An evidence review published in Annals of Internal Medicine finds that patients with chronic insomnia who undergo cognitive behavior therapy (CBT) can improve sleep without drugs or adverse outcomes. According to the authors, CBT works because it addresses the process that drives insomnia—anxiety about time spent awake in bed.

Clinical chronic insomnia affects up to 15% of adults and is associated with health issues such as anxiety, depression, and type 2 diabetes. Pharmacological approaches to treating insomnia are associated with tolerance, dependence, and adverse side effects, which makes talk-based therapy an appealing option for appropriate patients, the authors say.

Researchers reviewed 20 published randomized controlled trials assessing the efficacy of face-to-face, multi-component CBT on overnight sleep in adults with chronic insomnia and no underlying medical causes. They found that CBT helped patients enter sleep about 20 minutes faster, reduced the amount of time spent awake after falling asleep by nearly 30 minutes, and improved sleep efficiency by almost 10%. Study authors say that these findings are important because the psychological approach is safer and better tolerated than medication and teaches skills that can be maintained over time. They note that this approach takes significant effort from the patient compared to taking a pill.

CBT for insomnia includes five specific components that work together to change a patient’s thoughts and activities around sleep and their sleep environment. Cognitive therapy aims to identify, challenge, and replace dysfunctional beliefs and attitudes about sleep; stimulus control helps strengthen the association between bed and sleep; sleep restriction limits time spent in bed; sleep hygiene recommendations address environmental factors, physiologic factors, behavior, and habits that promote sound sleep; and relaxation techniques help to limit cognitive arousal and reduce muscular tension to facilitate sleep.

The author of an accompanying editorial notes that CBT is unfamiliar and underused by medical practitioners. More research is needed to determine if CBT for insomnia can improve the negative health outcomes associated with chronic insomnia.