Why You Cannot Sleep: A Clinical Guide to Insomnia in Pakistan
In the most recent prevalence study of mental health concerns in Pakistan, 38% of respondents reported sleep-related problems. It was the single highest category, edging out even depression and anxiety. That number captures a quiet truth our clinic sees every week. A great many adults in this country are not sleeping well, and most of them have stopped believing anything can be done about it.
This article is for the person who has tried everything. The person who has read articles, swapped tea for warm milk, downloaded apps, taken supplements, moved phones out of bedrooms, and still finds themselves staring at the ceiling at three in the morning, dreading the alarm at six.
I want to tell you something hopeful, because it is true: insomnia is one of the most treatable conditions in clinical practice when it is approached properly. The problem is that it is almost never approached properly. Patients are given sleeping pills, told to relax, sent home, and the underlying problem is never addressed. Real sleep returns only when the underlying mechanism is understood and the right tools are applied in the right order.
What insomnia actually is, in the body and the mind
Sleep is not something you do. It is something that happens to you when the conditions are right. The conditions for sleep are an active calming of the nervous system (parasympathetic dominance), a particular hormonal cascade beginning with melatonin, and an absence of internal or external alarms telling the body that it should remain on guard.
Insomnia is what happens when this system is disrupted. There are three broad ways it can break, and patients usually have a mix of all three:
The body cannot calm down enough to permit sleep. This is the form most common in patients with anxiety, in those carrying chronic stress, or in anyone whose nervous system has learned to stay vigilant through prolonged difficulty. The body lies down, the mind starts racing, the heart will not settle, and sleep cannot come.
The body's circadian rhythm has drifted out of phase. This is the form most common in patients exposed to bright light at night (phones, late-night work), shift workers, and those whose schedules have varied so much over months or years that the internal clock no longer knows when to release melatonin. The patient is exhausted at the wrong times of day and wide awake at the wrong times of night.
The mind has learned, through repeated experience, that bed is a place of struggle. This is the form that develops in patients who have had insomnia for months. Their nervous system now associates lying down with stress and failure. The bed itself becomes a trigger. Even when they are tired, they cannot fall asleep in their own bed, though they can sometimes nod off on the sofa or in a chair. This is called conditioned insomnia, and it genuinely requires retraining the brain's association with the bed.
Knowing which combination of these is producing your specific insomnia is the entire starting point of proper treatment. A "remedy" or "supplement" that does not know which problem it is solving cannot solve any of them well.
Why insomnia has exploded in Pakistan
Several conditions of modern Pakistani life have stacked together to produce the current epidemic.
Smartphones have collapsed the boundary between day and night. The screen delivers stimulating content and bright light at the precise hours when the body is trying to release melatonin and wind down. For many patients the phone is the last thing they look at before lying down and the first thing they reach for if they wake at three. The cost of this in sleep quality is enormous and chronically underestimated.
Ambient anxiety has risen across the country. Economic pressure, political uncertainty, the news cycle, social comparison, all keep the nervous system in low-grade activation throughout the day. By the time bed arrives, the system has not had a single moment of true calm to wind down from.
Caffeine consumption has increased and shifted later. The cup of tea or coffee at four in the afternoon, common in Pakistani offices, has a measurable effect on sleep that night even when the patient does not feel caffeinated. The half-life of caffeine in the body is five to six hours.
Sleep itself has become socially devalued. Patients describe long sleep as laziness and short sleep as discipline, despite a generation of evidence that sleeping less than seven hours consistently shortens life expectancy, impairs cognition, and is a leading risk factor for cardiovascular disease.
These conditions are not your individual failing. They are the environment your nervous system is trying to operate in.
When to take insomnia seriously
A bad night now and then is normal. The diagnostic threshold for clinical insomnia is difficulty falling asleep, staying asleep, or waking too early for at least three nights a week, for at least three months, causing distress or daytime impairment.
If that describes you, this is no longer something to wait out. Chronic insomnia damages every system in the body — cognitive function, mood, metabolism, immune function, cardiovascular health — and it perpetuates itself. Each bad night increases the anxiety about the next night, which makes the next night worse. Proper treatment breaks this cycle.
The other red flag worth attending to is sleep that is plentiful but unrefreshing. If you sleep eight hours and wake exhausted, the issue may be sleep quality rather than quantity, and conditions like sleep apnea (particularly common in adults with even modest weight gain) should be considered. A medical workup is sometimes the right first step.
How I approach insomnia in the clinic
My training is in clinical psychology, with additional training in homoeopathic medical sciences, and my approach to insomnia draws from both plus a careful understanding of what modern sleep science has established. Insomnia is the condition where this integration matters most, because no single tool can address all three mechanisms I described above.
The first conversation is always about understanding which form of insomnia this patient is actually carrying. The "I cannot fall asleep" patient needs different help from the "I fall asleep but wake at three and cannot get back" patient, who needs different help from the "I sleep but it is not restful" patient. Treatment without this distinction is guesswork.
Cognitive Behavioural Therapy for Insomnia (CBT-I) is the gold standard in modern sleep medicine and the first line of treatment for chronic insomnia in international guidelines. It works by restoring the brain's healthy association with the bed, retraining sleep timing, addressing the racing-mind patterns that prevent winding down, and correcting the maintaining behaviours (daytime napping, lying in bed awake, clock-watching at night) that keep insomnia running. The evidence base for CBT-I is strong; it produces outcomes superior to sleeping pills, and the gains last after treatment ends.
Most patients in Pakistan have never even heard of it. They have been prescribed sleeping pills.
Alongside this, where appropriate, I use gentle homoeopathic remedies in the early phase of treatment to ease the most acute symptoms while we build the underlying structure. The role of the remedy here is supportive, not constitutional: it helps the patient through the first weeks while the deeper work of nervous-system retraining takes hold. This is the layered approach that has come to define our practice. Surface first, depth later.
For patients whose insomnia is driven primarily by anxiety or depression, we treat the underlying condition in parallel, because insomnia and these conditions feed each other constantly. Trying to fix one without the other rarely works.
What you can begin tonight
A few things, all of which have actual evidence behind them, none of which require a prescription.
Fix the morning, not the night. The single most powerful intervention for chronic insomnia is exposure to bright daylight within the first hour of waking, ideally outdoors. This sets the circadian clock for the entire day and produces measurable melatonin timing improvements that night. Most patients try to fix sleep at bedtime; the leverage point is actually fourteen hours earlier.
Get out of bed if you cannot sleep. The hardest piece of advice for most patients to follow, and the most effective. If you have been lying in bed awake for more than twenty minutes, get up. Go to another room. Do something calm and unstimulating until you feel sleepy. Then return to bed. This breaks the conditioned association between the bed and struggling, which is what keeps long-term insomnia running.
Anchor the wake time, not the sleep time. The body sleeps better when it wakes at the same time every day, even on weekends. The wake time is the keystone of the sleep system. The sleep time will follow it.
Stop looking at the clock at night. Clock-watching converts every wakeful moment into an anxiety amplifier (now it is 3:14, only three hours of sleep left). Turn the clock to face the wall.
Caffeine cut-off at noon. For most adults with chronic insomnia this single change produces noticeable improvement within ten days.
These will not, on their own, resolve clinical insomnia. But they will quiet the noise enough that proper care, when you seek it, has something to work with.
A closing thought
Sleep is the single most powerful piece of preventive medicine available to any human being, and the most neglected. If you have been struggling for months, please do not accept that this is just how you are now. It is not. Most patients who do the work, in the right order, with the right support, recover real sleep within a few months. They had stopped believing it was possible. It was.
The door of the clinic is open, and the conversation begins with listening.
— Dr. Mohammad Zafar Iqbal MPhil Psychology · DHMS · Mind & Meaning Clinic, Lahore
