Sleep Problems and Insomnia: A Complete Guide for Indian Patients and Families
First — how much sleep do you actually need?
Somewhere between seven and nine hours for most adults. But the number is not the point, and the fixation on eight hours has caused a remarkable amount of unnecessary suffering.
Some people are genuinely fine on six and a half. Sleep also changes with age: older adults sleep more lightly, wake more often, and go to bed and rise earlier. That is ageing, not illness, and treating it as illness is how a seventy-year-old ends up on a nightly sedative for the next decade.
The real test is not hours. It is the day. Are you functioning? Alert enough? Not falling asleep in the afternoon against your will? Then your sleep is probably adequate, whatever the number on the tracker says.
Which brings up sleep tracking apps and watches. In my experience they help a small number of people and make a considerable number of people worse, by turning sleep into a nightly performance with a score in the morning. If you are anxious about your sleep, the tracker is very likely part of the problem.
What insomnia actually is ?
Insomnia means one or more of: difficulty falling asleep, difficulty staying asleep, waking too early and not getting back, or sleep that leaves you unrefreshed.
But that is only half the definition. The other half is the daytime. If you sleep five hours and feel completely fine, you are a short sleeper, not an insomniac. Insomnia requires a cost — tiredness, poor concentration, irritability, low mood, mistakes at work, a fuse that keeps getting shorter.
When it happens on most nights of the week and has gone on for three months or more, it is chronic insomnia, and it is a condition in its own right that deserves proper treatment.
Why insomnia outlives whatever started it
This is the most useful thing on this page, and the thing most people have never had explained to them.
Think of it in three parts.
What made you vulnerable. A naturally light sleeper. An anxious temperament. A family history. This was always true of you.
What set it off. A bereavement. A frightening medical report. A business crisis. A newborn. A stretch of night shifts. Something real, and usually obvious.
What keeps it going — and this is the part that matters. The trigger passes. The business recovers, the grief settles, the baby sleeps. And the insomnia continues, because in the meantime you have built a set of entirely sensible-seeming habits around it:
You start going to bed early to “get more chances at sleep.” So you lie awake for two hours. You sleep late on the days you can, so your body clock loses its anchor. You nap. You lie in bed reading on your phone because at least it passes the time. You watch the clock and calculate what you will get if you fall asleep right now. You cancel the morning meeting because you slept badly.
Every one of these is a reasonable response. Together they are the illness.
Two things happen as a result.
Your bed stops meaning sleep. After enough nights lying awake in it, the bedroom becomes a place your brain associates with frustration and alertness rather than sleep. People describe this precisely without knowing what it is: “I am exhausted on the sofa, and the moment I lie down in bed I am wide awake.” That is not mysterious. That is a learned association, and it can be unlearned.
Trying harder makes it worse. Sleep is one of the few things in life that cannot be achieved through effort. It arrives when you stop pursuing it. So the harder you try, the more alert you become, and the more you fail, the harder you try.
You are not bad at sleeping. You have become too good at trying.
The treatment is having limited availability in India.
For chronic insomnia, the recommended first-line treatment worldwide is cognitive behavioural therapy for insomnia — CBT-I. Not medication. Medication comes second.
It is short — typically four to eight sessions — and its effects tend to last after it ends, which is precisely where tablets fail.
Two of its components do most of the work, and both feel wrong at first:
Stimulus control. Break the association between the bed and being awake. The bed is for sleep only. If you are awake and frustrated for what feels like more than fifteen or twenty minutes, get up, leave the bedroom, sit somewhere dim doing something dull, and return only when sleepy. Repeat as often as needed. Get up at the same time every morning regardless of how the night went — including Sundays.
Sleep restriction. Counter-intuitive to the point of sounding cruel: temporarily reduce the hours you spend in bed to match the hours you are actually sleeping, then extend gradually as sleep consolidates. It works by making sleep pressure do the job that willpower cannot.
A serious caution about that second one. Sleep restriction should be done with a clinician guiding it, not from a website. It causes a period of increased daytime sleepiness — which matters if you drive or operate machinery — and it is not appropriate for everyone. In particular, deliberate sleep loss can destabilise bipolar disorder and can lower the seizure threshold in epilepsy. Do not run this on yourself if either applies to you.
And a word about “sleep hygiene.” You have read the list — dark room, no screens, cool temperature, no heavy dinner. It is sensible, and on its own it is not a treatment for chronic insomnia. The evidence on sleep hygiene as standalone therapy is weak. It is the foundation, not the building. People who follow the list faithfully and still cannot sleep often conclude they are a hopeless case, when in fact they were simply given the least effective part of the treatment.
Sleeping tablets: an honest account
I will say this plainly, because it is the reason many of you are reading.
Sleeping tablets are genuinely useful in the short term. A week of them after a bereavement, before a surgery, during an acute crisis — that is good medicine, and refusing to prescribe them in those situations is not caution, it is stinginess.
Taken nightly for months and years, most of them cause problems. Tolerance, so the same dose does less. Dependence, so stopping produces a rebound sleeplessness worse than the original problem — which the person then reads as proof that they need the tablet. Daytime dullness. Memory complaints. And in older adults, unsteadiness and falls, which is not a small thing when a hip fracture at seventy-five changes everything that follows.
The class of medicines most commonly involved is available across chemists’ counters in this country with a casualness that would surprise people in most other places. As someone whose practice is half de-addiction: I have treated men who arrived believing they had a sleep problem and left understanding they had a dependence, built over a decade, one perfectly ordinary night at a time.
If you are already on one nightly, do not stop suddenly. Abrupt withdrawal from some of these can be genuinely dangerous, not merely uncomfortable. It is done gradually, with a plan, with a doctor. It can absolutely be done — I do it regularly, and people sleep better afterwards than they did on the tablet — but it is not a thing to attempt alone on a Sunday.
Some other things people take:
Melatonin is not a sleeping tablet; it is a body-clock signal. It has a real role in circadian problems — shift work, jet lag, delayed sleep timing — and is generally underwhelming for ordinary insomnia. Preparations vary considerably in quality.
Antihistamines from the chemist cause drowsiness, lose that effect within days, and leave a hangover.
Alcohol is the one I want to be emphatic about. It is the most widely used sleep aid in India and one of the worst. It shortens the time to fall asleep, and then it fragments the second half of the night — which is why the classic pattern is falling asleep easily at eleven and lying wide awake at three. It also worsens snoring and sleep apnoea. If you are drinking to sleep, you are trading the first half of the night for the second, and paying interest.
Not everything that ruins sleep is insomnia
Some of the commonest causes of “I can’t sleep” are not insomnia, and treating them as insomnia does harm.
Obstructive sleep apnoea. The breathing repeatedly obstructs during sleep. The signs: loud habitual snoring, someone reporting that you stop breathing or gasp, waking unrefreshed however long you slept, morning headache, dry mouth, and daytime sleepiness that is heavy rather than merely tired — falling asleep in front of the television, in meetings, and at traffic signals.
Please take this one seriously. Untreated sleep apnoea is associated with high blood pressure, heart disease and stroke, and the daytime sleepiness makes driving dangerous. And giving a sedative to someone with untreated apnoea can make the breathing worse. If this description fits you, the next step is a sleep study, not a sleeping tablet.
Restless legs syndrome. An uncomfortable, hard-to-describe urge to move the legs, worse in the evening and at rest, relieved by moving. People say “crawling”, “current”, “restlessness inside the bones”. It is frequently linked to low iron stores, which are extremely common in India, especially in women. A ferritin test is worth doing. It is often missed for years and dismissed as a habit.
Body-clock problems. Some people are not sleeping badly; they are sleeping at the wrong time. Night shifts — and Nashik has plenty of shift workers in its industrial belt — pull the clock apart in ways that willpower does not fix. Younger adults commonly run a naturally delayed clock, sleeping at two and rising at ten, which is a problem only because the world starts at nine. These need a different approach: light timing, schedule, sometimes melatonin. Not sedation.
Other illnesses. Pain. Acid reflux. An overactive thyroid. Prostate trouble waking a man three times a night. Uncontrolled diabetes. Some prescribed medicines, including certain blood pressure and asthma drugs, and steroids. Ask about the drugs you are already on before adding another.
Sleep and mental illness go both ways
For years, poor sleep was treated as a symptom of psychiatric illness. It is that. But the traffic runs in both directions, and the other direction is the interesting one.
Persistent insomnia is a risk factor for developing depression later — not merely a sign of it. Treating the insomnia is therefore not just comfort care; in some people it is prevention.
Some patterns worth knowing:
In depression, the classic pattern is waking at three or four in the morning, unable to return to sleep, with the mood at its worst in the early hours. Some depressions do the opposite and produce excessive sleep.
In anxiety, the difficulty is usually at the start — a mind that will not stop rehearsing.
In bipolar disorder, there is a distinction that families should know because it matters enormously. There is a difference between cannot sleep and is exhausted and does not seem to need sleep and is energetic. Someone sleeping three hours and running on full power, talking fast, full of plans, is not having an insomnia problem. Reduced need for sleep is one of the earliest and most reliable warning signs of a manic episode, and it usually appears before anything else is obvious. If you see it in someone with bipolar disorder, treat it as urgent.
In PTSD, nightmares and dread of going to bed.
In alcohol dependence, sleep is disturbed while drinking and often severely disturbed for weeks after stopping — a period during which many people relapse specifically because they cannot sleep. Knowing this in advance changes outcomes.
A story from the consulting room
The following is a composite — assembled from patterns I have seen many times. It is not any one patient, and all details have been changed.
A man in his early fifties, running a small trading business, came in because his wife insisted.
The sleeplessness had started nine years earlier, during a bad stretch when a payment did not come through and he thought the business would close. His physician gave him a tablet. It worked beautifully. The crisis passed within four months. The tablet did not stop.
By the time I saw him he was taking one and a half of them, having gone up from one somewhere around the fourth year. He slept about five hours. He described his days as “fogged”. He had twice tried to stop, and on both occasions had not slept at all for two nights and gone straight back, more convinced than before that he could not manage without it.
Two things came out in the first consultation that had never been asked about.
He snored — loudly enough that his wife had moved to the other room years earlier — and he was falling asleep in the afternoon in his own shop. A sleep study confirmed moderate obstructive sleep apnoea. He had been given a sedative, nightly, for nine years, for a condition in which sedation is unhelpful.
And he was having a drink most evenings, which he had never mentioned to any doctor because it was two pegs and he did not consider it relevant.
The reduction took about five months and it was not smooth. The apnoea was treated. The alcohol stopped. He did a course of CBT-I, and told me afterwards, with some irritation, that the instruction to get out of bed when he could not sleep was the single most annoying and most effective advice he had ever received.
He sleeps around seven hours now, on nothing.
The point of this story is not the happy ending. It is the nine years — and the fact that nobody, across nine years and several doctors, ever asked him whether he snored.
What you can start this week
Ordinary, unglamorous, and more effective than most people expect:
- Fix your wake-up time.One time, seven days a week, no matter how the night went. This is the single strongest anchor for a disordered body clock, and Sunday lie-ins are the commonest thing quietly wrecking Monday nights.
- Get out of bed when you are awake.Lying there “resting” is what taught your brain that the bed is a place for being awake.
- Turn the clock away.Every calculation of how much sleep is left costs you sleep.
- Stop using alcohol to sleep.Expect the first week to be worse. It gets better.
- Last tea or coffee by mid-afternoon.Caffeine hangs around considerably longer than people assume.
- Keep the phone out of the bed.Not primarily the light — the content. Sleep does not arrive while your nervous system is being fed.
- No long daytime naps.A short one early in the afternoon is fine; a two-hour nap at six in the evening steals from the night.
- If you snore heavily and wake tired, ask for a sleep studybefore you ask for anything else.
If chronic insomnia persists past two or three months of this, see a doctor and ask specifically about CBT-I. Ask by name. You may need to ask more than once.
If it is somebody in your family
Do not supply the tablets. Handing over a strip from your own prescription is the commonest way a dependence starts in an Indian household. It is meant kindly, and it is not a kindness.
Mention the snoring. Partners are usually the only people who know. Say it to the doctor, in front of the patient, out loud. It changes diagnoses.
Do not enable the schedule. Letting someone sleep until noon because they “had a bad night” keeps the cycle turning.
Watch for the reverse pattern. If someone with bipolar disorder suddenly seems to need much less sleep and is unusually energetic — that is not good news, and it should not wait for the next scheduled appointment.
Frequently Asked Questions.
Is it dangerous to go a night without sleep?
No. Unpleasant, and it impairs concentration and driving. One bad night is not harmful in itself, and the fear of that harm keeps a great many people awake.
Can I be on a sleeping tablet for life?
For a small number of people, under supervision, sometimes. For most, no, and it is worth a serious conversation about coming off rather than accepting it as permanent.
Do sleeping tablets cause dementia?
The research is mixed and contested, and honest doctors will tell you it is not settled. There are enough other reasons to avoid indefinite nightly use without leaning on an uncertain one.
Will treating my sleep fix my depression?
Not on its own, but it is a substantial part of the work, and improving sleep often improves everything else more than people expect.
My father is eighty and wakes at four. Is that insomnia?
Probably not. Sleep genuinely changes with age. If he functions well in the day, that is his sleep, not a disease.
Sources
- Indian Psychiatric Society — Clinical Practice Guidelines
- American Academy of Sleep Medicine — clinical practice guidelines on chronic insomnia and the International Classification of Sleep Disorders
- National Institute for Health and Care Excellence (NICE) — guidance on insomnia management
- World Health Organization — mhGAP Intervention Guide