How long does CBT-I take to work?

Most people see significant improvement within 4-8 weeks. The first 1-2 weeks of sleep restriction can be challenging — you may feel more tired initially. By weeks 3-4, sleep consolidation typically kicks in. Full benefits are usually achieved by 6-8 sessions.

Will CBT-I work if I've had insomnia for years?

Yes. CBT-I is effective regardless of insomnia duration. Chronic insomnia that has persisted for decades still responds because the maintaining factors (conditioned arousal, maladaptive sleep behaviors, anxious thoughts) are present regardless of how long ago the insomnia started.

Can I do CBT-I on my own?

You can implement many CBT-I principles independently using workbooks or apps. However, working with a trained therapist is more effective, especially for sleep restriction therapy, which requires individualized titration of your sleep window. If cost is a barrier, digital CBT-I programs are a good middle ground.

Is melatonin a good alternative?

Melatonin helps with circadian rhythm issues (jet lag, delayed sleep phase) but has modest effects on general insomnia. It's relatively safe short-term but isn't a substitute for CBT-I. If you take it, use 0.5-1mg (not the 5-10mg doses commonly sold) about 1-2 hours before your target bedtime.

CBT-I: Why Cognitive Behavioral Therapy Is the Gold Standard for Insomnia

Chronic insomnia — difficulty falling asleep, staying asleep, or waking too early at least three nights per week for three or more months — affects roughly 10% of adults. Most people reach for sleep medications first, but the American College of Physicians recommends cognitive behavioral therapy for insomnia (CBT-I) as the first-line treatment, ahead of any medication. The reason is simple: CBT-I works better and lasts longer.

Why Not Just Take a Sleeping Pill?

Sleep medications (zolpidem, eszopiclone, benzodiazepines) can help in the short term, but they come with significant drawbacks:

They don't cure insomnia — they mask it. When you stop the medication, insomnia typically returns, often worse than before (rebound insomnia).
Tolerance develops, requiring higher doses for the same effect.
Side effects include next-day drowsiness, cognitive impairment, increased fall risk (especially in older adults), and potential dependence.
Long-term use is associated with increased risk of dementia, though causation isn't established.

CBT-I, by contrast, addresses the root causes of insomnia — the thoughts, behaviors, and physiological arousal that perpetuate poor sleep — producing improvements that persist long after treatment ends.

The Five Components of CBT-I

1. Sleep Restriction Therapy

This is the most powerful — and most counterintuitive — component. If you're spending 9 hours in bed but only sleeping 5, you're diluting your sleep drive and spending 4 hours lying awake, which trains your brain to associate bed with wakefulness.

Sleep restriction limits your time in bed to match your actual sleep time. If you sleep 5 hours, you get a 5.5-hour sleep window. This builds sleep pressure, consolidates sleep, and gradually extends as efficiency improves. The first week is tough — you'll feel more tired. But by week 2-3, most people fall asleep faster and wake less often.

2. Stimulus Control

This component re-establishes the bed as a cue for sleep rather than wakefulness. The rules are simple:

Go to bed only when sleepy (not just tired — genuinely drowsy)
Use the bed only for sleep and sex — no reading, TV, phones, or work
If you can't fall asleep within ~20 minutes, get up and go to another room. Do something calm until drowsy, then return
Wake at the same time every morning regardless of how you slept
No napping (at least initially)

3. Cognitive Restructuring

Insomnia breeds catastrophic thinking: "If I don't sleep tonight, I'll fail at work tomorrow." "I need 8 hours or I can't function." These thoughts create anxiety that makes sleep even harder — a vicious cycle.

Cognitive restructuring identifies and challenges these beliefs. You'll learn that one bad night doesn't ruin the next day, that your minimum functional sleep is probably less than you think, and that the anxiety about not sleeping is often worse than the actual sleep loss.

4. Sleep Hygiene Education

Sleep hygiene alone rarely fixes chronic insomnia, but it supports the other components:

Keep a consistent wake time (the most important single habit)
Avoid caffeine after noon (it has a 6-hour half-life)
Limit alcohol — it helps you fall asleep but fragments sleep in the second half of the night
Keep the bedroom cool (65-68°F/18-20°C), dark, and quiet
Avoid screens for 30-60 minutes before bed (the light suppresses melatonin, but the stimulation matters more)
Regular exercise improves sleep quality, but finish vigorous activity 3+ hours before bed

5. Relaxation Training

Progressive muscle relaxation, diaphragmatic breathing, and mindfulness meditation reduce the physiological hyperarousal that prevents sleep onset. These techniques lower heart rate, reduce muscle tension, and quiet the racing mind that characterizes insomnia.

How Effective Is CBT-I?

Multiple meta-analyses show CBT-I produces clinically meaningful improvements in 70-80% of patients. Average outcomes include:

Time to fall asleep reduced by 20+ minutes
Wake time during the night reduced by 30+ minutes
Total sleep time increased by 30+ minutes
Sleep efficiency (time asleep ÷ time in bed) improved to 85%+

Critically, these improvements are maintained at 6-month and 12-month follow-ups — unlike medication, which requires ongoing use.

How to Access CBT-I

Traditional CBT-I involves 4-8 weekly sessions with a trained therapist. Access has historically been limited (there aren't enough CBT-I specialists), but options are expanding:

In-person therapy: Search the CBT-I Provider Directory or ask your doctor for a referral to a behavioral sleep medicine specialist.
Digital CBT-I: Apps like Insomnia Coach (free, from the VA) and online programs like Somryst (FDA-cleared prescription digital therapeutic) deliver CBT-I components through structured modules. Studies show digital CBT-I is nearly as effective as in-person.
Telehealth: Many therapists now offer CBT-I via video sessions, dramatically expanding geographic access.

When to Combine with Medication

For severe insomnia, short-term medication (2-4 weeks) combined with CBT-I can provide immediate relief while the behavioral changes take effect. The medication is then tapered as CBT-I gains traction. This approach is sometimes more practical than white-knuckling through the first weeks of sleep restriction. Discuss this option with your prescriber — never combine sleep medications without medical guidance.

If you've struggled with depression alongside insomnia, treating the insomnia often improves the depression. The relationship is bidirectional, and CBT-I has been shown to improve depressive symptoms even when depression isn't directly targeted.