My GP and some friends recommended Sleepio, a CBT-based online programme for insomnia. It’s not cheap, but if you participate in their research you get it for free, and anecdotally it seems most people who request that option are accepted eventually (I had to wait a couple months, I think). I’m not sure how it compares to other CBT programmes; the only evidence they cite for their specific programme is a pretty small RCT (N=164, divided into 3 treatment groups) that they conducted themselves.
When it comes to drug therapy, I’m a little surprised there isn’t more attention given to mirtazapine (Remeron in the US), which is an anti-depressant that’s also sedating. The effect size for depression compares favourably to most alternatives (e.g. Cipriani et al., 2018), and there is good evidence it improves sleep in a large proportion of users (e.g. Wichniak et al., 2017). In the UK at least, it’s not supposed to be prescribed for insomnia alone, just comorbid insomnia and depression, and is considered a ‘second-line’ antidepressant after SSRIs, but I think it’s used off-label for insomnia alone in some countries.
Aside from weight gain and withdrawal effects, the main concern is that it’s mildly anti-cholinergic. Other drugs with a much stronger anti-cholinergic effect have recently been found to increase the risk of dementia in over-60s (e.g. Richardson et al., 2018), so there are theoretical grounds for suspecting it could cause non-clinical deficits in brain functioning of younger people. But chronic sleep deprivation and depression are also really bad for long- as well as short-term cognitive functioning, as are other drug therapies (e.g. diphenhydramine [Nytol/Benadryl] and other anti-histamines are much more strongly anti-cholinergic, and benzodiazepines/Z-drugs are bad for you in all kinds of ways). So if CBT etc doesn’t work, it might be worth considering.
My GP and some friends recommended Sleepio, a CBT-based online programme for insomnia. It’s not cheap, but if you participate in their research you get it for free, and anecdotally it seems most people who request that option are accepted eventually (I had to wait a couple months, I think). I’m not sure how it compares to other CBT programmes; the only evidence they cite for their specific programme is a pretty small RCT (N=164, divided into 3 treatment groups) that they conducted themselves.
When it comes to drug therapy, I’m a little surprised there isn’t more attention given to mirtazapine (Remeron in the US), which is an anti-depressant that’s also sedating. The effect size for depression compares favourably to most alternatives (e.g. Cipriani et al., 2018), and there is good evidence it improves sleep in a large proportion of users (e.g. Wichniak et al., 2017). In the UK at least, it’s not supposed to be prescribed for insomnia alone, just comorbid insomnia and depression, and is considered a ‘second-line’ antidepressant after SSRIs, but I think it’s used off-label for insomnia alone in some countries.
Aside from weight gain and withdrawal effects, the main concern is that it’s mildly anti-cholinergic. Other drugs with a much stronger anti-cholinergic effect have recently been found to increase the risk of dementia in over-60s (e.g. Richardson et al., 2018), so there are theoretical grounds for suspecting it could cause non-clinical deficits in brain functioning of younger people. But chronic sleep deprivation and depression are also really bad for long- as well as short-term cognitive functioning, as are other drug therapies (e.g. diphenhydramine [Nytol/Benadryl] and other anti-histamines are much more strongly anti-cholinergic, and benzodiazepines/Z-drugs are bad for you in all kinds of ways). So if CBT etc doesn’t work, it might be worth considering.