Difficulty sleeping is a common presenting concern in medical appointments. Sleeping problems may be secondary to a wide variety of concerns, from GERD to chronic pain to sleep apnea. Not all sleeping problems are insomnia, which is defined as:

1. A person having dissatisfaction with their quality of sleep due to difficulty falling asleep, difficulty staying asleep, and/or waking too early in the morning
   
   
2. Their sleep problems must be disruptive to other aspects of life, such as functioning at work, in school, or in relationships
   
   
3. The symptoms occur at least three night per week
   
   
4. The symptoms have persisted for at least three months
   
   
5. The sleeping problems are not caused by a medical condition or substance use 

Of note, many people with insomnia experience comorbid medical conditions, many of which have a bidirectional, exacerbating relationship with insomnia. In fact, research in the journal Sleep has found that people with chronic insomnia report more of the following conditions than people without insomnia: heart disease (21.9% vs 9.5%), high blood pressure (43.1% vs 18.7%), breathing problems (24.8% vs 5.7%), urinary problems (19.7% vs 9.5%), chronic pain (50.4% vs 18.2%), and gastrointestinal problems (33.6% vs 9.2%). 

Insomnia is a common condition that impacts up to 30% of American adults. Insomnia is associated with significant human suffering and increases risk of harm due to impaired thinking and behavior, which can result in events like card accidents. 

Research Shows That Therapy Outperforms All Medications

The VA and Department of Defense are among the top producers of healthcare research in the United States, and issue regularly-updated, research based Clinical Practice Guidelines for the treatment of Insomnia. These guidelines are issued routinely, based on large-scale research conducted by national experts, and are considered a leading source of treatment guidance for healthcare providers.

Based on meta-analyses and other reviews of the extant research literature, the Clinical Practice Guidelines include an evidence table that grades treatment options as having evidence that is one of the following: strong for, weak for, neither for nor against, weak against, or strong against. 

In the most recent guidelines, the only treatment for insomnia that has been awarded a “strong for” recommendation is Cognitive Behavioral Therapy for Insomnia, called CBT-i for short. Most patients who complete a course of CBT-i see significant improvements in their sleep quality and sleep satisfaction, with positive outcomes continuing to increase after treatment is complete. 

Several commonly-prescribed medications were determined to have “weak for” evidence. Per the guidelines, these interventions are not considered recommended, but do have some evidence base and may be a part of clinical care for some patients: 

• Daridorexant
• Doxepin
• Eszopiclone
• Lemborexant
• Suvorexant
• Zaleplon
• Zolpidem 

Other medications are categorized with evidence that is “weak against” their use, with the Clinical Practice Guidelines stating they suggest against their use for insomnia, including:

• Antipsychotic drugs
• Benzodiazepines
• Cannabis/CBD
• Diphenhydramine
• Trazodone

Additionally, many over-the-counter remedies have been issued a “weak against” recommendation, including the following:

• Chamomile
• Melatonin
• Passionflower
• Saffron
• Valerian 

With respect to behavioral interventions, while Cognitive Behavioral Therapy for Insomnia enjoys the only “strong for” recommendation, sleep hygiene as a standalone intervention has been evaluated as having evidence that is “weak against” its use. 

Which Patients Are Appropriate Referrals for CBT-i?

Given Cognitive Behavioral Therapy for Insomnia (CBT-i) is considered the gold-standard, first-line treatment for insomnia, any adult who meets the diagnostic criteria for insomnia is potentially a good candidate for CBT-i. At the very least, any adult who meets diagnostic criteria and is amenable to psychotherapy is an excellent referral for evaluation by a psychologist with specialty training in sleep disorders. 

However, there are variables that make a patient more likely to be successful in treatment of insomnia via CBT-i. Variables that are associated with successful treatment are:

• Higher insomnia severity at outset
• Higher dysfunctional sleep beliefs at outset
• Higher motivation for treatment at outset
• Lower depression severity

For patients who are suspected of having comorbid sleep apnea or other sleep disorders, such as restless leg syndrome, a full medical workup including a sleep study is often helpful in clarifying the diagnostic profile and informing implementation of CBT-i. 

What Should Patients Expect in CBT-i?

CBT-i is a highly structured, skills-based approach to therapy that typically requires six to eight weekly treatment sessions. There are several distinct components: 

1. Sleep Education: Patients are taught about the science of sleep, the rationale and evidence supporting CBT-i, and provided with detailed, evidence-based sleep hygiene education to support modification of the patient’s maladaptive sleep behaviors.
   
   
2. Sleep Restriction: Patients are guided through temporarily reducing their sleep time to consolidate their fragmented sleep and to increase homeostatic sleep pressure. Over time, patients are guided through gradually prolonging their duration of sleep while maintaining high sleep efficiency. 
   
   
3. Stimulus Control: Patients are taught to utilize behavioral principles to create an adaptive conditioning history, such that sleep-related stimuli (such as their bed) is associated with sleep, rather than wakeful behaviors (such as worrying or watching TV). 
   
   
4. Cognitive Restructuring: Patients are supported in identifying and changing dysfunctional beliefs about sleep that increase anxiety, interfere with healthy sleep behaviors, and contribute to chronic insomnia.
   
   
5. Relaxation Training: Patients are taught evidenced-based behavioral strategies for increasing relaxation and decreasing physiological and psychological arousal. 

Of note, CBT-i is a challenging therapy. Many patients experience sleep restriction as highly aversive and at least somewhat disruptive to daily life, especially in the first few weeks of CBT-i. Patients should be advised to expect temporary discomfort. They should also be advised to be thoughtful about the timing of seeking treatment. For many patients, planning CBT-i to overlap with slower, less stressful periods of life (such as summer break or planned medical leave) can be extremely helpful. 

How Can I Refer Patients for CBT-i?

CBT-i is a highly specialized therapy that requires implementation by mental health professionals with advanced training. Aviva Psychology Services offers a Specialty Insomnia Clinic staffed by psychologists with expertise in Insomnia and CBT-i. 

Patients can be referred to Aviva Psychology Services for CBT-i simply by being provided with the website, avivapsych.com, and clicking the “Become A Client” button to initiate services. 

For patients who want to learn more about CBT-i, Aviva provides the written resource Insomnia: A Chronic Problem With Quick Treatment in addition to educational material on the  Specialty Insomnia Clinic website. 

Selected References and Additional Reading:

1. Daniel J. Taylor, Laurel J. Mallory, Kenneth L. Lichstein, H. Heith Durrence, Brant W. Riedel, Andrew J. Bush, Comorbidity of Chronic Insomnia With Medical Problems, Sleep, Volume 30, Issue 2, February 2007, Pages 213–218, https://doi.org/10.1093/sleep/30.2.213
   
   
2. El-Solh, A.A., O’Brien, N., Akinnusi, M. et al. Predictors of cognitive behavioral therapy outcomes for insomnia in veterans with post-traumatic stress disorder. Sleep Breath 23, 635–643 (2019). https://doi.org/10.1007/s11325-019-01840-4 
   
   
3. K.C. Simon, L. Nadel, & J.D. Payne, The functions of sleep: A cognitive neuroscience perspective, Proc. Natl. Acad. Sci. U.S.A. 119 (44) e2201795119, https://doi.org/10.1073/pnas.2201795119 
   
   
4. National Institute of Health: National Heart, Lung, and Blood Institute. (2022). Insomnia - what is insomnia? Www.nhlbi.nih.gov. https://www.nhlbi.nih.gov/health/insomnia   
   
   
5. Newsom, R. (2024). Cognitive behavioral therapy for insomnia (CBT-I): An Overview. Sleep Foundation. https://www.sleepfoundation.org/insomnia/treatment/cognitive-behavioral-therapy-insomnia 
   
   
6. Tabatabaei, A., Nelson, E., Glaser, A., Ludwig, R., Russell, J., Phadnis, M. A., … Siengsukon, C. F. (2026). Predictors of Cognitive Behavioral Therapy for Insomnia in Older Adults. Behavioral Sleep Medicine, 1–10. https://doi.org/10.1080/15402002.2026.2657913 
   
   
7. ‌U.S. Dept of Health and Human Services, Office on Women’s Health. (2017). A-Z Health Topics: Insomnia. Retrieved from: https://womenshealth.gov/a-z-topics/insomnia 
   
   
8. VA/DOD Clinical Practice Guideline. (2024). Management of Chronic Insomnia Disorder and Obstructive Sleep Apnea Work Group Washington, DC: U.S. Government Printing Office. Retrieved from: https://www.healthquality.va.gov/guidelines/CD/insomnia/index.asp 
   
   
9. Vgontzas AN; Liao D; Pejovic S; Calhoun S; Karataraki M; Basta M; Fernández-Mendoza J; Bixler EO. Insomnia with short sleep duration and mortality: the Penn State Cohort. SLEEP 2010;33(9):1159-1164. 
   
   
10. Wall, D. (2021, March 10). Insomnia | Fact Sheet - ABCT - Association for Behavioral and Cognitive Therapies. ABCT - Association for Behavioral and Cognitive Therapies. https://www.abct.org/fact-sheets/insomnia/ 
    
    
11. Winokur, A. (2015). The Relationship Between Sleep Disturbances and Psychiatric Disorders: Introduction and Overview . Psychiatric Clinics of North America; 38(4): 603-614.
    
    
12. Zhang, B, Wing, Y.K. (2006). Sex differences in insomnia: a meta-analysis. Sleep: 29(1): 85–93.