Insomnia: signs, causes and what helps

What is insomnia, and how do I know if I have it?

Insomnia is trouble falling asleep, staying asleep or waking too early, even when you have the time to sleep, and it makes your day worse³. In Hindi it is called anidra.

The key part is "even when you have the time to sleep"³.

A call-centre worker who gets 5 hours because a shift ends at 3 am is short of sleep. That is a schedule problem. Insomnia is lying in a quiet bed at 11 pm, with 8 hours ahead, and still not sleeping.

To know if you have it, use the 3-3 rule. If poor sleep comes on at least 3 nights a week, and has gone on for at least 3 months, it is long-term insomnia³. Under 3 months, it is short-term insomnia⁶.

Most people have a bad week now and then. A wedding in the family, a move, a deadline or a hot spell in May can do it. This short-term insomnia often settles once the cause passes⁶.

The worry is when it does not settle. After a few weeks, the bed itself can start to feel like a place of struggle. Then sleep stays poor even after the wedding is over or the rains have come.

Once it lasts this long, it is a recognised condition, and it can be treated³⁷.

All 5 true? It is likely long-term insomnia³. Under 3 months, it is short-term⁶.

What are the symptoms of insomnia?

The symptoms of insomnia come at night and in the day. At night: slow to fall asleep, waking often or waking very early. In the day: tiredness, poor focus and a short temper³⁶.

You may lie awake for a long time, or fall asleep easily but wake at 2 or 3 am with your mind racing. Some people wake at 4:30 am, long before the alarm, and cannot drift off again.

Daytime signs matter as much as night ones. You may feel tired but unable to nap, forget small things, or snap at your family.

Insomnia does not always mean very few hours. Some people sleep 6 hours but in broken pieces, and wake feeling they have not slept at all.

What causes insomnia?

Insomnia is usually caused by several things at once. Stress, worry and low mood are the most common. Noise, heat, alcohol, caffeine, shift work and pain add to them⁶.

Stress, anxiety and depression are among the most common causes⁶. A fight at home, a sick parent or money worries can start a run of bad nights. Chapter 6 looks at this link in detail.

The room and the habits around it play a part too: noise, a room that is too hot, alcohol, caffeine and nicotine⁶. In a shared home in Mumbai or Chennai, a neighbour's late TV and a humid night can each cost an hour.

Shift work is a big cause. Among 190 nurses in South India on rotating and night shifts, 40.5% had insomnia².

Pain and other conditions can keep you awake, such as back pain, sleep apnoea or restless legs⁶. Sleep apnoea is when breathing stops and starts again and again in sleep, often with loud snoring and gasping. Chapter 1 explains the signs.

Restless legs is an urge to move the legs that gets worse at rest in the evening and delays sleep.

Then there is what keeps insomnia going after the first cause has gone. You start going to bed early "to catch up", lie awake longer, and worry about the next day.

Night after night, the bed becomes linked with being awake. CBT-I is designed to break this pattern⁷.

How common is insomnia in India?

Insomnia is very common in India, and rarely treated. 37% of Indians aged 60 and over have insomnia. Only 3% seek treatment¹.

That figure comes from the Longitudinal Ageing Study in India (LASI), a national survey of 31,464 older adults¹. For many families, a grandparent who "doesn't sleep much any more" is just part of life. It does not have to be.

A review of 100 Indian studies found insomnia in 11.1% of healthy adults and 34.7% of college students¹⁰. The review is a preprint, which means it has not yet been checked by other experts. Treat these numbers as a guide.

In studies of adults in other countries, about 30% to 36% have some insomnia symptoms³. About 10% to 11% have the full condition³⁷.

Can insomnia be treated without sleeping pills?

Yes, insomnia can be treated without sleeping pills. CBT-I is the first treatment in every major guideline, ahead of medicine⁴⁵⁷.

In 2016, the ACP, a US medical college, named CBT-I the first treatment for adults with long-term insomnia⁴. The American Academy of Sleep Medicine (AASM) gave it a strong recommendation in 2021⁷.

The 2023 European guideline rates CBT-I "very strong" for adults of any age, and digital CBT-I the same⁵.

The gains from CBT-I last. In follow-ups of up to 10 years, they largely held⁵. The European guideline calls this a major advantage over pills, because poor sleep often comes back when pills are stopped⁵.

What is CBT-I, and how does it work?

CBT-I, cognitive behavioural therapy for insomnia, is a short, structured course that changes the habits and thoughts that keep you awake⁷.

A course usually runs 6 to 10 sessions over 6 to 20 weeks⁸. A brief version, called BBTI (brief behavioural treatment for insomnia), runs 4 weekly sessions⁸.

You keep a sleep diary: a daily note of when you went to bed, roughly when you fell asleep, when you woke and how the day felt. Each week, you and the therapist adjust your plan from it.

CBT-I has several parts. Stimulus control and sleep restriction change what you do in bed. The thinking part works on worries like "If I don't sleep, tomorrow is ruined". Relaxation helps the body slow down⁷.

Sleep tips alone are not CBT-I. The AASM says good sleep habits on their own are not enough to treat insomnia⁷. They help, and Chapter 2 covers them, but CBT-I goes further.

How do stimulus control and sleep restriction work?

Stimulus control teaches your brain that bed means sleep again. Sleep restriction cuts time in bed so that sleep becomes deeper and steadier, then slowly adds time back⁸.

Stimulus control has a few simple rules⁸. Go to bed only when you feel sleepy, not just tired. Use the bed only for sleep and intimacy, not for phone, TV or work. Get up at the same time every day, weekends included.

The hardest rule: if you are awake for about 20 minutes, get up⁸. Do something calm in dim light and come back when you feel sleepy. Staying in bed and trying harder teaches the brain that bed is a place to be awake.

In a shared room or joint family, this could mean sitting in the hall, or on the balcony with a dim lamp, until the eyelids feel heavy.

Sleep restriction starts with your sleep diary. Say you are in bed 8 hours but sleep 5 and a half. Your time in bed is set to your sleep time plus about 30 minutes: 6 hours⁸.

As sleep starts to come within 30 minutes and stays steady, you add 15 minutes a week⁸. It feels hard at first, because you may be sleepier in the day. That is why it is best done with a trained therapist.

In these weeks, don't drive when you feel sleepy. Chapter 3 explains why.

Can I get CBT-I in India or online?

Yes, you can get CBT-I in India, in person or online. Ask at a sleep clinic, or at the psychology or psychiatry department of a large hospital.

Many large hospitals in cities like Bengaluru, Delhi, Hyderabad and Chennai have sleep clinics. When you call, ask directly whether they offer CBT-I, not just a sleep study or medicine.

Digital CBT-I is the same course delivered through an app or website.

If you live far from a big city, or cannot take time off for weekly visits, it is a real option. The European guideline gives it the same "very strong" rating as in-person therapy⁵.

Tele-MANAS on 14416 is free and confidential, at any hour¹². Its counsellors can talk through sleep worries and guide you to the next step.

Are sleeping pills, melatonin or sleep aids safe?

Sleeping pills, melatonin and sleep aids are not a long-term answer to insomnia. Prescribed sleeping pills can help for a few weeks, with supervision, but not for months⁴⁵.

The ACP says sleeping pills are meant for short use, ideally no longer than 4 to 5 weeks⁴. The European guideline limits benzodiazepines and similar drugs, a main group of sleeping pills, to 4 weeks or less⁵.

The NHS says sleeping pills are rarely prescribed because of side effects and the risk of dependence. When they are, it is for days or weeks, not months⁶.

If you have been taking a sleeping pill most nights for months, do not stop suddenly on your own. Ask the clinic or pharmacist who supplies it how to reduce it safely.

Pills also do not fix what keeps insomnia going. That is why every major guideline puts CBT-I first⁴⁵⁷.

Some cough and allergy medicines contain an antihistamine. An antihistamine is a medicine for allergies, and some kinds cause drowsiness, so people use them to sleep. Melatonin is the hormone the body makes in the dark to signal night, also sold as a tablet.

The AASM advises against antihistamines, melatonin, valerian and tryptophan for long-term insomnia⁹. "Herbal" or "natural" does not mean it works or that it is safe to take every night.

The NHS says pharmacy sleep aids may help for 1 to 2 weeks at most and can leave you drowsy the next day⁶.

In India, melatonin is sold in 2 ways: as a prescription medicine and as a supplement¹¹. Ask a pharmacist before you take it, because some products need a prescription¹¹.

When should I get help for insomnia?

Get help for insomnia when poor sleep has lasted 3 months, or sooner if it harms your day, your driving or your mood. A sleep clinic can offer CBT-I³⁷.