Insomnia: what works before the herbs

Chronic insomnia is best treated with a behavioural programme, and this is not a soft recommendation — cognitive behavioural therapy for insomnia (CBT-I) is the recommended first-line treatment in every major guideline, has stronger and more durable effects than hypnotic medication, and is available as a structured self-help programme or with a therapist. The sleep-restriction and stimulus-control components are the active ingredients and they are counter-intuitive: you spend less time in bed, not more.

Melatonin is not a sleeping pill. It is a timing signal, and it works best for circadian problems — jet lag, shift work, and delayed sleep phase — rather than for insomnia itself. For jet lag, the evidence supports taking it at the destination's bedtime for a few days. For sleep onset insomnia, the effect is small, and the doses in most trials are low (0.5-3 mg), with higher doses not clearly better. It is well tolerated; the commonest error is taking a large dose at the wrong time, which shifts the rhythm the wrong way.

Valerian has multiple trials with inconsistent results; pooled analyses find small or equivocal effects on sleep latency. It is well tolerated and it is not a benzodiazepine. Some people find it helps.

Passionflower has small trials showing improved sleep quality and, in one trial, comparable effects to a benzodiazepine at short-term follow-up. Gentle.

What actually helps insomnia, in order of evidence. Fixed wake time (which sets the rhythm and is the single most powerful behavioural lever); getting out of bed if awake for more than about 20 minutes; not napping; restricting time in bed to actual sleep time plus a small margin; no caffeine after midday; alcohol is a sedative that fragments the second half of the night, so it makes sleep worse despite feeling helpful; a cool dark room; and morning light exposure.

What is dangerous. Sedative-hypnotic drugs and alcohol together. Herbal sedatives combined with prescribed sedatives. And a person with insomnia and loud snoring, pauses in breathing, or daytime sleepiness may have sleep apnoea, which is a medical condition with cardiovascular consequences and is not treated by any herb.