When You Cannot Sleep: What to Try, and When It Is Something Else

One bad night is not insomnia. Insomnia is difficulty falling asleep, staying asleep, or waking too early — at least three nights a week, for three months or more, with a real cost during the day. That last part matters: if you sleep six hours and feel fine, you are a short sleeper, not a patient.

And the most useful thing on this page is probably the least expected: the single most effective treatment for long-term insomnia is not a medication. It is a structured behavioural approach, it outperforms sleeping tablets over the long run, and almost nobody is offered it first.

Sleep hygiene is real, and it is not the treatment

The standard list — dark room, cool room, no screens, consistent times, no caffeine after lunch, no alcohol as a nightcap, get morning light, keep the bed for sleep — is all correct. Do it. It is genuinely worth doing.

But it is worth being honest about what it is for. Sleep hygiene is good at preventing insomnia and poor at curing it. If you have not slept properly for six months, you have almost certainly tried all of it already, and being handed the list again is why people stop asking.

A few items in it are stronger than the rest:

Get up at the same time every day, including weekends. The wake time anchors the whole system, and it is the one most people sacrifice — then wonder why Sunday night is the worst night of the week.

Alcohol is the big trap. It genuinely helps you fall asleep and it fragments the second half of the night. A nightcap trades falling asleep for staying asleep, which is a bad trade for anyone whose problem is waking at 3am.

Get light in your eyes early. Ten or fifteen minutes outside in the morning does more for your body clock than anything you do in the evening — and in Phoenix, for most of the year, this is the easiest instruction on the list to follow.

The treatment that actually works

Cognitive behavioural therapy for insomnia (CBT-I) is the first-line treatment for chronic insomnia. It is not general talking therapy about your feelings — it is a short, practical, mechanical programme, usually four to eight sessions, and it works through apps and workbooks as well as in person.

Two of its components do most of the work, and both are counterintuitive enough that people abandon them early.

Get out of bed when you are not sleeping. If you have been lying awake for around twenty minutes, get up, go somewhere dim, do something undemanding, and go back when you are sleepy. Lying in bed trying is the thing that teaches your brain that bed is where you lie awake, and that learned association is a large part of why insomnia outlasts whatever started it.

Spend less time in bed, not more. This is the part that sounds mad. If you are in bed for nine hours and sleeping six, you are spending three hours a night practising being awake in bed. Compressing the window — deliberately, temporarily, under guidance — consolidates sleep, and the window is widened again as it does. It works, and the first week is unpleasant, which is exactly why it should be done with support rather than alone off a web page.

Get up at the same time regardless of how the night went. No lie-ins to make up for a bad night, no early bedtime the following evening. Both feel like repair and both extend the problem.

About sleeping tablets

They have a place, and it is short and specific. A few nights through an acute crisis, a bereavement, a hospital stay, jet lag.

As a long-term answer they are a poor deal. Tolerance builds, the benefit measured objectively is smaller than it feels, and stopping after months produces a stretch of worse sleep than before — which people naturally read as proof they need the drug. In older adults they meaningfully raise the risk of falls and confusion.

Over-the-counter sleep aids are mostly sedating antihistamines. They work for a few nights, then stop, and they leave a hangover. In older adults they are on the list of medicines to avoid.

Melatonin is not a sleeping tablet and is usually taken wrongly. It is a body-clock signal, not a sedative — most useful for jet lag or a shifted sleep schedule, in a small dose, a few hours before target bedtime rather than at lights out. As a supplement in the US it is not tightly regulated and the actual content of a bottle varies.

If you are already on something and want off it, that is a plan rather than a decision. Do not stop abruptly. It is worth an appointment.

When it is not insomnia

This is why sleep belongs in a clinic and not only in a self-help article. Several conditions present as insomnia and do not respond to anything above.

Obstructive sleep apnoea. The one to think of first. Heavy snoring, pauses in breathing, gasping or choking awake, waking unrefreshed after a full night, morning headache, daytime sleepiness that is dangerous behind the wheel. If your partner has watched you stop breathing, that is the appointment to make. It is common, very treatable, and untreated it drives high blood pressure, atrial fibrillation and stroke risk. It is also a frequent cause of blood pressure that will not come down despite medication.

Restless legs. An urge to move your legs in the evening, relieved by moving them. Often associated with low iron, and worth a blood test.

Depression and anxiety. Early-morning waking is a classic feature of depression. Anxiety more often prevents falling asleep. Both are treatable, and the sleep frequently improves as they do — our page on mindfulness and breathing covers where self-management stops being the right tool.

Thyroid problems, chronic pain, an enlarged prostate, heart failure, reflux, and the menopause all disrupt sleep through their own mechanisms.

Medication. Some antidepressants, steroids, decongestants, certain blood pressure medicines, stimulants for ADHD, and diuretics taken too late. Bring your list, including anything over the counter.

Shift work, which is its own category with its own strategies.

And caffeine, in more places than people count — tea, chocolate, cola, energy drinks, some painkillers. Its half-life is around five hours, so an afternoon coffee is still measurably present at midnight.

Come and talk to us if

• Poor sleep three or more nights a week for three months, with a daytime cost
• Snoring with pauses, or being told you stop breathing — do not wait on this one
• Falling asleep during the day, and especially while driving
• Early-morning waking with low mood, or loss of interest in things
• Legs that will not settle in the evening
• Wanting to come off a sleeping tablet
• New insomnia that started with a new medicine
• Sleep that is fine in duration but leaves you exhausted. That pattern points at quality rather than quantity, which usually means apnoea
• You have done everything on the hygiene list for months and it has not worked. That is not a failure — it is the point at which the right treatment is a different one

The Arizona part

Our sleep problems are shaped by heat and by light, and both arrive in summer.

Nights do not cool down here for months at a stretch, and body temperature has to fall a little for sleep to begin. A bedroom that stays warm delays that. Keep the bedroom genuinely cool overnight, run a fan for air movement, and if a warm shower before bed seems to help, that is not a coincidence — the rebound drop afterwards is real.

The summer routine inverts everything. People here get up before dawn to exercise, then do very little outdoors for fifteen hours. That is a sensible adaptation to the heat and it is hard on a body clock: very early rising with a bedtime that does not move earlier to match, which produces months of accumulated short sleep read as “just summer”.

Use the light deliberately, because we have plenty of it. Get outside early — that is the strongest signal available, and it is free here nearly every day of the year. And use blinds in the evening, since the extended summer daylight works against you in the hour before bed.

And the one worth checking if you have just moved here: a change in altitude, a much drier bedroom, and eight months of air conditioning all affect sleep in their first season. Our winter-in-Phoenix page covers what the cool months are actually good for, which includes the best sleeping weather of the year.

Sources

22. Insomnia — MedlinePlus Medical Encyclopedia, U.S. National Library of Medicine. https://medlineplus.gov/ency/article/000805.htm

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