Reviewed by Sahil Chopra, MD, and Stacey Gunn, MD.

Research by Savit Malhotra.

In our 6th and final installment of our insomnia series, we’ll be doing a deep dive into cognitive behavioral therapy for insomnia (CBT-I). We’ll be talking about what it is, how it works, how long it lasts, and the efficacy of this less risky treatment. 

Introduction

In the last few articles, we’ve spent a long time looking at the medications that are available to treat insomnia. While medications like Ambien and trazodone are effective, they can be risky. The side effects they can cause can be incredibly impactful to a person’s daily functioning as well as the possibility of developing dependence. For this reason, many people may choose to avoid this option altogether and go with a safer alternative: cognitive behavioral therapy for insomnia (CBT-I). In this article, we hope to give you a clearer idea of what CBT-I is and how, for many, it may be a better option than medications.  In fact CBT-I is so effective that the American Academy of Sleep Medicine recommends this as a first-line treatment to treat chronic insomnia. 

What is Cognitive Behavioral Therapy for Insomnia (CBT-I)?

CBT-I is a form of therapy that was developed not to target any physical organ, but instead the psychological aspects behind insomnia. It utilizes the techniques of stimulus control, sleep restriction, relaxation, and education to help a person develop a mindset that they can use to take control of their insomnia.[1] Different programs do tend to use different structures, but the underlying principles and efficacy of the treatment remain consistent. For example, some programs also target the foods and substances that a person is consuming, as well as their biological clock and sleep hygiene.[3] Clinicians will work with their patients to see what factors are contributing to their insomnia, and work with them to develop a customized plan to combat their lack of sleep. Oftentimes, CBT-I is the first recommendation that clinicians will make, far before medications and other more intensive treatments. In many ways, CBT-I is even a better option than medications. Its efficacy (which we will discuss in depth soon) is comparative and sometimes even better than the efficacy of medications. Since the treatment aims to change a person’s lifestyle, it can also often be much more long-lasting, reducing the need to constantly rely on pills.[2]

How Does CBT-I Work?

As previously mentioned, CBT-I consists of a number of different components that are customized to a person’s individual needs. A sleep medicine clinician will work very closely with their patients to help them develop a plan that works best for them. From there, the patient will actively practice the different techniques taught to them and maximize their potential for each individual category. Typically, CBT-I is administered in six to eight sessions of 30-90 minutes over the course of 6-16 weeks (though most people complete their program in 6 sessions).[15][16] As mentioned, these sessions consist of several different categories. Let’s take a look at some of these categories now: 

  1. Stimulus control is a common technique in CBT-I that works to establish the idea of one’s bed being used only for sleep and intimacy.[4] Many people with insomnia either consciously or subconsciously start to associate their bed as an anxiety-provoking place to be, and a stimulus-control model of getting out of bed when not sleeping helps to break this association. This means not using the bed for watching shows, not eating on the bed, not studying on the bed, or any other activities aside from sleep and intimacy. More so, after one wakes up or is unable to sleep, they should get out of bed within 20 minutes.[4] By doing so, the brain is able to develop a correlation between sleep and the bed, helping a person both fall asleep and wake up. Aside from this, stimulus control also works to establish a consistent wake-up time, only going to bed when sleepy, and avoiding excessive napping during the day.[5]
  2. Next, sleep restriction works to restrict the time a person spends in bed. This may seem confusing at first, as it seems we are looking to restrict how long a person sleeps for. But this is not the case, we are instead looking to minimize the time spent lying in bed awake.[6] This is where things start to get a little tricky. Let’s say that a person were to go to sleep at 8 pm, they wake up at 5 am, but they only sleep for 7 hours, so there are 2 extra hours of laying in bed awake. In this case, we might advise that the person instead go to bed at 10 pm, so that they can still get the full 7 hours of sleep they were averaging before, while minimizing the time they spend lying awake in bed. Once sleep is better consolidated, they can start moving their bedtime back by adding 15 minutes before they lie down. By doing so, one will be able to not only improve their sleep efficiency and quality but also reduce their daytime sleepiness.[7] This method also helps a person establish their circadian rhythm, or biological clock. This is the natural rhythm of when our body wants to sleep and wake up. 
  3. Sleep hygiene is often a factor that is overlooked by those struggling with insomnia, but it is just as important as any of the other components of CBT-I that we have discussed so far. Sleep hygiene refers to the individual routine that a person has in place before they sleep in order to maximize their sleep. For example, good sleep hygiene includes having a comfortable environment to sleep in (low noise, low lighting, comfortable bedding, a cool room, etc.), not eating certain foods and substances that can impact sleep (more on this soon), and not using any screen about 30 minutes before sleeping.[8][9] CBT-I helps a person develop these good habits and better their sleep hygiene by creating a routine that works best for their lifestyle. 
  4. When it comes to eating before bedtime, there are some foods and substances that are better avoided. For example, stimulants like caffeine should be avoided as one gets closer to bedtime, with some recommending that caffeine intake be stopped at least eight hours before sleeping.[10] Caffeine works by binding to the adenosine receptors in the brain (receptors that the neurotransmitter adenosine binds to, which is important for regulating sleep) and preventing adenosine from binding, thus promoting wakefulness.[11] Caffeine’s half-life (the amount of time it takes for half of the caffeine to be broken down) can vary among different people with different tolerance levels, which is why the longer you can go without caffeine before sleeping, the better. Alcohol is another substance that should be avoided as it can cause sleep fragmentation and increased wakefulness during the second half of the night.[12] In general, it is best to stop eating about 3 hours before going to bed. The reason for this is that digestion slows while a person is sleeping, causing some food to go undigested. This undigested food can disrupt a person’s sleep. More so, eating during the middle of the night can send signals to the brain, causing a cascade of effects that can disrupt a person’s circadian rhythm.[12][13] CBT-I can help a person create a routine of when they eat so that they are not hungry before they sleep, but also so that undigested food isn’t disrupting their sleep. 
  5. During CBT-I, a person is also taught certain relaxation techniques that can help them minimize stress and anxiety before they sleep. Short-term insomnia, for example, is often caused by some sort of temporary stress or something that is creating a sense of anxiousness within a person. Long term insomnia can develop when the stress becomes about sleep itself, rather than whatever was originally causing the insomnia in the first place, with the insomnia taking on a life of its own. CBT-I teaches certain techniques that help mitigate the effects of this stress or anxiousness in order to better promote sleep. For example, some of the techniques that may be taught are deep breathing, suggestive relaxation (which is similar to meditation), progressive relaxation, and guided imagery relaxation.[14] 

How Long Does CBT-I Last?

Now, we will start getting into the logistics of CBT-I, starting with how long it can last. The key component here is that CBT-I is not something that you can simply attend and expect to instantly feel the effects. Instead, CBT-I gives you the tools you need to optimize your sleep, but you need to be willing to put in the work as you go through the process.  Short term work for long term benefit. How long it lasts depends on the individual person.  Some people find that they need to rigidly stick with their sleep routine, otherwise their insomnia symptoms return.  Other people find that they can loosen up on the routine, and have a more casual approach to their sleep, but still maintain the benefits.  One study found that the benefits of CBT-I lasted an average of 40 months after the end of a person’s program.[17] For some patients who have previously completed a full course of CBT-I, but have symptoms return years later, often a quick refresher session or two can help them to get back on track. 

CBT-I’s Efficacy

If one were to Google, “Does CBT-I work?” one of the first results that appears is a research article titled “We know CBT-I works, now what?” This is because the benefits of CBT-I have long been proven due to the extensive research done on the topic. For example, there was a meta-analysis conducted in 2015 that found that, of 20 randomized controlled studies, there was significant improvement in several aspects. 

Figure 1 shows a forest plot of 20 randomized controlled trials.  The general consensus is at favor towards CBT-I.

(Trauer JM, Qian MY, Doyle JS, Rajaratnam SM, Cunnington D. Cognitive Behavioral Therapy for Chronic Insomnia: A Systematic Review and Meta-analysis. Ann Intern Med. 2015 Aug 4;163(3):191-204. doi: 10.7326/M14-2841. PMID: 26054060.)

For example, sleep latency was decreased by 19 minutes, time awake after sleep onset was decreased by 26 minutes, and total sleep time was improved by 8 minutes.[18] Referring back to the article previously mentioned (“We know CBT-I works, now what?”), there is an overwhelming number of studies included in this article that demonstrate the efficacy of CBT-I. The paper summarizes these findings very well, and we highly encourage anyone who is curious to read this paper in its entirety. In short, the paper highlights how wake after sleep onset and subjective sleep latency both decreased from 60 minutes to 30 minutes. Additionally, the paper states that there was about a 50% reduction in symptom severity in people’s symptoms before they started treatment versus after.[19] The following table has been included to summarize the findings presented in the paper:

‍

Figure 2 shows a number of different characteristics that were meta-analyzed across several different papers. Some of these characteristics include wake after sleep onset, total sleep time, and sleep latency. The table summarizes the pre- and post-results. All rights belong to the original authors. 

Conclusion

At the end of the day, CBT-I remains an incredibly effective solution to insomnia and can greatly improve a person’s sleep while minimizing potential risks. Medications are often an incredibly risky and expensive option, and for this reason, CBT-I should be considered as a first step before beginning more intensive treatment options. Additionally, while CBT-I programs are short, the benefits that arise last for a significant time, and the techniques learned can even last a lifetime. For all of these reasons, CBT-I is not an option that should be disregarded, and should even be the first treatment option to combat insomnia.

References

  1. Brief behavioral treatment for insomnia (BBTI). (n.d.). https://aasm.org/wp-content/uploads/2022/07/ProviderFS-BBTI.pdf
  2. What is CBTI?. Sleepwell. (n.d.). https://mysleepwell.ca/cbti/what-is-cbti/
  3. Stimulus control. Stanford Medicine Health Care. (2017c, September 12). https://stanfordhealthcare.org/medical-treatments/c/cognitive-behavioral-therapy-insomnia/procedures/stimulus-control.html
  4. Schoen Clinic UK. (2024, December 10). Cognitive behavioural therapy for sleep insomnia: How CBT-I works. https://www.schoen-clinic.co.uk/post/what-is-cbt-i-for-sleep-insomnia-and-how-does-it-work
  5. Stimulus control. Stanford Medicine Health Care. (2017b, September 12). https://stanfordhealthcare.org/medical-treatments/c/cognitive-behavioral-therapy-insomnia/procedures/stimulus-control.html
  6. Rosenberg, Dr. C., & Sleep Health Solutions. (2024b, December 3). What is sleep restriction therapy? does it work?: Treatment for insomnia. Sleep Health Solutions. https://www.sleephealthsolutionsohio.com/blog/how-sleep-restriction-therapy-works/
  7. Rosenberg, Dr. C., & Sleep Health Solutions. (2024a, December 3). What is sleep restriction therapy? does it work?: Treatment for insomnia. Sleep Health Solutions. https://www.sleephealthsolutionsohio.com/blog/how-sleep-restriction-therapy-works/
  8. Solodar, J. (2025, January 31). Sleep hygiene: Simple practices for better rest. Harvard Health. https://www.health.harvard.edu/staying-healthy/sleep-hygiene-simple-practices-for-better-rest
  9. Unknown. (2023, October 25). Why it’s time to ditch the phone before bed. Why It’s Time to Ditch the Phone Before Bed. https://intermountainhealthcare.org/blogs/why-it-is-time-to-ditch-the-phone-before-bed
  10. Caffeine and sleep. Sleep Foundation. (2024, April 17). https://www.sleepfoundation.org/nutrition/caffeine-and-sleep
  11. Institute of Medicine (US) Committee on Military Nutrition Research. (1970, January 1). Pharmacology of caffeine. Caffeine for the Sustainment of Mental Task Performance: Formulations for Military Operations. https://www.ncbi.nlm.nih.gov/books/NBK223808/#:~:text=Caffeine%20increases%20intracellular%20concentrations%20of,free%20fatty%20acids%20and%20glycerol.
  12. Foods and substances. Stanford Medicine Health Care. (2017a, September 12). https://stanfordhealthcare.org/medical-treatments/c/cognitive-behavioral-therapy-insomnia/procedures/foods-substances.html
  13. Cleveland Clinic. (2025, April 22). Is eating before bed bad for you? https://health.clevelandclinic.org/is-eating-before-bed-bad-for-you
  14. Jenlmat. (2018, July 22). Learning to relax. Rogel Cancer Center | University of Michigan. https://www.rogelcancercenter.org/breaking-habits-beating-us/learning-relax
  15. Walker, J., Muench, A., Perlis, M. L., & Vargas, I. (2022). Cognitive behavioral therapy for insomnia (CBT-I): A Primer. Klinicheskaia i spetsial’naia psikhologiia = Clinical psychology and special education. https://pmc.ncbi.nlm.nih.gov/articles/PMC10002474/
  16. Brandon Peters, M. (2024, June 29). What is cognitive behavioral therapy for insomnia (CBT-I)?. Verywell Health. https://www.verywellhealth.com/what-is-cognitive-behavioral-therapy-for-insomnia-cbti-3015310#:~:text=8-,What%20to%20Expect,advance%20you%20toward%20your%20goals.
  17. Study finds CBT offers long-term benefits for people with depression. Department of Psychiatry. (2016, January 7). https://www.psych.ox.ac.uk/news/study-finds-cbt-offers-long-term-benefits-for-people-with-depression#:~:text=These%20benefits%20were%20found%2C%20on,with%20their%20usual%20care%20alone.
  18. Trauer JM;Qian MY;Doyle JS;Rajaratnam SM;Cunnington D; (n.d.). Cognitive behavioral therapy for chronic insomnia: A systematic review and meta-analysis. Annals of internal medicine. https://pubmed.ncbi.nlm.nih.gov/26054060/
  19. Muench, A., Vargas, I., Grandner, M. A., Ellis, J. G., Posner, D., Bastien, C. H., Drummond, S. P., & Perlis, M. L. (2022, February 1). We know CBT-I works, now what?. Faculty reviews. https://pmc.ncbi.nlm.nih.gov/articles/PMC8808745/#sec1