Insomnia

What it is

Insomnia is persistent difficulty falling asleep, staying asleep, or waking too early and being unable to get back to sleep, despite having enough time and a suitable place to sleep, which then leaves the person tired, low, irritable or unable to function well in the day. The daytime cost is part of the definition: someone who sleeps few hours but feels and functions fine does not have insomnia, while someone who lies awake night after night and pays for it all day does.

It becomes a disorder, rather than a passing rough patch, when it happens at least three nights a week and has continued for three months or more. Shorter bouts triggered by a stressful event, an illness or a noisy environment are common and usually settle on their own; insomnia disorder is when poor sleep has taken on a life of its own and no longer needs the original trigger to keep going.

What it can feel like

The clock becomes an enemy. Lying awake doing mental arithmetic on how few hours remain. Falling asleep exhausted and then snapping awake at 3 a.m. with the mind already racing. Dreading bedtime because the bed has become a place of struggle rather than rest. Then the daytime toll: foggy thinking, short temper, low mood, heavy reliance on tea, coffee or khat to push through, and a quiet fear that something is wrong.

A cruel feature of insomnia is that trying harder makes it worse. Sleep cannot be forced; effort and anxiety about sleeping are themselves arousing, so the harder a person chases sleep, the more it retreats. Much of the condition is built from this loop: a few bad nights lead to worry about sleep, worry about sleep leads to more bad nights, and the bed itself becomes associated with frustration rather than drowsiness. Understanding this loop is the beginning of breaking it.

How common is it

Insomnia is among the most common health complaints in the world. Roughly a third of adults report insomnia symptoms at some point in a given year, and around 6 to 10 percent have insomnia disorder in its full, persistent form. It becomes more common with age, affects women more often than men, and frequently travels alongside depression, anxiety and chronic pain, each one feeding the others.

Most people who have it never seek help for it, often assuming nothing can be done or that sleeping tablets are the only option. Both assumptions are wrong, which is much of the reason this entry exists.

What causes it

Insomnia usually has more than one root. A helpful way clinicians think about it is in three parts: the traits that make a person prone to it (a tendency to worry, a naturally light sleeper, a family history), the trigger that starts a bad patch (stress, grief, illness, a new baby, shift work, a financial crisis), and the habits that then keep it going long after the trigger has passed (lying in bed awake for hours, daytime napping, irregular sleep times, checking the clock, using the phone in bed, drinking more caffeine to cope).

That last part is the most important and the most hopeful: even when the original cause is long gone, insomnia is held in place by patterns that can be changed. Medical and psychiatric conditions can also drive insomnia, including depression, anxiety, chronic pain, breathing problems and some medications, which is why a good assessment looks for them.

How it is diagnosed

There is no test for insomnia; it is diagnosed through a careful conversation about sleep and its daytime effects. A clinician will usually ask the person to keep a simple sleep diary for a week or two, noting roughly when they went to bed, how long sleep took, night-time waking and how they felt the next day. This diary is more useful than it sounds, because people's sense of their own sleep is often inaccurate, and the diary reveals the real patterns and the habits maintaining them.

The assessment also screens for other sleep disorders that can masquerade as insomnia, particularly sleep apnoea (where breathing repeatedly pauses in sleep) and restless legs, as well as for depression, anxiety, pain and the effects of caffeine, alcohol, khat and medicines. Sleep laboratory studies are not needed for ordinary insomnia and are reserved for cases where another sleep disorder is suspected.

How it is treated

The most important fact about insomnia treatment is also the least known: the recommended first-line treatment is not a pill. It is a structured talking therapy called cognitive behavioural therapy for insomnia, or CBT-I, and across many trials it works as well as sleeping tablets in the short term and clearly better over the long term, because its benefits last after the treatment ends while tablets stop working when they stop being taken.

CBT-I retrains the broken sleep system through a few practical methods used together. Stimulus control rebuilds the link between bed and sleep, by using the bed only for sleep and getting up if sleep does not come, so the bed stops being a place of wakeful struggle. Sleep restriction, done with a clinician, temporarily limits time in bed to build up the body's sleep drive and consolidate broken sleep, then expands it again as sleep strengthens. Cognitive work addresses the anxious, catastrophic thoughts about sleep that keep the system aroused. Good sleep habits (a regular rising time, a wind-down routine, limiting caffeine, alcohol and screens near bedtime, a dark and quiet room) support the core methods, though on their own these habits rarely cure established insomnia and are often oversold as the whole answer.

Sleeping tablets have a real but limited role. They can help in a short, acute crisis, used briefly and under medical guidance. The trouble comes with regular long-term use: the body adapts, the effect fades, stopping can bring rebound insomnia worse than the original, and several of these medicines (especially the benzodiazepine family, widely available in our pharmacies) cause dependence and are risky in older people, raising the chance of falls and confusion. They treat the symptom for a night; they do not fix the system. Where CBT-I is hard to access in person, effective self-help and digital versions exist and are a reasonable starting point.

Insomnia in the African context

Sleep is squeezed hard in many Kenyan lives by long commutes, shift work, crowded or noisy housing, and the stress of making ends meet, all of which can start a bad patch. Khat, widely chewed in parts of the country, is a powerful stimulant that keeps people awake, and heavy tea and coffee add to the load. Sleeping tablets, especially the benzodiazepine family, are often bought across the counter and used long-term without review, which carries a real risk of dependence.

The most useful and least known message is that the first-line treatment is not a tablet but CBT-I, a skill-based approach a person can learn.

Managing it day to day

These habits support better sleep and back up CBT-I. They rarely cure long-standing insomnia on their own, but they help.

• Keep a fixed rising time every day, including weekends, since a steady wake time anchors sleep.
• Use the bed only for sleep, and if you are awake and frustrated, get up, do something calm in dim light, and return when sleepy.
• Avoid caffeine, khat, and large meals late in the day, and be careful with alcohol, which breaks up sleep.
• Wind down before bed without screens, and keep the room dark, quiet, and cool where you can.
• Try not to nap long in the day, and try not to chase sleep by trying harder, since effort keeps you awake.

Helping someone

If someone close to you struggles with sleep, you can help.

• Take it seriously, since the daytime toll on mood and concentration is real.
• Support steady routines rather than encouraging long lie-ins or daytime naps.
• Gently encourage asking about CBT-I rather than relying on tablets bought without review.
• Be patient, since pushing someone to sleep, like pushing oneself, does not work.