The first-line treatment for insomnia is not a tablet
Cognitive behavioural therapy for insomnia is a structured course of four to eight sessions that addresses the behaviours and beliefs keeping insomnia going. It is the guideline first-line treatment for chronic insomnia in adults.
What CBT-I actually is
Cognitive behavioural therapy for insomnia is a structured, time-limited course combining education about how sleep is regulated with behavioural strategies, usually stimulus control and sleep restriction, and cognitive work on the beliefs that keep insomnia running. Relaxation techniques are sometimes added.
It is not a sleep-hygiene leaflet. The AASM’s 2021 guideline gives a strong recommendation for multicomponent CBT-I in adults with chronic insomnia, and separately suggests against using sleep hygiene on its own as a treatment. Sleep hygiene is embedded in the course; it is not the course.
What a course involves
A typical course runs four to eight weekly sessions. There is no single mandated curriculum, but standard protocols move through roughly this sequence:
- Assessment and a sleep diary kept for one to two weeks, including ruling out other sleep disorders that need treating first.
- Sleep restriction, which means prescribing a time-in-bed window close to the sleep you are actually getting, then widening it as efficiency improves.
- Stimulus control: the bed is for sleep only, you get up if you cannot sleep, the rise time stays fixed, and you stop watching the clock.
- Cognitive work on unhelpful beliefs about sleep and on daytime catastrophising.
- Relaxation or wind-down strategies where arousal is prominent.
- Relapse prevention: what to do after a bad night.
Sleep restriction is the part people find hardest, and it is worth knowing in advance that the first fortnight often feels worse before it gets better.
Against sleeping pills
The American College of Physicians recommends CBT-I as the initial treatment for chronic insomnia in adults, with medication considered where it is unavailable or has not worked, through shared decision-making and generally short-term.
Be careful with the stronger version of that claim. The College noted the evidence was insufficient for a direct head-to-head ranking against specific drugs, so “better than pills” overstates what was actually concluded. The defensible statement is that the therapy is first-line, its benefits persist after treatment ends in a way that drug trials generally do not demonstrate, and medicines are adjuncts or alternatives rather than the starting point.
Delivered remotely
A randomised trial of 60 adults compared six to eight weekly sessions by video against the same course in person and against a waiting list. Insomnia severity improved by 7.8 points in person and 7.5 by video, against 1.6 for the waiting list, meeting the study’s threshold for non-inferiority. It is a small trial, but it supports remote delivery where travel is the barrier.
Been on a sleeping tablet for longer than anyone intended?
Worth a conversation about what else is available and how to come off it safely. Do not stop on your own.
Call (614) 898-9340Sources
- Edinger JD et al. Behavioral and psychological treatments for chronic insomnia disorder in adults: an AASM clinical practice guideline. J Clin Sleep Med 2021;17(2):255–262. https://aasm.org/new-guideline-supports-behavioral-psychological-treatments-for-insomnia/
- Qaseem A et al. Management of chronic insomnia disorder in adults: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2016. https://www.acpjournals.org/doi/10.7326/m15-2175
- Arnedt JT et al. Telemedicine-delivered CBT-I versus in-person: a randomised non-inferiority trial. J Clin Psychiatry 2021. https://doi.org/10.4088/jcp.20m13723