Cathy A Alessi and Michael V Vitiello: Cognitive behavioral therapy for insomnia


This blog is part of a series of blogs linked with BMJ Clinical Evidence, a database of systematic overviews of the best available evidence on the effectiveness of commonly used interventions.

Cognitive behavioral therapy for insomnia (CBT-I) has been consistently demonstrated to be efficacious in a wide variety of settings and patient populations including older adults and settings. This efficacy has been demonstrated in both patients with uncomplicated insomnia and in those whose insomnia is comorbid with a variety of medical and psychiatric conditions including: chronic pain, breast cancer, chronic obstructive pulmonary disease, coronary artery disease, osteoarthritis, fibromyalgia, Alzheimer’s disease, depression, alcohol abuse, and post traumatic stress disorder. Additional randomized clinical trials of CBT-I are being conducted in numerous other patient populations, including; Parkinson’s disease, chronic fatigue syndrome, those receiving bone marrow transplants and those receiving kidney dialysis (see: In completed trials for both uncomplicated and comorbid insomnia the efficacy of CBT-I is generally at least comparable to available pharmacotherapies, with the advantage of a much lower risk profile. CBT-I has also consistently been demonstrated to have long-term benefit for up to two years post-treatment.

However, the most efficacious ways of packaging and delivering CBT-I also need to be better delineated. Earlier work on more efficiently packaging CBT-I, while maintaining its efficacy, emphasized strategies such as shortening the standard eight session treatment protocol to 2-5 sessions, using nurses rather than trained sleep professionals to deliver the intervention, and focusing on behavioral components to increase sleep drive and optimize circadian sleep/wake rhythms. More recent work has examined a variety of methods of delivering CBT-I more efficiently including via internet, DVD, audiotape, book, telephone, and standard mail. Interventions building upon smart phone applications or web-enabled pedometer/actigraphs that provide 24 hour sleep wake activity monitoring and feedback on basic sleep parameters could also eventually replace cumbersome written sleep logs for monitoring CBT-I treatment response and developing personalized behavioral treatment plans.

Increasing the future effectiveness of CBT-I requires examining many pragmatic issues that determine broad-based acceptance of evidence-based treatments in the community. These include demonstrations of effectiveness in primary care populations and within usual health care delivery systems, evaluations of stepped-care approaches, and systematic evaluation of the short- and long-term cost-effectiveness of treatment in terms of subsequent healthcare utilization and related costs, including comparisons with pharmacotherapy.

Given its demonstrated long-term efficacy, there is a clear need to better disseminate information about CBT-I and increase the availability of training for practitioners. Only when primary care physicians appreciate that CBT-I is effective, accept the importance of treating insomnia, and have access to well-qualified practitioners to whom they can refer, will the potential impact of CBT-I to improve patient well-being and quality of life and decrease healthcare utilization and related costs be realized in the broader healthcare arena.

The efficacy of CBT-I to improve both short and long term outcomes in both uncomplicated and comorbid insomnia patients has been repeatedly and conclusively demonstrated. Further demonstrations of efficacy, per se, in additional comorbid insomnia populations are likely not the best use of limited energy and resources. Rather, refining CBT-I techniques and methods of delivery to further increase both their efficacy and their effectiveness should be key goals for the field. Expanded training and dissemination of CBT-I to a larger and wider cadre of practitioners throughout the health care system is another important and worthy goal. Future research will further elucidate the potential additive benefits that CBT-I may have for enhancing quality of life in patients not only through improved sleep but through the impact of such improved sleep on comorbid conditions. The wider availability of CBT-I will also allow for better testing of its potential impact on healthcare utilization and related costs.

Cathy A Alessi is director of the geriatric research, education and clinical center and chief of the Division of Geriatrics at the VA Greater Los Angeles; and professor of medicine at the University of California, Los Angeles, USA. Her research interests focus on descriptive and interventional research on sleep problems in older adults.

Michael V Vitiello is professor of psychiatry and behavioral sciences, gerontology and geriatric medicine, and biobehavioral nursing, University of Washington, Seattle, Washington, USA. His research interests focus on the causes, consequences and treatments of disturbed sleep, circadian rhythms and cognition in older adults.

Competing interests: CA has received research funding from the Veterans Administration and the National Institutes of Health within the past 5 years. CA has also been a consultant for OptumRx, Inc within this time. MVV has received research funding from the National Institutes of Health within the last 5 years. MVV has also consulted for Pfizer, Ferring, Jazz Pharmaceuticals, and Merck during this time.