CBT-I is a structured, typically 6–8 session intervention that targets the cognitive and behavioral factors that perpetuate insomnia. It includes sleep restriction therapy (temporarily limiting time in bed to build sleep pressure and consolidate sleep), stimulus control (re-associating the bed with sleep rather than wakefulness or worry), sleep hygiene optimization, relaxation techniques, and cognitive restructuring of unhelpful beliefs about sleep.
Sleep restriction therapy feels counterintuitive — you're prescribed less time in bed when you're already not sleeping enough. But the mechanism is well-established: restricting time in bed builds homeostatic sleep pressure (adenosine accumulation), which produces more consolidated, efficient sleep. Over 4–6 weeks, the sleep window is progressively extended as sleep efficiency improves. Most patients see significant improvement within the first two weeks.
The long-term outcomes of CBT-I are superior to medications. A Cochrane review found that CBT-I produces durable improvement in sleep onset latency, wake after sleep onset, and sleep quality that is maintained at follow-up — while medication effects diminish after discontinuation. Digital CBT-I programs (Sleepio, Somryst) have FDA clearance and produce outcomes comparable to therapist-delivered CBT-I, dramatically improving access.
Medications have a role in acute insomnia and as adjuncts in some chronic cases. Doxepin 3–6 mg (Silenor) is FDA-approved for sleep maintenance. Suvorexant (Belsomra) and lemborexant (Dayvigo) — orexin receptor antagonists — have favorable safety profiles. Benzodiazepines and Z-drugs (zolpidem) are effective short-term but carry dependence risk and should not be prescribed for chronic insomnia without a CBT-I framework.