Insomnia: a promising cure

I once saw a talk by Anders Sandberg in which he said the best cognitive enhancers are caffeine, modafinil and sleep. The former two have diminishing returns, but the latter does not. It’s pretty clear that sleep is a major determinant of productivity and mood. I have noticed that a number of EAs suffer from insomnia and are searching for a viable cure, so I thought I would outline one that has worked incredibly well for me, and is well-supported by evidence. This is in the hope of substantially improving the productivity and mood of EAs, which I think is a very high value thing. This is a post about the best nootropic going (for insomniacs): CBT for insomnia, including sleep restriction.

Personal experience

I suffered from moderate to severe insomnia throughout my twenties, and had particularly severe insomnia for a couple of years before I turned 30. I was prescribed sleeping pills which don’t work or have bad side-effects. I have learned that this is pretty typical treatment in the UK. During the nadir, I would struggle to get to sleep for two hours, then sleep for four hours, then wake up at 5am and be unable to get back to sleep, lying in bed until 9am. I tried various sleeping pills for this, including melatonin (way too much, it turns out), which helped a bit.

I then tried CBT-insomnia including sleep restriction using an online course (called Shut-i which now appears not to be available for some reason) and was cured after about 2 months and have been ever since. I now sleep upwards of 8 hours every night. This approach has been similarly successful for a friend suffering severe insomnia who tried various prescribed sleeping pills with little success.

Evidence for CBT for insomnia

Anecdotes aside, CBT for insomnia is well-supported by evidence. For example, see these two systematic reviews and this review by the American Academy of Sleep Medicine. NICE, the respected utilitarianish body that determines healthcare prioritisation in the UK says that:

  • There is good evidence that stimulus control therapy, relaxation therapy, and cognitive behavioural therapy (CBT) are effective in the treatment of long-term insomnia [Morgenthaler et al, 2006; Wilson et al, 2010].

  • There is moderate evidence that sleep restriction, paradoxical intention, and biofeedback are effective in the treatment of long-term insomnia [Morgenthaler et al, 2006].

Update: Luke Muehlhauser has questioned the strength of the evidence on CBT-I in a comment below. Note that he does still recommend CBT-I to people suffering insomnia, given the limited costs associated with CBT-I. I disagree with Luke’s reading of the evidence, as I discuss in the comment.

Prevailing treatment for insomnia

In spite of the evidence, insomnia is very poorly treated, in the UK at least, with doctors often recommending sleeping pills that don’t work and have bad side-effects. I know people who have tried these without success and were told that they had run out of options. Given that CBT for insomnia is recommended by NICE, this is a pretty crazy situation. Moreover, the treatment is non-pharmacological and doesn’t require a trained therapist.

What does CBT for insomnia involve?

I recommend Overcoming Insomnia by Colin Espie for a good and short outline.

  • Sleep restriction. Personally, I found this the most effective aspect. People with insomnia tend to spend way too long in bed in the belief that this will increase their chance of sleep. This is the opposite of what you should do.

    • Stay in bed for at most as long as the total amount of sleep you ideally need. If you need 8 hours of sleep, spend at most 8hrs 30mins in bed, and no more.

    • Don’t read or watch TV in bed, just sleep/​have sex.

    • Insomnia sufferers should aim to more strictly restrict their time in bed. If you are sleeping five hours a night, you should aim to gradually limit the time you spent in bed, down from 7 hours to 5 hours. This reduces the psychological association between bed and lack of sleep, and so reduces the stress response you experience when in bed. Once you have broken the association, you can scale your time in bed back up. A full plan is outlined in the Espie book.

  • Sleep hygiene: outlined at this NHS link, and this NSF link.

  • Noting down and rationally dealing with worries, a la CBT, also mentioned in the NHS link.

  • Dimming the lights: A form of sleep hygiene that deserves a special mention. Many EAs wander round in orange goggles after 9pm, uncowed by social mores. This is a good thing—I suggest dimming the lights throughout your house, including the bathroom, about 2 hours before you go to bed.

NB. I am eternally grateful to Daria Belostotskaya for suggesting this solution to me.