Insomnia cognitive therapy, usually called CBT-I (cognitive behavioral therapy for insomnia), is a short structured course that combines rules about when and how you sleep with work on the thoughts that keep you awake. A meta-analysis of 20 trials with 1,162 adults with chronic insomnia found that after treatment people fell asleep 19 minutes faster, spent 26 minutes less awake in the night and had 10 points higher sleep efficiency, with no adverse outcomes reported. The American College of Physicians and the American Academy of Sleep Medicine give it a strong recommendation, and the European guideline names it first-line for adults of any age. Online versions did about as well as face-to-face CBT-I in pooled analyses of 11 and 15 trials.
Insomnia cognitive therapy has a long official name, cognitive behavioral therapy for insomnia, and a short one, CBT-I. It is the treatment that guidelines on both sides of the Atlantic put first for chronic insomnia, before any pill.
This page explains what is actually in a course, how large the effects were in randomized trials, what the first weeks feel like, how the CBT-I online programs compare, and how to find one. It does not replace a clinician's assessment, and it gives no advice on medicines.
Insomnia cognitive therapy: what CBT-I is and what a course contains
CBT-I is several techniques taught together, usually over a number of weeks with a therapist or a structured program. The AASM guideline assessed multicomponent CBT-I and the single pieces stimulus control, sleep restriction, relaxation and sleep hygiene. The meta-analysis below counted a trial as multicomponent CBT-I when it combined at least three of these: cognitive therapy, stimulus control, sleep restriction, sleep hygiene and relaxation.
| Part | What you do | What the AASM guideline says |
|---|---|---|
| Stimulus control | Use the bed only for sleep and sex; leave the bed if awake for long; keep a fixed wake time | Suggested as a single therapy (conditional) |
| Sleep restriction | Cut time in bed to the time you really sleep, then widen it as sleep consolidates | Suggested as a single therapy (conditional) |
| Cognitive therapy | Test the beliefs and worries that feed the sleeplessness (for example, ‘if I do not get 8 hours, tomorrow is ruined’) | Counted as one of the components in the meta-analysis below |
| Relaxation | Training in muscle relaxation or breathing | Suggested as a single therapy (conditional) |
| Sleep hygiene | Caffeine, light, noise and routine advice | Suggested not to use as a single therapy (conditional) |
| Multicomponent CBT-I | Several of the above together | Recommended (strong) |
Edinger JD, Arnedt JT, Bertisch SM, et al. Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med 2021. PMID 33164742
The last row of the table is the point of the page. Sleep hygiene on its own, the advice that dominates magazine articles, is the one piece the guideline suggests not using alone. The ordinary advice has its place and is in Sleep hygiene and insomnia, but it is the warm-up, not the treatment.
Cognitive therapy has also been tested on its own. In an eight-week randomized trial of 188 adults with persistent insomnia (average duration 14.5 years), 42.4% of the cognitive therapy group were treatment responders right after the course, against 67.3% for full CBT and 67.4% for behavior therapy alone; six months later the cognitive therapy group had gained (62.3%), behavior therapy had lost ground (44.4%) and full CBT held (67.6%). The authors concluded that full CBT is the treatment of choice, with behavior therapy acting faster and cognitive therapy more slowly.
Harvey AG, Bélanger L, Talbot L, et al. Comparative efficacy of behavior therapy, cognitive therapy, and cognitive behavior therapy for chronic insomnia: a randomized controlled trial. J Consult Clin Psychol 2014. PMID 24865869
How much does insomnia cognitive therapy help?
The most-cited summary is a meta-analysis of randomized trials comparing face-to-face, multicomponent CBT-I with inactive comparators. It included 20 studies with 1,162 participants (64% female, mean age 56) who had chronic insomnia and no other medical, sleep or psychiatric disorder. After treatment, the time to fall asleep improved by 19.03 minutes (95% CI 14.12 to 23.93), time awake after sleep onset by 26.00 minutes (15.48 to 36.52) and sleep efficiency by 9.91 percentage points (8.09 to 11.73). Total sleep time improved by only 7.61 minutes, and the confidence interval included zero (-0.51 to 15.74). No adverse outcomes were reported, and the changes seemed to be sustained at later time points.
Trauer JM, Qian MY, Doyle JS, et al. Cognitive Behavioral Therapy for Chronic Insomnia: A Systematic Review and Meta-analysis. Ann Intern Med 2015. PMID 26054060
The shape of that result is worth noticing. CBT-I mostly shortens the time you lie awake. It does not, on average, give you a lot more hours. Many people expect the opposite and judge the treatment by sleep time, so it helps to know that going in. The authors also point out the main limit: the trials excluded people whose insomnia came with other medical, sleep or psychiatric problems, so the results apply less clearly to those people.
What the guidelines recommend
Three guidelines point the same way. The American College of Physicians' 2016 guideline recommends that all adult patients receive CBT-I as the initial treatment for chronic insomnia disorder (strong recommendation, moderate-quality evidence), and that clinicians use shared decision-making about adding short-term medicines for those in whom CBT-I alone was unsuccessful.
Qaseem A, Kansagara D, Forciea MA, et al. Management of Chronic Insomnia Disorder in Adults: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med 2016. PMID 27136449
The European guideline of 2017 recommends CBT-I as first-line treatment for chronic insomnia in adults of any age (strong recommendation, high-quality evidence). It says a pharmacological intervention can be offered if CBT-I is not sufficiently effective or not available, and that light therapy and exercise need further evaluation for insomnia. It also says polysomnography can be used when another sleep disorder such as sleep-related breathing or limb movement disorder is suspected, which matters because a breathing disorder needs different treatment.
Riemann D, Baglioni C, Bassetti C, et al. European guideline for the diagnosis and treatment of insomnia. J Sleep Res 2017. PMID 28875581
The AASM guideline in the table gives its strong recommendation to multicomponent CBT-I. Whichever you read, the order is the same: behavior and thinking first, medicine as an option afterwards.
The hard part: the first weeks of sleep restriction
If CBT-I has a catch, it is sleep restriction. You limit your time in bed to roughly the time you currently sleep, and that makes you sleepier before you get better. Sixteen patients with psychophysiological insomnia who reported sleeping 6 hours or less had single-component sleep restriction for four weeks. Self-reported sleep and insomnia severity improved, but objective total sleep time in the lab fell by 91 minutes on the first night, 78 minutes on night 8 and 69 minutes on night 22. Vigilance lapses on a reaction task increased, reaction times slowed, and sleepiness scores were raised in weeks 1 to 3. Everything had returned to baseline levels at 3 months.
Kyle SD, Miller CB, Rogers Z, et al. Sleep restriction therapy for insomnia is associated with reduced objective total sleep time, increased daytime somnolence, and objectively impaired vigilance: implications for the clinical management of insomnia disorder. Sleep 2014. PMID 24497651
This is the reason to take care with driving or dangerous machinery in the early weeks, and to do the course with a clinician or a well-built program that adjusts the time in bed. A meta-analysis of 8 randomized trials of sleep restriction alone found large effects on insomnia severity (g = -0.93), sleep efficiency (g = 0.91), sleep onset latency (g = -0.62) and time awake after sleep onset (g = -0.83), and no effect on total sleep time (g = 0.02). Six of the 8 studies had a high risk of bias, and no more than three studies reported follow-up.
Maurer LF, Schneider J, Miller CB, et al. The clinical effects of sleep restriction therapy for insomnia: A meta-analysis of randomised controlled trials. Sleep Med Rev 2021. PMID 33984745
CBT-I online: what the digital trials found
Face-to-face CBT-I is hard to get. Online versions fill the gap, and the pooled results are good. A meta-analysis of 11 randomized trials with 1,460 participants found that internet-delivered CBT-I improved insomnia severity, sleep efficiency, sleep quality, time awake after sleep onset, time to fall asleep, total sleep time and number of awakenings, with effect sizes (Hedges' g) between 0.21 and 1.09. The effects were comparable to face-to-face CBT-I and generally maintained at 4 to 48 weeks. Longer treatment and more personal clinical support went with larger effects.
Zachariae R, Lyby MS, Ritterband LM, et al. Efficacy of internet-delivered cognitive-behavioral therapy for insomnia - A systematic review and meta-analysis of randomized controlled trials. Sleep Med Rev 2016. PMID 26615572
Another meta-analysis, of 15 trials, found that sleep efficiency (72% at baseline) improved by 7.2 percentage points, insomnia severity fell by 4.3 points and total sleep time rose by 20 minutes against control, and depression scores fell by 2.3 points. The differences against in-person therapy with a trained therapist were not significant.
Seyffert M, Lagisetty P, Landgraf J, et al. Internet-Delivered Cognitive Behavioral Therapy to Treat Insomnia: A Systematic Review and Meta-Analysis. PLoS One 2016. PMID 26867139
The biggest single trial randomized 1,711 people with insomnia symptoms to digital CBT-I, delivered by web and/or mobile, or to sleep hygiene education. The digital program gave small gains in functional health and psychological well-being and a large improvement in sleep-related quality of life (the difference at 24 weeks was -18.72 points on a 100-point impairment scale), and a reduction in insomnia explained 45.5% to 84.0% of the gains.
Espie CA, Emsley R, Kyle SD, et al. Effect of Digital Cognitive Behavioral Therapy for Insomnia on Health, Psychological Well-being, and Sleep-Related Quality of Life: A Randomized Clinical Trial. JAMA Psychiatry 2019. PMID 30264137
"Digital CBT-I" covers many products, so the trials do not vouch for each. A program worth considering has published randomized trial data of its own, guided tasks (sleep diary, a time-in-bed schedule that is adjusted weekly) and a way to get help from a person. An app that only counts hours is not CBT-I.
How to get started
Three ways in, in order of effort:
- Ask your doctor for CBT-I by name. Ask for a referral to a clinician or service that delivers multicomponent CBT-I, and about waiting times for the online alternative.
- Check for another sleep disorder first. If you snore loudly, have been seen to stop breathing, have restless legs or move a lot in your sleep, the guideline route is to assess that, because treatment of insomnia alone will not fix it. The overview is in Sleep disorders and insomnia.
- Use a CBT-I online program with trial evidence. Look for published randomized trials of that program, not just the method.
Tools for finding out how bad the problem is are in the insomnia test; the causes are in What causes insomnia; and if the problem is mostly a mind that will not stop, Overthinking therapy and Tired but can't sleep are the neighboring pages.
See a doctor if insomnia lasts more than a few weeks, if you are sleepy enough to be dangerous while driving, or if low mood, anxiety or thoughts of harming yourself come with it. CBT-I is for the sleep problem, and it works alongside other care for those.
Where SleepTrace fits, and where it does not
SleepTrace is not CBT-I and does not replace the sleep diary a course asks for; the diary records how you experienced the night, and that is what the treatment adjusts. What the app adds is a sound-based record: estimated sleep phases, labeled snoring, talking and coughing (3 playable clips a month on the free plan), timestamps for apparent breathing pauses and a sleep apnea indicator that is a screening estimate, not a diagnosis. That can show whether something other than worry, such as snoring or a cough, is breaking up your nights.
It cannot measure how long you lie awake in the dark, and its phase estimates are rough, so do not set your time in bed from them. If checking numbers makes you more anxious, a paper diary is enough. It runs on iPhone and Android. The app has to stay open and the phone should be charging, as for every night recording.
Frequently asked questions
CBT-I is cognitive behavioral therapy for insomnia, a structured program, run over several weeks, that combines behavioral parts such as stimulus control and sleep restriction with cognitive work on worries about sleep and, often, relaxation. In the AASM guideline the recommended form is multicomponent CBT-I.
Yes, in the trials. A meta-analysis of 20 randomized trials with 1,162 adults found that after treatment sleep onset latency improved by 19.03 minutes, time awake after sleep onset by 26.00 minutes and sleep efficiency by 9.91%, with no adverse outcomes reported and changes that appeared to be sustained. It excluded people whose insomnia came with other medical, sleep or psychiatric disorders.
In pooled analyses, about as good. A meta-analysis of 11 trials with 1,460 participants found effects comparable to face-to-face CBT-I, larger with more personal support, and another of 15 trials found no significant difference in sleep efficiency, total sleep time or insomnia severity between internet-delivered and in-person therapy.
Because it deliberately shortens time in bed. In 16 patients treated with sleep restriction alone, objective total sleep time fell by 91 minutes on the first night, daytime sleepiness rose in weeks 1 to 3 and vigilance lapses increased, then returned to baseline by 3 months. This is why the course is best done with guidance and why you should take care with driving in the early weeks.
Guidelines say no as a first step. The American College of Physicians recommends CBT-I as the initial treatment for chronic insomnia and a shared decision about adding short-term medicine only if CBT-I alone was unsuccessful, and the European guideline says medicine can be offered if CBT-I is not sufficiently effective or not available. What you take is a decision for you and your doctor.
In everyday use, and on this page, ‘insomnia cognitive therapy’ means CBT-I. Strictly, cognitive therapy is one part of the course and also exists as a stand-alone treatment, which Harvey and colleagues compared with behavior therapy and with the full course in a 2014 trial. It tests the beliefs and worries that feed the sleeplessness, such as ‘if I do not get 8 hours, tomorrow is ruined’. CBT-I adds behavioral parts like stimulus control and sleep restriction, and the AASM guideline gives its strong recommendation to that multicomponent form.
SleepTrace is a wellness app, not a medical device. This article is general information, not medical advice. If your symptoms are frequent, severe or worrying, please talk to a doctor.
CBT-I changes habits first and the feeling of your sleep later, so the early weeks can look discouraging. SleepTrace estimates your sleep phases from sound and shows how broken each night was, which gives you a trend to bring to your therapist. It records sound only and cannot teach the method; the course itself stays with a trained provider.
Hear your own night. SleepTrace turns a night of audio into your sleep phases, the sounds you made, and how it all trends. Works without a wearable, better with one. Your phone on the nightstand is enough to start. Get it for iPhone or Android →