Insomnia: Why CBT-I Is the First Treatment Guidelines Recommend

You lie awake for hours, or you wake at 3 a.m. and cannot get back to sleep. Night after night, you dread bedtime. If this sounds familiar, you are not alone. Insomnia is one of the most common health complaints. The good news is that there is a treatment that works well without pills, and guidelines recommend trying it first.

What insomnia is

Insomnia means trouble falling asleep, staying asleep, or waking too early, even when you have the chance to sleep [3]. It also affects how you feel during the day, causing tiredness, poor focus, or low mood.

• Short-term insomnia often follows stress, illness, or travel and lasts days to weeks.
• Chronic insomnia means sleep problems at least 3 nights a week for at least 3 months, with daytime effects.

Insomnia often occurs with anxiety, depression, chronic pain, or other sleep disorders such as sleep apnea. Caffeine, alcohol, nicotine, some medications, and irregular schedules can make it worse.

What CBT-I is

CBT-I (cognitive behavioural therapy for insomnia) is a structured program that targets the habits and thoughts that keep insomnia going. It is not the same as general sleep hygiene tips. It usually includes:

• Sleep restriction: limiting time in bed to the time you actually sleep, then slowly increasing it. This builds a stronger drive to sleep.
• Stimulus control: using the bed only for sleep and sex, getting up if you cannot sleep, and keeping a fixed wake-up time.
• Cognitive therapy: changing worries about sleep, such as the belief that one bad night will ruin the next day.
• Relaxation training: methods to calm the body and mind before bed.
• Sleep education: steady routines, a dark and quiet room, and limiting caffeine and alcohol.

Programs often run 4 to 8 sessions with a trained clinician, in a group, or through a digital program. You keep a sleep diary throughout.

How well it works

A 2015 analysis of 20 trials found that CBT-I helped people fall asleep about 19 minutes faster and spend about 26 fewer minutes awake after first falling asleep [2]. Sleep efficiency (the share of time in bed spent asleep) improved by about 10 percentage points. These gains tended to last after treatment ended, which is a key difference from sleeping pills.

What your doctor looks at

The guideline recommendation

The American College of Physicians (ACP) 2016 guideline makes a strong recommendation that all adults with chronic insomnia receive CBT-I as the first treatment [1]. It suggests medication only when CBT-I alone has not worked, using shared decision-making about the benefits, harms, and costs of short-term drug use [1]. Canadian clinicians follow similar advice.

Ruling out other causes

Your clinician may ask about:

• Loud snoring, gasping, or pauses in breathing, which can point to sleep apnea
• An urge to move your legs at night, which can point to restless legs syndrome
• Mood or anxiety symptoms
• Pain, frequent urination at night, or reflux
• Medications, alcohol, and caffeine
• Shift work or a late body clock

A sleep diary over 1 to 2 weeks helps show patterns.

Sleep medication facts

When medication is used, the evidence and labels point to caution:

• Zolpidem, zopiclone (common in Canada), eszopiclone (US), and zaleplon are called Z-drugs. In the US, the FDA added a boxed warning in 2019 about complex sleep behaviours, such as sleepwalking and sleep-driving, which have caused serious injuries [4].
• The FDA label for zolpidem recommends a lower dose for women because the drug clears more slowly, raising the risk of next-morning impairment [4].
• Benzodiazepines such as lorazepam and temazepam can cause dependence, falls, and memory problems.
• Orexin receptor blockers, such as lemborexant and daridorexant, are newer options available in Canada and the US.
• Low-dose doxepin is approved for trouble staying asleep.
• Over-the-counter antihistamines, such as diphenhydramine, are not recommended for chronic insomnia, especially in older adults, because of confusion and fall risk.

The ACP found that the benefit of most sleep drugs was modest and that evidence on long-term safety was limited [1]. Older adults face higher risks of falls and confusion with most sedating drugs.

Practical steps you can start now

• Get up at the same time every day, including weekends.
• Go to bed only when sleepy, not just tired.
• If you are awake for what feels like 20 minutes, get up and do something calm in dim light.
• Avoid naps, or keep them short and early.
• Cut back on caffeine after noon and limit alcohol in the evening.
• Keep screens and work out of bed.

These are parts of CBT-I, but the full program works best with guidance.

Questions to ask your clinician

• Does my sleep problem fit chronic insomnia, or could it be something else?
• Could sleep apnea, restless legs, or a medication be playing a role?
• Where can I get CBT-I, and is there a digital program you recommend?
• Is it covered by my health plan or provincial program?
• If I take a sleep medication now, what are the risks for me?
• How would we plan a slow, safe reduction if I want to stop a sleep medication?

When to get care quickly

Call 911 or go to the emergency department if you have thoughts of suicide or self-harm, or call or text 988 in Canada or the US. Get urgent care if you fall asleep while driving, have done things during sleep you cannot remember after taking a sleep medication, or have chest pain or trouble breathing at night.

Bottom line

Chronic insomnia is common, and CBT-I is the first treatment guidelines recommend for adults. It has few side effects, and its benefits tend to last longer than those of pills. Sleep medications may have a short-term role, but they carry real risks. Ask your clinician how to access CBT-I where you live.

Primary AI can show you the guideline and study sources behind this topic in plain language, so you can bring better questions to your appointment.