Insomnia Treatment: Evidence-Based Approaches Beyond Sleeping Pills

This article is general information published by the practice of Dr. Sholeh Toobaei, Specialist Psychiatrist, Dubai. It has not yet been individually reviewed by a clinician and is not a substitute for personal medical advice. Published: 1 September 2026.

Scope: This article is general information about insomnia and its treatment. It is not a diagnosis or treatment plan. If you are struggling with chronic insomnia, a professional assessment can help.

Chronic insomnia is not just "not being able to sleep"

Chronic insomnia is the most common sleep disorder, affecting approximately 10% of adults worldwide. It is defined as difficulty falling asleep, staying asleep, or waking up too early — at least three nights per week for at least three months — despite having adequate opportunity to sleep, accompanied by daytime impairment (fatigue, difficulty concentrating, mood disturbance, reduced energy).

Importantly, chronic insomnia is not simply a symptom of another condition. It is often comorbid with other conditions — depression, anxiety, chronic pain, sleep apnoea — but it is a distinct and independent condition that requires specific treatment. In fact, untreated insomnia is a risk factor for developing depression and anxiety, which means treating insomnia can be preventive, not just palliative.

The most important thing to understand about chronic insomnia is that it becomes self-perpetuating. The initial trigger — stress, travel, a life event — may have gone weeks or months ago, but the insomnia persists because the brain has learned to associate the bed, the bedroom, and bedtime with wakefulness and anxiety. This is called psychophysiological insomnia, and it is maintained by conditioned arousal — the bed has become a cue for alertness rather than sleep.

Why sleeping pills are not the answer

Sleeping medications — benzodiazepines, "Z-drugs" (zolpidem, zopiclone, zaleplon), and melatonin receptor agonists — can be helpful in the short term. But they are not a long-term solution for chronic insomnia, for several reasons:

Tolerance. The body develops tolerance to sleeping medications, meaning you need increasingly higher doses to achieve the same effect. This is true for benzodiazepines and Z-drugs. The medication that worked for two weeks may stop working after two months.

Rebound insomnia. When sleeping medications are stopped — even after short-term use — insomnia often returns, sometimes worse than before. This is called rebound insomnia, and it is one of the reasons people feel "stuck" on sleeping medications.

impaired memory. Benzodiazepines and Z-drugs impair memory consolidation — the process by which short-term memories are converted to long-term memories. This effect is dose-dependent and cumulative. Over months and years of use, the cognitive effects add up.

No impact on the underlying mechanisms. Sleeping medications induce sleep but do not address the conditioned arousal, the maladaptive thoughts about sleep, the poor sleep habits, or the hyperarousal that maintain chronic insomnia. They treat the symptom, not the cause.

The gold standard treatment for chronic insomnia is not a medication. It is Cognitive Behavioural Therapy for Insomnia (CBT-I).

What is CBT-I?

CBT-I is a structured, time-limited (typically 4–8 sessions) psychotherapy specifically designed for chronic insomnia. It is recommended as the first-line treatment for chronic insomnia by every major clinical guideline worldwide, including the American College of Physicians, the American Academy of Sleep Medicine, and the UK's NICE guidelines.

CBT-I works because it targets the specific mechanisms that maintain chronic insomnia:

Sleep restriction. This sounds counterintuitive — restricting time in bed when you are already struggling to sleep? — but it is one of the most effective components of CBT-I. The principle is simple: most people with chronic insomnia spend more time in bed than they actually sleep. They go to bed early, wake up in the middle of the night, lie there awake for hours, and get up at their usual time. This fragments sleep and makes it shallow.

Sleep restriction temporarily reduces time in bed to match actual sleep time — if you sleep 5 hours, your time in bed is set to 5 hours. This creates mild sleep deprivation, which increases sleep drive (the body's need for sleep). Within a few days, sleep becomes deeper and more consolidated. As sleep efficiency improves, time in bed is gradually increased. The result is typically more sleep, better-quality sleep, and less time lying awake in bed.

Stimulus control. This component addresses the conditioned arousal — the learned association between the bed and wakefulness. The instructions are specific: go to bed only when sleepy (not just "ready"). Use the bed only for sleep and sex (no reading, no television, no phone, no worrying in bed). If you are not asleep within 20 minutes (do not watch the clock), get out of bed. Go to another room. Do something quiet and unstimulating — read a book, listen to calm music, do some gentle stretching. Return to bed only when sleepy. Repeat as necessary.

This may feel extreme. But it works because it breaks the cycle: bed = wakeful anxiety. After a week or two of consistent stimulus control, the bed once again becomes a cue for sleep, not for frustration.

Cognitive therapy. People with chronic insomnia have thoughts about sleep that are anxiety-provoking and often unrealistic: "If I don't sleep eight hours tonight, tomorrow will be ruined," "I have been lying here for three hours — I am going to go crazy," "Tomorrow I have an important meeting and I cannot be tired." These thoughts increase anxiety, which increases arousal, which makes sleep even more difficult.

Cognitive therapy helps people identify and challenge these thoughts. Is it true that one bad night ruins the entire next day? (Most people function, imperfectly, after one bad night.) Is it true that lying awake means you are not sleeping at all? (Micro-arousals and fragmented sleep still provide some restorative benefit.) Is your assessment of how you will feel tomorrow accurate, or is it shaped by anxiety?

Sleep hygiene education. This is the most well-known but the least effective component of CBT-I on its own. It includes recommendations such as: avoid caffeine after midday, avoid alcohol close to bedtime (it fragments sleep even though it may help you fall asleep), maintain a regular sleep schedule (even on weekends), limit evening screen time (blue light suppresses melatonin), keep the bedroom cool and dark, and create a relaxing pre-sleep routine.

Sleep hygiene is important, but it is insufficient for chronic insomnia on its own. Think of it like this: sleep hygiene addresses the environmental factors that can contribute to sleep problems. CBT-I addresses the behavioural and psychological mechanisms that maintain chronic insomnia. Both are needed, but CBT-I is the active ingredient.

The neurobiology of CBT-I

CBT-I works because it changes the brain. Imaging studies show that after CBT-I, the hyperactivity in the brain's arousal systems that is seen in people with insomnia normalises. Specifically, the areas of the brain responsible for processing threat and generating anxiety become less active, and the prefrontal cortex — the rational, evaluating part of the brain — becomes more effective at regulating the emotional response to sleeplessness.

In other words, CBT-I does not just teach "techniques." It produces measurable neurobiological changes that reverse the hyperarousal state that maintains chronic insomnia.

When medication is appropriate

CBT-I is the first-line treatment for chronic insomnia. But medication has a role:

Short-term use. For acute insomnia — triggered by stress, travel, or a temporary life event — a short course of sleeping medication (1–2 weeks) can be helpful while the situation resolves.

Adjunctive use. Some people benefit from a low dose of medication while they are doing CBT-I, particularly if their insomnia is severe. The medication can provide enough relief to engage in therapy, and the goal is to taper off the medication as CBT-I takes effect.

Specific medications. Trazodone, a low-dose sedating antidepressant, is commonly prescribed off-label for insomnia. It is less habit-forming than benzodiazepines or Z-drugs but also less effective. Orexin receptor antagonists (suvorexant, lemborexant) are a newer class of sleeping medication that block the wakefulness-promoting neurotransmitter orexin rather than broadly suppressing the nervous system. They have a different side effect profile than traditional sleeping medications and may be useful for some people.

Melatonin. Melatonin supplements can be helpful for circadian rhythm disturbances (jet lag, shift work, delayed sleep phase) but have limited evidence for chronic insomnia. The evidence for melatonin receptor agonists (ramelteon) is somewhat stronger.

Important: benzodiazepines and Z-drugs should not be used long-term for insomnia. They are not safe for chronic daily use, and they do not address the underlying mechanisms of chronic insomnia.

The Dubai context

Insomnia treatment in Dubai has specific considerations:

Heat. The extreme heat in Dubai for much of the year can significantly disrupt sleep. A well-functioning air conditioner is not a luxury — it is a sleep intervention. But even with air conditioning, the short days and long days of summer and winter affect circadian rhythms. Maintaining a consistent sleep schedule despite seasonal changes is important.

Shift work. Dubai has a large expatriate workforce, and many people work shifts — healthcare workers, security personnel, hospitality staff, factory workers. Shift work disorder is a common cause of chronic insomnia. The treatment for shift work disorder is specific and different from the treatment for primary insomnia.

Religious practices. During Ramadan, the change in sleep schedule — eating and praying at night, being awake through much of the night — can cause significant sleep disruption. This is normal during the month. But for people with chronic insomnia, the Ramadan schedule can establish patterns that persist after Ramadan ends. Planning ahead with your clinician can help minimise the disruption.

Screen time. The indoor lifestyle forced by heat, combined with Dubai's entertainment options (television, gaming, social media), can contribute to poor sleep hygiene. Evening screen exposure suppresses melatonin and delays sleep onset. Limiting screen time — particularly on your phone — in the hour before bed is one of the simplest and most effective sleep interventions.

What you can do

Start tonight. Go to bed only when sleepy. If you are not asleep within 20 minutes, get out of bed. Use the bed only for sleep. Keep a consistent wake time — this is more important than a consistent bedtime. The wake time sets your circadian rhythm, and your circadian rhythm drives sleep pressure, which drives sleepiness.

Limit time in bed. If you are spending 9 hours in bed but only sleeping 6, you are fragmenting your sleep. Try restricting your time in bed to the actual amount you sleep — 6 hours — and see what happens. You will be more tired at first. But within a week or two, your sleep will become more consolidated, and you can gradually increase time in bed.

Do not clock-watch. Putting the clock face-down. Covering the clock. Turning your phone face-down. Clock-watching increases anxiety, which increases arousal, which makes sleep harder. The exact time is not useful information when you are lying in bed unable to sleep.

Challenge catastrophic thoughts. "If I don't sleep tonight, tomorrow will be a disaster." Most people who have chronic insomnia have had this night. Most people survive it. Functioning imperfectly after one bad night is normal. Your brain is more resilient than your anxiety tells you it is.

When should I seek help?

If your sleep difficulties have lasted more than three months, are happening at least three nights per week, and are affecting your daytime functioning — seek a professional assessment. Chronic insomnia is treatable, and CBT-I is more effective than sleeping medications in the long term, with benefits that persist after treatment ends.

Seek urgent help — call 999 (police) or 998 (ambulance) in the UAE, or go to the nearest emergency department — if your insomnia is accompanied by thoughts of self-harm, if you are experiencing severe daytime impairment (falling asleep while driving, severe confusion), if you are in severe emotional distress, or if you are in any way a danger to yourself. For non-urgent enquiries, use the appointment request form on this website. This practice does not operate a monitored telephone line, and a message sent through the form may not be read straight away.