Insomnia & Sleep

The approach covers CBT-I techniques and structured sleep restriction, treatment of any underlying cause, and short-term medication only in specific circumstances.

Book if

• You have trouble falling or staying asleep most nights
• Daytime functioning is suffering
• You have been using over-the-counter sleep aids and want a better approach
• You want to come off sleeping tablets safely

Needs a sleep study, not sleep advice

Loud snoring with witnessed pauses in breathing, waking gasping, or heavy daytime sleepiness suggests obstructive sleep apnoea. That is a cardiovascular risk factor as well as a sleep problem, and it needs proper investigation.

Where we will not help

We do not prescribe sleeping tablets remotely as routine treatment for insomnia. They cause dependence and tolerance, increase falls, impair driving, and stop working within weeks. Declining to prescribe them is not us being unhelpful — it is the correct treatment decision.

1. Look for the cause

Sleep apnoea, restless legs, an overactive thyroid, iron deficiency, anxiety, alcohol and several common medications all disrupt sleep. Treating the cause beats treating the symptom.

2. Sleep restriction — counterintuitive but effective

Spending less time in bed, not more, is the core of CBT-I. It feels wrong and it works better than anything else available.

3. Stimulus control

Bed for sleep only. Out of bed if awake more than twenty minutes. Same wake time every day, regardless of how the night went.

4. Review

CBT-I typically takes four to six weeks to show benefit, and the improvement lasts after you stop — which medication does not.

CBT-I takes four to six weeks, and it gets worse first

Sleep restriction — spending less time in bed rather than more — is the core of it, and the first fortnight is genuinely harder. Daytime sleepiness increases before sleep consolidates.

That is the treatment working, not failing, and it is where most people abandon it. It is also why doing it with support beats doing it alone.

• Weeks 1–2 — harder. Expected
• Weeks 3–4 — sleep begins to consolidate
• Weeks 4–6 — the point at which to judge it

Keep a sleep diary

Time to bed, estimated time asleep, wake time, night wakings, naps, caffeine and alcohol. Estimate rather than clock-watch — checking the time at night makes insomnia worse, and a two-week diary shows the pattern far better than memory does.

The rules that do the work

• The same wake time every day, regardless of how the night went. This is the single most important one, and lying in after a bad night is what perpetuates the cycle
• Out of bed if awake more than about twenty minutes. Somewhere else, dim light, back when sleepy
• Bed for sleep and sex only — no working, scrolling or television
• No naps during the restriction phase

What is reviewed

• Sleep efficiency from the diary, and whether time in bed can be extended
• Whether an underlying cause has been missed — apnoea, restless legs, thyroid, iron, anxiety, alcohol, or a medicine
• Whether daytime function is improving, which matters more than hours slept

Needs investigating rather than sleep advice

• Loud snoring with witnessed pauses in breathing, waking gasping, or heavy daytime sleepiness — obstructive sleep apnoea, which is a cardiovascular risk factor as well as a sleep problem and needs a sleep study. It is badly under-diagnosed, particularly in women
• An urge to move the legs at rest, relieved by moving — restless legs, often driven by low ferritin and treatable
• Falling asleep while driving — stop driving and be assessed. There are legal as well as safety implications

Coming off sleeping tablets

Never stop abruptly, particularly benzodiazepines or z-drugs — abrupt withdrawal can cause seizures. Reduction is gradual, planned, and combined with CBT-I, which is what makes it stick.

Rebound insomnia for one to two weeks is expected and is not proof you needed the tablets.

CBT-I is the treatment, and much of it is free

Cognitive behavioural therapy for insomnia outperforms medication and keeps working after it stops, which medication does not. It is the recommended first-line treatment.

• NHS talking therapies — free, self-referral, no GP needed, and many services offer CBT-I
• Digital CBT-I programmes, some available free through the NHS in parts of the country
• Books and structured self-help, which work for many people

Treat what is underneath

• Sleep apnoea — the big one, and badly under-diagnosed. Treating it transforms sleep and reduces cardiovascular risk
• Restless legs — frequently driven by low ferritin, and iron replacement often resolves it
• Anxiety and depression, where early waking is a classic pattern
• Thyroid disease, perimenopause — night sweats and 3am waking — and chronic pain
• Alcohol, which sends you to sleep and then fragments the second half of the night. Very commonly the whole explanation
• Medication — steroids, some antidepressants, beta blockers, decongestants and stimulants

Where medication has a limited place

• Melatonin — licensed in the UK for adults over 55 and for jet lag and shift work. Modest effect, and the most reasonable option
• Sedating antidepressants at low dose, where depression or pain coexists
• Short courses of a hypnotic for a specific acute crisis — bereavement, for instance — which is not remote-prescribing territory

What does not work

• Over-the-counter sedating antihistamines — tolerance builds within days, and they leave grogginess. Best avoided over 65, where they raise falls and confusion risk
• Alcohol as a sleep aid, which is actively counterproductive
• Sleep trackers, which cause real anxiety about sleep in people whose sleep was fine — there is a recognised term for it
• Spending longer in bed, which is the intuitive response and makes insomnia worse

What you pay us

• £40 for the consultation, covering CBT-I properly and looking for an underlying cause
• Blood tests where indicated — thyroid, ferritin — quoted first
• £40 for review at four to six weeks

The best treatment here is free

CBT-I is the most effective treatment for long-term insomnia, and it is available free. NHS talking therapies take self-referrals — no GP needed — and many services offer it, alongside free digital programmes in parts of the country.

We will point you there. If you take one thing from this page, make it that.

So what is the appointment for?

• Finding the cause. Sleep apnoea, restless legs from low ferritin, thyroid disease, perimenopause and medication effects are all treatable, and all commonly missed
• Being taught CBT-I properly, including the parts that feel wrong — sleep restriction in particular
• Referral for a sleep study where apnoea is suspected
• A plan to come off sleeping tablets safely, which is genuinely difficult alone

What we will not sell you

Sleeping tablets. We do not prescribe hypnotics remotely as routine treatment for insomnia — they cause dependence and tolerance, increase falls, impair driving, and stop working within weeks.

That is a clinical decision rather than an inconvenience, and if that is what you are looking for, please do not pay for an appointment: the answer will be no.

Also nothing else — no supplements, no sleep products, no devices.

Where not to spend money

• Over-the-counter sleep aids, which lose effect within days
• Expensive sleep trackers, which frequently make sleep anxiety worse
• Supplements and "sleep formulas", whose evidence does not approach that for CBT-I

Will you prescribe sleeping tablets?

Not as routine treatment for insomnia, and it is worth knowing before booking.

They cause dependence and tolerance, stop working within weeks, increase falls and fractures, and impair driving the following day. Declining is the correct clinical decision, not unhelpfulness — and it is the same answer at 9pm as at midday.

What actually works then?

CBT-I — cognitive behavioural therapy for insomnia. It outperforms medication in trials and keeps working after it stops, which medication does not.

It is available free through NHS talking therapies with no GP referral needed.

Why would spending less time in bed help?

Because lying awake trains your brain to associate bed with being awake. Sleep restriction compresses time in bed to roughly the time you actually sleep, which consolidates it — then extends gradually.

It is counterintuitive, it is harder for the first fortnight, and it is the most effective component there is.

Should I have a lie-in after a bad night?

No — and this is the rule that does most of the work. A fixed wake time every day, regardless of how the night went, is what re-anchors the rhythm.

Lying in shifts the following night later and perpetuates the cycle.

Could something else be causing this?

Very possibly, and it is what the appointment is for. Sleep apnoea, restless legs from low ferritin, thyroid disease, anxiety, depression, perimenopause, chronic pain, alcohol and several common medicines all cause insomnia and all are treatable.

How do I know if it is sleep apnoea?

Loud snoring with witnessed pauses in breathing, waking gasping or choking, waking unrefreshed, and heavy daytime sleepiness. A partner often notices before you do.

It needs a sleep study rather than sleep advice, it is a cardiovascular risk factor in its own right, and it is badly under-diagnosed in women, in whom it presents more as fatigue and insomnia than as classic snoring.

Does alcohol help me sleep?

It gets you to sleep and then ruins the second half of the night, fragmenting sleep and suppressing REM.

For a fair number of people this is the entire explanation, and stopping the nightcap for two weeks is the cheapest diagnostic test available.

What about melatonin?

Licensed in the UK for adults over 55 and for jet lag and shift work, and reasonable within that. The effect is modest.

Buying it unregulated from overseas is a poor idea — dose and content vary considerably from what the label claims.

Are over-the-counter sleep aids worth it?

Not really. The sedating antihistamines in them build tolerance within days and leave next-day grogginess.

Best avoided over 65, where they increase falls and confusion.

I want to come off sleeping tablets. Can you help?

Yes, and it is one of the more valuable things we do.

Never stop abruptly — with benzodiazepines or z-drugs, abrupt withdrawal can cause seizures. Reduction is gradual and planned, combined with CBT-I, which is what makes it hold. Expect one to two weeks of rebound insomnia, which is not evidence you needed them.

Is my sleep tracker telling me something useful?

Usually not, and it may be making things worse. Consumer trackers estimate sleep stages unreliably, and there is a recognised phenomenon of people developing genuine sleep anxiety from tracker data.

How you function in the day is a better measure than any score.