For chronic insomnia (three or more nights weekly lasting over three months), pursue cognitive behavioral therapy for insomnia (CBT-I) first, rather than initiating long-term sedative-hypnotic medications

Completing cognitive behavioral therapy for insomnia reduces sleep onset latency by an average of roughly 19 minutes and cuts nocturnal wakefulness by about 26 minutes. Although benefits slowly attenuate over time, meaningful improvements persist at 12 months. Digital self-guided courses deliver outcomes comparable to in-person clinical sessions. Sedative-hypnotic sleep medications offer modest benefits in older adults: for every 6 older adults taking sleeping pills, 1 experiences adverse effects, whereas only 1 in 13 experiences improved sleep.

Undertaking CBT-I through hospital sleep clinics, psychiatry, or clinical psychology departments involves registration and therapy session fees; online digital CBT-I courses are considerably less expensive. A complete course typically runs 6 to 8 weeks, requiring a daily sleep log. Stimulus control techniques can be implemented immediately at home: go to bed only when sleepy; get out of bed if awake after ~20 minutes; reserve the bed strictly for sleep and sex; maintain a consistent wake time seven days a week; avoid daytime naps. The most challenging component is sleep restriction therapy: initially restricting time in bed to match actual sleep duration induces transient daytime sleepiness during early weeks.

Diagnosis and treatment specifications for mental disorders issued by the National Health Commission of China (2020) define chronic insomnia according to international criteria: (1) difficulty initiating sleep, difficulty maintaining sleep, or early morning awakening; (2) daytime fatigue, cognitive impairment, or social/occupational dysfunction; and (3) symptoms occurring at least 3 nights per week for at least 3 months (symptoms under 3 months are classified as short-term insomnia). Guidelines designate CBT-I as the first-line intervention, comprising five core elements: sleep restriction, stimulus control, cognitive restructuring, relaxation training, and sleep hygiene education, generally structured across 6 to 8 weekly sessions. National guidelines indicate CBT-I produces short-term efficacy comparable to pharmacological treatment, with superior long-term durability, and recommend pharmacotherapy generally not exceed 4 consecutive weeks without formal monthly reassessments. The American College of Physicians (ACP, 2016) strongly recommends all adult patients receive CBT-I as initial treatment for chronic insomnia disorder, with adjunctive short-term medication considered only if CBT-I alone proves inadequate. A systematic review and meta-analysis pooling 20 randomized controlled trials (1,162 participants) found CBT-I reduced sleep onset latency by 19.03 minutes (95% CI 14.12–23.93), decreased wakefulness after sleep onset by 26.00 minutes (95% CI 15.48–36.52), and increased sleep efficiency by 9.91% (95% CI 8.09%–11.73%), with a non-significant change in total sleep time (+7.61 minutes, 95% CI -0.51 to 15.74) and zero reported adverse events. Another meta-analysis of 30 randomized controlled trials evaluated long-term durability: compared to untreated controls, symptom reduction exhibited effect sizes of Hedges' g = 0.64 at 3 months, 0.40 at 6 months, and 0.25 at 12 months, maintaining clinical significance up to one year. For internet-delivered digital CBT-I (dCBT-I), a meta-analysis of 11 randomized trials (1,460 participants) found effect sizes across sleep parameters ranging from g = 0.21 to 1.09, demonstrating parity with face-to-face therapy, particularly when paired with extended sessions and automated feedback. A large trial of 1,711 participants comparing dCBT-I against sleep hygiene education showed marked improvements in sleep-related quality of life and modest gains in daytime functional and psychological health. Regarding sedative-hypnotics, a BMJ meta-analysis pooling 24 randomized controlled trials in 2,417 older adults (aged >=60) taking sedatives for >=5 consecutive nights found medication increased total sleep time by 25.2 minutes and reduced nocturnal awakenings by 0.63. However, the number needed to harm (NNH) was 6 (95% CI 4.7–7.1), while the number needed to treat (NNT) for sleep improvement was 13: sedative users faced 4.78 times the odds of cognitive impairments (OR 4.78, 95% CI 1.47–15.47) and 3.82 times the odds of daytime psychomotor fatigue (OR 3.82, 95% CI 1.88–7.80).

Stimulus control rules derive from American Academy of Sleep Medicine (AASM) 2021 guidelines. Sleep restriction restricts in-bed duration to actual baseline sleep duration, progressively expanding as sleep efficiency exceeds 85–90%; AASM cautions that temporary daytime somnolence during initial weeks poses risks for drivers and heavy machinery operators, and sleep restriction should be used cautiously or under medical supervision in patients with bipolar disorder, uncontrolled epilepsy, or pre-existing severe daytime sleepiness. Providing generic sleep hygiene advice alone is ineffective and explicitly not recommended by guidelines as monotherapy. Occasional poor nights do not constitute insomnia disorder: stabilize wake times (Chapter 3, Rule 2), restrict afternoon caffeine (Chapter 3, Rule 4), and eliminate illuminated screens before bed (Chapter 3, Rule 8). Patients who snore heavily or experience breath-holding must first rule out obstructive sleep apnea, detailed in Chapter 3, Rule 27. Insomnia comorbid with persistent low mood is covered in Chapter 3, Rule 18. Benefit magnitude is rated Moderate: nocturnal sleep latency and wakefulness savings total ~45 minutes nightly, accumulating to hours weekly, though total sleep duration changes little. Melatonin is ineffective for chronic insomnia, detailed in Chapter 6, Rule 34. Primary beneficiary is yourself.

国家卫生健康委办公厅 (2020). 关于印发精神障碍诊疗规范（2020 年版）的通知（国卫办医函〔2020〕945 号），附件第十二章第二节「失眠障碍」. https://www.nhc.gov.cn/yzygj/c100068/202012/b4305ace9e14440792eb76d29602c88a.shtml；Qaseem A, Kansagara D, Forciea MA, Cooke M, Denberg TD; Clinical Guidelines Committee of the American College of Physicians (2016). Management of Chronic Insomnia Disorder in Adults: A Clinical Practice Guideline From the American College of Physicians. Annals of Internal Medicine, 165(2):125-133. https://doi.org/10.7326/M15-2175；Trauer JM, Qian MY, Doyle JS, Rajaratnam SM, Cunnington D (2015). Cognitive Behavioral Therapy for Chronic Insomnia: A Systematic Review and Meta-analysis. Annals of Internal Medicine, 163(3):191-204. https://doi.org/10.7326/M14-2841；van der Zweerde T, Bisdounis L, Kyle SD, Lancee J, van Straten A (2019). Cognitive behavioral therapy for insomnia: A meta-analysis of long-term effects in controlled studies. Sleep Medicine Reviews, 48:101208. https://doi.org/10.1016/j.smrv.2019.08.002；Zachariae R, Lyby MS, Ritterband LM, O'Toole MS (2016). Efficacy of internet-delivered cognitive-behavioral therapy for insomnia - A systematic review and meta-analysis of randomized controlled trials. Sleep Medicine Reviews, 30:1-10. https://doi.org/10.1016/j.smrv.2015.10.004；Espie CA, Emsley R, Kyle SD, 等 (2019). Effect of Digital Cognitive Behavioral Therapy for Insomnia on Health, Psychological Well-being, and Sleep-Related Quality of Life: A Randomized Clinical Trial. JAMA Psychiatry, 76(1):21-30. https://doi.org/10.1001/jamapsychiatry.2018.2745；Glass J, Lanctôt KL, Herrmann N, Sproule BA, Busto UE (2005). Sedative hypnotics in older people with insomnia: meta-analysis of risks and benefits. BMJ, 331(7526):1169. https://doi.org/10.1136/bmj.38623.768588.47；Edinger JD, Arnedt JT, Bertisch SM, 等 (2021). Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine clinical practice guideline. Journal of Clinical Sleep Medicine, 17(2):255-262. https://doi.org/10.5664/jcsm.8986