CBT-I explained: cognitive behavioural therapy for insomnia

The NHS says that if you have insomnia a GP may offer cognitive behavioural therapy (CBT), either face to face with a therapist or through an online self-help programme, which can help you change the thoughts and behaviours that keep you from sleeping. CBT for insomnia, often written CBT-I or CBTi, is the version of CBT designed for sleep problems rather than general mood or anxiety.

NICE Clinical Knowledge Summaries (CKS) says maladaptive behaviours and cognition are thought to be involved in the development of chronic insomnia, which is why a therapy targeting them makes sense. A UK specialist hospital sleep service describes CBT-I as addressing the unhelpful thoughts, feelings and behaviours that contribute to sleep disturbance, using both cognitive and behavioural approaches.

CKS defines insomnia as persistent difficulty getting to sleep, staying asleep or the quality of sleep despite adequate opportunity, resulting in impaired daytime functioning. Short-term insomnia lasts less than 3 months and chronic insomnia occurs at least several days a week for 3 months or longer. The NHS gives the same 3-month division. CKS says CBT-I is recommended for both short-term and chronic insomnia in adults of all ages.

Assessment comes first. CKS says a thorough history should identify contributing factors and physical and mental health conditions, and that other sleep disorders such as obstructive sleep apnoea and restless legs syndrome should be considered because they often co-exist. The NHS says a GP may refer you to a sleep clinic if you have symptoms of another sleep disorder such as sleep apnoea. A sleep diary kept for 1 to 2 weeks is described by CKS as helpful for identifying patterns.

Programmes differ in detail, but the hospital sleep service describes the following building blocks:

The NHS gives sleep habit advice that overlaps with part of CBT-I: only go to bed when sleepy, wake at the same time every day, relax for an hour before bed, keep the bedroom dark and quiet, exercise regularly in the day, avoid caffeine and alcohol close to bed, not nap in the day, and not sleep in after a bad night. CKS says good sleep hygiene should be considered in all people with insomnia.

CBT-I goes further by working directly on how much time is spent in bed and on the thoughts and worries about sleep, with a clinician or programme guiding the changes over several weeks. If habit changes alone have not helped, the NHS advises seeing a GP, which is where CBT-I is usually offered.

The NHS describes an online self-help programme as one way to receive CBT. CKS says a digitally delivered CBT-I programme is recommended by NICE, and can be offered for chronic insomnia. The specialist hospital service describes a standard course of 6 to 8 weekly sessions of 20 to 40 minutes, which can be attended in person or by video. Whichever format you use, the key is carrying out the behavioural changes consistently between sessions.

The NHS says GPs now rarely prescribe sleeping pills for insomnia because they can have serious side effects and you can become dependent on them, and that they are only prescribed for a few days or weeks at most if insomnia is very bad and other treatments have not worked. CKS says hypnotic medication should be avoided if possible and that, for short-term insomnia with severe daytime impairment, a short course of 3 to 7 days of a non-benzodiazepine hypnotic may be considered only where the insomnia is likely to resolve soon. Where it is not, CBT-I should be first-line, with a short-term hypnotic only as an adjunct if appropriate.

The NHS says pharmacy sleeping aids may help sleep for 1 to 2 weeks but should not be taken for longer, and should be checked with a doctor first. CKS also advises avoiding drug treatment in the long-term management of insomnia. Do not stop a prescribed sleeping medicine suddenly; see our related guide on benzodiazepine dependence for why.

CKS says benefits associated with CBT-I persist after treatment, unlike medication. The hospital sleep service describes CBT-I as effective for most people and says it can help manage mental health, physical and lifestyle issues that affect sleep, while warning that challenging unhelpful thoughts and behaviour can be uncomfortable, stressful and draining, and that sleep can get worse before it improves. It stresses continuing treatment to see lasting results. No treatment works for everyone, and underlying conditions such as sleep apnoea, pain or depression need their own treatment, which CKS says commonly co-exists with chronic insomnia.

NHS CBT-I is accessed through a GP, an NHS talking therapies or sleep service, or an online programme, and availability and waits vary. Private sleep services and psychologists also offer CBT-I. Ask whether the clinician is trained specifically in CBT-I, how many sessions are planned, whether a sleep diary is used, and whether other sleep disorders will be screened for first.