Insomnia and Sleep Disorders in Bangladesh: Evidence-Based Treatment That Works

Insomnia Is More Than Just Difficulty Sleeping

Insomnia is not simply "not being tired enough." It is a condition where the mind and body have lost the ability to switch into sleep mode, despite being tired. It can involve:

• Difficulty falling asleep (lying awake for more than 30 minutes)
• Waking during the night and being unable to return to sleep
• Waking too early
• Non-restorative sleep — waking feeling unrefreshed after a full night

When this happens 3 or more nights per week for more than 3 months, it is classified as chronic insomnia — a medical condition, not a personal failing.

What Causes Insomnia?

Hyperarousal: The most common cause of chronic insomnia is not stress itself, but the brain becoming conditioned to associate the bed with wakefulness and anxiety. Once this pattern is established, it perpetuates itself — you feel anxious about not sleeping, which keeps you awake.

Contributing factors in Bangladesh:

• Irregular sleep schedules (common with shift work, late-night phone use)
• Anxiety and depression
• Chronic pain (back pain, arthritis)
• Noise pollution — urban Bangladeshi bedrooms are rarely quiet
• Caffeine overconsumption — tea throughout the day and evening is culturally embedded
• Sleep apnoea (often undiagnosed — see below)

The Most Effective Treatment: CBT-I

Cognitive Behavioural Therapy for Insomnia (CBT-I) is recommended as the first-line treatment for chronic insomnia by sleep medicine organisations worldwide. It works better than sleeping pills, and the benefits last long after treatment ends.

CBT-I consists of:

Sleep restriction: Temporarily restrict time in bed to match actual sleep time — then gradually extend. This builds strong sleep pressure and re-trains the brain.

Stimulus control: Only use the bed for sleep (and sex). No phones, TV, eating, or worrying in bed. Get up if you cannot sleep after 20 minutes.

Cognitive restructuring: Challenge beliefs like "I need 8 hours or I cannot function" or "If I don't sleep tonight, tomorrow will be ruined." These thoughts fuel anxiety that worsens insomnia.

Relaxation training: Progressive muscle relaxation, slow breathing exercises before bed.

CBT-I is available online (apps: Sleepio, Somryst) and through psychologists. Even a book on CBT-I ("Say Good Night to Insomnia" by Gregg Jacobs) can produce significant improvement with self-guided practice.

Sleep Hygiene — What Actually Matters

Not all sleep hygiene advice is equal. The most evidence-based practices:

Do:

• Wake at the same time every morning — even weekends. This is the single most powerful sleep regulator.
• Get morning sunlight within 1 hour of waking — resets the circadian clock
• Reduce light exposure in the evening (dim room lights after 8pm, use night mode on phone)
• Keep the bedroom cool (18–22°C if possible)

Avoid:

• Caffeine after 2pm (tea, coffee, energy drinks)
• Alcohol — it causes fragmented sleep in the second half of the night
• Long daytime naps — keep naps under 20 minutes before 3pm if needed
• Intensive exercise within 2–3 hours of bedtime

Sleeping Pills — The Problems

Benzodiazepines and Z-drugs (clonazepam, alprazolam, zolpidem) are commonly prescribed in Bangladesh for insomnia.

Problems with long-term use:

• Tolerance develops — the same dose stops working
• Physical dependence and withdrawal symptoms
• Next-day cognitive impairment and sedation
• Significantly increased fall and accident risk in older people
• Does not treat the underlying cause — insomnia returns when stopped

If you are already on sleeping pills, do not stop abruptly — taper under medical supervision.

Sleep Apnoea — An Often Missed Cause

If you snore loudly, stop breathing during sleep (reported by a partner), and wake feeling unrefreshed despite adequate hours, you may have obstructive sleep apnoea. This requires a sleep study (polysomnography) and CPAP treatment. It is underdiagnosed in Bangladesh.