Chronic insomnia: causes, diagnosis and treatment in the UK

Insomnia is a persistent difficulty with getting to sleep, staying asleep, waking too early or not feeling rested, despite having a fair chance to sleep. NICE Clinical Knowledge Summaries (CKS) adds that it has to cause impaired daytime functioning before it counts as a disorder. Someone who sleeps six hours, feels fine and has no distress does not have insomnia in this sense, even if a relative says they should sleep more.

The Sleep Charity describes a diagnostic checklist in which every point should be met: the sleep difficulty happens despite adequate opportunity, on at least three nights a week, for at least three months, with distress or disruption to daily life, and it cannot be explained only by another illness, substance or sleep disorder. That final point is why a clinician will ask about your whole health rather than just your nights.

Sleep needs are individual. The NHS gives typical ranges of 7 to 9 hours for adults, but stresses that you probably are not getting enough if you are constantly tired during the day. The measure that matters is how you feel and function, not a number on a sleep tracker.

The Sleep Charity separates three symptom patterns. Sleep-onset insomnia is taking a long time to fall asleep. Sleep-maintenance insomnia is waking repeatedly and struggling to drift off again. Early-morning waking is surfacing earlier than you need to and being unable to return to sleep. Many people have a mixture, and the pattern can shift over months.

By day, the NHS lists feeling tired and irritable and finding it difficult to concentrate. CKS adds fatigue, depressed mood, general malaise and cognitive impairment. NHS inform points out that persistent insomnia can limit what you do in the day, affect mood and strain relationships with friends, family and colleagues.

• Lying awake for long spells before sleep arrives

• Waking several times in the night and finding it hard to settle

• Waking early and not being able to go back to sleep

• Feeling unrefreshed after waking

• Daytime tiredness, irritability and poor concentration

• Dreading bedtime because you expect another bad night

CKS says short-term insomnia often follows a stressful event or a change to normal routine, such as illness, financial difficulty, a new baby or a noisy environment, while chronic insomnia is thought to involve maladaptive behaviours and thinking. In practice this means that the original trigger may have gone long ago, yet the sleeplessness stays because of what the person does and believes about sleep.

Typical examples are going to bed very early to catch up, napping, lying in bed watching the clock, or building up dread about the night ahead. These responses feel sensible, but they weaken the link between bed and sleep. NHS inform makes a related point when it advises against watching the clock, because anxiety only makes insomnia worse.

Causes named by the NHS include stress, anxiety or depression, noise, a room that is too hot or cold, an uncomfortable bed, alcohol, caffeine or nicotine, illegal drugs, jet lag and shift work. Medical contributors include restless legs syndrome, an overactive thyroid, menopause, long-term pain, sleep apnoea, and several neurological and mental health conditions. Many medicines can also interfere with sleep, so it is worth reviewing your prescriptions with a GP or pharmacist rather than stopping anything yourself.

There is no blood test or scan for insomnia. CKS describes assessment as a thorough history that identifies contributing factors and any physical or mental health conditions, with other sleep disorders such as obstructive sleep apnoea, restless legs syndrome and parasomnias considered because they often coexist. A sleep diary kept for one to two weeks is described as helpful for spotting patterns and lifestyle factors that keep insomnia going.

The Sleep Charity suggests taking a completed two-week sleep diary to the GP and advises seeing the GP if sleep difficulty has lasted more than four weeks and is affecting wellbeing, before it becomes chronic. A diary typically records bedtime, estimated time to fall asleep, night waking, final wake time, caffeine and alcohol, and how you felt the next day.

A sleep study (polysomnography) is not routine for insomnia. CKS says referral to a sleep clinic or neurology may be needed if another sleep disorder is suspected, if there is doubt about the diagnosis, or if chronic insomnia has not responded to management in primary care.

CKS recommends cognitive behavioural therapy for insomnia (CBTi) as first-line treatment for chronic insomnia in adults of any age, and says the benefits persist after the course ends. It also names Sleepio, a digitally delivered CBTi programme recommended by NICE. NHS inform describes CBT-I as aiming to change unhelpful thoughts and behaviours that contribute to insomnia, and as effective for many people with long-lasting results. The NHS says a GP may offer CBT face to face with a therapist or through an online self-help programme.

The Sleep Charity breaks CBT-I into a cognitive part, which addresses worries and anxieties about sleep, and a behavioural part. It lists the behavioural techniques below and adds that sleep rescheduling can temporarily increase daytime sleepiness and is not recommended for people with certain medical conditions or certain jobs, so it should be supervised by a trained practitioner.

• Stimulus control: use the bedroom only for sleep and sex, and get up if you are not asleep before you become anxious or frustrated, returning only when sleepy

• Sleep rescheduling: limit time spent awake in bed, then bring bedtime forward as most of your time in bed is spent asleep

• Relaxation methods such as breathing exercises or progressive muscle relaxation

• Sleep hygiene guidance on environment and daily habits

The NHS says sleeping pills can have serious side effects and you can become dependent on them, and that they are prescribed only for a few days or weeks at most when insomnia is very bad and other treatments have not worked. CKS says hypnotic medication should be avoided if possible because of the potential for significant adverse effects, and that z-drugs should be avoided where possible in older people.

CKS lists prolonged-release melatonin and daridorexant in its prescribing information, and the Sleep Charity notes that a drug approved in the UK in 2023 can be used long term in chronic insomnia by blocking a brain transmitter that promotes wakefulness. Whether any of these is suitable depends on age, other conditions and other medicines, so it is a decision for the prescriber. Pharmacy sleep aids are not a fix either: the NHS says they may help for 1 to 2 weeks and should not be taken for longer.

The NHS suggests going to bed only when sleepy, getting up at the same time every day, winding down for at least an hour before bed, keeping the bedroom dark and quiet, and exercising regularly in the day. It advises avoiding smoking, alcohol, tea and coffee for at least 6 hours before bed, big late meals, exercise within 4 hours of bedtime, screens right before bed, daytime naps and sleeping in after a poor night.

NHS inform adds practical ideas: write worries down before bed so they are easier to set aside until morning, keep the bedroom a little cooler than the living area, and if you cannot sleep, get up, go to another room, do something relaxing and try again in around 20 minutes or when you feel tired.

The NHS suggests seeing a GP if changing your sleeping habits has not helped, if you have had trouble sleeping for months, or if insomnia is affecting your daily life so much that you find it hard to cope. NHS inform advises contacting your GP practice if poor sleep is affecting your daily life, you are not looking after yourself or you are finding it hard to manage responsibilities.

Do not drive when you feel sleepy. If low mood or anxiety is overwhelming, or you have thoughts of harming yourself, use NHS 111 and its mental health option, speak to your GP urgently, or call 999 in an emergency. Waiting lists for NHS talking therapies and sleep clinics vary by area, and some people also see a private psychologist or sleep specialist; the clinical approach described above should be the same either way.