Cognitive behavioral therapy for insomnia in adults

INTRODUCTION — Cognitive behavioral therapy for insomnia (CBT-I) is a multicomponent treatment for chronic insomnia disorder that aims to identify and target the multiple cognitive and behavioral factors that lead to the chronic nature of disrupted sleep. CBT-I is the mainstay of nonpharmacologic therapy for insomnia disorder and is preferred over medications as first-line therapy for chronic insomnia.

This topic reviews the conceptual basis, components, and delivery of CBT-I and other behavioral treatments for insomnia in adults. An overview of the treatment of insomnia and pharmacologic therapies for insomnia are presented separately. (See "Overview of the treatment of insomnia in adults" and "Pharmacotherapy for insomnia in adults".)

THEORETICAL FRAMEWORK — Insomnia disorder, once conceptualized as a common secondary symptom of other conditions, is now viewed as an independent sleep disorder worthy of clinical attention, even in the context of comorbidities [1,2]. Two core conceptual frameworks underlie the rationale for treatment of insomnia disorder with cognitive behavioral therapies (CBTs). The theories are not mutually exclusive and provide a conceptual framework for the development and treatment of insomnia.

●Predisposing, precipitating, and perpetuating factors – One theory suggests that insomnia develops in some individuals as a result of predisposing, precipitating, and perpetuating factors (table 1) [3]. Predisposing factors are conceptualized as risk factors and may include genetic risk, early life experiences, and some chronic comorbidities. Precipitating events are life events that lead to an acute disruption in sleep, such as an illness, injury, or symptom exacerbation; a change in social factors, such as living situation or marital status; or a traumatic event. Multicomponent CBT-I directly addresses perpetuating factors, which are believed to be the source of ongoing, chronic sleep-related problems.

●Conditioned arousal and sleep-related hyperarousal – A second theory is the development of a classically conditioned response to the sleep environment such that the bed and bedroom are associated with anxiety, alertness, and arousal rather than with sleepiness or sleep onset (figure 1). Stimulus control therapy is used to "unlearn" the association between the sleep environment and sleeplessness. (See 'Stimulus control therapy' below.)

BASELINE EVALUATION

Diagnostic confirmation — Insomnia disorder is a clinical diagnosis based on patient interview and history. The International Classification of Sleep Disorders, Third Edition, Text Revision (ICSD-3-TR) (table 2) [4] and the Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition (DSM-5) [5] use similar diagnostic criteria for insomnia disorder. (See "Evaluation and diagnosis of insomnia in adults".)

Clinicians should establish that the patient meets diagnostic criteria for insomnia disorder and rule out other conditions that may have similar clinical presentations but a different underlying etiology, such as insufficient sleep, circadian rhythm sleep-wake phase disorders, sleep apnea, and other sleep disorders, in preparation for behavioral treatments. One of the key goals of the evaluation is to distinguish between insufficient sleep that results from behavioral factors (eg, watching television late at night, then rising early to commute to work), versus an inability to sleep despite having a sufficient opportunity to sleep (table 3). Insomnia must also be distinguished from delayed sleep phase and other circadian rhythm disorders. (See "Evaluation and diagnosis of insomnia in adults", section on 'Differential diagnosis'.)

Patient eligibility and interest — Most patients who meet diagnostic criteria for insomnia disorder are appropriate for cognitive and behavioral interventions. CBT-I requires patients to be engaged with a multisession approach, and patients must be interested in a nonpharmacologic approach to their sleep problems.

While the number of mental health providers trained in the delivery of CBT-I continues to grow, an additional challenge is that some geographic regions still have few skilled providers able to deliver CBT-I [6]. In these situations, patients may benefit from self-guided treatments (eg, online, mobile applications, or printed). (See 'Alternative delivery modalities' below.)

There is some evidence that patients prefer nonpharmacologic approaches, such as CBT-I, over medications; however, medications are still commonly used in clinical practice. Women and younger individuals tend to have even stronger preferences for behavioral treatments over pharmacologic treatments of psychiatric disorders in general [7].

In a study examining the acceptability of pharmacologic treatments and nonpharmacologic treatments of insomnia among women veterans, nonpharmacologic treatments of insomnia were rated as "very acceptable" significantly more often than pharmacologic treatments for insomnia [8]. Another study, which investigated preferences among hospitalized patients on a geriatric assessment unit, found that 82 percent of participants felt nondrug alternatives were healthier than medications in managing sleep difficulties [9]. This may indicate a potential mismatch between patient preference for treatment and treatments they are given within routine clinical care.

Precautions — There are a few clinical situations in which the use of CBT-I may be inappropriate, and precautions should be taken. In some cases, CBT-I can be modified to improve safety. These precautions are generally based on the potential adverse effects of short-term sleep time reduction that can result from implementation of sleep restriction therapy. These conditions include:

●Patients with poorly controlled seizure disorder

●Patients with untreated bipolar disorder who have a history of a manic and/or hypomanic episode or who have had manic symptoms triggered by sleep loss in the past

●Patients who have experienced an acute change in health status, such as an illness, accident, or surgery

●Patients who are excessively sleepy during the day (eg, due to severe, untreated sleep apnea)

●Patients who may experience increased occupational risks as a result of increased sleepiness, such as transportation industry workers or individuals in occupations that require sustained alertness

In most instances, CBT-I can be adapted for individuals who are not candidates for sleep restriction therapy by using other components of CBT-I to improve sleep quality (eg, sleep hygiene, sleep/wake schedule stabilization, cognitive therapy approaches). Sleep restriction therapy and stimulus control therapy can also be modified and used in some cases.

Helping patients access CBT-I — Since healthcare providers who deliver CBT-I typically have specialized training, it may be necessary to seek out these providers specifically. There are two main resources to consider:

●The Society for Behavioral Sleep Medicine (SBSM) lists providers who are members of the organization by geographic region within and outside of the United States and provides accreditation to training programs. Individuals who are Diplomates of the American Board of Behavioral Sleep Medicine are also listed on the SBSM website.

●Accredited sleep disorders center through the American Academy of Sleep Medicine (AASM) are required to provide comprehensive care for insomnia disorder, either within the center or through referrals. Accredited centers can be searched by United States zip code on the AASM website.

Some patients may be interested in self-directed app-based treatments. Two free options are:

●Insomnia Coach, which is available through the Department of Veterans Affairs

●CBT-I Coach, which is available to assist individuals who are engaged in CBT-I with a treating healthcare provider

COMPONENTS OF THERAPY — CBT-I is a multicomponent treatment that is comprised of behavioral and cognitive components.

Sleep education — CBT-I requires patients to engage in a number of behaviors that are counterintuitive, and treatment begins with education about insomnia and sleep. This education then provides a framework for recommendations associated with the cognitive and behavioral strategies that follow. Education components typically cover all of the following:

●The "3 P's" model of how insomnia develops (see 'Theoretical framework' above)

●The two-process model of sleep regulation: sleep drive and circadian rhythms (figure 2) [10] (see "Overview of circadian rhythm sleep-wake disorders", section on 'Functions of the circadian system')

●Cognitive and physical arousal and the need for reducing arousal near bedtime

Sleep restriction therapy — Sleep restriction therapy is designed to address the maladaptive behavioral pattern adopted by many insomnia patients that leads to extended time in bed, and therefore, to extended periods of wakefulness during the night [11,12]. This approach is a recommended treatment for insomnia disorder [13,14] and is a multistep process carried out over multiple sessions.

During the treatment, the patient is asked to maintain a daily sleep diary (table 4 and table 5) that is used to calculate total sleep time and sleep efficiency (ie, the percent of time the patient is asleep out of the time they are in bed intending to sleep) [15]. The steps for implementation of sleep restriction therapy are shown in the table (table 6).

Sleep compression — Sleep compression is an alternative to sleep restriction therapy in patients with a contraindication to acute sleep loss, such as active bipolar disorder of poorly controlled epilepsy (see 'Precautions' above). Sleep compression is the inverse of sleep restriction therapy. The steps involved in sleep compression are shown in the table (table 7).

Stimulus control therapy — Stimulus control therapy is based on the theory of conditioned insomnia and is designed to help the patient relearn an association between the sleep environment and rapid sleep onset [16], and it is supported as a treatment for insomnia [14]. Stimulus control involves a set of instructions that are designed to eliminate situations in which the sleeper is in bed struggling with sleep and increase the frequency of falling asleep quickly in bed. Instructions for stimulus control are shown in the table (table 8).

Sleep hygiene — Sleep hygiene interventions involve targeting behavioral habits that negatively impact sleep. It is important to note that sleep hygiene alone is not considered an effective treatment for insomnia disorder, although this approach is typically incorporated into CBT-I [17,18].

Sleep hygiene can be implemented in a variety of ways; however, core principles address spending an appropriate amount of time in bed, dietary and substance use habits, and improving the sleep environment (table 9). Many of these recommendations are incorporated into other components of CBT-I (eg, having a regular rise time, avoiding naps) as part of sleep restriction and/or stimulus control approaches.

Cognitive therapy — Cognitive therapy involves identifying and addressing maladaptive thoughts that lead to negative emotions [19,20]. In the case of insomnia disorder, thoughts and beliefs about sleep can increase arousal near bedtime and delay or prevent sleep. Thoughts and beliefs can also increase the likelihood of engaging in unhelpful behaviors such as extending time in bed to try to catch up on sleep based on the belief that "casting a wide net" will lead to fewer daytime symptoms.

Counter-arousal measures, including relaxation — Relaxation-based strategies were some of the earliest treatments used for insomnia disorder [21]. Two common approaches are progressive muscle relaxation (PMR) and diaphragmatic breathing. Relaxation therapies are commonly incorporated into CBT-I treatments as a way to reduce arousal near bedtime. Neither approach is typically used as a stand-alone therapy.

●Progressive muscle relaxation – PMR involves learning to elicit a physical relaxation response by tensing and relaxing different muscle groups in the body, focusing on a relaxed state. Patients are instructed to practice this skill regularly and obtain mastery before applying the skills at bedtime. (See "Acute procedural anxiety and specific phobia of clinical procedures in adults: Treatment overview".)

●Diaphragmatic breathing – Diaphragmatic breathing (table 10) is a technique for breathing that also elicits a relaxation response by balancing oxygen and carbon dioxide levels. Anxiety is associated with faster, shallow breathing, which increases oxygen levels in the blood in preparation for a "fight or flight" response. As with PMR, patients are instructed to practice diaphragmatic breathing before using it to facilitate relaxation in bed when attempting to sleep.

●Mindfulness – Mindfulness-based approaches have also been used to address arousal in insomnia patients. These approaches involve contact with the present moment and engagement with experiences and emotions. They are sometimes combined with behavioral techniques, such as stimulus control and sleep restriction, and sometimes used separately to treat insomnia [22]. In one trial, mindfulness-based cognitive therapy (MBCT) was superior a sleep education control for insomnia outcomes at two- and five-month follow-up, although these differences were not sustained at the eight-month follow-up visit [23].

SEQUENCING AND COMBINATION WITH MEDICATIONS — A preference for CBT-I or other behavioral therapies over medication as initial therapy has been endorsed in clinical practice guidelines of the American Academy of Sleep Medicine [24], the British Association for Psychopharmacology [25], the American College of Physicians [26,27], and the European Sleep Research Society [28].

Hypothetically, combining CBT-I with medications is appealing, as medications may quickly improve sleep quality, while the full benefits of CBT-I may not be realized for several weeks. However, there is some evidence that the use of hypnotic medications can negatively impact outcomes of CBT-I [29], and medications do not appear to enhance treatment benefits of CBT-I alone [30].

When CBT-I is not sufficiently effective, clinical practice guidelines support the use of medications as an adjunctive treatment [26]. In such cases, patients and providers should discuss the risks and benefits of medications and develop a plan for monitoring potential adverse effects. (See "Pharmacotherapy for insomnia in adults".)

TREATMENT DURATION — CBT-I is a brief treatment, typically lasting four to eight sessions. A dose-response study showed that the greatest benefit was received with four or eight sessions as compared with one or two sessions [31]. There are other approaches that use brief interventions focused on the behavioral elements that may result in improvements in two to four sessions. (See 'Brief behavioral treatment approaches' below.)

EFFICACY OF THERAPY

Traditional one-on-one delivery — There is moderate-quality evidence that multicomponent CBT-I results in clinically significant improvement in chronic insomnia in patients with [32,33] and without [34-37] comorbid medical and psychiatric disorders [38,39]. Improvement in insomnia symptoms typically occurs gradually over the course of CBT-I delivery, and the benefits tend to be durable beyond the end of treatment [39].

A 2021 meta-analysis by the American Academy of Sleep Medicine (AASM) included 49 randomized trials of CBT-I versus a control condition (eg, wait list, sleep hygiene education, placebo) in nearly 4000 patients with chronic insomnia [38]. In-person, one-on-one CBT-I was the most common delivery method (21 trials with a total of 1174 patients). Outcomes demonstrating improvements that exceeded clinical significance thresholds compared with control included:

●Insomnia remission rate (absolute difference 33 percentage points higher for CBT-I versus control)

●Treatment responder rate (45 percentage points higher for CBT-I versus control)

●Insomnia severity index scores (large effect size for the difference between CBT-I versus control)

Improvements in sleep latency (13 minutes shorter for CBT-I versus control), sleep quality (small to moderate effect size for the difference between CBT-I versus control), wake after sleep onset by sleep diary (19 minutes lower for CBT-I versus control), and total sleep time by sleep diary (9.7 minutes longer for CBT-I versus control) were statistically significant but did not meet clinical significance thresholds. The overall quality of the evidence was rated as moderate due to modest effect sizes on some critical outcomes (imprecision) and lack of blinding in some trials (risk of bias). A separate meta-analysis found moderate improvements in quality of life associated with CBT-I, particularly in patients without comorbid medial or psychiatric disorders [40].

Although traditionally delivered in person, CBT-I can also be delivered using a telemedicine format. In randomized noninferiority trials, insomnia outcomes are similar for face-to-face and telemedicine-delivered CBT-I, and the therapeutic alliance is maintained despite the remote format [41,42].

Alternative delivery modalities — There is also moderate-quality evidence to support the efficacy of CBT-I using alternative delivery methods such as group CBT-I [43], telephone-based CBT-I [44,45], and internet-based CBT-I [46-55]. These modalities may help to overcome some of the access, economic, and cultural barriers that exist for one-on-one CBT-I.

The 2021 AASM meta-analysis included data from 28 randomized trials of CBT-I using various alternative delivery methods versus a control condition in nearly 3000 adults with chronic insomnia [38]. Outcomes for each delivery method were not analyzed separately due to heterogeneity across the studies.

One critical access barrier to CBT-I is the availability of skilled providers, and alternative delivery modalities may increase access to individuals who are unable to receive care in a one-on-one format in their local area. As an example, one trial enrolled 1711 patients with self-reported insomnia (out of nearly 10,000 screened) and randomly assigned them to receive a six-session digital CBT-I program or a control condition (access to sleep hygiene education material on the study website) [54]. Approximately half of patients in the intervention arm completed all six sessions of digital CBT-I, and 20 percent did not complete any sessions. Compared with controls in an intent-to-treat analysis, patients assigned to CBT-I showed greater improvement in a range of self-reported health outcomes, including small improvements in functional health and psychological well-being and larger gains in sleep-related quality of life and insomnia symptoms. However, specific sleep data were not reported.

Additional studies are needed to compare alternative delivery methods directly with face-to-face CBT-I [56]. In a small trial comparing face-to-face and clinician-guided online CBT-I with a wait-list control in 90 patients with insomnia, both delivery methods performed significantly better than the wait-list control, but face-to-face CBT-I was associated with larger treatment effects and better depression and anxiety outcomes than online delivery [57].

A caveat of the available literature is that the patient populations studied using alternative modalities differ in important ways, and there are different access barriers depending upon how treatment is offered. For example, telehealth or online programs may be desirable when travel to a treatment site is a barrier, but face-to-face sessions may be preferable when access to technology is a challenge, or when the patient has sensory impairments that make engagement with online content difficult (eg, visual or hearing impairment).

CBT-I to facilitate discontinuation of hypnotics — CBT-I is commonly used to address insomnia symptoms in patients who are attempting to discontinue sedative-hypnotic medication use. Treating the underlying insomnia can help decrease anticipatory anxiety and fear of rebound insomnia, which are common among patients attempting to stop medications [58,59].

Several small trials support the role of CBT-I in combination with hypnotic-taper interventions to improve the likelihood of a successful taper [60-62]. A systematic review identified eight such randomized trials in 482 adults [63]. CBT-I plus gradual medication taper improved the likelihood of hypnotic discontinuation at study completion compared with gradual taper alone (45 versus 27 percent; RR 1.68, 95% CI 1.19-2.39). Subjective sleep outcomes also improved more with CBT-I. Long-term (12-month) outcomes pooled from four trials were similar but did not reach statistical significance.

BRIEF BEHAVIORAL TREATMENT APPROACHES — There is a growing body of evidence to support the use of briefer, behaviorally-focused treatments for insomnia disorder (eg, brief behavioral treatment for insomnia [BBTI]) in adults [38,64-69]. These interventions are typically shorter in length compared with CBT-I and contain a subset of the behavioral components, such as stimulus control (table 8), abbreviated sleep restriction therapy (table 6), and sleep hygiene (table 9).

Although supporting evidence is of lower quality compared with traditional CBT-I, BBTI is an acceptable alternative for patients who prefer the shorter format or when resources do not allow for CBT-I [38,39].

A variety of interventions delivered face-to-face or remotely by clinicians with varied levels of expertise have been studied. One method that may be clinically feasible and cost effective is to train nurses or advanced practice providers to deliver sleep restriction therapy as a behavioral approach. In an open-label randomized trial in England involving 642 adults with insomnia disorder recruited from 35 general practices, four sessions of nurse-delivered sleep restriction therapy improved patient-reported insomnia severity scores compared with a sleep hygiene booklet alone [69]. At six-month follow-up, 42 percent of patients in the treatment arm met criteria for a clinical treatment response, compared with 17 percent in the control group. Other smaller trials have shown similar benefits from other nurse-delivered BBTI approaches [64,65].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Insomnia in adults".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topic (see "Patient education: Insomnia (The Basics)")

●Beyond the Basics topics (see "Patient education: Insomnia (Beyond the Basics)" and "Patient education: Insomnia treatments (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Overview – Cognitive behavioral therapy for insomnia (CBT-I) is the mainstay of nonpharmacologic therapy for insomnia disorder and is preferred to medications as first-line therapy for chronic insomnia. (See "Overview of the treatment of insomnia in adults".)

●Theoretical framework – CBT-I aims to identify and target factors that sustain insomnia and correct maladaptive, conditioned arousal to the sleep environment. (See 'Theoretical framework' above.)

●Baseline evaluation – Basic requirements for CBT-I include a clinical diagnosis of insomnia disorder (table 2) and a patient who is interested in a nonpharmacologic approach to their sleep problems. (See 'Baseline evaluation' above.)

For the sleep restriction component of therapy, caution is required in patients with poorly controlled seizures or other comorbidities that would increase the potential for adverse effects of short-term sleep time reduction. (See 'Precautions' above.)

●Components of therapy – CBT-I is a multicomponent treatment typically consisting of sleep education, sleep restriction therapy (table 6), sleep compression (table 7), stimulus control therapy (table 8), sleep hygiene (table 9), cognitive therapy, and counter-arousal measures, including relaxation (table 10). (See 'Components of therapy' above.)

●Treatment duration – CBT-I is a brief treatment, typically lasting four to eight sessions. Even shorter behavioral approaches are an acceptable alternative for patients who prefer the shorter format or when resources do not allow for CBT-I. (See 'Treatment duration' above and 'Brief behavioral treatment approaches' above.)

●Efficacy of therapy – In randomized trials, multicomponent CBT-I results in clinically significant improvements in sleep outcomes and quality of life in patients with and without comorbid medical and psychiatric disorders. (See 'Traditional one-on-one delivery' above.)

In addition to traditional face-to-face delivery, accumulating evidence supports alternative delivery methods such as group CBT-I, internet-based CBT-I, and brief behavioral treatments. (See 'Alternative delivery modalities' above and 'Brief behavioral treatment approaches' above.)