Is Cognitive Behavioral Therapy Effective for Insomnia?

Cognitive behavioral therapy (CBT) is one of the most popular psychotherapies that is prescribed for a wide variety of conditions.

Due to the strong correlation between conditions like depression and anxiety with insomnia, CBT is often part of an insomnia treatment plan.

However, a tailored plan is typically used, which you may see referred to as CBT-i or CBTI, which stands for cognitive behavioral therapy for insomnia.

While CBT-i is often effective, it’s not always the right choice. By the end of this short post, you’ll know:

• How effective CBT-i is
• How soon does CBT-i start to work
• If online or group CBT-i is as effective as in-person sessions

Research on CBT for Insomnia

Over the past few decades, many studies looking at this topic have been conducted.

A systematic review of these studies found that CBT-i is a better alternative to medication in most cases of insomnia (1):

CBT-I is effective for treating insomnia when compared with medications, and its effects may be more durable than medications. Primary care providers should consider CBT-I as a first-line treatment option for insomnia.

It’s safer, more effective, and can be used in combination with other treatments as well.

Just how effective is CBT-i?

A review of 20 studies (with over 1100 subject combined) found that (2):

Sleep onset latency (time to fall asleep) improved by 19.03 minutes, wake after sleep onset improved by 26.00 minutes, and total sleep time improved by 7.61 minutes.

These are average numbers.

Some people get great results, while others don't see any improvement at all. But overall, most people do see a significant improvement in getting to sleep or staying asleep.

CBT for Insomnia Doesn’t Work 100 Percent of the Time

Even though CBT-i is a proven treatment, it doesn’t necessarily work for everyone with insomnia, and even when it does work, it may not be a full “cure.”

For example, one randomized controlled trial for CBT-i found that (3):

Almost two thirds of the CBT group reduced their initial sleep log WASO by 50%

That’s a great result, but it also means that one third of the CBT group did not decrease their time spent awake after getting to sleep by 50%. Some saw smaller improvements, and some saw none.

There are limitations to cognitive behavioral therapy for insomnia, including:

• It will have minimal benefit if the cause of insomnia isn’t psychosomatic (e.g. poor sleep hygiene, nutritional deficiencies, hormone fluctuations, etc.)
• It’s more time consuming than alternatives
• There’s a significant cost
• The effectiveness varies based on the therapist

With that being said, one benefit of CBT that is important is that there’s a very low risk of adverse effects. It’s rare for CBT-i to actually worsen sleep quality.

How Long Does CBT For Insomnia Take to Work?

The standard CBT-i protocol involves weekly 30-60 minutes sessions for 4-8 weeks.

While some subjects do see sleep improvement within the first session or two, a systematic review found that (4):

Improvements from CBT-I are typically not seen until 3–4 weeks into treatment.

In addition, there’s often a small negative impact in total sleep time for the first few weeks of treatment.

That can lead to some patients giving up and dropping out of the treatment before it’s had time to work.

The good news is that CBT-i has a sustained long-term effect. A 2015 study found that (5)

At 3-month follow-up, 61.1% of CBT-I participants were in clinical remission from their insomnia and depression, compared with 5.6% of the self-help group.

Since CBT-i primarily focuses on restructuring thoughts and beliefs, it makes sense that the benefits carry forward for quite some time.

Is Online CBT a Viable Alternative to In-Person Sessions?

It’s not always easy to find a therapist that specializes in CBT-i, and even if you do there can be quite a wait list.

Taking an online CBT course instead would be ideal in this sort of situation, or if needing to minimize the cost of CBT for insomnia.

The good news is that online CBT-i does appear to be effective for many people. One study found (6):

Online CBT was associated with sustained improvement at post-treatment (+20%) relative to alternative treatment methods

However, while more research is needed, it appears that online CBT typically isn’t as effective as in-person sessions.

One study compared the two options and found (7):

Face-to-face treatment yielded a statistically larger treatment effect on insomnia severity than the online condition at all time points.

So while online CBT is a good option if there’s nothing else available, in-person CBT is still the preferred option.

Is Group CBT for Insomnia Effective?

Another way to bring down the cost of CBT is to administer as much of the treatment (i.e. the instructional portions) in group settings, and some therapists have started to offer this.

While not compared to one-on-one sessions, studies have shown that group CBT is still effective.

One study compared group CBT-i to the popular sleep medication zolpidem (8):

Compared to the zolpidem and healthy control groups, measures of sleep problems were significantly reduced after intervention in the GCBT group.

A small meta-analysis found all the same typical benefits of normal CBT-i even in a group setting (9):

Overall, we found medium to large effect sizes for sleep onset latency, sleep efficiency, and wake after sleep onset and small effect sizes for pain outcomes

Again, one-on-one in-person CBT-i is the best choice for most people, but group CBT-i may be a valid alternative in some situations.

References

1. Comparative effectiveness of cognitive behavioral therapy for insomnia: a systematic review
2. Cognitive Behavioral Therapy for Chronic Insomnia
3. Cognitive Behavioral Therapy for Treatment of Chronic Primary Insomnia
4. Comparative effectiveness of cognitive behavioral therapy for insomnia: a systematic review
5. A randomized controlled trial of cognitive behavioral therapy for insomnia: an effective treatment for comorbid insomnia and depression
6. A Randomized, Placebo-Controlled Trial of Online Cognitive Behavioral Therapy for Chronic Insomnia
7. Guided Online or Face-to-Face Cognitive Behavioral Treatment for Insomnia
8. Group cognitive–behavioral therapy in insomnia: a cross-sectional case-controlled study
9. A meta-analysis of group cognitive behavioral therapy for insomnia