Cognitive Behavioral Therapy for Insomnia (CBT-I)
Cognitive Behavioral Therapy for Insomnia (CBT-I) is the first-line treatment for chronic insomnia disorder in adults and should be offered before any pharmacological intervention. 1, 2
What CBT-I Is
CBT-I is a multicomponent behavioral intervention that combines cognitive and behavioral strategies to address the perpetuating factors maintaining chronic insomnia. 1, 3 The treatment must include at least three core elements: sleep restriction therapy, stimulus control, and cognitive therapy, along with education about sleep regulation. 1, 2
Core Components
Sleep restriction therapy limits time in bed to match actual sleep duration, creating mild sleep deprivation that strengthens homeostatic sleep drive and consolidates sleep. 1, 2 Time in bed is initially restricted to average sleep duration from diary data, then gradually adjusted based on sleep efficiency thresholds until sufficient sleep duration is achieved. 1, 4
Stimulus control extinguishes the association between bed/bedroom and wakefulness through specific instructions: (1) go to bed only when sleepy; (2) get out of bed when unable to sleep; (3) use bed only for sleep and sex; (4) wake at the same time daily; (5) avoid daytime napping. 1, 2
Cognitive therapy targets maladaptive thoughts and beliefs about sleep using structured psychoeducation, Socratic questioning, thought records, and behavioral experiments to address dysfunctional beliefs that perpetuate insomnia. 2, 4
Sleep hygiene education provides information about sleep-promoting behaviors but is ineffectual as monotherapy and should only serve as an adjunct to other components. 1, 2 Relaxation procedures may actually be counterproductive and are not essential. 4
Treatment Structure
CBT-I is typically delivered over 4-8 sessions by a trained professional, with sleep diary data collected throughout to monitor progress and guide adjustments. 1, 2 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. 2, 4
Brief Behavioral Therapy for Insomnia (BTI) consists of abbreviated 1-4 session versions emphasizing behavioral components and may be appropriate when resources are limited or patients prefer shorter treatment. 1, 2
Clinical Efficacy
The American Academy of Sleep Medicine analyzed 49 randomized controlled trials demonstrating clinically significant improvements across all critical outcomes. 1
Remission and response rates: 36.0% of CBT-I patients achieved remission compared to 16.9% in control conditions (odds ratio 3.28). 1, 5
Sleep parameters improve substantially:
- Sleep onset latency reduces by 19 minutes 6
- Wake after sleep onset decreases by 26 minutes 6
- Sleep efficiency improves by 9.91% 6
- Sleep quality shows clinically meaningful enhancement 1
These improvements are sustained long-term without need for additional interventions. 1
Effectiveness Across Patient Populations
CBT-I demonstrates moderate to large effect sizes in patients with comorbid psychiatric conditions (depression, PTSD, anxiety) and medical conditions (cancer, fibromyalgia, chronic pain). 1, 7, 5 Effect sizes for insomnia reduction are 0.5 for depression, 1.5 for PTSD, 1.4 for alcohol dependency, and 1.2 for psychosis/bipolar disorder. 7
CBT-I also produces small to medium improvements in comorbid psychiatric symptoms themselves (effect size 0.39), with larger effects on psychiatric conditions compared to medical conditions. 7, 5
Advantages Over Pharmacotherapy
CBT-I provides superior long-term effectiveness with minimal side effects compared to medications. 1 Treatment gains are durable without risk of tolerance or adverse effects associated with pharmacologic approaches. 1, 6, 5
Pharmacologic treatments are intended only for short-term use (4-5 weeks), with unknown long-term adverse effects and risks including cognitive impairment, falls, and fractures. 1, 8 The cost-effectiveness of CBT-I is favorable as it is time-limited with sustained benefits. 1
Critical Implementation Considerations
The principal harms of CBT-I are temporary: daytime fatigue, sleepiness, mood impairment (irritability), and cognitive difficulties during early treatment stages, but these resolve by end of treatment. 1
Sleep restriction therapy is contraindicated in specific populations:
- Those working in high-risk occupations (heavy machinery operators, drivers) 1, 2
- Those predisposed to mania/hypomania 1
- Those with poorly controlled seizure disorders 1
Common Pitfalls to Avoid
Do not offer medications as first-line treatment as this undermines long-term outcomes and creates dependency risk. 2
Do not use sleep hygiene education alone as it is ineffectual as monotherapy and may make patients less receptive to effective behavioral treatments. 2
Do not recommend over-the-counter antihistamines, melatonin, or herbal supplements as these lack efficacy data and carry safety concerns. 2, 8
Monitoring and Follow-Up
Collect sleep diary data before and during treatment to monitor progress. 2, 8 Follow up regularly during initial treatment (every few weeks) until insomnia stabilizes or resolves, then every 6 months to ensure maintenance of treatment gains. 2, 8