If you have insomnia — difficulty falling and/or staying asleep — you’ve probably tried everything you can think of to get a good night’s sleep: cutting back on coffee, turning off electronic devices, darkening your bedroom, maybe even over-the-counter or prescription medications.
All of these strategies can help to different degrees. But there’s 1 sleep-inducing method that often gets missed despite being very effective and completely safe: cognitive behavioral therapy for insomnia (CBT-I). In fact, the American College of Physicians (ACP) recommends that adults with chronic insomnia try CBT-I before using any kind of medication to help them sleep.
This might be surprising, since medications for insomnia get so much attention. While medication is an option, most are only approved for short-term use, says Rosanna Sutherby, PharmD, a community pharmacist and medical writer in High Point, North Carolina. Plus, medication is usually only considered by physicians when a patient hasn’t responded to CBT-I, says Lisa Medalie, PsyD, an insomnia specialist at the University of Chicago and founder of the DrLullaby app.
But what exactly is CBT-I and how does it work? What should you expect during a treatment session? Are there any risks or drawbacks? Here’s everything you should know about this powerful insomnia treatment. (By the way, one of the things that shouldn’t keep you up at night is the cost of your medications. Download our prescription discount card and save up to 80% at pharmacies nationwide.)
How CBT-I works
It’s helpful to start by defining cognitive behavioral therapy in general. It’s a form of talk therapy that focuses on changing unhelpful patterns of thinking and behavior into more positive, problem-solving ways of thinking and acting. The goal is to teach you the coping skills you need to deal with issues on your own, in the moment. Studies have shown CBT to be effective for all kinds of problems, including depression, anxiety and addiction.
CBT-I uses these same approaches to help people overcome their insomnia when it strikes at night. “It helps address insomnia by teaching people to improve control over [their] thoughts, emotions and behaviors, so that they more effectively transition into and back to sleep,” Dr. Medalie says.
Adults usually need 5 to 8 CBT-I sessions in total, says Dr. Medalie. “For children, it can be anywhere between 3 and 8 sessions, depending on the age group and type of insomnia.” She says some patients start seeing an improvement after the first visit. “Most need to consistently stick with changes for at least 1 month before observing significant changes.”
What you’ll learn during CBT-I treatment
CBT-I uses a variety of methods to retrain your mind and body how to sleep well again. Some methods focus on changing your thoughts about sleep. Others target changing your behavior. These approaches can be combined in different ways depending on your personal needs.
CBT-I is most effective when a combination of these methods is used. Here are some of the most common approaches a therapist will teach you during your CBT-I sessions:
Dr. Medalie says this method limits the number of hours you spend in bed to the amount of time you are typically asleep. Here’s an example: Let’s say you usually spend 8 hours in bed, but you’re only asleep for 5 of those hours. When you start using sleep restriction, you’ll only be allowed to be in bed for 5 hours, no matter how much sleep you get.
The purpose of sleep restriction is to build up your body’s need for sleep, says Dr. Medalie. Eventually, you’ll fall asleep faster, wake up less, and get some chunks of good sleep. Over time, as your sleep improves, you’ll be allowed to spend more time in bed.
This is a good approach if you have trouble falling asleep. Stimulus control helps you have a positive response to sleep cues, Dr. Medalie says. In other words, your bed and bedroom should be signals to your body that it’s time for rest and relaxation — not time to toss and turn all night.
With this method, you only use your bed for sleep and sex, period. No reading, watching television, or scrolling through social media on your phone are allowed. And you don’t go to bed until you are actually sleepy. If you can’t fall asleep within 15 to 20 minutes, you get up and do something relaxing. Again, the goal is to teach your body and mind that your bedroom is where you go to sleep happily through the night.
Feelings of tension and anxiety are often to blame for keeping us up at night. With relaxation training, you learn techniques to relax your body and mind. Examples include:
- Breathing exercises
- Progressive muscle relaxation (You tighten 1 group of muscles at a time as you breathe in, and then relax those muscles as you breathe out.)
- Biofeedback (This technique uses painless electrical sensors to measure things in your body, such as your heart rate, brain waves or breathing patterns. Then you use the information to learn how to make subtle changes in your body, such as slowing your breathing or heart rate.)
You’ll learn and practice new habits that help bring on sleep while getting rid of others that sabotage it. For example, at night you’ll stop using screens that give off blue light, such as your smartphone, tablet and television. The light can interfere with your body’s natural sleep-wake cycle. You’ll also create a quiet, dark, cool sleeping environment in your bedroom that can help you sleep better. And if you rely on an afternoon coffee break to get you through the second half of your day, that’s a habit you’ll learn how to break. Caffeine can affect your ability to fall asleep later that night.
You may have negative or inaccurate thoughts that crop up at night when your head hits the pillow, making sleeping even harder. For instance, it might be the time that you worry most about how well you’re doing at work or whether you’re being a good parent. As your mind starts to race with negative thoughts, it wakes you up instead of winding you down. In cognitive therapy, a therapist helps you change these thought patterns, so that you have more positive ones that help you relax.
The benefits and risks of CBT-I
CBT-I has a number of benefits, says Dr. Medalie. The biggest one is that it helps ease chronic or long-term insomnia. Plus, it’s effective for other types of insomnia, including short-term insomnia (such as during pregnancy or stressful life events) and early morning awakening insomnia. One research review in the Annals of Internal Medicine found that CBT-I can help participants:
- Fall asleep faster
- Wake up less often in the middle of the night
- Sleep longer overall
- Improve sleep efficiency, which means spending more time asleep instead of tossing and turning
CBT-I is long-lasting and has been shown to have minimal to no side effects or health risks. “Patients do tend to feel sleepy temporarily when starting sleep restriction, but this is short-lived and not unlike their baseline sleepiness,” Dr. Medalie says. (Learn how to fight fatigue with these tips.)
Where to find a CBT-I provider
You can get CBT-I from any health care professional who has been specially trained in this technique. Look for providers who are board-certified, recommends Dr. Medalie. You can find providers who are trained in CBT-I through organizations such as the Society of Behavioral Sleep Medicine.
Unfortunately, there’s a shortage of CBT-I providers, so many people are turning to digital CBT-I. Dr. Medalie notes that this is an effective way to get everyone access to care. This is especially important because insomnia is so prevalent in all age groups. Research has shown that internet-based CBT-I is just as effective as face-to-face CBT-I.
There are many online resources and apps that offer digital CBT-I. The Department of Veterans Affairs has an app called CBT-I Coach that anyone can use. Dr. Medalie also developed a digital platform called DrLullaby that’s geared toward children ages 4 months to 18 years (and their exhausted parents). The app offers approaches that are customized for different age groups. It also includes the CBT-I steps for adults, as well as access to 30-minute video sessions with sleep coaches. It is available for iOS.
When to consider insomnia medication
Because CBT-I is so safe and effective, it’s a good idea to start there. But if CBT-I doesn’t fully fix your sleep issues, Dr. Medalie suggests talking to your doctor about trying a sleep medication. Remember, these are generally used short-term because they can be habit-forming. They make it harder for you to learn to sleep well on your own.
Fortunately, there are plenty of options available. As with all medications, it’s best to talk to your doctor before trying anything on your own. Here are some to consider:
Over-the-counter (OTC) antihistamines
Dr. Sutherby says OTC products with antihistamines (an allergy treatment) such as Benadryl® and Unisom® are all right if you’re just taking them for a night or 2. However, they can interfere with certain medications and may cause side effects such as dry mouth and constipation.
These prescription-only medications include temazepam (Restoril®), triazolam (Halcion®) and estazolam. “They’ll help you fall asleep and stay asleep, but because they are benzos, they have that potential for abuse and dependence. You don’t want to use them for longer than 7 to 10 days,” Dr. Sutherby says.
Doxepin (Silenor®) is a prescription antidepressant approved by the U.S. Food and Drug Administration (FDA) for treating insomnia. One of its side effects is drowsiness. “[It does] have plenty of drug interactions, but [it doesn’t] have that potential for abuse or dependence like benzos,” notes Dr. Sutherby. Get a coupon for doxepin now.
- Ambien: There are 2 formulations. The regular one helps you fall asleep. If you have problems falling and staying asleep, you’ll want the Ambien CR® version, Dr. Sutherby says. It’s a slower-releasing medication that lasts longer throughout the night.
- Sonata: As with regular Ambien, Sonata helps you fall asleep. This one is short-acting, so it’s a good option if you wake up (or are still awake) in the middle of the night, says Dr. Sutherby.
- Lunesta: This medication is approved for long-term treatment. Dr. Sutherby says you must devote at least 7 to 8 hours to sleep to use it, otherwise you’ll wake up drowsy.
This medication, called ramelteon (Rozerem®), is relatively new. “It’ll mimic your body’s natural melatonin,” explains Dr. Sutherby. (Melatonin is a hormone your body makes to help bring on sleep.) Rozerem is for people who have trouble falling asleep. It’s not addictive, and it can also be used long-term.
Lemborexant (Dayvigo®) and suvorexant (Belsomra®) block a substance in your body that helps you stay awake, so they work differently than other medications, says Dr. Sutherby. They could be a good option if other medications aren’t working anymore or if you can’t tolerate them.
A note of caution about sleep medications
Keep in mind that insomnia medications can have side effects such as grogginess, coordination problems and feeling impaired the next morning. They can also cause what’s called “complex sleep-related behaviors.” Examples include driving, making phone calls, or having sex while you’re asleep.
Dr. Medalie notes that if you stop taking these medications suddenly, you may experience significantly worse insomnia. She says that they also aren’t approved for children or recommended for adults who are 65 years or older. Be sure that you and your doctor talk about the risks and benefits of trying insomnia medications.
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CBT-I basics: American College of Physicians, Sleep Foundation and American Academy of Sleep Medicine
Insomnia treatment basics: Sleep Foundation
Benefits of CBT-I study: Annals of Internal Medicine. (2015). “Cognitive behavioral therapy for chronic insomnia: A systematic review and meta-analysis.”
Online CBT-I study:Sleep Medicine Reviews (2016). “Efficacy of internet-delivered cognitive-behavioral therapy for insomnia – A systematic review and meta-analysis of randomized controlled trials.”