The sledgehammer and the mosquito
Not long before he wrote this book, William Dement served as a consulting sleep expert at an FDA hearing on the sleeping pill Halcion. One of the physician witnesses opened his remarks with a line built to get a laugh: "Using a sleeping pill is like swatting a mosquito with a sledgehammer." Dement did not laugh. To him, that line summed up decades of bad thinking about insomnia.
In part three I covered what insomnia is (a symptom with a long list of possible causes) and how Dement went about finding which one was yours. This part is about treatment, and Dement lands somewhere I didn't expect. He was more enthusiastic about sleeping pills than almost any doctor in 1999, and also more enthusiastic about simple behavioral tricks than his reputation suggests. Twenty-seven years later, science has kept half of his argument and rewritten the other half, and the rewrite is the most useful part of this series so far.
What is primary insomnia, and why do I sleep better in hotels?
Once every other cause has been ruled out, two diagnoses are left, which used to be lumped together as . The common one is psychophysiological insomnia, also called learned or conditioned insomnia. It often starts with a stretch of ordinary, stress-driven bad nights. Then the person starts to dread bedtime. The worry about not sleeping becomes the thing that keeps them awake, and the bedroom itself turns into a cue for alertness. Patients often tell Dement that getting ready for bed is the hardest part of their day.
The giveaway is that these people often sleep better anywhere else. A hotel, a friend's couch, a strange city. Dement collected stories of patients who slept soundly on the floor of O'Hare during a storm, or hanging off the side of a mountain, and then lay awake for hours in their own beds. The second diagnosis, idiopathic insomnia, is much rarer: a lifelong inability to sleep well that starts in childhood and probably comes from something in the brain's own sleep machinery.
Then Dement hits a paradox. If insomniacs really lose as much sleep as they report, the sleep debt from part one should make them nod off during the day. Mostly it doesn't. When his team gave the daytime nap test to several hundred chronic insomniacs, they turned out to be, as a group, more alert than normal sleepers. About 14 percent of the insomniacs hit the test's ceiling and never fell asleep at all, compared with only 2 percent of good sleepers.
Part of the answer is that people misjudge their own nights, sometimes wildly. Dement describes a research patient who said that every night it took him one to four hours to fall asleep. In the lab, it never took more than 30 minutes and averaged about 15. Another said she never slept more than five and a half hours, and her own estimates averaged about four. The recordings averaged six hours and twenty minutes.
The deeper answer came from researchers Mike Bonnet and Donna Arand. They took normal sleepers and, for a week, disturbed their nights to copy the exact sleep patterns of people with insomnia. The good sleepers ended up with ordinary sleep-deprivation symptoms and got sleepier on the daytime test. The real insomniacs had something else: tension, confusion, higher body temperature, a faster metabolism around the clock, and more daytime alertness. Their bodies were running hot all day and all night. The conclusion was that in primary insomnia, the bad nights and the miserable days may both come from the same source, a nervous system stuck in . Psychiatry's diagnostic manual eventually caught up: in 2013, DSM-5 dropped the old split between primary and secondary insomnia and now treats insomnia disorder as worth treating in its own right.
Does sleep hygiene actually work?
Dement's general advice comes in layers, and the first is , which sounds like a shower routine and is mostly about the clock. Keep a regular schedule all seven days. Skip caffeine near bedtime. Train your sleep the way a runner trains for a race at the same time every morning, so the body knows what's coming. He admits to leaving many a dinner party early on "doctor's orders," which may be the most relatable sentence in the whole book.
On its own, sleep hygiene rarely cures chronic insomnia, and current guidelines treat it as a foundation with stronger tools built on top. It's also where my gym, sauna and paper book routine from part two lives. For a brain like mine that runs on novelty, a night that looks exactly like the last one is a feature.
What is stimulus control, and what is "worry time"?
The second layer is : keep whatever winds you up as far from bedtime as you can. Dement lists the classic mistakes. People watch the late news, full of murder and corruption, then wonder why they can't sleep. They do homework, pay bills, check email right before bed, or use the last hour of the night to get a jump on tomorrow's headaches. In 2026 the late news lives in your pocket and never ends.
His best example is a colleague's patient named Ron, an electronics engineer who couldn't leave his work at the office. Ron spent the hours before bed worrying about what might go wrong the next day, and he'd had chronic insomnia for years. By bedtime, Dement writes, Ron was ready for battle. The fix was a scheduled half hour right after dinner called . Ron wrote down everything stressing him and how he'd handle each item. After those 30 minutes, worrying was off limits for the rest of the night, and he filled the evening with calm things, like a good book. It played a key part in his recovery.
As someone with ADHD, I find this both obvious and revolutionary. The things that keep my brain lit up at 11:40 p.m. usually feel like ideas, which are worse than worries because they feel like gifts. A list on paper gives them somewhere to go where they won't be lost by morning.
The modern version of stimulus control, developed by psychologist Richard Bootzin in the 1970s, adds a rule that sounds harsh at first: use the bed only for sleep and sex, and if you can't fall asleep after what feels like about 20 minutes, get up and do something quiet in dim light until you feel sleepy. The point is to retrain the brain to connect the bed with sleep instead of with lying there, furious, doing math about how many hours are left.
Do relaxation and counting tricks help you fall asleep?
Relaxation techniques go after the body's side of hyperarousal. The best known is progressive relaxation: tense and release your muscles one group at a time, feet, then legs, then hands, then arms, while paying attention to your breathing. Practiced during the day and again at bedtime, Dement says, it can drain off the anxiety that blocks sleep at the start of the night and in the middle of it.
Cognitive tricks go after the mind. Counting sheep is the classic, and its upgraded version is to start at a number like 1,000 and keep subtracting 17. It's dull enough to crowd out worry and just hard enough to need your full attention. Every high school algebra class in America was accidentally running this experiment.
The strangest one is : try to stay awake as long as you can. It sounds like a prank, but it takes away the fear of not sleeping, and the sleep debt quietly takes over. Dement also describes a study of self-hypnosis, which he says is really a relaxation technique close to meditation. Patients lay still with their eyes closed and silently thought "in" and "out" with each breath, and it worked about as well as progressive relaxation.
What is sleep restriction therapy, and what is CBT-I?
Dement's favorite formal technique is , and he describes it with real glee. The idea is to order a patient not to sleep. If someone says they only get four hours a night, he takes them at their word: fine, go to bed at 3 a.m. and get up at 7. He likes the move because it sidesteps any argument about whether the patient is exaggerating. After about a week, the patient has built up so much sleep debt that they fall asleep fast and stay asleep. Then he adds half an hour each week until they reach a solid seven and a half hours.
This is where Dement looks most like a prophet. Sleep restriction and stimulus control became two pillars of , cognitive behavioral therapy for insomnia, a structured program, often four to eight sessions, that combines those techniques with relaxation and with work on the beliefs that feed bedtime dread. In 2016 the American College of Physicians recommended CBT-I as the first treatment for adults with chronic insomnia, ahead of any pill. In April 2026 the American Academy of Sleep Medicine published a guideline on combining treatments: CBT-I plus medication beats medication alone, but for most people, adding a pill to CBT-I offers only a small extra benefit, and the effects of CBT-I tend to last after treatment ends. You can get it from a clinician, and validated versions now exist as apps and online programs.
Sleep restriction makes you sleepier before it makes you better, which matters if you drive or operate anything heavy, and it isn't right for people with certain medical and psychiatric conditions. Dement himself said it takes a lot of commitment and isn't for everyone. Do it with a clinician.
Does valerian root actually work for sleep? What about melatonin?
Here I have to report on myself. Dement surveys the alternative therapies people asked him about at his lectures. Hypnosis needs a hypnotist and works best on highly suggestible people. Biofeedback, where machines teach you to read and lower your own tension, showed some promise but needs equipment. Acupuncture practitioners claimed success rates around 90 percent, which he found dubious. Massage works wonderfully, as long as someone gives you one in your own bed at bedtime every night, which describes almost nobody.
Then herbs. In part two I told you I take valerian root after the sauna and shower. Dement's verdict on valerian, herbal teas, warm milk and the rest is that they haven't been well tested, and the few studies are small. If you try them and they help a rough patch, he says, fine. If you have chronic insomnia, see a sleep specialist. The American Academy of Sleep Medicine's 2017 guideline was less polite: it suggested that doctors not use valerian for chronic insomnia, because the evidence doesn't show a meaningful effect.
Read honestly, that makes my valerian mostly a ritual, the last step of a routine that tells my body the day is over. Rituals count for something with insomnia, since so much of the fight is teaching the brain that bedtime is safe. I'm just not going to call it medicine.
Melatonin gets its own section in the book, and it's a great story. In the early 1990s some of Dement's colleagues found it promising, and researchers asked the FDA's drug side for permission to test it in people. The FDA said it wanted more animal safety data first. Meanwhile, the agency's food side let melatonin be sold as a dietary supplement with no testing at all. Dement calls it a classic case of the left hand not knowing what the right hand was doing. Books and TV promoted melatonin for sleep, happiness, longevity and virility, and, in his words, one of the largest uncontrolled clinical trials in medical history began.
What melatonin really does is tell the body it's dark. Taken at the right time, it can shift the clock, which is why it can help with jet lag and why the ADHD study in part two paired it with morning light. As a knockout pill it's weak, and the 2017 guideline also suggested against it for chronic insomnia. The quality problem Dement worried about is still here. A 2023 study in JAMA tested 25 melatonin gummy products sold in the US and found 22 of them mislabeled, with actual melatonin ranging from about three-quarters to more than three times what the label said. One contained no melatonin at all, just CBD.
Supplements, valerian included, can interact with other medications. For melatonin, timing matters more than amount, and both are questions for a doctor or pharmacist, especially for kids.
What were the first sleeping pills?
To explain why everyone was so afraid of sleeping pills in 1999, Dement walks through their history, and it plays like a horror anthology. For most of human history the options were alcohol, opium, or both. Into the nineteenth century, a common sleeping potion was laudanum, a tincture of opium also used for stomach trouble. Morphine, the opium poppy's active ingredient, produces nearly every side effect you'd want to avoid in a sleeping pill, starting with addiction.
The first synthetic sleep drug, chloral hydrate, arrived in 1869. It could be addictive, an overdose could kill, and it became notorious as the active ingredient in "knockout drops," the slipped-into-your-drink sedative of old crime movies. Then came bromides, salts so unexciting as medicine that "bromide" became English slang for a tired cliché, which is now my favorite fact in the entire book. In 1903 came barbital and the barbiturates, which ruled into the 1970s under names like Seconal, Nembutal and Amytal. At low doses Amytal lowered people's inhibitions, which is how it got its reputation as a "truth serum."
Barbiturates were addictive, tolerance built quickly, and the gap between a helpful dose and a lethal one was small. Accidental and intentional overdoses, often combined with alcohol, made headlines through the 1950s and 1960s. Dement believed that era poisoned attitudes toward every sleeping pill that came after it. Then the benzodiazepines arrived, Librium and then Valium, developed for anxiety and found to help sleep as a side effect, and far safer in an overdose. The first one approved specifically as a sleeping pill was Dalmane, in the early 1970s. Halcion followed and ran into trouble over rare reports of violent or bizarre behavior. In 1992 the US approved zolpidem, better known as Ambien, a short-acting drug that Dement considered the best-evaluated and safest sleeping pill available.
- AncientAlcohol and opium
- 1800sLaudanum, then bromide salts
- 1869Chloral hydrate, the first synthetic sleep drug
- 1903Barbital launches the barbiturate era
- 1960sLibrium and Valium, the first benzodiazepines
- 1970sDalmane, the first benzodiazepine approved as a sleeping pill
- 1992Ambien (zolpidem) approved in the US
- 2014Belsomra, the first orexin blocker
- 2016CBT-I recommended as first treatment for chronic insomnia
- 2019FDA boxed warning on Ambien and two related drugs
Are sleeping pills safe, or addictive?
Dement's case for sleeping pills was a contrarian one in 1999. In his undergraduate course, 94 percent of students agreed that sleeping pills are addictive, and three-quarters agreed you shouldn't take them for more than a month. In a study of about 500 primary care doctors, around 90 percent said the same. Meanwhile, national surveys from the early 1980s found that only about 10 percent of insomnia patients had ever been prescribed a sleeping pill, and most of them took it for only a few nights. To Dement, the scandal was how rarely they were prescribed.
He tells the story of a Cornell undergraduate in the middle of a personal crisis who hadn't slept properly in days and had started skipping classes. The student health doctor wouldn't prescribe her anything. Dement called the doctor himself, explained who he was, and asked for even three or four nights of medication. The doctor flatly refused to be anyone's pill pusher, in a tone, he writes, that made him feel like the local drug dealer. All he could do was tell the student to find a doctor who would help her.
The picture since 1999 is more complicated than either side of that phone call expected. Ambien works, but in 2019 the FDA added its most serious warning, a boxed warning, to zolpidem and two related drugs, eszopiclone (Lunesta) and zaleplon (Sonata), after reports of complex sleep behaviors such as sleepwalking and sleep driving that people didn't remember afterward. The agency counted 66 cases of serious injury and 20 deaths over 26 years. In 2013 it had already lowered the recommended dose for women, who clear the drug more slowly and could still be impaired the next morning.
There's also a genuinely new class of drug, with a Stanford connection Dement would have loved. In 1999, the year this book came out, Emmanuel Mignot's lab at Stanford discovered that narcolepsy in dogs came from a broken receptor for a brain chemical called hypocretin, also known as , which helps keep us awake. Starting with suvorexant (Belsomra) in 2014, the FDA approved drugs that block orexin, turning down the brain's wake signal instead of sedating the whole brain. They have side effects of their own and aren't right for everyone, but the idea came out of the sleep center Dement built.
Over-the-counter sleep aids are the one place where 1999 and 2026 fully agree. Dement disliked them. Most rely on antihistamines, allergy drugs that happen to cause drowsiness, with effects that linger into the next day, side effects like dry mouth and constipation, tolerance that builds quickly, and when you stop. The 2017 guideline suggested doctors not use diphenhydramine, the most common one, for chronic insomnia.
Every medication in this section has real risks and interactions, and nothing here is a recommendation to take or avoid any of them. Don't start, stop or combine sleep medications, or mix them with alcohol, without a doctor who knows your history.
How do doctors treat insomnia that won't go away?
Dement ends the chapter with a case that pulls everything together. A Stanford professor came to him with insomnia that had been getting worse for a long time. She was ambitious, under heavy pressure to earn tenure, worked right up until bedtime, and stayed up late. He went down the list. She had a mild delayed clock, but that didn't seem to be the main problem. Restless legs, fibromyalgia and reflux seemed unlikely. Then he asked about the bedroom. Her husband was a lark who was already asleep by the time she came to bed, and lying awake in the dark beside him while he slept soundly made her resentful, which made sleep even harder.
He started simple: cut back on caffeine and alcohol, take a warm bath before bed, keep a sleep diary, and when the lights went out, focus on a pleasant memory, a favorite movie, a past vacation, walking through it piece by piece. She went along with all of it and slept a little better. Then they added worry time in the early evening. Two weeks later she came back discouraged. Her stress had turned into a fear of not sleeping, the start of the conditioned insomnia from section two.
So he dug further. An overnight sleep study ruled out the hidden causes from part three and showed her clock was running later than he'd guessed. He added bright light in the morning and an earlier wake-up time to pull her clock back. Knowing that the dread of another bad night was now part of the problem, he also prescribed a low dose of Ambien for one week, mostly so she'd know that if things got desperate, she could sleep. And he asked her to call him every morning to tell him how the night had gone.
I'll leave the ending to the book. The detail I keep thinking about is that phone call: one of the most famous sleep doctors in the world checking in every morning like a coach. The method around it holds up. Rule out the hidden causes, start with behavior, fix the clock, and treat medication as a tool with a time limit and a plan. Today's guidelines would sign off on nearly all of it, with CBT-I doing most of the heavy lifting.
The crossing
Four parts in, the best picture I have of my own sleep is a customs office: a set of questions to ask at the border every night. What time is my clock really on? What's keeping me up, a worry, an idea, a screen? Is something physical going on that a test would catch? Is the bed still a place for sleep, or has it become a place for lying awake? The one I've taken from this chapter is worry time, with an edit. Ron put his on the calendar right after dinner. I do mine when I can feel the anxiety starting to rise and spiral, the moment one worry starts recruiting others. What goes on the page is mostly worries, and writing them down gives them somewhere to go besides my pillow.
The newest part of my routine started by accident. This past summer my apartment had no air conditioning, and the coolest place in it was the bathtub, so I started sitting in the tub with the shower running over me. When the weather turned, I kept the habit and switched the water to warm. Now I crack the shower door and set a small heater outside it, so the whole bathroom fills with heat while the water runs. Dement may have been onto something when he prescribed a warm bath to his Stanford professor: research since suggests that warming up and then cooling down afterward helps the body ease toward sleep, which means the getting out matters as much as the getting in. The part I'm still working on is the phone, which I usually bring with me and which breaks every rule in section four.
Dement wanted everyone to understand sleep well enough to manage their own, and to recognize when it was time to ask for help. That's a modest goal for a man who more or less invented a field, and it's still the right one. The trouble with the sledgehammer line is that it gets the size of the problem wrong. A mosquito at 1 a.m. is a small problem with a small fix. Three months of bad nights is a big one, and it deserves a real plan.
Questions people search
What is the best treatment for chronic insomnia?
Cognitive behavioral therapy for insomnia (CBT-I). The American College of Physicians recommends it as the first treatment for adults with chronic insomnia, and the American Academy of Sleep Medicine's 2026 guideline found its benefits tend to last after treatment ends.
What is sleep restriction therapy?
A technique that limits your time in bed to about the amount you actually sleep, then slowly extends it as your sleep becomes more solid. It builds up sleep pressure so you fall asleep faster and wake less. It's best done with a clinician, since it makes you sleepier at first.
Does valerian root work for sleep?
The evidence is weak. The American Academy of Sleep Medicine suggests doctors not use valerian to treat chronic insomnia. Some people find it a calming part of a bedtime routine, but it can interact with other medications, so check with a doctor or pharmacist.
Is melatonin good for insomnia?
Melatonin is better at shifting the timing of your body clock than at knocking you out, which is why it can help with jet lag and delayed sleep phase. It isn't recommended for chronic insomnia, and a 2023 study found most melatonin gummies didn't contain the amount on the label.
Are sleeping pills addictive?
It depends on the drug. Older barbiturates were highly addictive. Modern prescription sleep medications carry less risk of that, but have other risks, including next-day grogginess and, for Ambien and related drugs, rare complex sleep behaviors such as sleep driving. A doctor can weigh them for your situation.
Are over-the-counter sleep aids safe?
Most rely on antihistamines such as diphenhydramine, which can cause next-day grogginess, dry mouth and constipation, and lose effect quickly. Sleep specialists generally advise against them for ongoing insomnia, and older adults are more sensitive to their side effects.
What is "worry time"?
A scheduled half hour in the early evening to write down what's stressing you and how you'll handle it, so the worrying is finished before bedtime instead of following you into bed.
Why do I sleep better in a hotel than at home?
It's a classic sign of conditioned, or learned, insomnia. Your own bedroom has become a cue for alertness and worry, and a new room doesn't carry that baggage. Stimulus control and CBT-I are built to break that link.
Sources
- William C. Dement and Christopher Vaughan, The Promise of Sleep (Delacorte Press, 1999), chapter 6.
- Qaseem et al., "Management of chronic insomnia disorder in adults: a clinical practice guideline from the American College of Physicians," Annals of Internal Medicine, 2016.
- Sateia et al., "Clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults: an American Academy of Sleep Medicine clinical practice guideline," Journal of Clinical Sleep Medicine, 2017.
- Buysse et al., "Combination treatment for chronic insomnia disorder in adults: an American Academy of Sleep Medicine clinical practice guideline," Journal of Clinical Sleep Medicine, 2026.
- US Food and Drug Administration, Drug Safety Communication on complex sleep behaviors with eszopiclone, zaleplon and zolpidem, April 2019.
- Cohen et al., "Quantity of melatonin and CBD in melatonin gummies sold in the US," JAMA, 2023.
- Lin et al., "The sleep disorder canine narcolepsy is caused by a mutation in the hypocretin (orexin) receptor 2 gene," Cell, 1999.
- American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, fifth edition (2013), insomnia disorder.
- Haghayegh et al., "Before-bedtime passive body heating by warm shower or bath to improve sleep: a systematic review and meta-analysis," Sleep Medicine Reviews, 2019.
I'm a guy who reads a lot, not a doctor. Nothing here is medical advice. If sleep is wrecking your days, talk to a physician or a sleep specialist.