CBT-I is delivered over the course of 4–8 sessions that occur weekly or every other week for 30–60 minutes each. By changing sleep-related behaviors and thoughts, CBT-I may target those factors that cause insomnia to persist over time. This is accomplished by establishing a learned association between the bed and sleeping through stimulus control, restoring homeostatic regulation of sleep through sleep restriction, and altering anxious sleep-related thoughts through cognitive restructuring. The goal of CBT-I is to target those factors that may maintain insomnia over time, such as dysregulation of sleep drive, sleep-related anxiety, and sleep-interfering behaviors. CBT-I is a non-pharmacological approach to treatment comprised of several strategies. Perhaps the most important disadvantage is that medications are usually not curative, leading to long-term treatment over many years despite a lack of safety and efficacy data for their long-term use beyond 1–2 years.Īn alternative treatment approach is cognitive behavioral therapy for insomnia (CBT-I). The disadvantages are the potential for side-effects, dependence, and tolerance over time. The advantages of medications are that they are widely available and, when effective, lead to clinical improvement rapidly. Numerous trials have documented moderate efficacy with benzodiazepine receptor agonists. The most common approach to the management of insomnia is medication treatment. In addition, there is evidence that insomnia may confer risk for medical illness including hypertension, heart disease, and diabetes, and is associated with increased overall health care costs. Insomnia is independently associated with significant morbidity including fatigue, impaired concentration and memory, irritability, difficulty in interpersonal relationships, decreased quality of life, and increased risk of new-onset psychiatric illness. There is now evidence to suggest that insomnia often persists following resolution of these ‘primary’ conditions, and that it generally does not spontaneously resolve over time if left untreated. In the past insomnia was considered to be a symptom of these conditions with the assumption that treatment of these ‘primary’ conditions would lead to the resolution of insomnia, eliminating the need for targeted insomnia treatment. Insomnia can exist as a primary disorder or co-morbid with other conditions including depression and chronic pain. The prevalence of insomnia in primary care patients is as high as 69% compared to 33% in the general population. Primary care providers should consider CBT-I as a first-line treatment option for insomnia. ConclusionsĬBT-I is effective for treating insomnia when compared with medications, and its effects may be more durable than medications. Very low grade evidence supports use of CBT-I to improve psychological outcomes. Low to moderate grade evidence suggests CBT-I has superior effectiveness to benzodiazepine and non-benzodiazepine drugs in the long term, while very low grade evidence suggests benzodiazepines are more effective in the short term. Resultsįive studies met criteria for analysis. Evidence base quality was assessed using GRADE. Extracted results included quantitative sleep outcomes, as well as psychological outcomes and adverse effects when available. sleep latency) in order to be included in the analysis. Trials had to report quantitative sleep outcomes (e.g.

In accordance with PRISMA guidelines, we systematically reviewed MEDLINE, EMBASE, the Cochrane Central Register, and PsycINFO for randomized controlled trials (RCTs) comparing CBT-I to any prescription or non-prescription medication in patients with primary or comorbid insomnia. A potential alternative to medications is cognitive behavioral therapy for insomnia (CBT-I). Insomnia is common in primary care, can persist after co-morbid conditions are treated, and may require long-term medication treatment.

Behavioral insomnia definition