CBT-I: Cognitive Behavioral Therapy for Insomnia — Evidence and Mechanisms
CBT-I is the first-line recommended treatment for chronic insomnia; meta-analyses of 80+ RCTs show 50–70% remission rates, superior to hypnotic medications at 6- and 12-month follow-up.
| Measure | Value | Unit | Notes |
|---|---|---|---|
| Remission rate — CBT-I at follow-up | 50–70 | % of patients | Trauer et al. 2015 meta-analysis; chronic insomnia diagnosis; 6–12 month outcomes |
| Wake after sleep onset (WASO) reduction | 55–65 | % reduction | Sleep restriction component; consistent across multiple RCTs |
| Sleep efficiency improvement | +15 | percentage points | Typical gain from ~70% to 85%+ within 6 weeks of CBT-I |
| Superiority over medication at 12 months | Significant | long-term advantage | Morin et al.; medication shows faster short-term gains, CBT-I better at 1 year |
| Standard CBT-I course duration | 6–8 | weeks | 4–8 weekly sessions; digital CBT-I (dCBT-I) shows comparable efficacy |
What CBT-I Treats
Chronic insomnia (≥3 nights/week, ≥3 months) affects 10–15% of adults. Its persistence is maintained by a cycle of: poor sleep → increased arousal about sleep → hypervigilance → bed-wake association → more poor sleep. CBT-I breaks this cycle through behavioral and cognitive interventions rather than pharmacological suppression.
Core Components and Effect Sizes
Sleep Restriction Therapy
The most potent single component. Time in bed is restricted to match actual sleep time (e.g., if average sleep is 5.5h, bed time is limited to 5.5h). This builds homeostatic sleep pressure, improves sleep efficiency, and extinguishes the conditioned arousal that develops when spending hours awake in bed. Once efficiency exceeds 85% for 5 days, time in bed expands by 15-minute increments.
Stimulus Control
Conditioned insomnia: after weeks of lying awake in bed, the bed environment becomes a cue for wakefulness. Rules: go to bed only when sleepy; get out of bed if awake >20 minutes; use bed only for sleep and sex. Reconditioning typically takes 2–4 weeks.
Cognitive Restructuring
Common dysfunctional beliefs:
- “I must get 8 hours or I can’t function”
- “My insomnia is destroying my health”
- “I’ve always been a bad sleeper — nothing will work”
Thought records and Socratic questioning challenge these beliefs. Evidence shows people dramatically overestimate sleep deprivation effects on next-day function (state misperception).
Digital CBT-I (dCBT-I)
App-based and web-based CBT-I programs (e.g., Sleepio, Somryst) show efficacy approaching in-person therapy in RCTs. A 2017 Lancet Psychiatry trial found Sleepio reduced insomnia symptoms significantly more than control and had secondary benefits on depression, anxiety, and daytime functioning. This scales access — a critical issue given that only ~1% of insomnia sufferers ever see a sleep specialist.
Comparison to Pharmacotherapy
| Outcome | CBT-I | Hypnotics |
|---|---|---|
| 4-week response | Slower | Faster |
| 12-month outcomes | Superior | Inferior |
| Dependence risk | None | Moderate–high (BZDs) |
| Rebound insomnia | Minimal | Common |
| Cognitive effects | None | Possible |
Combination therapy (CBT-I + short-term medication) may suit severe cases where sleep restriction is intolerable without pharmacological support in the initial phase.
Related Pages
Sources
- Morin CM et al. — Psychological and behavioral treatment of insomnia: update of the recent evidence. Sleep (2006)
- Trauer JM et al. — Cognitive behavioral therapy for chronic insomnia: a systematic review and meta-analysis. Ann Intern Med (2015)
- Edinger JD & Means MK — Cognitive-behavioral therapy for primary insomnia. Clin Psychol Rev (2005)
- Riemann D et al. — European guideline for the diagnosis and treatment of insomnia. J Sleep Res (2017)
Frequently Asked Questions
What are the core components of CBT-I?
CBT-I has five main components: (1) Sleep restriction therapy — temporarily limiting time in bed to match actual sleep time, building sleep pressure; (2) Stimulus control — using bed only for sleep/sex to re-associate the bedroom with sleepiness rather than wakefulness; (3) Sleep hygiene — addressing behaviors that impair sleep; (4) Cognitive restructuring — challenging dysfunctional beliefs about sleep (catastrophizing, unrealistic expectations); (5) Relaxation techniques — progressive muscle relaxation, imagery, or mindfulness to reduce arousal. Sleep restriction and stimulus control produce the largest effect sizes.
Why is CBT-I recommended over sleeping pills?
Sleep medications work faster short-term but CBT-I shows superior outcomes at 6 and 12 months. Medications don't change the underlying sleep system dysregulation — hyperarousal, circadian misalignment, sleep state misperception — that CBT-I directly addresses. Long-term medication use risks dependence, tolerance, rebound insomnia on cessation, and cognitive side effects (especially benzodiazepines and Z-drugs in older adults). CBT-I produces durable changes in sleep architecture. NICE, AASM, and European sleep guidelines all list CBT-I as first-line treatment.