Can’t Sleep? Why Insomnia Treatment Rarely Starts with a Sleeping Pill

Can’t Sleep? Why Insomnia Treatment Rarely Starts with a Sleeping Pill

A concise, evidence-based look at what actually works for chronic insomnia — and why every major U.S. specialty society now recommends starting somewhere other than the medicine cabinet.

By Jacinta Wangui, DNP, FNP · Evolving eHealth

Roughly 30–40% of American adults report insomnia symptoms in any given year, and about 10% meet the strict clinical criteria for chronic insomnia disorder — trouble sleeping at least three nights a week for three months or longer [1,2]. When it gets bad enough, most people reach for a pill. That instinct is understandable. It also runs directly counter to what the current evidence — and every major U.S. specialty guideline — actually recommends.

Why “Just Take Something” Isn’t the First Answer

For chronic insomnia, both the American College of Physicians (ACP) and the American Academy of Sleep Medicine (AASM) recommend cognitive behavioral therapy for insomnia (CBT-I) as the initial treatment — before any medication is considered [3,4]. This isn’t a soft, holistic preference. It’s a specific, structured, short-term therapy that consistently outperforms sleeping pills in long-term outcomes.

A recent systematic review and network meta-analysis found that CBT-I produced a long-term remission rate of 41%, compared with 28% for pharmacotherapy alone, with a remission odds ratio of 1.82 favoring CBT-I at a median follow-up of 24 weeks [5]. The distinction that matters clinically: CBT-I and sleep medications have roughly similar short-term effects, but only CBT-I keeps working after treatment ends [5]. Sleep medications work only while you’re taking them — and, as we’ll see, often bring problems of their own.

What CBT-I Actually Is

CBT-I is not talk therapy about your feelings around sleep. It’s a structured, typically 4–8 session protocol built around specific techniques: stimulus control (retraining the association between bed and sleep), sleep restriction therapy (temporarily narrowing time in bed to consolidate sleep), cognitive restructuring around unhelpful thoughts about sleep, and sleep hygiene education [3,4]. It can be delivered in person, via telehealth, or through validated digital programs — all with meaningful evidence of efficacy.

The Case Against Starting with a Sleeping Pill

The two largest classes historically prescribed for insomnia — benzodiazepines (lorazepam, temazepam, clonazepam) and “Z-drugs” (zolpidem/Ambien, eszopiclone, zaleplon) — carry real risks that grow with age and duration of use. A meta-analysis of benzodiazepine-related falls in older adults found an odds ratio of 1.42 for falls, mediated through orthostatic hypotension, dizziness, sedation, and impaired coordination [6]. The 2019 American Geriatrics Society Beers Criteria — the standard reference for medications to avoid in older adults — recommends against both benzodiazepines and Z-drugs in this population [6]. Roughly 44% of benzodiazepine prescriptions written for older adults are potentially inappropriate [6]. Signals for cognitive decline and dementia risk with long-term use exist in the literature but remain inconsistent after adjustment for confounders — enough to warrant caution, not yet enough to call causal [6].

When medication does have a role — and sometimes it does, particularly for short-term situational insomnia or when CBT-I alone hasn’t been enough — the newer dual orexin receptor antagonists (DORAs) such as suvorexant, lemborexant, and daridorexant are increasingly preferred. Rather than sedating the whole brain like benzodiazepines and Z-drugs, DORAs selectively block the wakefulness-promoting orexin system, preserving more normal sleep architecture [7]. Randomized trial data show meaningful improvements over placebo in sleep onset and wake-after-sleep-onset, with a generally more favorable next-day and dependency profile than the older options [7]. They are not risk-free, and they still work best as an adjunct to — not a substitute for — the behavioral work.

When Insomnia Isn’t Really Insomnia

One of the most important reasons a real evaluation matters is that a substantial share of what patients describe as “insomnia” is actually something else — and treating it as insomnia will fail. The most common masquerader is obstructive sleep apnea, which classically presents with loud snoring, witnessed breathing pauses or gasping, morning headache, or unrefreshing sleep despite adequate time in bed [8]. A neck circumference over 17 inches in men or 15.5 inches in women raises suspicion further [8]. Depression, anxiety, thyroid disease, restless legs syndrome, chronic pain, alcohol use, and medications (including some blood pressure and asthma drugs) are all common contributors that a sleeping pill will not fix. Any of these warrants a full evaluation, and possibly a sleep study, rather than an empiric prescription.

Certain findings warrant urgent, not routine, medical attention: witnessed breathing pauses during sleep, drowsy driving, chest pain or shortness of breath at night, or any thoughts of self-harm [8].

The Bottom Line

For chronic insomnia, the strongest evidence — and every current major U.S. guideline — points to starting with CBT-I, not a prescription pad [3,4,5]. Sleeping medications have a role, especially short-term and when carefully matched to the patient and situation, but “which pill” is rarely the right first question. The right first question is: what kind of insomnia is this, what’s driving it, and have the behavioral tools that actually work long-term been offered yet? That’s the conversation a real evaluation begins with.

References

1. Sleep Statistics: Facts & Latest Data in America. CFAH, 2024. cfah.org/sleep-statistics
2. Short Sleep Duration and Sleep Difficulties Among Adults, United States, 2024. CDC NCHS Data Brief. cdc.gov/nchs/products/databriefs/db559.htm
3. Management of Chronic Insomnia Disorder in Adults: A Clinical Practice Guideline. American College of Physicians. acponline.org
4. Behavioral and Psychological Treatments for Chronic Insomnia Disorder in Adults — Clinical Practice Guideline. American Academy of Sleep Medicine, 2021. aasm.org/combination-treatment-chronic-insomnia-guideline
5. Furukawa TA, et al. Initial treatment choices for long-term remission of chronic insomnia disorder in adults: a systematic review and network meta-analysis. Psychiatry Clin Neurosci, 2024. pmc.ncbi.nlm.nih.gov/articles/PMC11804918
6. Therapeutic dilemmas with benzodiazepines and Z-drugs: insomnia and anxiety disorders versus increased fall risk — a clinical review; 2019 AGS Beers Criteria referenced. Eur Geriatr Med. pmc.ncbi.nlm.nih.gov/articles/PMC10447278
7. Comparative efficacy and safety of daridorexant, lemborexant, and suvorexant for insomnia: a systematic review and network meta-analysis. Transl Psychiatry, 2025. pmc.ncbi.nlm.nih.gov/articles/PMC12187915
8. How Is Sleep Apnea Diagnosed? American Sleep Apnea Association. sleepapnea.org/diagnosis

This article is for general education and isn’t a substitute for individualized care. Chronic insomnia, and conditions that look like it, deserve a proper evaluation — we’re glad to help.