Cognitive Behavioral Therapy in the Treatment of Insomnia

James Haynes, MD; Malissa Talbert, MD; Steven Fox, MD; Elizabeth Close, MD


South Med J. 2018;111(2):75-80. 

In This Article

Abstract and Introduction


Insomnia disorder is present in as much as 30% of the general adult population. Given the significant adverse effects of pharmacotherapy, cognitive behavioral therapy (CBT) has been found to be an effective alternative in individuals with insomnia. CBT for insomnia (CBTi) encompasses sleep hygiene, stimulus control, sleep restriction, cognitive therapy, and relaxation training. In this article we review evidence that establishes CBTi as a useful treatment affecting remission, sleep onset latency, wakefulness after sleep, sleep efficiency, and sleep quality in adults with insomnia to include older adults and adolescents. In addition, we briefly highlight various CBTi delivery methods as well as barriers to accessing this safe and effective therapy.


Thirty percent of the general population complains of at least one symptom of insomnia, including trouble falling asleep, staying asleep, or early awakening.[1] After applying narrower criteria from both the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition or the International Classification of Sleep Disorders, 3rd Edition, approximately 10% of the population meets the criteria for insomnia disorder, with half of these individuals experiencing a chronic course.[1,2] The risk factors for insomnia include lower socioeconomic status, female sex, older age, African American race, comorbid depression/psychiatric disorders, and shift work.[1–3] Furthermore, insomnia often coexists with other conditions, including malignancy, chronic pain, cardiopulmonary disease, and substance abuse.[1–3]

Both the economic and health effects of chronic insomnia are significant. The incidence of diabetes mellitus, coronary artery disease, hypertension, and the metabolic syndrome are higher in patients with chronic insomnia.[4] Absenteeism and tardiness are more prevalent in employees with insomnia.[4] Individuals with chronic insomnia have higher healthcare expenditures than their well-rested counterparts.[1,4]

Cognitive behavioral therapy for insomnia (CBTi) offers an attractive alternative to the long-term efficacy and safety concerns associated with sedative-hypnotics and the adverse effects of other commonly used sleep medications. CBTi uses several components, including sleep hygiene (SH), stimulus control (SC), sleep restriction (SR), cognitive therapy, and relaxation training (RT).[3,5] We present the evidence supporting the effectiveness of CBTi in adults, adolescents, and older adults; some potential options for CBTi implementation in primary care; and alternatives and relative contraindications to its use in patients with various comorbidities.