Insomnia: what CBT-I is and why it is first-line treatment
Sleep
Key points
- CBT-I is first-line treatment for chronic insomnia (ACP 2016; European guideline 2017).
- Meta-analysis: falling asleep about 19 minutes faster and about 26 minutes less time awake at night.
- Components: sleep restriction, stimulus control, working with thoughts, sleep hygiene, relaxation.
- Available in person, online and through digital programs.
What chronic insomnia is
Chronic insomnia means trouble falling or staying asleep, or waking too early, at least 3 nights a week for at least 3 months, with daytime consequences such as fatigue, irritability or poor concentration. It affects roughly 10% of adults.
What the guidelines recommend
The American College of Physicians recommends CBT-I as the initial treatment for chronic insomnia in adults, before medication (Qaseem et al., 2016). The European guideline for insomnia makes the same recommendation (Riemann et al., 2017).
A meta-analysis of randomized trials found that CBT-I shortened the time to fall asleep by about 19 minutes, reduced time awake after falling asleep by about 26 minutes and improved sleep efficiency by about 10 percentage points (Trauer et al., 2015).
What CBT-I involves
- Sleep restriction: temporarily limiting time in bed to your actual sleep time to strengthen sleep drive.
- Stimulus control: using the bed only for sleep and sex; getting up if you cannot sleep.
- Cognitive work: changing worries and beliefs about sleep that keep you awake.
- Sleep hygiene: regular schedule, less caffeine and alcohol, a dark, quiet bedroom.
- Relaxation techniques.
Where to get CBT-I
- A psychologist or therapist trained in behavioral sleep medicine (the Society of Behavioral Sleep Medicine has a directory).
- Your primary care doctor or a sleep clinic.
- Digital CBT-I programs, some covered by insurance.
Why not just sleeping pills
Sleeping pills can help in the short term, but they carry risks such as next-day drowsiness, falls and dependence, and insomnia usually returns when they are stopped. CBT-I teaches skills that keep working after treatment ends.
Frequently asked questions
How long does CBT-I take?
Usually 4 to 8 weekly sessions. Many people notice improvement within a few weeks.
Is there a free CBT-I app?
The U.S. Department of Veterans Affairs offers a free app called CBT-i Coach, designed to be used alongside therapy but available to anyone.
Sources
- Qaseem et al. (2016). Management of Chronic Insomnia Disorder in Adults: A Clinical Practice Guideline From the American College of Physicians. Annals of Internal Medicine 165(2):125-133. doi:10.7326/M15-2175
- Riemann et al. (2017). European guideline for the diagnosis and treatment of insomnia. Journal of Sleep Research 26(6):675-700. doi:10.1111/jsr.12594
- Trauer et al. (2015). Cognitive Behavioral Therapy for Chronic Insomnia. Annals of Internal Medicine 163(3):191-204. doi:10.7326/M14-2841
Keep reading
Sleep Sleeping through stressful times: how to recover when nights are restless
How stress, emergencies and anxious news cycles disrupt sleep, and habits that help you recover: a steady wake time, daylight, limiting news and relaxation.
Sleep Napping: how long to nap for real benefits
Why a 10- to 20-minute nap boosts alertness without grogginess, what experiments show about nap length and the best time of day to nap.
Sleep Caffeine and sleep: how many hours before bed to stop
How much caffeine shortens and lightens sleep, the cutoff time recommended by a 2023 meta-analysis and how much caffeine is in common drinks.
Related topics from other pillars
Sleeping pills and sedatives: risks you should know
What a BMJ meta-analysis found about sleeping pills in older adults, why risks often outweigh benefits and what guidelines recommend instead.
StressProgressive muscle relaxation: a simple technique for anxiety
What progressive muscle relaxation is, what a meta-analysis found about relaxation training for anxiety and a step-by-step 10- to 15-minute routine.
Physical ActivityExercise and sleep: how physical activity helps you sleep
What a meta-analysis of 66 studies found about exercise, sleep duration and sleep quality, and whether evening workouts keep you awake.
Sleep tools
How much sleep do you need? Recommendations by age
Recommendations from the American Academy of Sleep Medicine and the National Sleep Foundation.
QuizSocial jet lag calculator
The difference in your sleep midpoint between workdays and days off.
QuizWhen should you stop drinking coffee? Calculator
According to a meta-analysis, have a regular coffee at least about 8.8 hours before bed.
PDF · DiaryTwo-week sleep diary
Record bedtime, wake time, awakenings, caffeine, alcohol and how you feel.
PDF · TrackerMonthly 24-hour sleep tracker
A visual sleep rhythm tracker that shows your schedule and social jet lag.
PDF · ChecklistBedtime routine checklist
A step-by-step wind-down routine with a weekly tracker.