Doctors’ first choice for insomnia is retraining your sleep with CBT-I

Key takeaways

• The American College of Physicians’ 2016 guideline says every adult with chronic insomnia should start with cognitive behavioral therapy for insomnia (CBT-I), a strong recommendation¹.
• In a 2023 English trial, nurses spent under 1.5 hours with each patient tightening sleep schedules, and six months later 42% had improved meaningfully, versus 17% given a booklet⁶⁷.
• In a Canadian trial, people who paired CBT with a sleeping pill and then dropped the pill had a 68% remission rate six months later, versus 42% for those who stayed on the pill⁸.
• The sleep-window step can leave you drowsy at first, and sleep doctors advise against it for people with bipolar disorder, psychotic disorders or seizures⁴⁵.
• Among veterans treated with CBT-I in a Veterans Affairs program, suicidal thinking fell by about a third; if sleepless nights bring thoughts of self-harm, call or text 988²¹¹.

Picture lying awake for months, then hearing that the fix is to spend less time in bed.

That was the prescription in HABIT, a trial run at 35 family medical practices across England⁶. Practice nurses, who needed no background in sleep disorders or talk therapy, met with 321 adults who had insomnia⁶⁷. Over four short sessions, they set fixed times for bed and rising, discouraged naps and trimmed the hours spent in bed⁷.

All told, each patient spent under 90 minutes with a nurse⁷. Six months later, 42% had a clinically meaningful improvement, compared with 17% of people who got only a booklet of sleep tips⁷. The results appeared in The Lancet in August 2023⁶.

The method, called sleep restriction, is one part of cognitive behavioral therapy for insomnia, or CBT-I. The full program also retrains the habits and worries that keep you awake. It uses no drugs, and leading physician and sleep medicine groups recommend it before any pill¹¹⁰.

The catch is access. Proven treatment rarely reaches people with chronic insomnia, said Simon Kyle of the University of Oxford, who led the study⁷. This is how CBT-I works and how to start safely.

Chronic insomnia has a definition, and one rough week doesn’t meet it

Insomnia becomes chronic when trouble falling or staying asleep happens at least three nights a week for three months or longer, according to the National Heart, Lung, and Blood Institute (NHLBI)¹⁴.

About 1 in 10 people has chronic insomnia, according to the American Academy of Sleep Medicine (AASM)⁵. Women and older adults are more likely to meet the diagnosis².

Insomnia tends to feed itself. The AASM notes that people with insomnia typically spend several more hours in bed than they spend asleep⁵. Our sleep pressure article (topic 206) explains why those extra hours backfire.

In 2025, the Department of Veterans Affairs (VA) and the Department of Defense (DoD) began urging that anyone with sleep complaints be checked for both insomnia and sleep apnea¹². People with both report more fatigue and mental health problems than people with either alone¹². Our sleep apnea article (topic 236) covers that side.

Every major guideline puts CBT-I first

In 2016, the American College of Physicians (ACP) advised that all adults with chronic insomnia disorder get CBT-I as their first treatment¹. It graded that a strong recommendation based on moderate-quality evidence¹. If CBT-I alone doesn’t work, the College said, patient and clinician should weigh adding a short course of medicine together¹.

The AASM’s 2021 guideline on behavioral treatments gave CBT-I its only strong recommendation³. Brief therapies, stimulus control, sleep restriction and relaxation training (see topic 227) each got a conditional one, meaning they may help but call for judgment case by case³. Sleep hygiene tips used alone got a conditional recommendation against³.

A Defense Health Agency guide to the 2025 VA/DoD guideline sums up its advice: offer CBT-I, suggest a brief version as an option, and favor CBT-I over medicine as the first step¹³.

Full CBT-I usually runs four to eight sessions with a trained clinician, guided by a sleep diary⁴. Brief versions take one to four⁴.

Inside CBT-I: the tools that retrain your nights

CBT-I is a bundle, not one trick, and the AASM rates the full package above any single piece³.

A sleep diary. Each morning, you note when you went to bed and woke up, any naps, and your caffeine, alcohol and daytime sleepiness¹⁴. NHLBI suggests one to two weeks of records before an appointment and offers a free printable diary¹⁴.

Stimulus control. The goal is to make your bed a cue for sleep again, not for worry. The AASM’s rules, in plain terms⁵:

• Go to bed only when you feel sleepy.
• Use the bed for sleep and sex only. No phone or TV in bed.
• If you seem to have been awake about 20 minutes, get up, do something relaxing and return when sleepy. Estimate; don’t watch the clock.
• Get up at the same time every day. The AASM calls a fixed rise time more important than a fixed bedtime (see topic 211 for a plan).

Sleep restriction, or the sleep window. Your clinician uses your diary to write a “sleep prescription.” Time in bed is set to roughly your average sleep time, with about half an hour added, and often starts near six hours⁵. You adjust weekly. Falling asleep within 30 minutes and lying awake less than 30 minutes at night earns you 15 more minutes. If either takes longer, you subtract 15⁵.

Cognitive work. CBT-I also examines the beliefs and habits that keep sleep fragile². Picture someone who lies awake thinking, “If I don’t sleep, tomorrow is ruined.” A therapist might help that person test the thought against the diary’s record of past bad nights and the days after.

The brief version. Brief behavioral treatment for insomnia, or BBTI, packs stimulus control and sleep restriction into four weekly sessions⁵. Only the first visit has to be in person, and clinicians familiar with health coaching can deliver it⁵.

The sleep window is powerful, and it comes with safety rules

The first weeks can be rough. A summary of the AASM guideline in American Family Physician (AFP) notes that sleep restriction can bring temporary daytime sleepiness and poorer concentration, and CBT-I can briefly raise fatigue and irritability⁴.

Before you shrink your sleep window, check with a clinician if any of these apply:

• Bipolar disorder, psychotic disorders or seizures. The AASM doesn’t recommend sleep restriction for these conditions, though people with them can still get CBT from a behavioral sleep medicine specialist⁵. The AFP summary also flags people prone to mania or seizures⁴.
• Heavy daytime sleepiness. A Defense Health Agency guide tells clinicians to adapt or delay CBT-I for people with excessive daytime sleepiness¹³.
• A high-risk job. Sleep restriction may be a poor fit for high-risk occupations, the AFP summary says⁴, such as running heavy equipment or driving for a living.
• Signs of another sleep disorder. Loud snoring, pauses in breathing or creeping leg feelings in the evening need their own evaluation¹⁵. The AASM sends patients with sleep apnea or restless legs syndrome to sleep medicine⁵.
• A sleeping pill. Plan any change with your prescriber.

Because sleep restriction can leave you sleepier for a while⁴, don’t drive or run machinery when you feel drowsy, especially in the first weeks. Our article on sleep debt (topic 210) lists the warning signs on the road.

CBT-I matches pills at first and pulls ahead over time

In a 2009 JAMA trial, Charles Morin’s team at Université Laval in Quebec randomly assigned 160 adults with persistent insomnia to six weeks of CBT alone or CBT plus the sleeping pill zolpidem (Ambien) at bedtime⁸.

After six weeks, the groups looked alike. About 60% in each responded, and remission rates of 39% and 44% were close enough to be chance⁸. The pill added a bit more total sleep⁸.

The bigger lesson came later. Among people who started on the combination, those who then stopped zolpidem and kept up CBT had a 68% remission rate at the six-month follow-up⁸. Those who stayed on zolpidem alongside CBT through the extended phase reached 42%⁸. PubMed lists NIH support for the study⁸.

The AASM’s 2017 drug review saw the same pattern: pills and CBT-I work about equally well at first, but people who finish CBT-I are more likely to keep their gains¹⁰.

In HABIT, six-month scores on the Insomnia Severity Index, a standard questionnaire that rates insomnia, averaged 10.9 with sleep restriction and 13.9 with the booklet⁶. At 12 months, the sleep restriction group also had fewer depressive symptoms and better work productivity⁷.

The UK’s public National Institute for Health and Care Research paid for the trial, and the analysis judged it good value for money⁶. One limit: most participants were well educated and White⁷.

How strong is the evidence?

Approach	What the research shows	Evidence level
Full CBT-I for chronic insomnia	Strong ACP and AASM recommendations; gains last after treatment ends13410	Strong evidence
Brief behavioral therapy	Moderate-quality evidence for remission and sleep quality; a conditional AASM recommendation34	Strong evidence, with a weaker guideline rating than full CBT-I
Sleep restriction or stimulus control alone	Low-quality evidence in the 2021 review4; one large positive sleep restriction trial since6	Promising but early
Sleep hygiene tips alone	Minimally effective; AASM advises against them as the only treatment34	Evidence says no, or unsafe (failed as a treatment; not unsafe)
Prescription sleep medicines, short term	About as effective as CBT-I at first; every AASM drug recommendation is weak910	Strong evidence of a short-term effect, with harms to weigh
Trazodone, melatonin or valerian for chronic insomnia	AASM suggests against each910	Not enough evidence of benefit
CBT-I to lower suicidal thinking	One VA study of 405 veterans; no comparison group described11	Promising but early

Medicines can help short term, but no sleeping pill earned a strong rating

In its 2017 drug guideline, the AASM rated every recommendation weak, meaning the right choice differs from person to person⁹. It gave that weak support to suvorexant and to doxepin at 3 or 6 milligrams for staying asleep, and to zolpidem, eszopiclone, zaleplon, temazepam, triazolam and ramelteon for falling asleep, staying asleep or both⁹.

It suggested against trazodone, the antihistamine diphenhydramine, melatonin, valerian, L-tryptophan and tiagabine for chronic insomnia⁹. The AASM’s Michael Sateia said there was little evidence for sedating antidepressants such as trazodone, though they may suit some people with psychiatric conditions¹⁰.

The 2025 VA/DoD guideline lists daridorexant (Quviviq), doxepin, eszopiclone and zolpidem as options for people who have tried CBT without enough relief¹².

Reporting on the ACP guideline, Psychiatric News noted that sleeping pills have been linked to worsening depression and suicidal thoughts, changes in thinking and behavior, and impaired driving². Then-ACP president Wayne Riley said that, ideally, people would take them for four to five weeks at most². Our travel sleep article (topic 218) explains the FDA’s boxed warning on zolpidem, eszopiclone and zaleplon about sleepwalking and sleep driving.

For readers who prefer to work with the body rather than override it, CBT-I is a natural fit. It uses no drugs, teaches skills you keep, and puts you in charge of your nights. The price is a few weeks of discipline and some sleepier days. Our melatonin (topic 233) and sleep-aid (topic 234) articles cover supplements.

Insomnia, depression and suicide risk are linked, and treating sleep helps

Insomnia is linked to a higher risk of developing psychiatric disorders, the HABIT researchers note⁷. Treating sleep may lift mood, too.

In 2015, a VA team reported on 405 veterans with insomnia who got up to six CBT-I sessions from newly trained VA therapists¹¹. The share reporting suicidal thoughts fell from 32% to 21%, a drop of about a third²¹¹. The link held after the researchers accounted for changes in depression, and depression and quality of life improved as well¹¹.

The VA funded the work¹¹. The report doesn’t describe a comparison group, so the drop can’t be credited to CBT-I alone.

If sleepless nights come with hopelessness or thoughts of harming yourself, call or text 988 to reach the 988 Suicide & Crisis Lifeline at any hour. If someone is in immediate danger, call 911.

Your two-week CBT-I starter plan

This plan is our own, built from the AASM’s brief-therapy steps⁵ and NHLBI’s diary advice¹⁴. It’s a starting point, not a replacement for care. If anything in the safety list above applies to you, do only the diary and wake-time steps until you’ve talked with a clinician.

Days	What to do	Why
1 to 14	Fill in a sleep diary each morning: bedtime, wake-ups, rise time, naps, caffeine, alcohol	NHLBI suggests one to two weeks of records14
1 to 14	Keep one wake time seven days a week; go to bed only when sleepy	Core stimulus control rules5
1 to 14	If you seem to be awake about 20 minutes, get up, do something calm and return when sleepy	The 20-minute rule, no clock-watching5
1 to 14	Set a 15-minute “worry window” in the early evening: write each worry and one next step, then close the notebook	Our suggestion; topic 240 covers tested worry techniques
8	Average your nightly sleep from week one and add 30 minutes. That’s your trial window	The AASM’s sleep prescription formula5
8 to 14	Count back from your wake time to find your earliest bedtime, and stay up until then	Limits time in bed, as the AASM method does5
14	If you fell asleep within 30 minutes and were awake under 30 minutes a night, add 15 minutes. If not, hold steady and book a visit	The AASM adjusts by 15 minutes a week5

A worked example. Picture someone whose diary shows about 5 hours and 45 minutes of sleep across 8 hours in bed. Adding 30 minutes gives a window of 6 hours and 15 minutes. With a 6:30 a.m. wake time, the earliest bedtime is 12:15 a.m.

Our suggestion, not a guideline rule: if your math lands below six hours, don’t go lower on your own. Six hours is a typical starting point in the AASM’s fact sheet⁵. Anything shorter is a call to make with a clinician, so bring the diary in.

When to see a clinician

Tell a clinician about your sleep if:

• poor sleep is getting in the way of your daily life¹⁴, especially if it happens at least three nights a week and has lasted three months, the line for chronic insomnia¹⁴;
• you regularly take more than 30 minutes to fall asleep, or wake several times or too early and can’t get back to sleep¹⁵;
• you’re sleepy during the day, nap often or doze off at the wrong times¹⁵;
• a bed partner notices loud snoring, snorting, gasping, choking or pauses in your breathing¹⁵;
• you feel creeping or tingling sensations in your legs or arms, especially in the evening, that ease when you move or rub them¹⁵.

Dozing off at the wrong time is a warning sign on its own¹⁵. If it happens behind the wheel, stop driving until you’ve been evaluated. Our upcoming article on when to seek a sleep evaluation (topic 241) goes deeper.

Questions readers ask

The bottom line

The insomnia treatment with the best long-term record doesn’t come in a bottle. CBT-I uses a diary, a firm wake time, a tighter sleep window and new ways of thinking about sleep, and its gains tend to outlast a pill’s.

The hard part is getting it. Start with a diary and a steady wake time, ask your primary care office about CBT-I, and use free or digital options if no specialist is nearby. Get a clinician’s help first if you have bipolar disorder, seizures, signs of sleep apnea or a job where drowsiness is dangerous.

Related reading

• Sleep pressure builds all day, and your body clock decides when it wins
• Your sleep schedule may matter as much as your hours, so start with your wake-up time
• A warm shower and a to-do list do more for sleep than a nightcap
• Some apps now come by prescription, with evidence that ranges from strong to thin
• Sleep apnea care now goes well beyond CPAP, and mouth tape isn’t part of it

Sources

1. Qaseem A, Kansagara D, Forciea MA, Cooke M, Denberg TD; Clinical Guidelines Committee of the American College of Physicians. “Management of Chronic Insomnia Disorder in Adults: A Clinical Practice Guideline From the American College of Physicians.” Annals of Internal Medicine, 2016;165(2):125-133 (abstract via University at Buffalo record). researchconnect.buffalo.edu
2. Psychiatric News (American Psychiatric Association). Report on the American College of Physicians insomnia guideline, 2016. psychnews.psychiatryonline.org
3. Edinger JD, et al. “Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine clinical practice guideline.” Journal of Clinical Sleep Medicine, 2021 (abstract via QxMD). pubmed.ncbi.nlm.nih.gov
4. American Family Physician. “Behavioral and Psychological Treatments for Chronic Insomnia Disorder: Updated Guidelines From the American Academy of Sleep Medicine.” Practice Guidelines, January 2022;105(1). aafp.org
5. American Academy of Sleep Medicine. “Brief Behavioral Treatment for Insomnia (BBTI).” Provider fact sheet, updated 2025. aasm.org
6. Kyle SD, Siriwardena N, Lee V, et al. “Clinical and cost-effectiveness of nurse-delivered sleep restriction therapy for insomnia in primary care (HABIT): a pragmatic, superiority, open-label, randomised controlled trial.” The Lancet, 2023;402(10406):975-987 (University of Oxford repository record). ora.ox.ac.uk
7. University of Oxford, Nuffield Department of Clinical Neurosciences. “Brief sleep therapy delivered by nurses improves insomnia.” News release on the HABIT trial, 2023. ndcn.ox.ac.uk
8. Morin CM, et al. “Cognitive behavioral therapy, singly and combined with medication, for persistent insomnia: a randomized controlled trial.” JAMA, 2009;301(19):2005–2015. Abstract via QxMD: qxmd.com ; news release via ScienceDaily, May 2009: sciencedaily.com
9. American Academy of Sleep Medicine. “Clinical Practice Guideline for the Pharmacologic Treatment of Chronic Insomnia in Adults: Guideline at a Glance” (Sateia MJ, et al., Journal of Clinical Sleep Medicine, 2017). aasm.org
10. Psychiatric News (American Psychiatric Association). “AASM Releases Guideline on Pharmacologic Treatment for Insomnia.” 2017. psychnews.psychiatryonline.org
11. American Academy of Sleep Medicine. “Cognitive behavioral therapy for insomnia reduces suicidal thoughts in veterans.” News release on a VA study co-led by Bradley Karlin, Sleep, February 2, 2015. aasm.org
12. Aker JA. “New clinical practice guideline recognizes insomnia and sleep apnea can occur together.” Defense Health Agency, January 22, 2026. dha.mil
13. Defense Health Agency, Psychological Health Center of Excellence. “Behavioral and Psychological Treatments for Insomnia: A Provider’s Guide.” September 2025. health.mil
14. National Heart, Lung, and Blood Institute. “Insomnia: Diagnosis.” National Institutes of Health. nhlbi.nih.gov
15. MedlinePlus. “Sleep Disorders.” National Library of Medicine, updated December 4, 2025. medlineplus.gov