Sleep problems

What are sleep problems?

Most people have a few bad nights when they are stressed, unwell or travelling. Sleep usually settles once the cause passes. A sleep problem becomes a health concern when it goes on for weeks or months and starts to affect how you feel, think and function during the day.

The most common sleep problem is insomnia: difficulty falling asleep, staying asleep, or waking too early and being unable to get back to sleep. Doctors call it chronic insomnia when it happens several times a week for at least three months, despite having enough time and a suitable place to sleep, and it affects daytime life. The World Health Organization lists it in ICD-11 among the sleep-wake disorders.

Insomnia is common. About 6 to 10 in every 100 adults have insomnia that meets diagnostic criteria, and it becomes more likely with age and is more common in women. Other important sleep problems include sleep apnoea, where breathing repeatedly stops during sleep, and restless legs syndrome.

Signs of insomnia

• Lying awake for a long time before falling asleep
• Waking often during the night and struggling to get back to sleep
• Waking very early, well before the alarm, and feeling unable to sleep again
• Feeling unrefreshed even after a full night in bed
• Tiredness, low energy or wanting to nap during the day
• Poor concentration, forgetfulness and mistakes at work or in studies
• Irritability, low mood or feeling anxious
• Worrying about sleep through the day and dreading bedtime

Over time, many people get caught in a cycle. A few poor nights lead to worry about sleep, the worry keeps the mind alert at bedtime, and the bed itself becomes linked with frustration rather than rest.

What disturbs sleep?

Insomnia rarely has one cause. Common contributors include:

• Stress and worry: work pressure, exams, money problems, family conflict or loss
• Mental health conditions: anxiety often makes it hard to switch off; depression commonly causes early morning waking; bipolar disorder and trauma can also disturb sleep
• Alcohol: a drink may help you fall asleep, but it breaks up sleep later in the night; people who drink heavily often sleep very badly when they cut down
• Caffeine and nicotine: tea, coffee, colas, energy drinks and cigarettes or gutka late in the day keep the brain alert
• Screens: phones, laptops and late-night web series keep the mind busy, and scrolling in bed pushes sleep later
• Shift work and travel: night shifts, rotating rosters in call centres and hospitals, and frequent flights confuse the body clock
• Pain and physical illness: back pain, arthritis, acid reflux, breathing problems, frequent urination at night and hormonal changes
• Some medicines and other substances: certain medicines and drugs such as cannabis can affect sleep, especially when stopped
• Habits: irregular bedtimes, long afternoon naps and little daytime activity
• Family history: insomnia sometimes runs in families

Treating the cause, where there is one, is an important part of getting sleep back on track.

Sleeping pills: why they stop working, and why not to stop suddenly

Some people buy sleeping pills from a chemist without a prescription, or continue an old prescription for years without review. They can be useful for a short time, for example during a crisis, but they are not designed for long-term use.

Many sleeping pills, including benzodiazepines, are habit-forming. With regular use, three problems often develop:

• Tolerance: the brain adapts, so the same dose works less well and people feel they need more
• Dependence: the body comes to rely on the pill, and sleep feels impossible without it
• Rebound insomnia: missing a dose brings back sleeplessness, often worse than before, which convinces people they cannot manage without the pill

They can also cause next-day drowsiness, slowed reactions, poor memory and unsteadiness. Mixing them with alcohol or other sedating medicines is dangerous, because breathing and alertness can be seriously affected.

If you have taken sleeping pills regularly for a long time, do not stop them suddenly. Stopping abruptly can cause severe anxiety, sleeplessness and, in some cases, fits (seizures), which can be life-threatening. The safe approach is a gradual, personalised reduction planned with a doctor, ideally alongside CBT for insomnia. Never take sleeping pills prescribed for someone else.

Snoring with pauses in breathing: possible sleep apnoea

Snoring on its own is common and often harmless. But loud, regular snoring with pauses in breathing, choking or gasping during sleep, together with heavy daytime sleepiness, can be a sign of obstructive sleep apnoea (OSA). In OSA, the throat repeatedly narrows or closes during sleep, cutting off breathing for a few seconds and briefly waking the brain many times a night, often without the person knowing.

Community studies in India have found OSA in about 2.4 to 5 in every 100 men and 1 to 2 in every 100 women. Signs to look out for include:

• Loud snoring most nights, often noticed by a spouse or family member
• Pauses in breathing, choking or gasping during sleep
• Falling asleep easily during the day, in meetings, while watching TV or in traffic
• Feeling unrefreshed despite a full night’s sleep

Untreated sleep apnoea raises the risk of road accidents, heart attack and stroke. It needs a medical evaluation, usually including a sleep study. It can be treated, most often with a breathing device used at night, along with weight reduction and avoiding alcohol and sedatives. Sleeping pills can make sleep apnoea worse, which is another reason not to take them without a proper assessment.

Restless legs syndrome

Restless legs syndrome causes an irresistible urge to move the legs, often with uncomfortable crawling, pulling or aching sensations. It comes on when resting, is worse in the evening and at night, and eases with movement, which makes it hard to fall asleep. It is linked with low iron, pregnancy and kidney disease, and some medicines can worsen it. Cutting down on alcohol, caffeine and nicotine can help, and a doctor may check your iron levels.

When to see a doctor

Consider a consultation if:

• Poor sleep has lasted more than a few weeks and is affecting your day
• You rely on sleeping pills or alcohol to sleep
• You want to reduce sleeping pills you have taken for a long time
• Your family notices loud snoring, pauses in breathing or gasping
• You feel very sleepy during the day, especially while driving
• Sleep problems come with low mood, anxiety, worry or irritability

How sleep problems are assessed

The psychiatrist will ask about your sleep pattern, bedtime routine, work shifts, naps, caffeine, alcohol, tobacco and other substances, medicines, physical health, mood and stress. With your permission, a spouse or family member can describe snoring, breathing pauses or unusual movements at night.

You may be asked to keep a sleep diary for one or two weeks, noting when you go to bed, how long it takes to fall asleep, night waking and how you feel in the morning. Blood tests, such as iron levels, may be suggested. If sleep apnoea is suspected, you will be advised to have a sleep study. The diagnosis follows international criteria (ICD-11).

Treatment

Treatment depends on the type of sleep problem and what is driving it. For insomnia, it usually combines the following.

1. CBT for insomnia (CBT-I)

Cognitive behavioural therapy for insomnia is the recommended first treatment for chronic insomnia, and its benefits tend to last longer than those of medicines. It typically runs over about six to eight weeks, in person or online, and includes:

• Sleep education: understanding how sleep works and what disrupts it
• Stimulus control: using the bed only for sleep, and getting up if you cannot sleep, so the bed becomes linked with sleep again
• Sleep restriction: setting a regular, carefully planned sleep window that builds a stronger drive to sleep
• Cognitive therapy: calming unhelpful worries such as fearing that one bad night will ruin the next day
• Relaxation: breathing, muscle relaxation or meditation to quieten the body and mind

CBT-I takes effort in the first few weeks, and sleep can feel worse before it improves. Guidance from a trained therapist or doctor helps you stay on track through this phase.

2. Practical sleep habits

Good habits alone rarely fix long-standing insomnia, but they support every other treatment. Try these:

• Keep fixed timings. Get up at the same time every day, including weekends, even after a poor night.
• Go to bed only when sleepy, not simply because it is late.
• Limit caffeine. Avoid tea, coffee, colas and energy drinks from mid-afternoon.
• Avoid alcohol and tobacco in the evening; they disturb sleep.
• Put screens away at least an hour before bed, and keep the phone out of reach.
• Make the bedroom dark, quiet and cool. Blackout curtains or an eye mask help shift workers.
• Get daylight and exercise during the day, but avoid heavy exercise close to bedtime.
• Keep naps short and early, or avoid them.
• Eat dinner a few hours before bed, and avoid heavy, spicy meals late at night.
• Leave the bed if you can’t sleep. If you have been lying awake for a while, get up, do something calm in dim light, and return when sleepy.
• Stop clock-watching. Turn the clock away.

3. Treating depression, anxiety and alcohol use

When sleep problems come with depression, anxiety or heavy drinking, treating the underlying condition often improves sleep considerably. Sleep problems can also linger after mood or drinking improves, so they deserve attention in their own right, often with CBT-I.

4. Careful, time-limited use of medicines

Medicines are not the first answer to long-standing insomnia, but they have a place. A doctor may suggest a short, time-limited course during a crisis, or a medicine that also treats underlying depression or anxiety. Any medicine is prescribed at the lowest effective dose, for a planned period, and reviewed regularly.

For people already taking sleeping pills long-term, a key part of treatment is a slow, supervised reduction. Medicines must only be started, changed or stopped with a doctor.

5. Other sleep conditions

If sleep apnoea is suspected, you will be referred for a sleep study and specialist treatment. Restless legs may improve with iron supplements when levels are low and a review of medicines.

Outpatient, online or inpatient care?

• Outpatient care suits most people with sleep problems.
• Online consultations work well for CBT-I, sleep diary reviews and planning gradual reduction of sleeping pills.
• Inpatient care may occasionally be advised for severe dependence on sleeping pills or alcohol, where reducing them safely needs close supervision.

Dr. Tarwani sees patients at Sukoon Health in Gurugram and South Delhi, where inpatient rehabilitation is also available, and online.

For families

Sleep problems affect the whole household. A few things help:

• Take your family member’s sleeplessness seriously; it is not laziness or fussiness
• If your spouse snores loudly and seems to stop breathing, encourage a medical check
• Don’t offer your own sleeping pills to anyone, including elderly parents
• Speak up if a family member seems unusually drowsy, confused or unsteady on sleeping pills
• Support steady routines, such as quiet evenings and no loud TV late at night
• Watch for low mood, heavy drinking or talk of hopelessness, and help them seek care

You are welcome to consult Dr. Tarwani first, on your own, to plan the next steps.

Common myths

• “A peg of whisky helps you sleep.” Alcohol breaks up sleep and makes it less refreshing.
• “Sleeping pills are harmless if a doctor once prescribed them.” Many are habit-forming and are meant for short-term use with regular review.
• “Snoring means deep, good sleep.” Loud snoring with pauses in breathing can be sleep apnoea, which needs attention.
• “Lying in bed longer will help me catch up.” Spending extra time awake in bed usually makes insomnia worse.
• “Insomnia is all in the mind, so nothing can be done.” Insomnia is a recognised health condition, and CBT-I and treating its causes help.