CBT-I as First-Line Treatment for Chronic Insomnia
Cognitive Behavioral Therapy for Insomnia (CBT-I) is the recommended first-line treatment for chronic insomnia disorder, with a strong recommendation from the Veterans Administration/Department of Defense guidelines and the American Academy of Sleep Medicine. 1, 2
Why CBT-I Should Be Offered First
CBT-I should be prioritized over pharmacotherapy as initial treatment due to superior long-term efficacy, sustained benefits without tolerance or adverse effects, and clinically meaningful improvements in sleep parameters. 1, 2, 3
The evidence demonstrates:
- Sleep onset latency improves by 19 minutes 4
- Wake after sleep onset improves by 26 minutes 4
- Sleep efficiency improves by 9.91% 4
- Benefits are sustained for up to 2 years 3
Critical Components That Must Be Included
Effective CBT-I must include at least three of the following core components: sleep restriction therapy, stimulus control, cognitive restructuring, and sleep hygiene education. 2, 5
The most recent and highest quality evidence identifies the critical active ingredients:
- Cognitive restructuring (incremental odds ratio 1.68) - addresses maladaptive thoughts about sleep 6
- Sleep restriction therapy (incremental odds ratio 1.49) - limits time in bed to match actual sleep duration, creating mild sleep deprivation that strengthens homeostatic sleep drive 2, 6
- Stimulus control (incremental odds ratio 1.43) - strengthens the association between bed/bedroom and sleep by going to bed only when sleepy and using bed only for sleep and sex 2, 6
- Third-wave components (incremental odds ratio 1.49) such as mindfulness-based strategies 6
Sleep hygiene education alone is ineffective as monotherapy and should only serve as an adjunct to other components. 1, 2, 7
Relaxation procedures may be counterproductive (incremental odds ratio 0.81) and are not essential. 6
Treatment Structure and Delivery
Standard CBT-I is typically delivered over 4-8 sessions with a trained CBT-I specialist, using sleep diary data throughout treatment to monitor progress. 2, 5
In-person one-on-one delivery is most effective (incremental odds ratio 1.83), though telehealth and group formats can increase access when resources are limited. 5, 6
Brief Behavioral Therapy for Insomnia (1-4 sessions) emphasizing behavioral components can be offered when resources are limited or patients prefer shorter treatments. 2, 5
Efficacy in Special Populations
CBT-I is effective for insomnia comorbid with psychiatric disorders, with moderate to large effect sizes: 1, 8
- Depression: effect size 0.5 for insomnia severity 8
- PTSD: effect size 1.5 for insomnia severity 8
- Alcohol dependency: effect size 1.4 for insomnia severity 8
CBT-I is particularly suitable for older adults, providing sustained benefits without the risk of falls, cognitive impairment, or adverse effects associated with medications. 2
When Pharmacotherapy May Be Considered
Medications should only be considered as second-line treatment when patients are unable to participate in CBT-I, still have symptoms despite CBT-I, or as a temporary adjunct during CBT-I. 3
If short-term pharmacotherapy is offered:
- Low-dose doxepin (3 mg or 6 mg) for sleep maintenance 1
- Nonbenzodiazepine benzodiazepine receptor agonists for sleep onset and maintenance 1
Critical Pitfalls to Avoid
Do not offer medications as first-line treatment, as this undermines long-term outcomes and creates dependency risk. 3
Do not use over-the-counter antihistamines (diphenhydramine), melatonin, or herbal supplements (valerian, chamomile) - these lack efficacy data and carry safety concerns including daytime sedation and delirium risk in older adults. 1, 3
Do not use sleep hygiene education as stand-alone treatment - it is insufficient for chronic insomnia and may make patients less receptive to effective behavioral treatments. 1, 2, 5
Do not use kava (strong recommendation against). 1
Implementation Considerations
Sleep diary data must be collected before and during treatment to monitor progress and guide adjustments. 5
Sleep restriction therapy may be contraindicated in patients working in high-risk occupations, those predisposed to mania/hypomania, or those with poorly controlled seizure disorders. 2, 5
Temporary daytime fatigue, sleepiness, mood impairment, and cognitive difficulties may occur during early treatment stages but typically resolve by the end of treatment. 5
The most efficacious combination - cognitive restructuring, third-wave components, sleep restriction, and stimulus control delivered in-person - increases remission rate by 33% with a number needed to treat of 3.0. 6