Cognitive behavioural therapy for insomnia (CBT-I): what the evidence shows

Cognitive behavioural therapy for insomnia (CBT-I) is a structured program that helps people identify and replace thoughts and behaviours that prevent them from sleeping well [1]. It is often recommended as an initial treatment for adults experiencing chronic insomnia [3].

CBT-I is a psychological approach that aims to provide lasting benefits without the risks sometimes linked with medication, such as tolerance or side effects [1]. This therapy focuses on changing sleep patterns and addressing underlying concerns that contribute to poor sleep [1].

What is CBT-I?

CBT-I is typically a "multicomponent" therapy, meaning it combines several different techniques [1, 4]. While many people are familiar with "sleep hygiene," this is only one part of CBT-I, and it is considered the least effective component when used on its own [4].

The main components of CBT-I often include:

• Cognitive Therapy (Cognitive Work) This part of CBT-I helps you identify and challenge unhelpful thoughts and beliefs about sleep [1]. For example, you might believe you need a perfect eight hours of sleep every night, or that you'll never be able to sleep well again. Cognitive therapy helps you reframe these thoughts into more realistic and helpful ones, which can reduce anxiety about sleep [1].
• Stimulus Control This technique aims to strengthen the connection between your bed and sleep, and weaken the connection between your bed and wakefulness [1, 4]. It involves specific rules, such as:
  • Only go to bed when you feel sleepy [1].
  • Use your bed only for sleep and intimacy, not for activities like reading, watching TV, or using electronic devices [1].
  • If you can't fall asleep within about 20 minutes, get out of bed and go to another room. Return to bed only when you feel sleepy again [1].
  • Wake up at the same time every day, including weekends, to help regulate your body's internal clock [1].
• Sleep Restriction This component temporarily limits the amount of time you spend in bed to match the actual amount of time you spend sleeping [1, 4]. The goal is to create a mild sleep deprivation that makes you fall asleep more quickly and stay asleep more soundly [1]. Over time, as your sleep improves, the amount of time you are allowed to spend in bed is gradually increased [1].
• Sleep Hygiene This involves adopting healthy daily habits and environmental factors that support good sleep [1]. Examples include:
  • Maintaining a regular sleep schedule [1].
  • Creating a comfortable and dark sleep environment [1].
  • Avoiding caffeine and alcohol before bed [1].
  • Getting regular physical activity [1]. While important, sleep hygiene alone is generally not enough to treat chronic insomnia [4].
• Relaxation Techniques These methods help reduce physical and mental tension that can interfere with sleep [1, 4]. Common techniques include progressive muscle relaxation, diaphragmatic breathing, and mindfulness meditation [1]. These practices can help calm your body and mind before bed [1].

Evidence for CBT-I's Effectiveness

Multiple large reviews of research studies have examined how effective CBT-I is for adults with chronic insomnia.

Trauer et al. (2015) Meta-analysis

A 2015 meta-analysis, which combined the results of 20 randomized, controlled trials, looked at the efficacy of face-to-face, multimodal CBT-I in adults with chronic insomnia [1]. The studies included 1162 participants, with an average age of 56 years, and 64% were female [1]. The researchers focused on studies where CBT-I incorporated at least three of the following components: cognitive therapy, stimulus control, sleep restriction, sleep hygiene, and relaxation [1].

The analysis found that CBT-I led to several improvements in sleep measures reported by participants: * Sleep onset latency (SOL), the time it takes to fall asleep, improved by an average of 19.03 minutes (with a 95% confidence interval of 14.12 to 23.93 minutes) [1]. * Wake after sleep onset (WASO), the time spent awake after initially falling asleep, improved by an average of 26.00 minutes (with a 95% confidence interval of 15.48 to 36.52 minutes) [1]. * Total sleep time (TST) improved by an average of 7.61 minutes (with a 95% confidence interval of -0.51 to 15.74 minutes) [1]. * Sleep efficiency (SE%), the percentage of time spent asleep while in bed, improved by an average of 9.91% (with a 95% confidence interval of 8.09% to 11.73%) [1].

The study also noted that these changes appeared to be sustained at later follow-up times [1]. No adverse outcomes were reported in the included studies [1].

However, the researchers noted some limitations, including narrow inclusion criteria that limited how broadly the findings could apply to patients with other sleep problems [1]. The accuracy of estimates at later time points was also less clear [1]. The conclusion of the meta-analysis was that CBT-I is an effective treatment for adults with chronic insomnia, showing clinically meaningful improvements [1].

van Straten et al. (2018) Meta-analysis

Another meta-analysis published in 2018 included 87 randomized controlled trials, comparing 118 different CBT-I treatments involving 3724 patients to 2579 patients who received no treatment [2]. This broader review included studies that used at least one component of CBT-I [2].

The interventions showed significant positive effects across several measures: * Insomnia Severity Index (effect size g = 0.98) [2]. * Sleep efficiency (effect size g = 0.71) [2]. * Pittsburgh Sleep Quality Index (effect size g = 0.65) [2]. * Wake after sleep onset (effect size g = 0.63) [2]. * Sleep onset latency (SOL) (effect size g = 0.57) [2]. * Number of awakenings (effect size g = 0.29) [2]. * Sleep quality (effect size g = 0.40) [2].

The smallest effect was observed on total sleep time (effect size g = 0.16) [2].

The meta-analysis also explored different delivery formats for CBT-I [2]. It found that face-to-face treatments consisting of at least four sessions appeared to be more effective than self-help interventions or face-to-face interventions with fewer sessions [2]. The results were generally consistent across different patient groups, including those with or without other medical conditions, younger or older patients, and those using or not using sleep medication [2]. The authors concluded that CBT-I, whether as a full package or its individual components, is effective for treating insomnia [2].

Clinical Practice Guidelines

Leading medical and sleep organizations have developed guidelines based on the evidence for CBT-I.

American College of Physicians (ACP) Guideline

In 2016, the American College of Physicians (ACP) published a clinical practice guideline for managing chronic insomnia disorder in adults [3]. This guideline was based on a systematic review of randomized, controlled trials published between 2004 and September 2015 [3].

The ACP made a strong recommendation that: * All adult patients should receive cognitive behavioural therapy for insomnia (CBT-I) as the initial treatment for chronic insomnia disorder [3]. This recommendation was supported by moderate-quality evidence [3].

The ACP also made a weaker recommendation that: * Clinicians should use a shared decision-making approach, discussing the benefits, harms, and costs of short-term medication use, to decide whether to add pharmacological therapy for adults with chronic insomnia disorder if CBT-I alone was unsuccessful [3]. This recommendation was supported by low-quality evidence [3].

American Academy of Sleep Medicine (AASM) Guideline

The American Academy of Sleep Medicine (AASM) also released a clinical practice guideline in 2021 for behavioural and psychological treatments for chronic insomnia disorder in adults [4]. This guideline was developed by a task force of sleep medicine and sleep psychology experts who systematically reviewed the literature [4].

The AASM issued a strong recommendation that: * Clinicians should use multicomponent cognitive behavioural therapy for insomnia for the treatment of chronic insomnia disorder in adults [4].

The AASM also provided several conditional recommendations, meaning clinicians should consider them based on clinical knowledge, experience, and patient preferences: * Clinicians may use multicomponent brief therapies for insomnia for the treatment of chronic insomnia disorder in adults [4]. * Clinicians may use stimulus control as a single-component therapy for the treatment of chronic insomnia disorder in adults [4]. * Clinicians may use sleep restriction therapy as a single-component therapy for the treatment of chronic insomnia disorder in adults [4]. * Clinicians may use relaxation therapy as a single-component therapy for the treatment of chronic insomnia disorder in adults [4].

Importantly, the AASM conditionally suggests that: * Clinicians should not use sleep hygiene as a single-component therapy for the treatment of chronic insomnia disorder in adults [4]. This reinforces that sleep hygiene is best used as part of a broader, multicomponent CBT-I approach [4].

Who Delivers CBT-I in Canada?

CBT-I is a specialized therapy typically delivered by regulated health professionals who have specific training in this area. In Canada, the titles and regulations for professionals who can offer CBT-I can vary by province and territory.

Often, counselling and psychology clinics in Calgary and other cities offer CBT-I. Psychologists, psychotherapists, and other mental health professionals with specific training in CBT-I are among those who may provide this treatment.

If you are seeking CBT-I, it is important to confirm the credentials and regulatory status of any professional you consider. You can often do this through provincial regulatory bodies. For example, in Alberta, the College of Alberta Psychologists oversees the practice of psychology [5]. The Canadian Psychological Association [6] can also provide information about the profession in Canada. It's important to ensure that the professional is licensed or registered to provide services in your province or territory. You can learn more about related therapies, such as CBT for anxiety and depression in adults.

What this means for you

If you are an adult experiencing chronic insomnia, the evidence suggests that cognitive behavioural therapy for insomnia (CBT-I) is an effective initial treatment [1, 3]. It is a structured approach that goes beyond simple sleep hygiene tips, addressing the thoughts, behaviours, and habits that contribute to poor sleep [1, 4].

CBT-I has been shown to improve how quickly you fall asleep, reduce the time you spend awake during the night, and increase the overall efficiency of your sleep [1, 2]. While the components of CBT-I can be used individually, the strongest recommendations are for a multicomponent approach that combines several techniques [4].

A licensed health professional trained in CBT-I can assess your specific situation and help you determine if this therapy is appropriate for you. They can guide you through the different components of CBT-I and tailor the program to your needs.