Cognitive Behavioral Therapy for Insomnia (CBT-I) Treatment Recommendations
Cognitive Behavioral Therapy for Insomnia (CBT-I) should be used as the first-line treatment for chronic insomnia disorder due to its superior long-term efficacy, clinically significant improvements in sleep parameters, and minimal side effects compared to pharmacological options. 1, 2
Core Components of Effective CBT-I
CBT-I is a multicomponent intervention that typically includes:
Sleep restriction therapy - Limits time in bed to match actual sleep duration, enhancing sleep drive and consolidating sleep; shows significant positive effects on insomnia severity (d = -0.45) and improves subjective sleep continuity and quality 2, 3
Stimulus control - Designed to extinguish the association between bed/bedroom and wakefulness; improves self-reported and objective total sleep time 2, 3
Cognitive restructuring - Targets maladaptive thoughts and beliefs about sleep that perpetuate insomnia; significantly increases remission rates (incremental odds ratio 1.68) 2, 4
Sleep hygiene education - While not effective as a standalone treatment, it serves as a useful adjunct when combined with other CBT-I components 1, 5
Treatment Structure and Delivery Options
The American Academy of Sleep Medicine recommends:
Standard CBT-I format - Typically delivered over 4-8 sessions with a trained CBT-I specialist 1, 2
Brief Therapies for Insomnia (BTIs) - Abbreviated versions (1-4 sessions) emphasizing behavioral components; recommended when resources are limited or for patients preferring shorter treatments 1, 2
Delivery modalities - In-person one-on-one delivery is the most widely evaluated and generally considered the most effective (incremental odds ratio 1.83), but other options include group therapy, telephone delivery, and internet-based programs 1, 4
Efficacy and Outcomes
CBT-I demonstrates clinically meaningful improvements in:
Sleep onset latency - Improved by 19.03 minutes (95% CI, 14.12 to 23.93) 6
Wake after sleep onset - Improved by 26.00 minutes (95% CI, 15.48 to 36.52) 6
Sleep efficiency - Improved by 9.91% (95% CI, 8.09% to 11.73%) 6
Remission rates - The most efficacious combination (cognitive restructuring, third-wave components, sleep restriction, and stimulus control in in-person format) shows a number needed to treat of 3.0 (95% CI, 2.3-4.3) 4
Implementation Considerations and Cautions
Sleep diary monitoring - Sleep diary data should be collected before and during treatment to monitor progress and guide adjustments 2
Contraindications - Sleep restriction therapy may be contraindicated in certain populations, including those working in high-risk occupations (e.g., heavy machinery operators, drivers), those predisposed to mania/hypomania, or those with poorly controlled seizure disorders 1, 2
Side effects - Principal harms include temporary daytime fatigue, sleepiness, mood impairment (irritability), and cognitive difficulties (attention problems) during early treatment stages, but these typically resolve by the end of treatment 1
Relaxation techniques - Recent evidence suggests relaxation procedures may be potentially counterproductive as a component of CBT-I (incremental odds ratio 0.81; 95% CI, 0.64-1.02) 4
Advantages Over Pharmacological Treatment
CBT-I provides sustained benefits without the risk of tolerance or adverse effects 2, 6
Produces results equivalent to sleep medication initially, with fewer episodes of relapse and continued improvement after treatment ends 7
Reduces the need for pharmacologic therapy, thereby reducing patient risk of drug-related adverse events 1