What chronic insomnia really is
Chronic insomnia is difficulty initiating or maintaining sleep, occurring three or more nights per week for three months or longer, despite adequate opportunity to sleep — and accompanied by daytime impairment. It is one of the most common reasons patients come to us. It is also one of the most treatable.
Our first-line approach: CBT-I
Cognitive Behavioral Therapy for Insomnia is a structured, time-limited program with measurable outcomes. Across six to eight sessions, patients typically achieve sustained sleep improvement — without medication side effects or rebound on discontinuation.
- Sleep restriction therapy — temporarily limiting time in bed to consolidate sleep
- Stimulus control — reassociating the bed with sleep, not wakefulness
- Cognitive restructuring — addressing thoughts that perpetuate the cycle
- Relaxation training — somatic and cognitive techniques
- Sleep hygiene education — necessary but not sufficient on its own
When pharmacology has a role
- Acute insomnia from a known trigger (bereavement, surgery, jet lag)
- Severe insomnia with safety implications, used short-term while CBT-I begins
- Insomnia refractory to CBT-I in patients who have completed a full program
- Comorbid conditions that make medication appropriate
When we prescribe, we do so at the minimum effective dose, for the shortest duration, with a clear taper plan.
Comorbidity workup
Many "insomnia" patients have an unrecognized contributing condition — sleep apnea, restless legs, depression, anxiety, hyperthyroidism, or shift-work disorder. We rule these out before declaring primary insomnia.
Pharmacology is the last lever, not the first. CBT-I is the standard.— Seoul Sleep Center principle