Non-pharmacological treatments for insomnia: a focus on components of cognitive behavioral therapy for insomnia
Article information
Abstract
Insomnia is a prevalent disorder that affects 4% to 22% of the population in the United States. While cognitive behavioral therapy for insomnia (CBT-I) remains the gold standard for non-pharmacological treatment, accessibility barriers exist owing to a shortage of trained professionals and high costs. This review examines the efficacy of the individual components of CBT-I as stand-alone interventions to improve treatment accessibility, digital CBT-I, and other non-pharmacological interventions. Guidelines from organizations such as the American Academy of Sleep Medicine and, European Sleep Research Society, along with recent meta-analyses, support the effectiveness of these components as stand-alone treatments. Sleep restriction therapy and stimulus control therapy show promise as effective interventions. Although recommended by certain guidelines, relaxation therapy has yielded mixed results. Sleep hygiene education, a common component of CBT-I, has not demonstrated significant efficacy as a stand-alone treatment. Cognitive strategies have shown promise in recent studies. Sufficient clinical evidence supports the efficacy of digital CBT-I in treating insomnia. Internationally, various platforms for digital CBT-I have already been developed and are in use, and in South Korea, some digital CBT-I software programs have received digital therapeutic device approval in 2023. This review highlights the potential of individual components of CBT-I as effective stand-alone interventions for insomnia, as well as digital CBT-I, emphasizing their importance for improving the accessibility of non-pharmacological insomnia treatments in clinical settings where full CBT-I may not be available.
Introduction
Insomnia is a common disorder with a prevalence ranging from 4% to 22% in the United States [1]. It is characterized by difficulties in initiating or maintaining sleep or early morning awakening, accompanied by daytime dysfunction despite adequate opportunities for sleep. Diagnosis is based on criteria from the International Classification of Sleep Disorders, 3rd edition or the Diagnostic and Statistical Manual of Mental Disorders, 5th edition [2,3].
Insomnia treatment is categorized into pharmacological and non-pharmacological methods, primarily represented by cognitive behavioral therapy for insomnia (CBT-I). Although various hypnotic/sedative drugs are available, they are recommended only for short-term use (less than 4 weeks) to avoid dependency or tolerance [4]. Additionally, especially in older adults, pharmacological treatments carry increased risks of falls, confusion, and physical dependence [5], and studies have explored their potential associations with cognitive decline [6]. Thus, CBT-I is considered the most effective and safest treatment for insomnia [4].
Guidelines from the American Academy of Sleep Medicine (AASM), European Sleep Research Society, and other professional sleep associations recommend CBT as a first-line treatment for chronic insomnia in adults of all ages [7-9]. Pharmacological treatments are recommended only when CBT-I is insufficient [4,8,9].
CBT-I is a multicomponent therapy consisting of various strategies to correct cognitive errors related to sleep, along with behavioral therapy strategies such as sleep restriction therapy (SRT) and stimulus control therapy (SCT), and additional elements such as relaxation techniques and sleep-related education, including sleep hygiene [10]. CBT-I is typically conducted over 4–8 sessions by certified health professionals [9]. It is a safe therapy with lasting effects and only transient initial side effects such as daytime drowsiness or fatigue [8]. Despite its effectiveness and safety, CBT-I may face accessibility barriers due to a shortage of trained professionals in some regions, higher out-of-pocket costs compared with pharmacological treatments, and the need for extended time and effort [8,9,11]. Particularly in South Korea, commercialization requires national insurance coverage, but meeting the criteria for insurance allowance is challenging. Even when national insurance allowance is approved, the cost is often low. Moreover, the treatment requires a significant time commitment, making it less appealing, and the lack of trained professionals make its clinical application even more difficult [12].
Recently, some individual components of CBT-I, such as SRT and SCT, have been considered as useful independent therapies for insomnia [4,8,9]. This article aimed to review the literature including the clinical practice and individual effectiveness of each component of CBT-I, considering their potential for improving accessibility to non-pharmacological treatments for insomnia in clinical settings.
Sleep restriction therapy
SRT is a therapy that readjusts the bed-sleep association through sleep time restrictions [10,13,14]. This therapy is decided by sufficient discussion with the patient, based on at least 1 week of sleep diary data. The treatment process involves several steps: (1) setting a fixed wake-up time that aligns with the lifestyle of the patient; (2) restricting time in bed to approximate the average total sleep time (TST; minimum 5 hours); (3) refraining from lying down outside designated sleep times and attempting to stay awake; and (4) adjusting time in bed weekly based on sleep efficiency, increasing by 15 minutes if efficiency is above 85% to 90% or decreasing by 15 minutes if efficiency falls below 80%. Patients are informed about the potential initial side effects, such as daytime drowsiness, and are cautioned to avoid activities with a high injury risk [9,10,15].
The 2021 AASM guidelines conditionally recommend SRT as a stand-alone treatment for chronic insomnia in adults, based on six randomized controlled trials (RCTs) [8]. This recommendation is supported by the 2023 World Sleep Society (WSS) [9]. Additionally, the 2023 update of the European Insomnia Guidelines suggests the efficacy of SRT for the treatment of insomnia [4]. A 2021 meta-analysis of eight RCTs showed that SRT effectively improves insomnia severity and sleep continuity in the short term, with post-treatment effect sizes as large as CBT-I [16]. A 2024 component network meta-analysis of 241 RCTs found SRT to be potentially beneficial for insomnia treatment (incremental odds ratio [iOR], 1.49; 95% confidence interval [CI], 1.04–2.13), associated with improvements in subjective sleep quality, sleep efficiency, and wake after sleep onset (WASO) [17].
Stimulus control therapy
SCT seeks to decondition the incorrect association between the bed/bedroom and wakefulness and restore the connection with sleep. It involves instructions such as [8,10,18]: (1) lying in bed only when sleepful; (2) leaving the bed if unable to sleep (after about 10–15 minutes); (3) using the bed only for sleep and sexual activity; (4) waking up at the same time every morning; and (5) avoiding naps. Although SCT is a relatively easy method to manage, some instructions, such as “get out of bed if you cannot sleep,” may need to be modified for safety in patients at high risk of fall, such as those with limited mobility or those using sedatives [9,10,18,19].
The latest (2021) AASM guidelines conditionally recommend SCT as a stand-alone treatment for insomnia, based on eight additional studies [8]. This recommendation is supported by the 2023 WSS [9]. The 2023 update of the European Insomnia Guideline update also acknowledges the effectiveness of SCT for treatment of insomnia [4]. A 2023 network meta-analysis confirmed the individual effectiveness of SCT in insomnia treatment, despite variations in guideline details, showing associations with increased TST, decreased sleep onset latency, and WASO [18]. A meta-analysis conducted in the same year highlighted a slightly greater impact of SCT on sleep onset latency and TST outcomes than other cognitive and behavioral interventions, although methodological limitations precluded definitive conclusions [20]. A 2024 component network meta-analysis found SCT to be potentially beneficial for insomnia treatment (iOR, 1.43; 95% CI, 1.00–2.05) and is associated with improvements in sleep latency, SE, and subjective sleep quality [17]. A systematic review and meta-analysis in 2024 analyzed 11 studies comparing SCT alone with comparative therapies. Studies that combined stimulus control with other CBT-I components (e.g., sleep hygiene) were excluded, thereby expanding the evidence for SCT as a stand-alone therapeutic element [20].
Relaxation therapy
Insomnia is a disorder characterized by excessive arousal or difficulty in controlling arousal [21], and relaxation training aims to reduce pre-sleep anxiety and arousal. Techniques include physical relaxation methods to reduce physical tension (e.g., progressive muscle relaxation and diaphragmatic breathing) and cognitive relaxation methods to reduce cognitive arousal (e.g., meditation and guided imagery) [8,10]. Currently, evidence does not support the superiority of any one technique [4]. Relaxation therapy requires consistent practice and is better to practice during daytime and low-stress periods until patients become proficient [10].
Based on five studies, the 2021 AASM guidelines conditionally recommend relaxation therapy as a stand-alone treatment for insomnia [8], with endorsement from the WSS in 2023 [9], and the 2023 update of the European Insomnia Guidelines [4]. Conversely, a component network meta-analysis in 2024 suggested that relaxation therapy might potentially yield adverse outcomes (iOR, 0.81; 95% CI, 0.64–1.02) [17].
Psychoeducation and sleep hygiene
Sleep hygiene and psychoeducation provide general recommendations and theoretical rationales for lifestyle and environmental factors that promote or hinder sleep [4,8,10,22]. Sleep hygiene includes maintaining an appropriate bedroom environment; regular routines; exercise; medications; limiting fluid intake before sleep; alcohol; caffeine; eating regularly; not looking at the clock in bed; and refraining from napping during the day. Psychoeducation may also include the roles and functions of sleep, circadian rhythm regulation models, normal sleep components, and age-related changes in sleep patterns. However, sleep hygiene behaviors may sometimes act as safety-seeking behaviors in patients with insomnia [4,8,10].
The 2021 AASM guidelines recommend against the use of sleep hygiene as a stand-alone therapy due to insufficient evidence [8], a position supported by the 2023 WSS [9]. Similarly, a 2024 component network meta-analysis found sleep hygiene education to be non-essential (iOR, 1.01; 95% CI, 0.77–1.32) [17]. However, sleep hygiene remains a common component of CBT-I and may be helpful in a comprehensive multicomponent treatment approach.
Cognitive strategies
Cognitive arousal is considered a fundamental prerequisite for insomnia, and mental events, dysfunctional sleep efforts, and heightened emotions are also common [4,23,24]. Many cognitive strategies have been developed to address these issues and are provided as a component of CBT-I in most studies [7,10,23,25]. Cognitive strategies include cognitive control, which is a method of clearing excessive thoughts before bed; imagery training, which is effective at reducing the racing mind at bedtime; paradoxical intention, which is designed to prevent counterproductive sleep efforts (a willingness to try to stay awake rather than fall asleep); and cognitive restructuring, which modifies common misconceptions about sleep and reconstructs dysfunctional beliefs about insomnia and its daytime consequences, using Socratic questioning and behavioral experiments [4,10,26].
The 2021 AASM guidelines do not recommend cognitive therapy or paradoxical intention as stand-alone therapies owing to insufficient evidence [8]. In the case of cognitive therapy, as mentioned above, most is integrated into CBT-I multicomponent treatment, and the evidence was assessed as insufficient because no studies have compared cognitive therapy monotherapy with a control group. However, the AASM task force noted that cognitive therapy could be considered an alternative treatment if CBT-I is unavailable [8]. Additionally, the 2023 update of the European Insomnia Guidelines suggests the efficacy of paradoxical intention as a stand-alone therapy for insomnia [4]. The 2024 component network meta-analysis of 241 RCTs found cognitive restructuring to be beneficial for insomnia treatment (remission iOR, 1.68; 95% CI, 1.28–2.20) [17].
Digital CBT-I
Digital therapeutics are technologies based on software designed to prevent, manage, or treat diseases [27,28]. CBT-I is based on a structured manual and involves manual-based education and training over a certain period, therefore, it is suitable for implementation as an internet or smart device-based digital therapeutic device [12,29], Sufficient clinical evidence support that digital CBT-I can be effective in treating insomnia [4]. Using digital CBT-I allows patients to overcome the spatial and temporal constraints of visiting healthcare facilities and provides the potential to offer treatment to more patients at a lower cost. Additionally, it allows for the recording and monitoring of whether education and training are effectively applied in patients' real lives and can offer personalized feedback and treatment [12,30]. Therefore, in the Korean clinical environment where resources for face-to-face CBT-I are limited, digital CBT-I may be considered a powerful clinical alternative for non-pharmacological treatment of insomnia [12,29].
Internationally, various digital CBT-I programs such as Sleepio and CBT-I Coach are already in use [12,30]. Recently in South Korea, digital therapeutic software aimed at treating insomnia such as AIMED's Somzz and WELT's SLEEP Q were developed and approved by the Ministry of Food and Drug Safety in 2023 [12], and started non-covered prescriptions in psychiatric hospitals in 2024. However, they have not yet been widely used. The actual non-covered cost of Somzz in clinical settings is around 200,000 KRW (1 USD=1,400 KRW), but the Health Insurance Review & Assessment Service has set the non-covered standard cost at 25,390 KRW, which could dampen enthusiasm for developing and supplying digital CBT-I.
Other cognitive behavioral intervention
Third wave therapies such as mindfulness, acceptance and commitment therapy (ACT) are being considered as treatment for insomnia [4]. Mindfulness-based treatments for insomnia have shown significant therapeutic benefits in two meta-analyses [31,32]. However, there are still few studies, and further researches on long-term effects are needed. ACT has only been studied in small-scale RCTs. While some studies suggest that ACT may be effective compared to active control groups [33-35], larger-scale RCTs are required to confirm these findings.
Other therapeutic interventions
Other non-pharmacological approaches for insomnia include exercise therapy, light therapy, repetitive transcranial magnetic stimulation, and acupuncture. However, most studies are of very low quality, and reported results are based on a small number of studies, limiting their interpretation [4,36].
Several studies including meta-analyses have reported on the effects of exercise on insomnia [37-46]. The types of exercises studied include yoga, aerobic exercise, and Tai Chi. However, results have been inconsistent, and many studies suffer from poor methodological quality; thus, further high-quality research is needed [4,36].
A meta-analysis conducted in 2023 on the effects of light therapy on insomnia suggested it as potentially effective compared to placebo for both objective and subjective WASO [47]. However, due to significant heterogeneity in research methods such as choice of light wavelength and exposure time, consistent conclusions are difficult to draw; further research is needed. The European insomnia guideline update in 2023 suggested that integrating exercise therapy or light therapy into CBT-I might provide additional benefits [4].
For repetitive transcranial magnetic stimulation and acupuncture, some studies have reported subjective sleep improvement in insomnia patients, however, results for physiological indicators had tendency to show either insignificant or mixed results [36,43]. Methodological limitations further restrict interpretation [4]. Moreover, in acupuncture studies, high redundancy in publications citing the same original study may have led to overestimation of its effects [36].
Conclusions
CBT-I remains the gold standard for the treatment of insomnia and is a safe and effective approach with long-term benefits that extend beyond the treatment period. However, despite the proven efficacy of CBT-I, several barriers, including limited access to trained professionals and poor patient compliance, continue to challenge its broader implementation. Particularly in South Korea, gaps between evidence and practice are evident due to various clinical challenges. The lack of resources including the shortage of trained professionals, administrative hurdles in fee setting, and the intensive time and effort required for multicomponent CBT-I make it more challenging to effectively utilize multicomponent CBT-I. Addressing these limitations by exploring the independent use and accessibility of the CBT-I components may enhance treatment options, particularly in regions or settings where comprehensive CBT-I may not be feasible. Currently, individual components such as SRT and SCT are promising stand-alone interventions. Evidence suggests that each component of CBT-I—SRT, SCT, relaxation therapy, and cognitive strategies—independently contributes to significant improvements in insomnia. Digital CBT-I could also enhance the accessibility of non-pharmacological treatments for insomnia if supported by realistic administrative measures such as appropriate insurance allowance settings. A general summary of non-pharmacological treatments for insomnia is shown in Table 1. Further research focusing on the individual and combined effects of CBT-I components, as well as innovative delivery methods, could be helpful in improving accessibility and providing viable non-pharmacological insomnia treatment options to a broader population
Non-pharmacological treatments for insomnia: a focus on components of CBT-I
Notes
Conflicts of interest
No potential conflict of interest relevant to this article was reported.
Funding
None.
Author contributions
Conceptualization; Data curation: YJL. Investigation: SP, YJL. Methodology; Project administration; Resources; Supervision: YJL. Validation: EJL, DL. Visualization: YJL. Writing – original draft: SP, YJL. Writing – review & editing: YJL, EJL, DL. All authors read and approved the final manuscript.