Of all the potential issues associated with stress, medical and psychiatric challenges, insomnia may be the most pervasive and distressing. No wonder that so many of us will do anything to help ourselves sleep better when it starts to slip. For many, that means taking a medication or substance that might help sleep, but quite often, these agents cause more problems than they’re worth (more on that later)
Fortunately, there are treatments out there that are readily available, help people fall asleep faster, stay asleep, and feel more rested during the day. In fact, they’re so effective that the American College of Physicians says that they should be the first-line option for anyone experiencing insomnia. However, 8 years after initially making that recommendation, I find the most people with sleep problems have not been offered this treatment or even know about it. T
That’s why I am writing this blog today: to tell you more about the safest, most effective approach to help us all sleep better: Cognitive Behavioral Therapy for Insomnia (CBT-I) is a simple, structured, and evidence-based approach to alleviating insomnia.
Recommendations from the American College of Physicians (ACP)
Since 2016, the American College of Physicians has recommended CBT-I as the first-line treatment for chronic insomnia. Their clinical guidelines include the following key points:
CBT-I should be offered to all adults with chronic insomnia disorder before considering pharmacological treatments.
CBT-I is effective in both the general adult population and older adults with chronic insomnia, leading to improved sleep and daytime functioning.
Non-drug interventions, such as CBT-I, have fewer risks than pharmacological treatments, which can cause dependency and adverse side effects including increased mortality risk.
If CBT-I alone is insufficient, short-term pharmacologic therapy can be considered, but should ideally not exceed four weeks.
Sleep medications may be associated with serious risks, including cognitive impairment, dependence, and increased risk of falls, especially in older adults. Therefore, they should be used cautiously and as a last resort.
CBT-I can also improve comorbid psychiatric disorders, such as depression, anxiety, and PTSD, making it a beneficial holistic treatment approach
How Does CBT-I Work?
CBT-I focuses on exploring the connection between the way we think, the things we do, and how we sleep. During treatment, a trained CBT-I provider helps to identify thoughts, feelings, and behaviors that are contributing to the symptoms of insomnia.
Thoughts and feelings about sleep are examined and tested to see if they’re accurate, while behaviors are examined to determine if they promote sleep. A provider will then clarify or reframe misconceptions and challenges in a way that is more conducive to restful sleep. Treatment often takes from 5-8 sessions, although the length may differ depending on a person’s needs and can be incorporated into current treatment.
Core Components of CBT-I
Sessions may include cognitive, behavioral, and educational components:
Cognitive interventions: Cognitive restructuring attempts to change inaccurate or unhelpful thoughts about sleep (and sleeplessness, which research shows is not as harmful as most of us think).
Behavioral interventions: Stimulus control (which means the only thing we try to do in bed is sleep), sleep restriction (decreasing the time we spend in bed to improve sleep efficiency and restfulness), and incorporating relaxation techniques help to establish healthy pre-sleep habits.
Psychoeducational interventions: Providing information about the connection between thoughts, feelings, behaviors and sleep is central to CBT I
Effectiveness of CBT-I
When these techniques are used together as multicomponent CBT-I, as many as 70% to 80% of patients with primary insomnia experience improvements. Benefits include less time to fall asleep, more time spent asleep, and waking up less during sleep. Results are often maintained for months or years after the intervention, in stark contrast with medication for sleep which tend to work less effectively over time and stop working immediately upon stopping them (including causing withdrawal effects).
The ACP based its recommendations on extensive reviews of randomized controlled trials and psychological, behavioral, and pharmacological therapies for chronic insomnia. Their guidelines emphasize that while medication may sometimes be necessary, CBT-I provides better overall long-term value due to its noninvasive nature and effectiveness.
Getting Started with CBT-I
The first thing I do with any patient who is having trouble with insomnia, is to review principles of CBT I along with barriers to implementation. We then create a plan to begin implementing them. Discussing CBT I with your medical or mental health provider or asking a referral to a CBT I specialist is a good first step.
To learn more about CBT I on your own, I recommend the book “Say Good Night to Insomnia” by Gregg Jacobs which outlines the most typical multifaceted CBT I approach with the strongest evidence-base.
I also recommend a book that I find complements Dr. Jacobs’ book well: “Sound Sleep, Sound Mind” by Barry Kraków, MD. In the book, Dr. Kraków introduces the concept of the "Sleep Dynamic Therapy," a multi-faceted approach that addresses thoughts, behaviors, and physical sensations affecting sleep. The book provides practical strategies such as cognitive restructuring, breathing exercises, and relaxation techniques including practicing guided imagery exercises before bedtime, allowing their mind to shift from anxious thoughts to peaceful visualization. He also advocates using progressive muscle relaxation.
Several digital CBT-I (sometimes called dCBT-I) applications have been developed in order to adapt to this trend, reduce the cost of treatment, and offer the benefits of bringing CBT-I to a wider audience. The Department of Veterans Affairs offers their own app, called CBT-I Coach, that is appropriate for non-veterans and veterans alike. I also commonly recommend the “Insight Timer” app which is free and has a number of sleep-related programs an guided meditations to allow each person to customize an approach that works well for them.
Final Thoughts
There is no doubt that insomnia can have a significant, debilitating impact on one’s quality of life. And while medications that cause sleepiness can be a temporary solution, they also carry significant risks and side effects, especially long-term. Fortunately, CBT-I offers a proven, effective solution for those sleepless nights. By addressing inaccurate sleep-related thoughts, modifying sleep-related behaviors, and improving sleep hygiene practices, CBT-I empowers individuals to dramatically improve their sleep.
I strongly agree with the recommendations from the ACP: individuals struggling with chronic insomnia should consider CBT-I as a primary treatment option and generally avoid sleep medications. If you or someone you know is struggling with insomnia, CBT-I may be the key to achieving restful and restorative sleep.