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Insomnia

A common sleep problem: as many as 35% of adults complain of insomnia, and about 10% have chronic insomnia12. Treatable for most people, with cognitive behavioral therapy for insomnia as the first-line approach1.

Neurological & Mental Health Evidence-Based

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โš ๏ธ Medication safety: please read first. The nutrition and supplement approaches on this page are meant to work alongside your prescribed treatment, never to replace it. Never stop, reduce or change your sleeping medication without your prescriber's guidance. Doing so can be dangerous. Several supplements interact with sleeping medication or add to its drowsiness, so talk to your prescriber or pharmacist before starting anything on this page.
Definition

What Is Insomnia?

Insomnia is the persistent difficulty initiating or maintaining sleep, or waking earlier than intended, despite adequate opportunity, resulting in daytime impairment. It is not "being a light sleeper"; it is a clinical, treatable disorder.

Clinically, chronic insomnia is defined by the DSM-⁠5 and ICSD-⁠3 criteria as a sleep disturbance occurring at least three nights per week for at least three months, accompanied by daytime consequences such as fatigue, mood disturbance, cognitive impairment or functional decline. The condition is more common in women, in shift workers, in people over 60 and in anyone with chronic pain, anxiety, depression or trauma history.

Insomnia is often described by which part of the night is disrupted, as in the four patterns below.

Insomnia, a person lying awake in bed at night, with trouble falling asleep, waking at night, waking too early and tiredness during the day
💡 Key Insight: Cognitive Behavioral Therapy for Insomnia (CBT-I) is recommended as the first-line treatment for chronic insomnia1 in adults, ahead of any pharmacotherapy, by the American College of Physicians and the American Academy of Sleep Medicine. (Source: American College of Physicians Clinical Practice Guideline, 2016.)

Sleep-Onset Insomnia

Difficulty falling asleep, defined as taking more than 30 minutes to initiate sleep on at least three nights per week. Commonly linked to a delayed circadian phase ("night-owl drift"), anxiety or a racing mind at bedtime.

  • โ†’Hallmarks: Lying awake with racing thoughts, mind "switches on" at lights-out, often tired by day but wired by night
  • โ†’Primary lever: Phase-advance the circadian clock, morning sunlight, evening light reduction, consistent wake time

Sleep-Maintenance Insomnia

Frequent or prolonged awakenings during the night, often between 1 and 4 AM, with difficulty returning to sleep. Commonly linked to alcohol, perimenopause and sleep-disordered breathing.

  • โ†’Hallmarks: Falls asleep easily, wakes at 2 to 4 AM, lies awake 30+ minutes, often anxious or hot
  • โ†’Watch-out: Screen for sleep apnea5 and perimenopause before adding sleep aids

Early-Morning Awakening

Waking 1 to 3 hours earlier than intended and unable to fall back asleep, despite adequate prior sleep duration. Strongly associated with depression, and with the earlier sleep timing common in older adults.

  • โ†’Hallmarks: 3 to 5 AM wakeups, rumination, often co-occurs with low mood
  • โ†’Primary lever: Screen and treat underlying depression, evening light therapy

Mixed / Nonrestorative Insomnia

A combination pattern, or a sleep duration that looks adequate on paper but does not feel restorative on waking. Often involves fragmented architecture, suppressed deep sleep, or undiagnosed sleep apnea or restless legs syndrome.

  • โ†’Hallmarks: "Slept 8 hours, feel like 4," morning grogginess, daytime fatigue despite full nights
  • โ†’Primary lever: Rule out obstructive sleep apnea (OSA), restless legs syndrome (RLS) and periodic limb movements; investigate sleep architecture (a sleep study)
By the Numbers

Insomnia by the Numbers

Up to 35%
of adults complain of insomnia; it is more common in older adults, women, people under stress and people with depression12
15 to 20%
of people have short-term insomnia, lasting up to three months, at any given time12
10%
have chronic insomnia: trouble sleeping at least three times a week for at least three months12
2.6ร—
the odds of later depression in people with insomnia, across 21 long-term studies14
41% vs 28%
long-term remission when treatment starts with CBT-I, against starting with a sleeping medicine, across 13 trials16
First
CBT-I is the recommended initial treatment for chronic insomnia in all adults; medicine is weighed, short term, only if it has not worked17
Signs & Symptoms

Symptoms of Insomnia

Insomnia is rarely a single complaint: trouble falling or staying asleep, or waking too early, comes with tiredness, irritability and poor concentration by day13.

SymptomWhat happens
Nighttime Sleep Symptoms
Prolonged Sleep Latency (Difficulty Falling Asleep)Taking more than 30 minutes to fall asleep on at least three nights per week. Linked to delayed melatonin onset, screen exposure and heightened arousal at bedtime.
Frequent Nighttime AwakeningsWaking three or more times per night, often unable to identify a cause. Awakenings can be linked to alcohol, hormonal shifts (perimenopause) or breathing interruptions (sleep apnea), and often have no single cause.
Early-Morning Waking (3 to 5 AM)Waking 1 to 3 hours before the desired wake time, with full alertness and inability to return to sleep. Strongly associated with depression, and with the earlier sleep timing that comes with age. Often accompanied by rumination and anxiety.
Night Sweats & Hot FlashesSudden waking drenched in sweat, often around 2 to 4 AM. Common in perimenopause and hyperthyroidism; also with alcohol use.
Loud Snoring, Gasping or ChokingLoud snoring, breathing that stops and starts, gasping or choking noises in sleep, and headaches on waking are signs of sleep apnea, which needs a doctor's assessment15.
Restless Legs & Periodic Limb MovementsAn uncomfortable urge to move the legs that emerges at rest in the evening, relieved temporarily by movement. Drives sleep-onset and maintenance insomnia. Linked to low iron stores, with iron treatment usually advised when ferritin is 75 ng/mL or lower59, and to certain medications (SSRIs, antihistamines).
Daytime & Systemic Symptoms
Chronic Daytime Fatigue & Brain FogPersistent tiredness despite time in bed, with reduced word recall, mental speed and short-term memory. Often misattributed to "just being busy."
Anxiety, Irritability & Mood LabilityInsomnia and anxiety or low mood feed each other; across 21 long-term studies, insomnia more than doubled the odds of later depression14.
Reduced Immunity & Frequent IllnessIn healthy men, one night of partial sleep loss lowered natural killer cell activity by about a quarter; in healthy adults given a cold virus, those sleeping under 6 hours were about four times as likely to catch the cold as those sleeping over 7 hours10.
โš ๏ธ Pattern to watch for: Difficulty initiating or maintaining sleep + daytime fatigue or cognitive impairment + 3+ nights per week for 3+ months is the diagnostic threshold for chronic insomnia disorder. Loud snoring, witnessed apneas, restless legs or 2 to 4 AM wakeups need checking for other causes before pursuing any pharmacological "sleep aid."
Causes

Causes of Insomnia

Insomnia usually has more than one contributor, and some, such as sleep apnea, restless legs and depression, need treatment in their own right13.

CauseHow It Contributes to InsomniaWhat Helps
Stress, anxiety and depressionAmong the most common causes of insomnia, and insomnia in turn more than doubles the odds of later depression, so each feeds the other1314CBT-I, and treatment for the anxiety or depression itself; see the anxiety and depression guides
Irregular timing, shift work and jet lagShift work and jet lag are common causes, and napping, sleeping in after a bad night and screens right before bed all work against a regular sleep pattern13A fixed wake time every day, morning daylight and no screens before bed, as the treatment section sets out
Caffeine, alcohol, nicotine and late mealsAlcohol, caffeine and nicotine are among the most common causes, and a big meal late at night gets in the way of sleep13The caffeine and alcohol cutoffs and the earlier, lighter dinner in the diet section
The bedroomNoise, a room that is too hot or too cold and an uncomfortable bed are common causes13A dark, quiet bedroom, with curtains, an eye mask or earplugs if needed, and a comfortable bed
Sleep apneaBreathing that stops and starts in sleep, with gasping or choking noises and loud snoring, breaks sleep up and leaves people tired by day15A doctor's assessment and an overnight breathing test; many people need a CPAP machine, and losing weight, stopping smoking and drinking less alcohol help some15
Restless legs and low ironRestless legs syndrome causes insomnia; brain iron deficiency is implicated in it, and guidelines recommend iron treatment when iron levels are low139A ferritin test first, and iron only if it is low, as the supplement section sets out
Health conditions, menopause and medicinesAn overactive thyroid, menopause, long-term pain and many medicines can all cause insomnia13Treating the condition, and a medication review with your prescriber; never stop a prescribed medicine on your own
Diagnosis

How Insomnia Is Diagnosed

Insomnia is a clinical diagnosis supported by tracking and targeted labs. The goal is not just to confirm the disorder but to identify the underlying drivers (sleep apnea, restless legs, perimenopause, low iron, depression and anxiety) that determine the treatment plan.

TestWhat it shows
At-Home Screening
These are not diagnostic on their own, but strong patterns can guide your next steps before investing in formal testing:
Sleep Diary (2 weeks minimum)Track bedtime, lights-out time, estimated sleep latency, number of awakenings, wake time, total sleep time and daytime function each day for 14 days. This is one of the most useful records a sleep specialist will ask for. Free templates from the American Academy of Sleep Medicine work well.
Wearable TrackingWearables are imperfect for absolute sleep-stage data but excellent for trend tracking, resting heart rate, HRV, breathing rate and skin temperature shifts.
STOP-BANG & Insomnia Severity Index (ISI)The STOP-BANG questionnaire screens for OSA risk (snoring, tired, observed apnea, BP, BMI, age, neck, sex); a score of 3 or more warrants a sleep study. The Insomnia Severity Index (7 items) scores severity; 15+ indicates moderate to severe insomnia and supports a formal CBT-I referral. Both are free online.
Lab & Clinical Tests
Thyroid PanelTSH, with free T4 if the TSH is abnormal. Hyperthyroidism classically presents with insomnia, palpitations and night sweats.
Iron, Ferritin & CBCLow iron stores are a common, treatable contributor to restless legs syndrome and fragmented sleep, even when hemoglobin is normal5, and iron treatment is usually advised in RLS when ferritin is 75 ng/mL or lower9. Always pair with full iron studies (serum iron, TIBC, transferrin saturation) and B12 to catch deficiencies that perpetuate insomnia.
Metabolic / Blood Sugar PanelFasting glucose and HbA1c, where diabetes is suspected.
Sex Hormone & Reproductive Panel (women)Perimenopause is a common cause of new sleep-maintenance problems in midlife women, often through night sweats; your clinician can advise whether any hormone testing would help.
Home Sleep Apnea Test (HSAT) or PolysomnographyA home sleep test is the right first step for STOP-BANG-positive patients. An in-lab polysomnography is the gold standard for complex cases, periodic limb movement disorder, REM behavior disorder or atypical presentations.
Treatment Comparison

Conventional and Holistic Treatment for Insomnia

๐ŸŒฟ HOLISTIC
๐Ÿ’Š CONVENTIONAL
๐ŸŒฟ

Holistic / Functional Approach

CBT-I and a regular body clock first, with diet and supplements in a supporting role, alongside medical care

Primary Treatment
CBT-I + circadian-anchoring routine (morning light, fixed wake time) + targeted nutrition + magnesium/​glycine/L-theanine
Duration
2 to 6 weeks for noticeable improvement
Effect on Underlying Disorder
Long-term remission possible without ongoing medication, because the effects of CBT-I persist after the course ends1
Daytime Outcome
Better sleep and daytime function for many; long-term remission is more likely when treatment starts with CBT-I than with a sleeping medicine16

Full Holistic Approach Includes

  • CBT-I (Cognitive Behavioral Therapy for Insomnia), the recommended initial treatment for chronic insomnia in all adults17
  • Fixed wake time 7 days a week, even on weekends: get up at the same time every day, and do not sleep in after a bad night13
  • 10 to 20 minutes of outdoor light within 30 minutes of waking, the strongest signal for setting the body clock7
  • Evening light hygiene: dim lights after sunset, and for 90 minutes before bed no screens, or blue-light glasses if you do use them
  • Cool, dark, quiet bedroom (65 to 68ยฐF / 18 to 20ยฐC), bed used only for sleep and intimacy
  • Protein-anchored dinner finished 3 hours before bed; no alcohol within 6 hours of bed
  • Targeted supplements: magnesium glycinate, L-theanine, glycine, low-dose melatonin (0.3 mg) and ashwagandha
  • Address underlying drivers: obstructive sleep apnea (CPAP if confirmed), low ferritin with restless legs, perimenopausal progesterone and depression
โš ๏ธ Side effects: First 1 to 2 weeks of CBT-I include intentional mild sleep restriction2 that can transiently increase daytime tiredness; by week 3 sleep efficiency usually improves. Sleep restriction is done with guidance, and is not used with untreated sleep apnea, bipolar disorder or epilepsy, where lost sleep is a trigger2. No tolerance, dependence or rebound on discontinuation. Mild loose stools possible with magnesium citrate (use glycinate instead).
Supplement Protocol

Evidence-Based Supplements for Insomnia

Supplements do not replace CBT-I or medical care, and none approaches CBT-I in the evidence6.

Supplement What it is for Typical range Timing Notes & cautions
Magnesium GlycinateTrials in older adults show modest effects on sleep6.300 to 400 mg elemental magnesium per dayEvening, 30 to 60 min before bedCitrate causes loose stools; oxide is poorly absorbed. The top of this range is above the 350 mg/day upper intake level for supplemental magnesium; above that, diarrhea is common. With kidney disease, take it only on your clinician's advice.
GlycineSmall trials suggest improved subjective sleep quality6.3 g per day30 to 60 min before bedSlightly sweet powder, mixes in water.
L-TheanineAmino acid found in tea. A meta-analysis of randomized trials found small improvements in self-rated sleep, with few studies of pure L-theanine19.200 to 400 mg per dayEvening or 30 min before bedNo tolerance or dependence.
Melatonin (low-dose)The body's natural circadian signal. Low doses act as a chronobiotic that shifts the circadian phase; higher doses are generally no more effective and can cause next-day grogginess3.0.3 to 0.5 mg per day30 to 60 min before bed (sleep-onset) or 5 to 7 hours before bed (phase advance)Most OTC products are 3 to 10 mg, far too high. Lower doses are generally as effective as higher ones3. It is sold as a supplement in the US but is prescription only in several other countries, and guidelines found too little strong evidence to recommend it for chronic insomnia20. Start at the lowest available dose. Discuss it with your prescriber if you take sedatives, anticoagulants or immunosuppressants.
Ashwagandha (root extract)Some preparations may help insomnia and stress; it may be safe for up to 3 months, and long-term safety is unknown21.300 to 600 mg per dayWith dinner or before bedAvoid with any thyroid disorder. Rare cases of liver injury have been linked to it. Avoid in pregnancy, breastfeeding, autoimmune disease and before surgery, and ask your prescriber first if you take thyroid medication, sedatives or medicines for diabetes, blood pressure, seizures or immune suppression21.
Apigenin (from Chamomile)The main flavonoid in chamomile. There is very little evidence for chamomile in insomnia; the one insomnia study in a 2019 review found no benefit22.Not recommended for insomnia (the only insomnia study found no benefit)Not applicableAvoid if allergic to ragweed/​daisy family. Interactions with a blood thinner and with some medicines broken down by the liver have been reported; check with your prescriber if you take either22.
Iron Bisglycinate (if ferritin 75 ng/mL or lower)Restoring iron stores improves restless legs syndrome when ferritin is low5, and can improve sleep. An often overlooked contributor to fragmented sleep in women.25 to 50 mg elemental iron per dose, every other day or as your clinician advisesEmpty stomach, with vitamin C; every other day improves absorptionRetest every 3 months. Stop when ferritin is consistently above 75 ng/mL. The top of this range sits above the 45 mg/day tolerable upper intake level for adults. That is appropriate only when correcting a confirmed deficiency under clinical supervision, not as general supplementation. Test ferritin first, and retest rather than staying on it indefinitely.
Vitamin D3 (with K2)Observational studies link low vitamin D with poorer sleep quality, shorter sleep and daytime sleepiness28; this does not show that supplementing improves sleep.D3: set the dose with your clinician; most adults need no blood test first; K2 (MK-⁠7): 100 to 200 mcg per dayWith a fat-containing meal, morning preferredVitamin K can change how a vitamin K antagonist blood thinner works, so take K2 alongside one only if your prescriber agrees23.
Tart Cherry ExtractContains melatonin. A review of seven small studies found some improvement in sleep, but the evidence is limited and mixed18.500 mg standardized extract, or 8 to 12 oz (240 to 360 mL) tart cherry juiceEvening, 1 to 2 hours before bedJuice contains natural sugars; choose unsweetened or use the extract.
Valerian RootTraditional sedative herb, not shown to help chronic insomnia. The trial evidence is inconsistent, and a sleep medicine guideline recommends against it24.300 to 600 mg standardized extract per day30 to 60 min before bedSmells unpleasant. Effect builds over 2 to 4 weeks. Some people experience paradoxical stimulation. Do not take it with alcohol or sedatives; very rare liver injury has been reported24.
What to Expect

What to Expect Over Time

Insomnia usually improves with changes to sleep habits, and CBT-I is the first treatment when it persists1317.

Treatment and supportive care, together
First Weeks

Get up at the same time every day, and stop alcohol, tea and coffee at least 6 hours before bed13. A prescribed sleeping pill is for a few days or weeks at most, and a pharmacy sleep aid for 1 to 2 weeks; either can leave you drowsy, so do not drive when you feel sleepy13.

Months 1 to 3

A course of CBT-I is the recommended initial treatment; medicine is weighed, short term, only if CBT-I alone has not worked17. Snoring with pauses in breathing needs assessment for sleep apnea15.

Months 3 to 12

Long-term remission is more likely after starting with CBT-I than with a sleeping medicine, about 41% against 28%16. Never stop a regularly taken sleeping medicine abruptly; a benzodiazepine is reduced gradually with your prescriber26.

Long Term

Insomnia more than doubles the odds of later depression14, so sleep problems that persist or return are worth treating rather than enduring.

When to Seek Care

See a doctor promptly if you have fallen asleep while driving, and do not drive when you feel sleepy13; also for loud snoring with pauses in breathing, gasping or choking15. If insomnia comes with low mood or thoughts of suicide or self-harm, call or text 988 in the US, or call 911 if you are in immediate danger27. See a doctor if better habits have not helped, or poor sleep is making daily life hard to cope with13.

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Next Steps

CBT-I Comes First for Insomnia

Insomnia usually improves with changes to sleep habits, and CBT-I is the first treatment when it persists. Get up at the same time every day, and see a doctor if better habits have not helped. Never stop a regularly taken sleeping medicine abruptly.

Explore Bipolar Disorder โ†’ Explore Migraine โ†’

References & Evidence Notes

Each numbered entry below is either a source you can follow or a note setting out what the evidence does and does not support. Both are numbered together so the markers in the text line up.

Last reviewed October 20, 2026. Supplement entries are cross-checked against the NIH National Center for Complementary and Integrative Health and the Linus Pauling Institute Micronutrient Information Center.8 The most useful fact on this page is that the best-evidenced treatment for chronic insomnia is not a drug or a supplement. Cognitive behavioral therapy for insomnia (CBT-I) is first-line in every major guideline, ahead of any medication; its benefits persist after treatment ends, which is not true of sleeping pills. It is underused mainly because it is harder to access than a prescription. Two cautions. Persistent insomnia is frequently a symptom of something else, and obstructive sleep apnea, restless legs, depression, thyroid disease and alcohol are the usual culprits, so loud snoring, witnessed pauses in breathing or daytime sleepiness deserve investigation rather than a sedative. And do not stop a prescribed hypnotic abruptly, particularly a benzodiazepine or z-drug, because withdrawal causes rebound insomnia and can be dangerous.

  1. On CBT-I: cognitive behavioral therapy for insomnia combines sleep restriction, stimulus control, cognitive restructuring and sleep hygiene. Guidelines from the American Academy of Sleep Medicine and the American College of Physicians recommend it as first-line treatment for chronic insomnia in adults. Effects are comparable to hypnotics in the short term and superior over the longer term, because they persist after the course ends. Digital CBT-I programs have randomized evidence and improve access. ↩
  2. On sleep restriction, the part that feels wrong and works: deliberately limiting time in bed to consolidate sleep is the most effective single component of CBT-I and initially increases daytime sleepiness, which is why it is done with guidance and is not recommended for people with untreated sleep apnea, bipolar disorder or epilepsy, where sleep deprivation is a trigger. ↩
  3. On melatonin, and on dose: melatonin is a chronobiotic that shifts circadian timing more than it sedates, and it is most useful for delayed sleep phase and jet lag. Physiological doses of around 0.3 to 1 mg taken several hours before the desired bedtime are generally as effective as, or more effective than, the 3 to 10 mg commonly sold, and higher doses can cause next-day grogginess. Over-the-counter melatonin content has repeatedly been found to differ substantially from the label. ↩
  4. On hypnotics: benzodiazepines and z-drugs are effective short-term and carry tolerance, dependence, falls and cognitive effects, particularly in older adults, where they appear on prescribing-caution lists such as the American Geriatrics Society Beers Criteria of medications best avoided in older people, PubMed 37139824. Withdrawal after regular use causes rebound insomnia and, with benzodiazepines, can be medically dangerous, so tapering is planned with a prescriber. ↩
  5. On what else to exclude: obstructive sleep apnea, restless legs syndrome (which is associated with iron deficiency and improves with iron repletion when ferritin is low), depression and anxiety, hyperthyroidism, chronic pain and alcohol (which fragments the second half of the night despite shortening sleep onset). Treating the cause usually beats treating the symptom. ↩
  6. On magnesium, glycine and other supplements: magnesium has small trials in older adults with modest effects, glycine has small trials suggesting improved subjective sleep quality, and valerian has inconsistent evidence. None approaches CBT-I. The upper intake level for supplemental magnesium is 350 mg/day; above that the usual effect is loose stools. ↩
  7. On light and timing: morning bright light exposure and evening light restriction shift circadian phase and are low-cost, well-supported measures. Consistent wake time matters more than consistent bedtime, because wake time anchors the circadian system. ↩
  8. National Center for Complementary and Integrative Health (NIH), nccih.nih.gov, and the Linus Pauling Institute Micronutrient Information Center, lpi.oregonstate.edu/mic. ↩
  9. On iron and restless legs: international restless legs guidelines recommend oral iron for adults with restless legs syndrome when serum ferritin is 75 ng/mL or lower, and intravenous iron can be used at higher ferritin levels, PubMed 29425576. ↩
  10. On sleep and immunity: after one night of partial sleep deprivation, natural killer cell activity fell to 72% of baseline in 23 healthy men, PubMed 7871104; and among 164 healthy adults given rhinovirus, those sleeping under 6 hours had about four times the odds of a clinical cold compared with those sleeping over 7 hours, PubMed 26118561. ↩
  11. On kiwifruit: in a four-week self-controlled study of 24 adults with sleep problems, eating two kiwifruit an hour before bed shortened sleep onset by 35% and lengthened total sleep time by 13%, with no control group, PubMed 21669584. ↩
  12. On how common insomnia is: the American Academy of Sleep Medicine states that as many as 35% of adults complain of insomnia, that short-term insomnia, lasting up to three months, affects 15 to 20% of people at any given time, and that about 10% have chronic insomnia, occurring at least three times a week for at least three months. It is more common in older adults, women, people under stress and people with medical or mental health problems such as depression, American Academy of Sleep Medicine, insomnia. ↩
  13. On causes, self-help and sleeping pills: NHS guidance lists stress, anxiety or depression, noise, a room that is too hot or cold, an uncomfortable bed, alcohol, caffeine or nicotine, jet lag and shift work as the most common causes, with restless legs syndrome, an overactive thyroid, menopause, long-term pain, sleep apnea and many medicines among the others. It advises getting up at the same time every day, no alcohol, tea or coffee for at least 6 hours before bed, no big meal late at night and not driving when sleepy. It says pharmacy sleep aids may help for 1 to 2 weeks, should not be taken for longer and can cause drowsiness that makes driving difficult, and that sleeping pills are rarely prescribed, and then only for a few days or weeks at most, NHS, insomnia. ↩
  14. On insomnia and depression: a meta-analysis of 21 longitudinal studies found that insomnia predicted later depression, with an overall odds ratio of 2.60, about two and a half times the odds of people without sleep difficulties, PubMed 21300408. ↩
  15. On sleep apnea: NHS guidance lists breathing that stops and starts during sleep, gasping, snorting or choking noises, waking a lot and loud snoring, with tiredness, poor concentration and headaches on waking by day, and advises seeing a doctor for any of the main symptoms. Tests check breathing overnight; many people need a CPAP machine, while losing weight, stopping smoking and drinking less alcohol help some, NHS, sleep apnea. ↩
  16. On long-term results: a 2024 network meta-analysis of 13 trials with 823 adults with chronic insomnia found CBT-I more beneficial than medicine over the long term (median 24 weeks), with long-term remission of 41% after starting with CBT-I against 28% after starting with medicine, and fewer dropouts, PubMed 39188094. ↩
  17. On first-line treatment: the American College of Physicians recommends cognitive behavioral therapy for insomnia as the initial treatment for chronic insomnia in all adults (a strong recommendation on moderate-quality evidence), and a shared decision, weighing the benefits, harms and costs of short-term use, on whether to add medicine when CBT-I alone has not worked, PubMed 27136449. ↩
  18. On tart cherry: a 2025 systematic review found seven intervention studies, three of which reported better sleep duration, efficiency or sleep onset, with large differences in dose, duration and participants; the authors describe the evidence as limited and heterogeneous, PubMed 40964149. ↩
  19. On L-theanine: a 2025 meta-analysis of randomized trials (19 articles, 897 participants) found small improvements in self-rated time to fall asleep, daytime functioning and overall sleep quality, and noted the lack of studies of pure L-theanine and that the right dose and duration are not known, PubMed 40056718. ↩
  20. On melatonin: the NIH National Center for Complementary and Integrative Health notes that the American Academy of Sleep Medicine (2017) and American College of Physicians (2016) guidelines found not enough strong evidence on its effectiveness or safety to recommend it for chronic insomnia, that it is a dietary supplement in the US but available only on prescription in several other countries, that products may not contain what the label says, and that it may stay active longer in older people and cause daytime drowsiness, NCCIH, melatonin. ↩
  21. On ashwagandha: the NIH National Center for Complementary and Integrative Health reports that some preparations may help insomnia and stress, that it may be safe for up to 3 months while long-term safety is unknown, that rare cases of liver injury have been linked to it, that it should be avoided in pregnancy and breastfeeding, before surgery and in autoimmune or thyroid disorders, and that it may interact with medicines for diabetes, blood pressure, seizures and thyroid disease, with immunosuppressants and with sedatives, NCCIH, ashwagandha. ↩
  22. On chamomile: the NIH National Center for Complementary and Integrative Health finds very little information on chamomile for insomnia (a 2019 review found one insomnia study, which showed no benefit), notes allergic reactions in people allergic to ragweed, chrysanthemums, marigolds or daisies, and reports interactions with a blood thinner and with some drugs broken down by the liver, NCCIH, chamomile. ↩
  23. On vitamin K and blood thinners: US National Library of Medicine guidance states that vitamin K, or foods containing it, can change how a vitamin K antagonist blood thinner works, and that people taking one need to keep their vitamin K intake steady from day to day, MedlinePlus, vitamin K. ↩
  24. On valerian: the NIH National Center for Complementary and Integrative Health reports that the evidence for sleep problems is inconsistent, that the American Academy of Sleep Medicine's 2017 guideline recommended against valerian for chronic insomnia in adults, that because it may be sleep-inducing it should not be taken with alcohol or sedatives, and that liver injury has been reported in very rare cases, most often with other herbs, NCCIH, valerian. ↩
  25. On sleep medicines and dementia: a 2025 umbrella review of 68 meta-analyses, mostly of observational data, found moderate certainty of a higher risk of dementia with anticholinergic medicines and very low certainty of a higher risk with benzodiazepines and z-drugs; for those two, the link disappeared when analyses allowed a gap between prescription and diagnosis, which suggests early symptoms of dementia may prompt the prescriptions, PubMed 40707785. ↩
  26. On stopping a benzodiazepine: US National Library of Medicine guidance for a benzodiazepine used for anxiety and insomnia advises not stopping it or taking fewer doses without talking to your doctor, who will usually reduce the dose gradually, and lists seizures among the withdrawal symptoms that need a doctor or emergency care, MedlinePlus; a 2018 review notes that abrupt cessation can cause death, PubMed 29713452. ↩
  27. On help in a crisis: the US National Institute of Mental Health advises anyone who is struggling or having thoughts of suicide to call or text the 988 Suicide and Crisis Lifeline at 988, or chat at 988lifeline.org, and to call 911 in life-threatening situations, NIMH, depression. ↩
  28. On vitamin D and sleep: Gao Q, et al. The Association between Vitamin D Deficiency and Sleep Disorders: A Systematic Review and Meta-Analysis. Nutrients. 2018. PubMed 30275418. Nine observational studies with 9,397 participants: vitamin D deficiency was linked with higher odds of sleep disorders (odds ratio 1.50), including poor sleep quality, short sleep and sleepiness; the authors call for randomized trials to test the link. ↩