Cognitive Behavioral Therapy for Insomnia (CBTI)
Currently, Cognitive Behavioral Therapy for Insomnia (CBTI) is the recommended first-line treatment for insomnia in adults. The treatment uses one or more behavioral or cognitive strategies along with patient education on sleep. In CBTI, patients are taught to use the following five key strategies: stimulus control, sleep restriction, sleep-interfering arousal/activation, foods and substances, and biological clock considerations.
Eric Zhou describes the various components of CBTI.
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CBTI Strategy |
Description |
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Stimulus control |
Set a regular morning wake time, go to bed only when tired, and get out of bed if unable to fall asleep. The bedroom environment should be made more comfortable for sleep, rather than wakefulness. |
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Sleep restriction |
Restrict time in bed to only sleeping and limit time awake in bed. After marked improvements in quality of sleep, time in bed is gradually increased by 15-30 minutes increments. This increases sleep time while maintaining decreased time awake in bed. |
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Sleep-interfering arousal/activation |
Increase relaxation and stress management activities to better cope with sleep-related worries. The transition from “trying to sleep” to “allowing sleep to happen” is a desired outcome. In addition, negative thoughts about the consequences of sleep loss are challenged and reduced. Sleep specialists encourage that the last hour before bedtime to be reserved for unwinding. Keep the bedroom quiet and safe, avoid watching the clock, and limit exercise within four hours before bedtime. |
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Foods and substances |
Limit alcohol, stimulants like caffeine or nicotine, and food close to bedtime. Alcohol increases wakefulness in the second half of the night, while undigested food can disrupt sleep. Stimulants keep you alert and make it harder for you to fall asleep. |
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Biological clock considerations |
A sleep specialist may help align your circadian clock to your bedtime and wake time with the use of bright light exposure. This helps you feel sleepy during your bedtime and make it easier to wake during rise time. |
While participating in a complete CBTI program may be most beneficial, shortened programs are now available to patients who can only attend a few sessions. Moreover, there are now abbreviated behavioral treatments for insomnia. These are condensed versions of CBTI that includes fewer sessions over a shorter treatment time course. These shorter programs also focus on changing behaviors and opinions of sleep to improve sleep.
Telemedicine and Digital Treatment Programs
Variations of CBTI, such as its online delivery, have increased its accessibility. According to studies, telemedicine delivery of CBTI remains as effective as in-person CBTI1, 2. There are several digital (computer-delivered) CBTI interventions that are now available. In 2020, one has received FDA-approval 3.
References
- Arnedt, J. Todd, et al. "Telemedicine versus face-to-face delivery of cognitive behavioral therapy for insomnia: a randomized controlled noninferiority trial." Sleep 44.1 (2021): zsaa136.
- Bertisch, Suzanne. “Cognitive Behavioral Therapy for Insomnia by Telemedicine: Is It as Good as in-Person Treatment?” Harvard Health, 15 June 2021.
- FDA March 2020 510(K) Clearance. https://www.fda.gov/medical-devices/510k-clearances/march-2020-510k-clearances.