
When “Insomnia” Is Actually Sleep Apnea
Sleep apnea wakes you up. Many patients do not remember the wakings. They just remember lying awake at 3am, frustrated, wondering why they cannot fall back asleep.
This is one of the most consistently missed diagnoses in Indian sleep practice, and it is missed most often in women. Published data put the comorbidity of insomnia and OSA at roughly 30 to 50 percent of OSA patients reporting significant insomnia symptoms, a condition now formally recognised as COMISA (comorbid insomnia and sleep apnea).
Classical sleep apnea presents as a loud snorer with witnessed breathing pauses, usually male, usually overweight. Women more often present with fatigue, insomnia, morning headache, anxiety, and unrefreshing sleep. They are told they are stressed, prescribed a sleeping pill, and the apneic events go untreated. The sleep quality stays bad.
Signs we ask about specifically. If two or more apply, we recommend ruling out sleep apnea before starting insomnia treatment:
Treating the apnea often resolves the “insomnia” without further work. We run a home sleep study first if apnea is suspected.
The First-Line Treatment Most Clinics Do Not Offer: CBT-I
CBT-I outperforms sleeping pills at six months and beyond. It is the explicit first-line recommendation in the ACP 2016 clinical practice guideline and the AASM 2021 clinical practice guideline. Most Indian patients have never heard of it.
CBT-I is not talk therapy for sleep. It is a structured 6 to 8 session programme that retrains how the body and mind approach sleep. Three components do most of the work.
Stimulus control: relinking the bed with sleep
If you have spent months lying in bed awake, anxious, scrolling, your brain has learned that the bed is a place for wakefulness. Stimulus control breaks that association. Bed is for sleep only, get out of bed if you are awake for more than about 20 minutes, return only when sleepy, keep a fixed wake time regardless of how the night went. Three to four weeks of consistent practice usually shifts the conditioning.
Sleep restriction: the counter-intuitive technique that works
If you are spending nine hours in bed and sleeping five of them, we briefly reduce your time in bed to closer to your actual sleep time. The night becomes more concentrated. Sleep efficiency rises. Once you are sleeping a solid 85 percent of your time in bed, we expand the window gradually.
Fragmented, low-pressure sleep across nine hours is worse than consolidated sleep across six. Sleep restriction builds the homeostatic sleep drive that chronic insomnia has flattened. It is done under supervision.
Cognitive therapy: the thoughts that keep you awake
The third component addresses the thoughts that fire at 2am: “If I do not sleep I cannot function tomorrow.” “Something is wrong with me.” “I have lost the ability to sleep.” These thoughts raise physiological arousal, which keeps you awake, which proves the thought right. Cognitive therapy is the structured work of identifying these thoughts and testing them against evidence.
CBT-I has durable effects. Unlike sleeping pills, the benefit persists after treatment ends, because the underlying conditioning has changed.
Where Sleeping Pills Fit, and Where They Do Not
Sleeping pills are a tool, not a treatment. We use them. We just do not start with them, and we do not leave you on them.
There is a real role for medication: acute insomnia after a major stressor, severe sleep deprivation that is impairing safety, a short bridge while CBT-I is getting underway. The honest issue is that most patients on long-term sleeping pills were never offered anything else.
On long-term sleeping pills? If you have been on zolpidem or a benzodiazepine every night for years, the question is not “should I stop.” It is how to taper safely while we treat what is actually driving the insomnia. Abrupt discontinuation of long-term benzodiazepines is genuinely unsafe. That work needs supervision.
Lifestyle Changes That Actually Move the Needle
Sleep hygiene tips are mostly true and mostly insufficient on their own. They work better as a layer on top of CBT-I, not as a replacement. Some matter more than others.
Consistent wake time
The single strongest lever, seven days a week. Not bedtime. Wake time anchors the circadian rhythm. Catching up on weekends actively undermines sleep on Sunday and Monday nights.
Caffeine cut-off
If you are caffeine-sensitive, no coffee, tea, or cola after 1pm. Caffeine's half-life is about 5 hours. An evening espresso can still be active at midnight.
Alcohol
A nightcap shortens sleep onset and wrecks sleep architecture. It suppresses REM sleep in the first half and causes rebound awakening in the second. Two drinks at 9pm and waking at 3am are connected.
Light and exercise
15 to 20 minutes of bright outdoor light within an hour of waking anchors your circadian clock. Regular daytime exercise improves sleep. Vigorous training within 2 hours of bed can delay onset in some people.
What we did not list: warm milk, lavender pillow sprays, sleep apps with breathing music. They are pleasant. They are not treatment.
When to See a Sleep Physician
If your insomnia has lasted three months, it is chronic. That is the threshold to come in. Sooner if any of the following apply:
A first visit covers history, sleep diary review, screening for apnea risk, and a discussion of whether a sleep study or a CBT-I referral is the right next step. For most patients, it is both, in that order.
Frequently Asked Questions
What is the best treatment for insomnia?
For chronic insomnia (lasting three months or longer), the AASM and ACP both recommend CBT-I as the first-line treatment. Medication is second-line and short-term. The best treatment depends on whether the insomnia is primary or driven by another condition, which is why a sleep physician evaluates root cause before prescribing.
Can a doctor actually cure insomnia?
Most cases of chronic insomnia respond well to treatment, and CBT-I in particular produces durable improvement that lasts after treatment ends. Insomnia driven by another condition, such as sleep apnea or thyroid disease, often resolves when that condition is treated. Primary insomnia responds to CBT-I in roughly 70 to 80 percent of patients in clinical trials.
Is insomnia a mental illness or physical?
Neither label fits cleanly. Insomnia is a sleep disorder with both physiological and cognitive components. The arousal system is over-active, conditioning around the bed has shifted, and worry about sleep maintains the cycle. It can coexist with depression and anxiety, but most insomnia is not a psychiatric illness. It is a treatable medical condition.
How long does insomnia treatment take?
CBT-I is typically delivered in 6 to 8 sessions over 6 to 10 weeks. Most patients notice change within 3 to 4 weeks. If sleep apnea is the underlying cause, CPAP improves sleep within days to weeks of starting therapy. Medication-based approaches act faster but the benefit ends when the drug stops.
What medications are used for chronic insomnia?
Common options include Z-drugs (zolpidem), low-dose sedating antidepressants (trazodone, doxepin, mirtazapine), melatonin and melatonin agonists, and in some cases benzodiazepines. Each has trade-offs around tolerance, dependency, and side effects. Long-term nightly use of any of these is rarely the right answer.
What is CBT for insomnia?
CBT-I (Cognitive Behavioural Therapy for Insomnia) is a structured 6 to 8 session programme using four components: stimulus control (relinking the bed with sleep), sleep restriction (consolidating fragmented sleep into a more efficient window), cognitive therapy (addressing the thoughts that keep you awake), and sleep hygiene. It is the first-line treatment in both AASM and ACP clinical practice guidelines.
I have been on zolpidem for years. Can I stop?
Not abruptly, and not alone. Long-term nightly zolpidem use creates tolerance and rebound insomnia on withdrawal. The right approach is a structured taper combined with CBT-I, supervised by a sleep physician. Many patients who have been on a sleeping pill for years come off entirely within a few months of starting this approach.
Should I take melatonin for insomnia?
Melatonin works best for circadian-rhythm sleep disorders such as jet lag, delayed sleep phase, and shift work, and has a modest effect on primary sleep onset insomnia. It is not a strong treatment for sleep maintenance insomnia or insomnia driven by apnea, anxiety, or pain. The doses sold over the counter in India are often higher than what the evidence supports.
Book an Insomnia Evaluation
If your sleep has been broken for three months or longer, a first consultation takes about 45 minutes. We will take a full history, screen for sleep apnea risk, and tell you whether the next step is a sleep study, a CBT-I programme, or both.
Book an insomnia evaluation at Basheer Bagh or Jubilee Hills, Hyderabad.
All consultations are strictly confidential. We rule out sleep apnea before we treat insomnia.
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