For long-term insomnia, cognitive behavioural therapy for insomnia, known as CBT-I, is the recommended first treatment in American and European guidelines, ahead of sleeping tablets. Tablets can help faster in the short term, but the evidence favours CBT-I over the longer term. It usually takes four to eight sessions, and its effects tend to last.
What is CBT for insomnia?
CBT-I is a structured, talking and behavioural treatment. It usually combines sleep education, stimulus control, sleep restriction, relaxation and work on the thoughts that keep you awake, guided by a sleep diary, over four to eight sessions (AASM, 2021).
Stimulus control rebuilds the link between bed and sleep. You go to bed only when sleepy, get up when you cannot sleep, keep the bed for sleep and sex, get up at the same time each day and avoid naps. Sleep restriction limits time in bed to the time you actually sleep, then extends it as sleep consolidates (AASM, 2021).
How well does CBT-I work?
A review of 20 trials in adults with chronic insomnia found CBT-I cut the time to fall asleep by about 19 minutes and time awake in the night by about 26 minutes, and raised sleep efficiency by about 10 percentage points. The gains seemed to last, and no harms were reported (Trauer, 2015).
How does it compare with sleeping tablets?
In the short term the two are close. A review of 21 studies found behaviour therapy and sleeping tablets gave similar short-term results, with behaviour therapy cutting the time to fall asleep by more (Smith, 2002).
Over the longer term the evidence leans towards CBT-I. A systematic review found low to moderate quality evidence that CBT-I works better than sleeping tablets in the long term, and very low quality evidence that some tablets work better in the short term (Mitchell, 2012).
The two can be combined. In a trial of 160 adults, those who started with CBT plus a sleeping tablet and then continued with CBT alone had the best results six months later, with 68% in remission against 42% of those who kept taking the tablet as needed alongside CBT (Morin, 2009).
What do the guidelines say?
The American College of Physicians was direct in 2016. "ACP recommends that all adult patients receive cognitive behavioral therapy for insomnia (CBT-I) as the initial treatment for chronic insomnia disorder" (ACP, 2016). The American Academy of Sleep Medicine makes a strong recommendation for it too (AASM, 2021).
The 2023 European Insomnia Guideline recommends CBT-I as first-line treatment for adults of any age, in person or digitally. It suggests medicine when CBT-I has not been effective enough, and advises most sleeping tablets for short-term use of up to four weeks, with some used for up to three months (European Insomnia Guideline, 2023). At The Wellness, medicine is considered where suitable, after a doctor's assessment.
What are the downsides of each?
Sleeping tablets carry real risks, especially later in life. A review of trials in people over 60 found they added about 25 minutes of sleep a night, while side effects affecting thinking were nearly five times as common and daytime tiredness nearly four times as common as with a placebo. The authors concluded the benefits may not justify the risks, particularly for people at risk of falls (Glass, 2005).
CBT-I asks more of you. Improvement is not immediate, and it takes several visits (AASM, 2021). It is also adapted with care for people with bipolar disorder or poorly controlled epilepsy, which is one reason it is best guided by a specialist.
Why treat insomnia at all?
Insomnia is more than tiredness. People without depression who have insomnia have about twice the risk of developing it (Baglioni, 2011), and a RAND Europe study funded by a drug company linked chronic insomnia to 45 to 54 lost working days a year (RAND Europe, 2023). If your problem is waking in the early hours, read why you wake at 3am.
CBT for insomnia at The Wellness
Our CBT for Insomnia programme is £1,495, an eight-week programme of six to eight sessions with a specialist, using sleep restriction, stimulus control and a sleep diary. Most people begin with a Sleep Consultation at £450, because broken sleep and insomnia can be features of sleep apnoea, which needs a different treatment (NICE NG202). Where breathing is the question, the Home Sleep Study is £1,395 and The Sleep Clinic programme, the most chosen option, is £2,995.
The Sleep Clinic is in Marylebone. Book a sleep consultation and start with a proper assessment.
This article is general information and does not replace a consultation. If you are falling asleep at the wheel, stop driving until you have been assessed. If you have chest pain, severe breathlessness or signs of a stroke, call 999.
Frequently asked questions
Is CBT for insomnia better than sleeping pills?
In the short term the two give broadly similar results. Over the longer term the evidence favours CBT-I, whose benefits tend to last after treatment ends. American and European guidelines recommend it as the first treatment for chronic insomnia.
How long does CBT for insomnia take to work?
It usually takes four to eight sessions, and improvement builds over weeks rather than overnight, unlike a tablet.
Can I do CBT for insomnia online?
Yes. The 2023 European Insomnia Guideline recommends CBT-I as first-line treatment whether it is delivered in person or digitally.
Can I have CBT-I while I take sleeping tablets?
Often, yes, and a doctor can plan how to reduce the tablets. In one trial, people who started with both and then continued with CBT alone had the best results six months later.
Does CBT-I work for older people?
The European guideline recommends CBT-I for adults of any age, including people with other health conditions. In trials in people over 60, sleeping tablets added little sleep and caused more side effects than a placebo.
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