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CBT-I for insomnia

Cognitive behavioural therapy for insomnia (CBT-I) is a structured, multicomponent programme combining cognitive work around sleep with behavioural methods such as stimulus control and sleep restriction. In randomised trials of adults living with long-term insomnia symptoms it shortened time to fall asleep and time awake at night, including when delivered over the internet and alongside other health conditions, and major clinical guidelines recommend it as the first approach. Sleep restriction can bring temporary daytime sleepiness in the first weeks.

Evidence retrieved up to

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5 research claims

Marks

What the research shows

In randomised trials of adults living with long-term insomnia symptoms, multicomponent CBT-I shortened the time taken to fall asleep and reduced time awake during the night compared with inactive comparisons, with changes that appeared to last after the programme ended.

No known concerns at usual amountsBenefit

Who this is about

adults living with chronic insomnia symptoms without other medical, sleep or psychiatric conditions

Details and sources

Practical note

Graded moderate: a 2015 meta-analysis of 20 randomised trials (1162 participants) found consistent improvements in sleep diary measures (about 19 minutes faster sleep onset, 26 minutes less time awake after sleep onset, sleep efficiency up about 10 percentage points); downgraded one level because participants and therapists cannot be blinded and outcomes were self-reported. Total sleep time did not change significantly, and later follow-up estimates were less precise. Programmes combined at least three of cognitive therapy, stimulus control, sleep restriction, sleep hygiene and relaxation.

Safety note

Sleep restriction, a usual CBT-I component, can bring short-term daytime sleepiness and slower reactions in the first weeks; the trials and guidelines describe CBT-I delivered or overseen by trained practitioners, and persistent sleep problems are best discussed with a health professional.

Sources

Clinical practice guidelines from the American College of Physicians and the American Academy of Sleep Medicine recommend multicomponent CBT-I as the first approach for adults living with chronic insomnia, based on systematic reviews graded with GRADE methods.

No known concerns at usual amountsBenefit

Who this is about

adults living with chronic insomnia symptoms

Details and sources

Practical note

Graded moderate, matching the American College of Physicians' own rating of moderate-quality evidence behind a strong recommendation; the American Academy of Sleep Medicine also issued a strong recommendation. The same AASM guideline advises against sleep hygiene education on its own as a single-component approach.

Safety note

Sleep restriction, a usual CBT-I component, can bring short-term daytime sleepiness and slower reactions in the first weeks; the trials and guidelines describe CBT-I delivered or overseen by trained practitioners, and persistent sleep problems are best discussed with a health professional.

Sources

In randomised trials of adults with insomnia symptoms alongside a psychiatric or medical condition, CBT-I improved self-reported sleep onset, time awake, sleep efficiency and sleep quality, more participants no longer met insomnia criteria afterwards, and symptoms of the accompanying condition improved slightly to moderately.

No known concerns at usual amountsBenefit

Who this is about

adults living with insomnia symptoms alongside a psychiatric or medical condition

Details and sources

Practical note

Graded moderate: a 2015 meta-analysis of 37 randomised trials found 36.0% of CBT-I participants versus 16.9% of comparison participants no longer met insomnia criteria after the programme; downgraded one level for risk of detection and performance bias, which the authors flag. Effects on the accompanying condition were larger for psychiatric than medical conditions; total sleep time did not change significantly.

Safety note

Sleep restriction, a usual CBT-I component, can bring short-term daytime sleepiness and slower reactions in the first weeks; the trials and guidelines describe CBT-I delivered or overseen by trained practitioners, and persistent sleep problems are best discussed with a health professional. People with another health condition are best supported by the practitioner who knows that condition.

Sources

Internet-delivered CBT-I programmes improved insomnia severity, sleep onset, time awake and sleep quality in randomised trials of adults with insomnia symptoms, with effects comparable to face-to-face CBT-I and generally maintained at follow-up.

No known concerns at usual amountsBenefit

Who this is about

adults living with insomnia symptoms

Details and sources

Practical note

Graded moderate: a 2016 meta-analysis of 11 randomised trials (1460 participants) found benefits on every sleep outcome measured; downgraded one level for risk of bias (no blinding, and higher dropout in intervention groups was linked to smaller effects). Longer programmes and more personal clinical support were associated with larger effects. The American College of Physicians notes CBT-I can also be delivered in groups, by telephone or through self-help books.

Safety note

Sleep restriction, a usual CBT-I component, can bring short-term daytime sleepiness and slower reactions in the first weeks; the trials and guidelines describe CBT-I delivered or overseen by trained practitioners, and persistent sleep problems are best discussed with a health professional.

Sources

During the first weeks of sleep restriction, a usual component of CBT-I, adults with insomnia symptoms slept less as measured in the laboratory and showed more daytime sleepiness and slower reactions, which returned to baseline by three months.

Take care: see the safety noteRisk

Who this is about

adults living with insomnia symptoms who are starting sleep restriction

Safety note

The study authors draw implications for the safe delivery of CBT-I; temporary sleepiness matters most for driving and other safety-critical tasks during the early weeks of sleep restriction.

Details and sources

Practical note

Graded very low: a single uncontrolled study of 16 adults (starts low as non-randomised, downgraded for imprecision). Laboratory-measured sleep fell by an average of 69 to 91 minutes on the measured nights in the first three weeks, while self-reported sleep and insomnia severity improved over the programme.

Sources