CBT-I: The First-Line Treatment for Insomnia

What CBT-I is

Cognitive behavioral therapy for insomnia, or CBT-I, is a specific type of cognitive behavioral therapy that addresses the thoughts and behaviors that keep you from sleeping well and teaches new strategies to sleep better. [1] The NHLBI describes it as a 6- to 8-week treatment plan, usually recommended as the first treatment option for long-term insomnia. [2] This page is an overview; it is not a substitute for working with a trained provider.

Why it is called first-line

Established recommendation. The American College of Physicians recommends that all adults receive CBT-I as the initial treatment for chronic insomnia disorder, graded as a strong recommendation with moderate-quality evidence. [3] The American Academy of Sleep Medicine's patient page says CBT-I is recommended for chronic insomnia disorder in adults. [1] The NIH's complementary health center also calls multicomponent CBT-I the most strongly recommended insomnia treatment. [4]

What research shows

1. Does CBT-I improve sleep in adults with chronic insomnia?

   Established recommendation

   A meta-analysis of 20 randomized trials (1,162 people) found time to fall asleep improved by about 19 minutes and time awake after falling asleep by about 26 minutes. [5]

2. Does it last?

   Promising

   Changes seemed to be sustained at later time points, though estimates were less clear. [5]

3. Harms?

   Limited reporting

   No adverse outcomes were reported in that review. [5]

4. Does it apply to insomnia with other conditions?

   Insufficient evidence from this source

   That review excluded insomnia alongside medical, sleep or psychiatric disorders, so its applicability there is less clear. [5]

In that review total sleep time improved by only about 8 minutes, a result that was not statistically clear. [5]

The parts of CBT-I

• Cognitive therapy helps you feel less nervous about not being able to sleep. [2]
• Relaxation or meditation therapy teaches you how to relax and fall asleep faster. [2]
• Sleep education helps you learn good sleep habits. [2] See Sleep hygiene.
• Sleep restriction therapy gives you a specific amount of time to spend in bed, even if you cannot sleep during this time. With time this helps you sleep better, and the time is increased as sleep improves. [2]
• Stimulus control therapy helps you have a regular sleep-wake cycle so you link bed with sleep: go to bed only when sleepy, get out of bed if you cannot sleep, and use the bed only for sleep and sexual activity. [2]

How it is delivered

CBT-I can be done by a doctor, nurse or therapist, in person, by telephone or online. [2] In the UK, the NHS offers CBT for sleep problems such as insomnia, and a GP may offer it face to face or through an online self-help program. [6][7] NHS CBT usually involves 5 to 15 sessions depending on what it is for, with practice between sessions. [6] Ask a clinician for a referral to a provider trained specifically in CBT-I.

How CBT-I compares with other options

Medicines and supplements are covered in Insomnia, Melatonin and Natural sleep aids compared. Breathing and relaxation techniques are usually part of CBT-I; see Relaxation, breathing and mindfulness for sleep. The full therapy explanation will also live in the Therapies section when it is built; see Therapies.