CBT-I as First-Line Treatment for Insomnia
Cognitive Behavioral Therapy for Insomnia (CBT-I) is the mandatory first-line treatment for chronic insomnia disorder in adults, and should be offered before any pharmacological intervention. 1, 2
Why CBT-I Must Come First
The American Academy of Sleep Medicine issues a STRONG recommendation for multicomponent CBT-I based on 49 high-quality studies demonstrating clinically meaningful improvements in remission rates, sleep quality, sleep latency, and wake after sleep onset. 1 This recommendation applies equally to:
- Patients with insomnia alone 1
- Patients with comorbid psychiatric conditions (depression, PTSD, anxiety) 1, 3
- Patients with comorbid medical conditions 1
The evidence shows moderate to large effect sizes: insomnia severity improves by 0.5-1.5 standard deviations depending on comorbidity, with sustained benefits up to 2 years without risk of tolerance, dependence, or adverse effects that plague pharmacotherapy. 3, 4
Core Components That Must Be Included
Effective CBT-I requires at least 3 of these 5 evidence-based components delivered over 4-8 sessions: 1, 2, 5
- Sleep Restriction Therapy: Limit time in bed to match actual sleep duration (minimum 5 hours), then adjust weekly based on sleep efficiency >85% 1, 2
- Stimulus Control: Go to bed only when sleepy, use bed only for sleep/sex, leave bed if awake >20 minutes, maintain regular wake time 1, 2
- Cognitive Therapy: Address dysfunctional beliefs about sleep using Socratic questioning and behavioral experiments 1, 2
- Sleep Hygiene Education: Adjunct only—never as standalone treatment 1, 6
- Relaxation Training: Progressive muscle relaxation to reduce somatic arousal 1
Treatment Structure and Delivery
Standard CBT-I format: 4-8 sessions with a trained specialist, using sleep diary monitoring throughout to guide adjustments. 2, 7 In-person one-on-one delivery is most effective (odds ratio 1.83). 7
Brief Behavioral Therapy for Insomnia (1-4 sessions) can be offered when resources are limited or patients prefer shorter treatment, though it emphasizes behavioral components over cognitive restructuring. 1, 7
Critical Contraindications for Sleep Restriction
Do not use sleep restriction therapy in: 2, 7
- High-risk occupations (pilots, truck drivers, heavy machinery operators)
- Patients predisposed to mania/hypomania
- Poorly controlled seizure disorders
When Pharmacotherapy May Be Considered (Second-Line Only)
Medications should only be considered after CBT-I has failed, patient cannot participate in CBT-I, or as temporary adjunct during CBT-I. 6 If medications are necessary:
- First choice: Low-dose doxepin (3-6 mg) for sleep maintenance 1
- Alternative: Nonbenzodiazepine BzRAs (eszopiclone, zolpidem, zaleplon) for short-term use only 1, 6
- Sleep onset only: Ramelteon 1, 6
What NOT to Do: Common Pitfalls
The American Academy of Sleep Medicine explicitly recommends AGAINST: 1, 6
- Diphenhydramine or other antihistamines (weak against)
- Melatonin (weak against—insufficient evidence)
- Valerian and chamomile (weak against)
- Kava (STRONG against)
- Sleep hygiene education as standalone treatment (weak against)
- Long-term pharmacotherapy without concurrent behavioral interventions 6
Never offer medications as first-line treatment—this undermines long-term outcomes and creates dependency risk. 2
Expected Outcomes and Monitoring
CBT-I produces clinically significant improvements: 1, 4
- Sleep onset latency: 19 minutes improvement
- Wake after sleep onset: 26 minutes improvement
- Sleep efficiency: 9.91% improvement
- Total sleep time: 7.6 minutes improvement (modest but meaningful)
Collect sleep diary data before and during treatment, with regular follow-up until insomnia stabilizes, then every 6 months. 2 Temporary daytime fatigue and sleepiness may occur during early treatment but typically resolve by treatment end. 7
Special Consideration for Anxiety Disorders
CBT-I demonstrates medium effect sizes (0.5) for reducing anxiety symptoms in patients with comorbid generalized anxiety disorder, with larger effects in younger patients with moderate baseline anxiety. 8 The anxiolytic effect operates through reducing perceived insomnia severity and rumination in response to fatigue. 8
For patients with PTSD and comorbid insomnia, CBT-I shows particularly robust effects with effect sizes of 1.3-1.5 for both insomnia and PTSD symptom reduction. 3