What are the steps for the psychological treatment of insomnia?

Psychological Treatment Steps for Insomnia

Cognitive Behavioral Therapy for Insomnia (CBT-I) should be the first-line treatment for all adults with chronic insomnia, delivered over 4-8 sessions before considering any pharmacological intervention. 1, 2

Step 1: Initial Assessment and Sleep Diary Collection

• Collect sleep diary data for 1-2 weeks before starting treatment to establish baseline sleep patterns, including sleep onset latency, wake after sleep onset, total sleep time, and sleep efficiency 2, 3
• Confirm diagnosis of chronic insomnia: difficulty initiating or maintaining sleep occurring at least 3 nights per week for at least 3 months, causing clinically significant distress or impairment 1
• Polysomnography is not indicated for uncomplicated chronic insomnia and should be reserved for cases where other sleep disorders are suspected 2

Step 2: Implement Multicomponent CBT-I (Standard Approach)

CBT-I must include the following core behavioral and cognitive components delivered together: 1, 2

Sleep Restriction Therapy

• Limit time in bed to match the patient's actual average sleep duration from their sleep diary 1, 2
• Calculate initial time in bed prescription: if patient sleeps 5 hours but spends 8 hours in bed, restrict time in bed to 5 hours (minimum 5 hours) 1
• Adjust weekly based on sleep efficiency thresholds: if sleep efficiency >85%, increase time in bed by 15-30 minutes; if <80%, decrease by 15-30 minutes 2, 3
• Caution: Sleep restriction is contraindicated in patients with poorly controlled seizure disorders, bipolar disorder at risk for mania, or those working in high-risk occupations requiring alertness 2

Stimulus Control Therapy

• Go to bed only when sleepy, not by the clock 1, 2
• Get out of bed when unable to sleep within 15-20 minutes and return only when sleepy 1, 3
• Use the bed and bedroom for sleep and sex only—no reading, watching television, or using electronic devices in bed 1, 2
• Wake up at the same time every morning regardless of sleep quality 1
• Eliminate daytime napping 1, 2

Cognitive Therapy

• Identify and challenge dysfunctional beliefs about sleep using structured psychoeducation, Socratic questioning, and thought records 1, 2
• Target common maladaptive cognitions such as catastrophizing about consequences of poor sleep, unrealistic sleep expectations, and performance anxiety about sleeping 1, 2
• Use behavioral experiments to test and modify unhelpful beliefs measured by the Dysfunctional Beliefs and Attitudes About Sleep (DBAS) scale 1, 2

Relaxation Training

• Teach structured exercises to reduce somatic tension (progressive muscle relaxation, abdominal breathing, autogenic training) and cognitive arousal (guided imagery, meditation) 1

Sleep Hygiene Education

• Address environmental factors (light, noise, temperature) and lifestyle behaviors (caffeine, alcohol, exercise timing) that affect sleep 1
• Important: Sleep hygiene alone is insufficient as monotherapy and must be combined with other CBT-I components 2, 4

Step 3: Alternative Delivery When Resources Are Limited

Brief Behavioral Therapy for Insomnia (BBT) can be offered when full CBT-I is unavailable or patients prefer shorter treatment: 1, 2

• Deliver abbreviated version in 1-4 sessions emphasizing behavioral components (stimulus control and sleep restriction) 1
• Include education about sleep regulation and tailored behavioral prescription based on pretreatment sleep diary 1
• May include brief relaxation or cognitive therapy elements but focuses primarily on behavioral interventions 1

Alternative delivery modalities with demonstrated efficacy: 1

• Internet-based CBT-I programs 1
• Telephone-delivered CBT-I 1
• Group therapy format 1
• Self-help books with therapist guidance 1

Step 4: Monitoring and Adjustment

• Continue collecting sleep diary data throughout treatment to guide weekly adjustments to sleep restriction parameters 1, 2
• Reassess every 2-4 weeks until insomnia stabilizes or resolves 2, 3
• Monitor for improvements in sleep efficiency (target >85%), total sleep time, sleep quality, and daytime functioning 1, 3
• Follow up regularly during active treatment, then every 6 months once stable 2, 4

Step 5: Special Populations and Comorbidities

CBT-I is effective for insomnia with psychiatric and medical comorbidities: 2, 5

• For insomnia with depression: CBT-I produces moderate to large effect sizes (0.5) on insomnia severity and improves depressive symptoms (0.5) 5
• For insomnia with PTSD: CBT-I produces large effect sizes (1.5) on insomnia severity and improves PTSD symptoms (1.3) 5
• For insomnia with alcohol dependency: CBT-I produces large effect sizes (1.4) on insomnia severity 5
• Use the same core CBT-I components without modification for comorbid conditions 2

Common Pitfalls to Avoid

• Never use sleep hygiene education as a stand-alone treatment—it lacks efficacy as monotherapy and should only serve as an adjunct 2, 6
• Do not offer medications as first-line treatment—this undermines long-term outcomes and creates dependency risk 2
• Avoid over-the-counter antihistamines, melatonin, or herbal supplements—these lack efficacy data and carry safety concerns 2, 4
• Do not skip sleep restriction therapy due to patient concerns—it is a critical component that enhances sleep drive and consolidates sleep 2
• Never add multiple sedating medications simultaneously if pharmacotherapy becomes necessary, as this increases daytime sedation risk 3

When to Consider Pharmacotherapy

Pharmacotherapy should only be considered after CBT-I has been unsuccessful, is unavailable, or the patient cannot participate: 4

• If adding medication, continue CBT-I throughout drug tapering to prevent relapse 6
• Preferred non-narcotic options include low-dose doxepin (3-6 mg) for sleep maintenance insomnia 4
• Benzodiazepine receptor agonists carry significant risks, particularly in older adults, and should be used cautiously and short-term 4

Expected Outcomes

CBT-I produces clinically meaningful improvements sustained for up to 2 years: 4, 7

• Sleep onset latency improves by 19 minutes 7
• Wake after sleep onset improves by 26 minutes 7
• Sleep efficiency improves by 9.91% 7
• 70-80% of patients achieve significant improvement 8
• Benefits persist without risk of tolerance, dependence, or adverse effects inherent to medications 4, 7