Chapter
Behavioral Treatment I: Therapeutic
Approaches and Implementation
Colleen E. Carney; Meg Danforth
Chapter Highlights
Highlights
• Behavioral techniques are highly effective,
even as monotherapy techniques, but most
commonly as a multicomponent treatment;
they are the backbone of a frontline treatment
approach to chronic insomnia.
• Key behavioral techniques in a multicomponent
cognitive behavioral therapy (CBT) include stimulus
control to manage conditioned arousal and sleep
restriction therapy to increase the drive for sleep.
• There are several treatment delivery options
available to fill gaps in access to providers for
INTRODUCTION
Behavioral approaches are effective for treating chronic
insomnia, even in those with comorbid medical or psychiat-
ric conditions. In this chapter we will outline how behavioral
approaches are based on research on the factors that cause,
perpetuate, or exacerbate sleep difficulties. Based on these
factors, behavioral principles guide treatment development,
which are then tested and refined until they are shown to be
efficacious. We will discuss successful behavioral strategies,
such as stimulus control (SC), sleep restriction therapy (SRT),
relaxation training, and counterarousal strategies, as well as
combinations of these methods into a treatment called cogni-
tive behavioral therapy for insomnia (CBT-­I). We will also
discuss implementation and delivery issues, the use of these
tools in comorbid disorders and other special populations, and
a discussion of common treatment tracking tools.  ops high stimulus value of the bed for the sleeping response.
BEHAVIORAL APPROACHES TO INSOMNIA
The tradition of behavioral approaches to conditions such
as insomnia involves the identification of precipitating and
perpetuating factors for the condition1 and the application
of learning principles to develop and test interventions to
address these putative etiologic factors. The assumption is that
changing behaviors can positively affect sleep regulatory sys-
tems, indirectly challenge beliefs that may be unhelpful for
sleep, and alleviate insomnia symptoms. This is not to say
that a behavioral failure on the part of the patient is to blame;
instead, the assumption is that behavior can exert a power-
ful influence on biology and provide relief, irrespective of the
original cause. A classic example is SC, a behavioral treatment
95
cognitive behavioral therapy for insomnia (CBT-­I),
including digital and bibliotherapy options, or
offering group therapy to serve more clients at
once.
• It is important to include a self-­reported
questionnaire to assess clients’ perspectives on
their symptoms, such as the Insomnia Severity
Index, and most essentially, a daily monitoring
tool (the Consensus Sleep Diary) to track
treatment targets and improvements.
to address the inadvertent pairing of the bed with wakeful-
ness characteristic of most protracted insomnias.2 When the
bed loses its stimulus value for sleep, clients can reestablish an
association of the bed with sleep with a set of behavioral rules.
Key in behavioral therapy is the idea that the intervention is
tested and shown to be efficacious. Some treatments that are
integral to multimodal CBT-­I have demonstrated efficacy as
a monotherapy as well. We describe each approach herein;
treatment approaches and their components are summarized
in Table 95.1.
Stimulus Control
The conceptual model behind SC2 is that a stimulus can
become associated with a variety of responses. Ideally, the bed-
room environment is associated with sleep, and there devel-
In insomnia the bed loses its stimulus value for sleep because
initial nights of sleep disturbance in the bed is paired with
wakefulness and thus begins to elicit wakefulness. The goal
in treatment is to restrict stimuli at the initiation of sleep to
stimuli associated with sleep only and/or to avoid stimuli asso-
ciated with wakefulness before sleep initiation. At the core of
SC is the recognition that in the early stages of sleep disrup-
tion, there will be more time awake in bed than previously
experienced. Over time, the bed is paired with the experience
of wakefulness and can become a conditioned stimulus for the
response of wakefulness. This is outside of the awareness of
people with insomnia and may be the consequence of hav-
ing acute sleep disturbance. Once the acute sleep disturbance
resolves, the expectation is that normal sleep resumes; how-
ever, if conditioned wakefulness/conditioned arousal occurs,
883
884 PART II • Section 11  Insomnia

Table 95.1 Behavioral Approaches

Psychological Treatments
Stimulus control
Sleep restriction therapy
Relaxation therapy
Paradoxical intention
Cognitive therapy
Counterarousal Strategies
Sleep hygiene
Cognitive behavioral
therapy for insomnia
Mindfulness
Treatment Summary
Follow five rules to reassociate the bed with sleep only:
1. Do not go to bed until you are sleepy (e.g., actively falling asleep).
2. If you are in a sleep-­incompatible state while in bed, leave the bed/bedroom; do not return until
you are sleepy.
3. Get out of bed at the same time every morning, irrespective of how you slept.
4. Reserve the bed for sleep only (do not engage in wakeful activities in bed).
5. No naps.
Restrict time in bed to the average total sleep time of the last 2 weeks.
After implementing the prescription for 2 weeks:
1. If the sleep problem has resolved, continue with the prescription.
2. If there is evidence of excessive sleepiness, extend the time in bed prescription by 15 to 30 minutes
for the next 2 weeks, and continue extending at subsequent appointments until sleepiness has
resolved. Any reemerging sleep problems are addressed by restricting time in bed back to the
previously effective prescription
Collection of relaxation practices that entail daily practice of one or more of the following:
1. Progressive muscle relaxation
2. Imagery/autogenic training
3. Deep/diaphragmatic breathing
Instruction to go to bed at regular time and initiate effort to stay awake while in bed, all night long.
Direct challenge of sleep believes using one or more of the following:
1. Thought records
2. Socratic questioning
3. Behavioral experiments
Addressing active mind in the presleep period. Commonly used counterarousal strategies include
1. Buffer zone (wind-­down time before bed)
2. Constructive worry or scheduled worry hour
3. Daily mindfulness practice
Set of rules derived from basic sleep research to correct habits that could interfere with sleep:
1. Caffeine: cessation by early afternoon and limit use to no more than (dose and timing instructions
tend to vary)
2. Nicotine reduction/elimination
3. Exercise regularly but not within a few hours of bedtime
4. Avoid middle-­of-­the-­night eating
5. Reduce alcohol, marijuana, and other sleep-­interfering substances
6. Optimize environment: limit light, noise, and extremes in temperature
Multicomponent, empirically based and empirically supported therapy to modify sleep-­interfering
behaviors. The most common elements are
1. Stimulus control
2. Sleep restriction
3. Cognitive therapy
4. Counterarousal strategies; some versions have relaxation therapy
5. Sleep hygiene
Daily practice of directing one’s attention to the present moment, nonjudgmentally

this becomes a perpetuating factor and will likely turn the
acute problem into a chronic insomnia. The answer then is to
address the conditioned arousal by reassociating the bed with
sleep by being in bed only when asleep.
To accomplish the reassociation of the bed/bedroom with
sleep, clients are instructed to wait for the experience of
sleepiness to guide their decision to get into bed. Sleepiness is
characterized by behaviors observed at sleep onset (e.g., head
falling forward or back because of a loss of muscle tone, eyes
rolling back into the head, lapses in attention, falling asleep,
etc.). Waiting for sleepiness and associated behaviors, rather
than using the clock to determine when to get into bed,
increases the likelihood of falling asleep quickly (i.e., because
they are already actively falling asleep). If after getting into
bed, the client notices that they are no longer sleepy, they are
in an arousing or sleep-­incompatible state, or 15 minutes has
elapsed (i.e., sleepiness is present when sleep onset occurs in
less than 15 minutes), they leave the bed/bedroom and return
only when sleepiness returns.3 Most providers resist giving
time guidance (i.e., 15 minutes) because it may encourage
clock watching; however, case formulation can provide guid-
ance on this issue. If a client is not getting out of bed for long
periods of time while awake, the 10-­minute/sleepiness guide-
line may help with adherence to this rule. In contrast, clients
who watch the clock are told to turn away the clock from view
and to focus on the internal sensation of sleepiness/readiness
to sleep. This step is repeated as many times as is needed to
reestablish the association of the bed with sleep (breaking the
 Chapter 95  Behavioral Treatment I: Therapeutic Approaches and Implementation
association of the bed with wakefulness). The third rule is to
get out of bed at the same time every morning irrespective of
the previous night’s sleep. This helps to establish a firm time
and a place for a sleep opportunity, thereby establishing stimu-
lus value for the bed within a certain window associated exclu-
sively with sleep. There is not a way to establish a set bedtime
given that sleepiness must be present to go to bed, but rise
times are easily set with an alarm clock. Prohibited are wake-
ful activities in bed because wakefulness in the bed weakens
the association of the bed with sleep. Some couples choose
to move sexual activity to a different room (i.e., because it is
a wakeful activity), whereas other couples choose to make sex
an exception and continue to have sex in their bed/bedroom.
Daytime naps are disallowed, to further establish the bed and
a particular window of sleep opportunity with sleep. Chapter
96 is dedicated to reviewing its efficacy, but briefly; multiple
studies support the use of SC on its own, including studies
enrolling those with sleep-­onset insomnia,4–6 older adults,7,8
and those in group and individual therapy.5–8 Although SC
has support as a monotherapy,7 it is most commonly com-
bined with SRT in clinical practice.  between-­session practice. The visualization is typically some-
Sleep Restriction Therapy
SRT9 is derived from biologic drive studies demonstrating
that responses are increased by removing or limiting access
to it. For example, remove food and increased food-­seeking
behaviors occur. Remove the opportunity to sleep and there is
a greater propensity to sleep once access is provided. Behav-
iors such as eating, drinking, and sleeping are homeostatically
controlled, and SRT leverages this principle with impressive
effects. Clients are asked to spend less time in bed—engage in
less sleep effort and build sufficient drive for sleep. This results
in greater consolidation of sleep and sleep depth.10,11
SRT is an unfortunately named treatment, as the goal is to
restrict the time in bed to closely match the current average sleep
duration, rather than reducing sleep duration. Many providers
refer to this treatment as “time-­in-­bed restriction.”12 Time-­in-­
bed restriction leverages the homeostatic system by prescribing
only the mean total sleep time as a window for time in bed for
the 2-­week period preceding the appointment. There are some
variations in the prescription, wherein some time is added to
the window (e.g., 30 minutes to account for normative sleep-­
onset latency).3 Typically, there is a minimum prescription (e.g.,
5 to 6 hours) to protect against excessive sleepiness; but again,
there is some variation in this practice and no empirical stud-
ies available to guide this clinical decision. This restriction in
time in bed creates greater sleep efficiency and consolidation
of sleep. This procedure, in addition to greater efficiency, can
result in sleepiness, and hence extension of time in bed is pre-
scribed as therapy progresses.13,14 An extension in the time-­in-­
bed prescription typically occurs in the context of a complaint
of subjective sleepiness, a mean sleep-­onset latency less than 10
minutes, and/or a mean sleep efficiency greater than 85% or
90%. When delivered alone, the number of weekly treatment
sessions vary from two to six. It is a well-­established treatment
on its own,7,15,16 particularly for the gold standard outcomes
of Insomnia Severity Index (ISI) and sleep diaries, but is most
often used as part of a multicomponent CBT-­I.  Paradoxical intention has been tested as a treatment for sleep-­
Relaxation Therapy
Relaxation therapy (RT) refers to a collection of empirically
supported relaxation practices to reduce 24-­hour basal levels
885
of arousal. The RT strategies tested in insomnia include those
involving breathing, imagery, and muscle relaxation tech-
niques. Various relaxation strategies are effective in insom-
nia, although there are smaller effect sizes with RT relative
to CBT-­I.17,18 Lichstein and colleagues19 suggest that most
relaxation therapies used for insomnia should conform to
Benson’s20 recommendations for relaxation, that is, practicing
in a quiet environment and in a comfortable position, with
an object to dwell upon and a passive attitude. Most of the
relaxation therapy studies in insomnia were published decades
ago, focusing on sleep-­onset insomnia, so it is unclear whether
it generalizes to sleep maintenance or more mixed insomnia
presentations.
Guided imagery is a relaxation technique that uses con-
tinuous visualization of a relaxing scene/situation. Instruc-
tions are similar to other forms of relaxation in that clients are
asked to practice during the day and eventually at night, in a
comfortable position and place in which they are less likely to
be disturbed. The first visualization is typically in the thera-
pist’s office and is often recorded to take home for at-­home,
thing autobiographically relevant, in the past, and a scenario
that was relaxing and relatively easy to contemplate. When
clients experience difficulty recalling such a scene, the thera-
pist and client collaboratively discuss possible relaxing scenes
until the client settles on one that is personally relevant. For
example, the client may picture moments from a beach vaca-
tion and visualize the sights, sounds, tastes, touch, and smell
of the imagined scene.
Progressive muscle relaxation (PMR) involves tensing and
then releasing 16 muscle groups in a gradual paced progres-
sion, focusing on the contrasting sensations of tension and
release.21 This practice is typically taught in-­session, led by
the therapist, and then practiced daily with an audio record-
ing between sessions. The use of audio between sessions is
considered an important part of skill acquisition.22 PMR is
a deep relaxation technique used widely for problems such as
stress, anxiety, and in chronic conditions, such as headaches or
anxiety. There are varying instructions as to when the practice
occurs, but in general, the instruction is to practice it during
the day to build the skill of releasing tension and lowering
basal levels of tension, and then eventually PMR is com-
pleted in the presleep period to produce a state of relaxation
presleep.23
Autogenic training24 is a relaxation training technique in
which clients lay down, or assume a suitably comfortable posi-
tion, and repeat in their mind suggestions of feeling warmth
and heaviness. Sometimes there are repetitions of statements
such as “I am at peace.” Imagining warmth and heaviness pro-
gressing through the body purportedly creates a physiologic
state of vasodilation and reduced muscle tone, a state con-
ducive to lowered arousal. Similar to PMR, this technique is
taught across multiple sessions with a therapist and through
daily practice.25 The daily practice eventually also includes use
of the technique in the pre-­sleep period. 
Paradoxical Intention
onset insomnia with a relatively simple instruction to “go to
bed and attempt to stay awake all night long in bed.” There
may be several reasons why this is an effective treatment. First,
it is an exposure of sorts to a significant fear in those with
886 PART II • Section 11  Insomnia
insomnia: staying awake all night. In addition, Espie and col-
leagues26 have built a body of research supporting that one
major issue in insomnia is that people with insomnia exert
effort to sleep. Exerting effort to sleep is counter to the state
needed to enter sleep; thus the paradoxical suggestion to exert
effort to resist sleepiness makes it difficult to do so. Whereas
some clients may believe they already stay awake all night in
bed, the key difference in this treatment is that they are inten-
tionally avoiding effort to sleep. The length of treatment ses-
sions varies between two sessions,27 4 sessions6,28 and eight
sessions.4 The flexible number of sessions and strong empiri-
cal support raises the issue of whether there is any benefit of
multicomponent CBT-­I over this approach. However, most
people with insomnia do not have sleep-­onset insomnia exclu-
sively, perhaps limiting the utility of this treatment.  ing, body scan, and walking meditation). Thereafter person/
Cognitive Therapy and Counterarousal Strategies
Each of the behavioral interventions described earlier is an
individually effective therapy for chronic insomnia.29 The “C”
in CBT-­I stands for “cognitive” therapy (CT); at the time of
this writing, there are not enough published empirical tests
of CT as a monotherapy to establish it as a treatment on its
own; however, there is extensive evidence for the effective-
ness of CT used in combination with other therapies. Read-
ing descriptions of CT from past CBT trials, there appeared
to be some variability in what was labeled CT. Belief change
is targeted in many ways, including psychoeducation, direct
challenge of beliefs typically via Socratic questioning, thought
records, and behavioral experiments. There has been one large
scale randomized controlled trial (RCT) in CT, and in this
contemporary version, there is the predominant use of behav-
ioral experiments as the tool.30 Presumably the shift toward
behavioral experiments has occurred because of research sup-
porting an advantage for behavioral experiments over verbal
challenge (i.e., in thought records).31 Behavioral strategies are
effective on their own, leading some to conclude that CT is
unnecessary, but one possibility is that CT may be important
because belief change may help sustain long-­term benefits
of CBT-­I over behavioral approaches.14 Moreover, decreas-
ing the rigidity of sleep beliefs is linked to multiple indices
of clinical improvement.32 Clearly, more studies are needed
to understand the role of cognition and methods to modify
thinking in resolving chronic insomnia.
Worry in the presleep period is one of the strongest cog-
nitive predictors of delayed sleep-­onset latency.33 For those
who tend to worry in bed, the behavioral insomnia thera-
pies are proven strategies: SC eliminates the bed as a condi-
tioned stimulus for worry and wakefulness, whereas SRT may
increase the homeostatic drive for sleep to the point that the
client ceases to worry because they are asleep. However, there
are a variety of processing/problem-­solving techniques that
have focused more directly on presleep cognitive arousal. One
of the original problem-­solving cognitive strategies is a writ-
ing procedure that takes place in the evening, developed by
Espie and Lindsay34; this technique is similar to a procedure
called constructive worry.35 The premise is that unresolved
problems lead to worry and interfere with sleep onset by
increasing arousal. Creating a plan during the day to address
the problem decreases the likelihood that such worries will
follow the person to bed. With constructive worry, clients are
asked to set aside time several hours before bedtime to iden-
tify the problems that have the greatest likelihood of keeping
them awake at night as well as the next, most immediate steps
they can take toward resolving the problem. When combined
with the behavioral insomnia therapies, the constructive worry
procedure reduced insomnia symptom severity and worry to a
greater degree than did behavioral therapy (combined SC and
SRT) alone.36 
Mindfulness
Mindfulness is a treatment that trains clients to observe,
describe, and experience the present moment, nonjudgmen-
tally. In therapy sessions a trained facilitator presents key
principles of mindfulness (e.g., beginner’s mind, nonstriving,
letting go, nonjudging, and acceptance) and guides individu-
als through various formal meditations (e.g., mindful eat-
group members are invited to participate in a brief period
of inquiry regarding their in-­session and at-­home practice
of mindfulness. Essential to mindfulness therapy are daily,
between-­session exercises of attentional training. Relative to
behavioral strategies in which there is a change in sleep hab-
its only, mindfulness approaches require a greater daily time
commitment but may appeal to those who view their arousal
as key in maintaining their insomnia. Mindfulness may also
be easier to adhere to for those who do not wish to or find
it difficult to change their sleep habits; however, there is no
evidence that insomnia can be effectively treated without sleep
behavior change. Three RCTs have tested mindfulness along
with effective behavioral insomnia strategies as a group ther-
apy with promising results.37–40 
Sleep Hygiene
Sleep hygiene (SH) is the number one disseminated treatment
strategy on the internet and the number one cited treatment
strategy among providers,41 but this is unfortunate, as SH is
used effectively as a placebo control treatment in clinical tri-
als42–44 and has not been adequately tested as a stand-­alone
treatment in insomnia clients with specific abnormal sleep
hygiene behaviors. The reason SH is used as a placebo control
condition is that it is credible to patients but is generally not
an efficacious stand-­alone therapy for insomnia disorder.45,46
Perhaps one of the reasons SH continues to be a component
of CBT-­I is that it is a low-­resource treatment, typically con-
sisting of a handout of recommendations only, and is occa-
sionally clinically relevant for selected patients. It should be
noted that SC, an effective treatment, can be delivered as a
handout set of instructions. Unlike SC and SRT, or even CT,
SH was not tested in those with insomnia except in the con-
text of answering other research questions. The variability in
the instructions makes it difficult to say anything definitive
about this “treatment.” Addressing sleep hygiene factors in
treatment may occasionally be necessary, but it is insufficient
as an isolated insomnia intervention. In other words, drinking
caffeine before bed is ill-­advised because the stimulant proper-
ties will have a negative effect on sleep, but reducing or even
eliminating caffeine is rarely sufficient to address sleep in indi-
viduals with insomnia disorder. Thus SH remains in CBT-­I
for cases in which this might be an issue, but because good and
poor sleepers do not reliably differ on SH practices,47–49 and as
it is less tied to those with insomnia,50 it is often unnecessary.
It is also possible that SH actually causes harm. For instance,
receiving this advice could delay effective treatment, its lack of
efficacy could affect the perception of effective therapies such
 Chapter 95  Behavioral Treatment I: Therapeutic Approaches and Implementation
as CBT-­I, and inclusion in CBT-­I approaches may unduly
burden clients, but this has not been studied empirically.  strated efficacy as monotherapies, does not require in-­clinic
Multicomponent Cognitive Behavioral
Therapy for Insomnia
The most common treatment for insomnia is the combination
of SC, SRT, SH, CT, and RT and/or other types of counter-
arousal techniques, thus receiving the name of multicompo-
nent CBT-­I. Multimodal CBT-­I is typically defined by the
inclusion of at least SRT and SC.51 Multicomponent therapy
is highly effective,7 and CBT-­I is effective and durable even
across those with comorbid conditions.51 See Table 95.2 for
an example of a session-­by-­session outline of CBT-­I.
Brief behavioral therapy for insomnia (BBTI) is a multi-
component treatment that combines psychoeducation, SC,
and a prescription of SRT based on a pre–session-­one sleep
diary. It is purportedly brief, although the number of treat-
ments has varied across studies. For example, BBTI was
initially delivered in two sessions,52 but several studies have
increased it to two in-­person sessions plus two phone or elec-
tronic follow-­ups,53 which is the optimal dose of sessions
for CBT-­I.54 Another study combined BBTI with imagery
rehearsal therapy for nightmares for eight sessions.55 Given
that the session length of BBTI may be as long as CBT-­I,
and CBT-­I is a more established treatment with direct tech-
niques to address unhelpful thinking that may improve adher-
ence, why use BBTI? One reason BBTI is regarded as a useful
alternative is that BBTI is a strictly behavioral approach and
may appeal to providers with less experience or training in CT.
Table 95.2 Sample Session-­by-­Session Outline for a
Four-­Session Model
Week Therapeutic Activities
Week 1 Diagnostic and treatment planning assessment,
Week 2 assign diaries
Week 3 Completion of sleep diaries
Begin psychoeducation, stimulus control,
sleep restriction therapy, and sleep hygiene
instructions
Week 4 At-­home implementation of strategies
Week 5 Troubleshoot adherence to homework and
determine if changes are necessary to schedule
Begin cognitive therapy and time permitting,
add counterarousal strategies/relaxation
therapy
Week 6 At-­home implementation of strategies
Week 7 Troubleshoot adherence and determine if
changes are necessary to schedule
Continue with cognitive therapy; add
counterarousal strategies (if it was not added
at session 2)
Introduce termination issues
Week 8 At-­home implementation of strategies
Week 9 Troubleshoot adherence
Determine if changes are necessary to schedule
Finish cognitive therapy
Termination issues and relapse prevention
From Edinger JD, Carney CE. Overcoming Insomnia: A Cognitive-­Behavioral
Therapy Approach, Therapist Guide. 2nd ed. Oxford University Press; 2015:141.
887
Also, BBTI combines two behavioral treatments with demon-
follow-­ups, and is primary care friendly. 
IMPLEMENTATION OF COGNITIVE BEHAVIORAL
THERAPY FOR INSOMNIA
Individual Treatment Format and Dosing
The most commonly used and most researched method of
delivery for CBT-­I has been individual therapy consisting of
one-­on-­one outpatient sessions between a clinician and a single
patient.21,54 Most published RCTs using this treatment format
have used doctoral-­level or graduate student psychologists as
therapists, although many have trained other professionals, such
as nurses, with similar success rates.56 Several meta-­analyses and
systematic reviews suggest that individual CBT-­I is an effective
short-­term and long-­term treatment for insomnia disorder.57
CBT-­I is designed to be a brief intervention, with most proto-
cols consisting of four to eight sessions of individual therapy.58
Edinger and colleagues54 found that four individual, biweekly
sessions represents the optimal dosing of multicomponent
CBT-­I, with greater short-­and longer-­term improvement in
sleep relative to fewer or more treatment sessions.
Table 95.2 provides a sample four-­session outline. Assumed
in this four-­session model is that a full diagnostic and treatment
planning assessment occurred before the start of session one. In
this model, once a diagnosis of insomnia disorder is made, and
the provider and client agree to proceed with CBT-­I, clients
are provided with daily sleep diary instructions and assigned
2 weeks of monitoring. Providers query any anticipated barriers
in completing the diaries daily and engage in troubleshooting
of barriers (e.g., placing the diary in a conspicuous spot, set-
ting a timer reminder for the morning to complete it, challeng-
ing catastrophic beliefs that answering questions about habits
could worsen, rather than improve, sleep, etc.). Thus treatment
session one begins with the sleep diary data necessary for cre-
ating a schedule for the time-­in-­bed prescription. 
Other Delivery Methods
Many organizations, including the American College of Phy-
sicians,59 have formally endorsed CBT-­I as the first-­line treat-
ment for adults with chronic insomnia. When offered a choice,
most patients prefer CBT-­I to the use of hypnotic medica-
tions,60 as do prescribers.61 That said, one barrier to the more
widespread dissemination of CBT-­I has been a lack of trained
clinicians to deliver this treatment. In the last decade there
have been calls for a stepped-­care model for the treatment of
insomnia.62,63 To this end, researchers have established effi-
cacy for alternative methods of delivering CBT-­I to patients,
including group therapy,64 self-­help books,65 abridged pro-
tocols for primary care settings,14,56,66,67 telephone-­and
video-­based therapy,68,69 and digital CBT-­I.70–72 Innovative
approaches were implemented during the COVID-19 pan-
demic (see Chapter 213).72a 
Use in Older Adults and Those with Co-­occurring
Mental Health and Medical Conditions
There is ample support for the effectiveness of unaltered
CBT-­I in older adults and those with co-­occurring medical
and mental health conditions.46,51,73 This is not surprising, as
older insomnia patients and those with comorbid conditions
share the same chronic insomnia perpetuating factors with
888 PART II • Section 11  Insomnia
adults who present only with insomnia: behaviors that prevent
adequate “buildup” of homeostatic sleep drive, behaviors that
interfere with the circadian timing of sleep, and hyperarousal.
For example, there can be decreased activity and increased
time in bed in older adults and those with co-­occurring condi-
tions; as such, the treatment targets in these comorbid patients
are the same.74
Although CBT-­ I is effective in an unaltered state for
older adults and those with co-­occurring conditions, some
have argued for modifications. For example, Smith and col-
leagues75 (2005) speculated there may be unique delivery
issues among particular populations that require special altera-
tions of, or additions to, CBT-­I to optimize insomnia treat-
ment outcomes (e.g., the partial sleep deprivation occurring in
SRT may increase risk for panic attacks, psychotic or manic
symptoms). In such cases clinicians may opt for countercon-
trol,76 which replaces the SC rule of leaving the bedroom with
sitting-­up and giving up the effort to sleep until sleepiness
returns. Thus, during the countercontrol modification of SC,
patients remain in bed. Countercontrol is primarily used in
those with high fall risk (e.g., frail older adults, those with
medication that may make them less steady on their feet at
night, physical limitations or housing limitations that prevent
going to another room). In addition, there may be a number
of situations in which (1) SRT is modified (e.g., setting a pre-
scription limit of no less than 6 hours), (2) SRT is replaced
with sleep compression so that time in bed is reduced more
gradually (i.e., 30 minutes per week),77 or (3) SRT is removed
altogether78 to limit potential negative effects (e.g., lowering
seizure or panic attack thresholds, or increasing mania or psy-
chotic symptoms).
Although there are some situations in which CBT-­I may
be adapted, in addition, there have been some notable aug-
mentations to CBT-­I. Fatigue is notable problem in cancer
populations, so one augmentation to CBT-­I has been to add
fatigue management.79 Although not specific to older adults,
cognitive and psychoeducation preparation for hypnotic
medication taper has been added to CBT-­I, as well as post–
CBT-­I support during a medically supervised taper, for older
adults who are hypnotic dependent.80 Those with posttrau-
matic stress disorder often receive a nightmare treatment (e.g.,
imagery rescripting and rehearsal therapy),81 in which they
rehearse alternative dream scenarios to address co-­occurring
nightmares. In those with serious mental illness, most notably
in those with psychotic disorders78 and bipolar disorders,82,83
there is often circadian treatment targets of extreme vari-
ability and phase delay, which are not explicitly targeted by
CBT-­I. Thus CBT-­I has been augmented in various ways, for
instance, targeting sleep inertia with morning strategies to
help those with bipolar disorder adhere to morning rise time
goals.83 Such approaches are labeled transdiagnostic, to rec-
ognize that some populations may have more sleep problems
than insomnia only, and broader behavioral sleep medicine
techniques would be most helpful.84  rest, usually worn around the nondominant wrist. Movement
ASSESSMENT TOOLS USED IN COGNITIVE
BEHAVIORAL THERAPY FOR INSOMNIA
Assessment Tools for Treatment Monitoring in CBT-­I
Insomnia disorder is diagnosed based on the person’s reported
symptoms, which take precedence over any objective findings.
As such, self-­report measures of symptoms are essential, and
the sleep diary represents a critical tool to identify behavioral
targets for insomnia intervention, to guide the implementa-
tion of behavioral interventions, to identify challenges with
treatment adherence, and to measure treatment outcomes.85
Although there are several versions of sleep diaries available in
the literature, the Consensus Sleep Diary (CSD)86 was devel-
oped in consultation with a group of 25 leading experts to
provide a standardized diary. The CSD is a prospective tool
completed upon awakening that queries the subjective experi-
ence of the previous night. Examples of core items include
the time the patient got into bed, the estimated amount of
time it took to fall asleep, and the time at which they got out
of bed. An expanded version includes optional items query-
ing habits, such as naps, medications, alcohol, and so forth.
Indices such as naps, alcohol, time in bed, and the variability
of bedtimes and rise times, calculated by examining the differ-
ence between the earliest and latest times, provide informa-
tion to generate hypotheses about possible behaviors to target.
Ongoing completion of the CSD over the course of treatment
allows the clinician to test hypotheses using the patient’s own
data (e.g., decreasing time in bed by 1 hour should lead to
improved sleep indices) and to modify treatment in response.
The CSD is especially critical to the implementation of SRT
in CBT-­I: The initial time-­in-­bed prescription is derived from
the patient’s average total sleep time on the CSD, and in sub-
sequent sessions, the clinician uses data from CSD to assess
adherence to behavioral targets and to make adjustments to
the time-­in-­bed prescription. The CSD is also used in CT to
test beliefs the patient has about their sleep system. For exam-
ple, data collected using the CSD may challenge the accuracy
of a patient’s all-­or-­nothing statement about “not sleeping.”
The CSD has good treatment sensitivity for the diary in
detecting improvement after CBT-­I.87
Another important self-­report measure is the ISI.88 The
ISI is a seven-­item measure of perceived insomnia severity
assessing initial, middle, and late insomnia; satisfaction with
sleep; sleep-­related preoccupation; and the impact and notice-
ability of sleep difficulties. Each item is rated on a five-­point
scale, and the summation of the items yield a total score rang-
ing from 0 to 28. Cut-­off scores of 10 in community sam-
ples and 14 in primary care clinics have been recommended
to detect insomnia, although a change score of 8 points has
been suggested to define an optimal treatment response.89,90
The ISI has been shown in several studies to be sensitive to
therapeutic changes, which is why it may be particularly useful
to track treatment progress.30,91,92 Although there are strong
psychometric properties for the ISI, it remains unclear as to
what clients “mean” by their ISI score. Construct questions are
essential to understand in a patient-­centered approach, and
more answers are needed. 
Actigraph
An actigraph is a device used to monitor cycles of activity and
and/or light data are recorded on the device over an extended
period of time (days to weeks) and are transformed with
mathematical algorithms into estimates of sleep parameters
(e.g., total sleep time, sleep latency, wake after sleep onset).
Actigraphy does not measure sleep directly, nor the subjective
experience of sleep as with the CSD, but rather draws infer-
ences about sleep and wake patterns based on movement. As
such, those lying awake motionless for hours or those awake
 Chapter 95  Behavioral Treatment I: Therapeutic Approaches and Implementation
but in sedentary jobs all day pose challenges to the assump-
tions underlying this technology. Actigraphy has acceptable
correlations with other estimates of global sleep-­wake param-
eters, such as total sleep time and sleep efficiency, but are
much less accurate in estimating discrete or event-­to-­event
sleep-­wake parameters, such as sleep onset latency and time
awake after sleep onset. Thus, if it is ever used in a clinical set-
ting for insomnia, it would most likely assess 24-­hour global
patterns, which is most often done to assess sleep-­wake pat-
terns in those with atypical circadian rhythms, or adherence
to into time-­in-­bed prescriptions.93 Its use in clinical settings
for insomnia is limited due to questionable validity, cost, and
limited coverage by third-­party payers. Of note, in recent
years, consumer-­grade sleep-­tracking devices have become
increasingly available, affordable, and popular. Clinicians and
their patients should be aware that the vast majority of these
devices have been developed commercially without support-
ing evidence for reliability and validity.94 Although a poten-
tially useful complement to self-­report and polysomnography
measures, actigraph devices and algorithms are not all equiva-
lent and there may be significant variability in the reliability
and validity of nocturnal sleep-­wake data,95 as well as nap
data derived from different devices.96 This equipment does
not capture subjective experience—the quintessential feature
of this disorder.
There are many other valuable assessment tools, including
those for other symptoms, such as fatigue; assessment tools of
most relevance to cognitive therapy; and tools that are use-
ful in other sleep disorders, such as polysomnography, but the
primary tools used in behavioral insomnia treatment are (1)
prospective subjective diaries and (2) retrospective subjective
questionnaires, such as the ISI.  2006;29:1155–1173.
SUMMARY
• B ehavioral approaches are those grounded in learn-
ing theory and empirically tested and supported; the
assumption that altering behavior can affect change in
physiology and thoughts is common across behavioral
approaches.
• The behavioral approaches with the strongest support
include SC, SRT/time-­in-­bed restriction, and a multicom-
ponent treatment that combines these two with other tech-
niques.
• Relaxation therapy and other counterarousal techniques
are effective in their own right, albeit with smaller effect
sizes than SC and SRT.
• There are many effective delivery methods, including brief
individual and group therapy, self-­help books, telephone-­
and video-­based therapy, and digital CBT-­I; such variabil-
ity is important to meet the needs of areas with limited
access to therapists.
889
CLINICAL PEARLS
• S leep hygiene education is not an effective treatment
for insomnia; for a primary care–friendly alternative,
consider stimulus control (SC), which can be used as
a monotherapy. Like the other behavioral therapies,
SC will require some follow-­up, which can be done by
phone.
• It is important to assess clients’ perspectives on their
symptoms using a self-­report questionnaire, such as the
Insomnia Severity Index, and to track treatment targets
and improvements using the daily Consensus Sleep
Diary.
• Sleep diary data are essential for calculating the initial
time prescription for sleep restriction therapy and
making adjustments to this in subsequent sessions; this
cannot be done using clients’ retrospective estimates of
sleep time.
• Patients who cannot access in-­person individual
cognitive behavioral therapy for insomnia (CBT-­I) should
consider alternative delivery mechanisms, including
digital CBT-­I.
SELECTED READINGS
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9457(21)00248-3.
Bootzin RR. Stimulus control treatment for insomnia. Proc Am Psychol Assoc.
1972;7:395–396.
Buysse DJ, Ancoli-­ Israel S, Edinger JD, Lichstein KL, Morin CM.
Recommendations for a standard research assessment of insomnia. Sleep.
Carney CE, et al. The consensus sleep diary: standardizing prospective sleep
self-­monitoring. Sleep. 2012;35:287–302.
Espie CA, Lindsay WR, Brooks DN, Hood EM, Turvey TA. Controlled
comparative investigation of psychological treatments for chronic sleep-­
onset insomnia. Behav Res Ther. 1989;27:79–88.
Geiger-­Brown JM, et al. Cognitive behavioral therapy in persons with comor-
bid insomnia: a meta-­analysis. Sleep Med Rev. 2015;23:54–67.
Moss TG, Lachowski A, Carney CE. What all treatment providers should
know about sleep hygiene recommendations. Behav Ther. 2013;36:76–84.
Ong JC, et al. A randomized controlled trial of mindfulness meditation for
chronic insomnia. Sleep. 2014;37:1553–1563.
Qaseem A, et al. Management of chronic insomnia disorder in adults: a clini-
cal practice guideline from the American College of Physicians. Ann In-
tern Med. 2016;165:125–133.
Siriwardena AN, et  al. General practitioners’ preferences for managing in-
somnia and opportunities for reducing hypnotic prescribing. J Eval Clin
Pract. 2010;16:731–737.
Spielman AJ, Saskin P, Thorpy MJ. Treatment of chronic insomnia by restric-
tion of time in bed. Sleep. 1987;10:45–56.
Vincent N, Lionberg C. Treatment preference and patient satisfaction in
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 Chapter 95  Behavioral Treatment I: Therapeutic Approaches and Implementation 889.e3

REVIEW QUESTIONS 7. The goal of sleep restriction therapy is to

A. Match the time in bed to about the amount of time
1. The purpose of stimulus control is to: they sleep, to consolidate sleep
A. Fall asleep faster B.  Set an earlier bedtime and rise time
B.  Reassociate the bed with sleeping C. Shorten the amount of sleep during the night and add
C. Manage anxiety naps
D. Become sleepier D. Use bright light in the morning and dim the lights in
the evening
2. All of the following are steps in stimulus control E.  All of the above
EXCEPT:
A. If you are in a sleep-­incompatible state while in bed, 8. CBT-­I is a multicomponent, empirically based and sup-
leave the bed/bedroom; do not return until you are ported therapy to modify sleep-­interfering behaviors.
sleepy. Major elements of CBT-­I are
B.  Manage blue light exposure before bed. A. Stimulus control
C. Get out of bed at the same time every morning, irre- B.  Sleep restriction
spective of how you slept. C. Cognitive therapy
D. Reserve the bed for sleep only (do not engage in D. Sleep hygiene
wakeful activities in bed). E.  All of the above
3. All of the following can occur as part of cognitive behav- 8. In progressive muscle relaxation technique, the patient is
ioral therapy for insomnia (CBT-­I), but which of the fol- taught to recognize and control tension through a series
lowing are effective strategies on their own? of exercises that consist of
A. Sleep hygiene A. First tensing and then focusing on the release of 16
B.  Relaxation therapy muscle groups
C. Stimulus control B.  Imagining warmth and heaviness progressing through
D. Sleep restriction the body, purportedly creating a physiologic state of
vasodilation and reduced muscle tone
4. How would you best characterize the CBT-­I delivery C. Directing attention to the present moment while
literature in older adults and/or those with co-­occurring relaxing muscles
mental and/or medical comorbidities? D. Breathing in for 4 seconds, holding the breath for 7
A. CBT-­I is effective in a nonmodified form. seconds, and exhaling for 8 seconds while relaxing 10
B.  CBT-­I is effective in an adapted form (e.g., counter- muscle groups
control for those at risk for falls). E.  None of the above
C. CBT-­I is effective with adjunct strategies such as
fatigue management. 10. The treatment that reassociates the bed with sleep is called
D. All of the above are true. A. Stimulus control
B.  Sleep restriction
5. How would you characterize the importance of sleep C. Sleep hygiene
diary data for treatment tracking in CBT-­I? D. Cognitive therapy
A. Nonessential; objective measures such as polysom- E.  All of the above
nography or actigraphy are preferred
B.  Important for the identification of perpetuating fac-
tors (i.e., treatment targets) and whether they are
changing with treatment
C. Important for deriving the time-­in-­bed prescription
for sleep restriction therapy (SRT)
D. All are correct EXCEPT “A”

6. SRT works by
A. Increasing physical activity to build up sleep drive
B.  Increasing the amount of time the individual spends
in bed to decrease fatigue
C. Reducing the amount of time the individual spends in
bed in order to build up pressure for sleep
D. Extending the time in bed prescription to sleep longer
E.  None of the above
889.e4 PART II • Section 11  Insomnia

ANSWERS
1. B.

2. B.

3. A.

4. B.

5. D.

6. C.

7. A.

8. C.

9. A.

10. A.
Chapter
96 Behavioral Treatment II: Efficacy,
Effectiveness, and Dissemination
Rachel Manber; Norah Simpson; Lauren Asarnow; Colleen E. Carney
Chapter Highlights
• O ver the past 10 years, cognitive behavioral
therapy for insomnia (CBT-­I) has increasingly
been recognized as the “gold-­standard”
treatment (or standard-­of-­care treatment) for
chronic insomnia by several major medical/
health care organizations. These include the
American College of Physicians, the American
Academy of Sleep Medicine, the British
Association for Psychopharmacology, and,
more recently, the European Sleep Research
Society.
• There is a wealth of empirical evidence for the
efficacy of CBT-­I in reducing insomnia severity
and improving sleep among individuals with
insomnia, either alone or comorbid with other
disorders. This chapter also discusses evidence
for the effects of CBT-­I on a range of outcomes
beyond sleep. The discussions in each subsection
also highlight areas for future research.
EFFICACY
Cognitive behavioral therapy for insomnia (CBT-­I) is a brief
and effective multicomponent treatment that alters behaviors
and thoughts associated with insomnia disorder (see Chapter
95 for a detailed description of treatment components and how
to implement them). Many meta-­analytic studies and reviews
provide robust empirical support for CBT-­I as an effective
treatment for insomnia disorder across a range of insomnia
and sleep outcomes. The discussion that follows focuses pri-
marily on evidence for efficacy of CBT-­I relative to a control
condition. Among the many outcome measures in efficacy tri-
als, remission of a disease is the most desired outcome and is
an index of clinically meaningful outcome. A meta-­analysis
of five randomized controlled trials (RCTs) of adults with
insomnia reports a remission rate of 53%1; these studies
determined remission based on established cut-­off score on
the Insomnia Severity Index or the Pittsburgh Sleep Qual-
ity Index. Remission rates are lower when insomnia co-­occurs
with another disorder, as demonstrated by a meta-­analysis of
22 RCTs that enrolled participants with both insomnia and
another medical or psychiatric conditions. This meta-­analysis
estimated that slightly more than one-­third of patients who
890
• T he chapter describes real-­world
implementation of CBT-­I, including known
barriers to large-­scale implementation of CBT-­I
and strategies to overcome these barriers.
• There are efforts to increase access to CBT-I
through training of additional providers,
including evidence of real-­world effectiveness,
and the use of alternatives to the currently
prevailing delivery model that relies on
individual psychotherapy in the clinician’s office,
for example, using group, telehealth, and direct-­
to-­consumer self-­help options, including digital
programs.
• This chapter discusses how use of these
alternative models of delivery can help
overcome some of the known barriers to
treatment access and engagement, as well as
how stepped-­care implementation models
combine different delivery methods to facilitate
the broad dissemination of CBT-­I.
received CBT-­I experienced remission of their insomnia dis-
order, which, after controlling for publication bias, yielded an
odds ratio of 2.6 relative to control conditions.2 Regarding
change in insomnia symptom severity, although based on a
small number of studies, meta-­analyses suggest moderate to
large effects relative to control conditions.1,3,4 For subjective
estimates of sleep parameters based on sleep diaries, meta-­
analyses found medium to large effect sizes for sleep onset
latency, time awake after sleep onset, sleep efficiency, and
subjective sleep quality relative to control conditions.2,5 For
sleep duration, which is an important component of overall
sleep health (see Chapter 94)6 that treatment-­seeking patients
wish to improve, results are more nuanced. Although the cited
meta-­analyses did not find an increase in subjective total sleep
time with CBT-­I relative to control conditions immediately
posttreatment, a meta-­analysis conducted by Okajima and
colleagues3 (2011) found a statistically significant increase in
self-­reported sleep duration at follow-­up assessments con-
ducted at 3 and 12 months posttreatment, with a small effect
size relative to control conditions. In contrast to the robust
evidence for improvement in subjective sleep, meta-­analyses
examining objective sleep parameters yielded mixed results.
 Chapter 96  Behavioral Treatment II: Efficacy, Effectiveness, and Dissemination
Okajima and colleagues’3 meta-­analysis of 14 studies reported
moderate effect sizes for wakefulness after sleep onset and
sleep efficiency.3 In contrast, Mitchell and colleagues’5 meta-­
analysis of 12 controlled studies reported an absence of signif-
icant effects on polysomnography (PSG)-­defined sleep, small
or no effects on actigraphy-­based sleep continuity parameters,
and a moderate reduction in total sleep time posttreatment.5
Thus, whereas the effects of CBT-­I on subjective sleep param-
eters are robust, effects on objective sleep parameters (PSG
and actigraphy) are mixed and more modest. It is important
for future research to develop a nuanced understanding of the
impact of treatment for insomnia disorder on sleep outcomes.
However, given that symptoms bring patients with insomnia
disorder into contact with health care providers, efficacy of
CBT-­I in subjective domains remains of primary importance.
The documented positive effects of CBT-­I on self-­reported
outcomes immediately posttreatment are also durable. Two
meta-­analysis of follow-­up data provide evidence for contin-
ued efficacy of CBT-­I at 3, 6, and 12 months posttreatment
relative to control conditions,3,7 with moderate effect sizes
for sleep onset latency, minutes awake after sleep onset, sleep
efficiency, and insomnia severity. Although the effects tended
to decline over time, they remained clinically meaningful at
the 12-­month follow-­up.7 Whereas most RCTs of CBT-­I
include follow-­up periods of 1 year or less, several studies have
included longer follow-­ups. A seminal study by Morin and
colleagues8 demonstrated sustained gains from CBT-­I over a
2-­year naturalistic follow-­up period.8 A recent study of web-­
based CBT-­I reported a large effect size for insomnia severity
over a 3-­year posttreatment follow-­up period relative to con-
trol conditions.9 Further, an observational clinic-­based study
reported significant improvements in sleep that were main-
tained for up to 10 years (mean follow-­up, 7.8 years10). Given
evidence for some decline in effect sizes during follow-­up and
the potential bias in long-­term follow-­up, where one may not
assume that data are missing at random, there is a critical need
in the field to assess the long-­term benefits of CBT-­I using
strategies for minimizing attrition. Knowledge gained from
such research could guide the development of strategies for
relapse prevention and possibly scheduling additional main-
tenance sessions.
Evidence for the efficacy of CBT-­I is further strength-
ened by studies of CBT-­I that were conducted in populations
with medical and psychiatric comorbidities and in different
age groups. Meta-­analyses have concluded that CBT-­I is an
effective treatment of insomnia among cancer survivors11 and
adults with pain conditions,12 as well as in samples with a mix
of medical and psychiatric conditions.2,13,14 There is also evi-
dence from adequately powered randomized controlled trials
that CBT-­I is effective among postmenopausal15 and pregnant
women16 and among adults with depression, including those
taking antidepressant medications.17,18 There is strong evi-
dence that CBT-­I improves insomnia and sleep among older
adults19 and emerging evidence that it is also effective among
adolescents.20 Although efficacy of CBT-­I among those with
comorbidities is clear, it is less clear if there is differential effi-
cacy of CBT-­I among people with or without comorbidities,
although, as noted earlier, remission rates in meta-­analyses of
CBT-­I in samples with comorbidities are somewhat smaller
than in analyses when comorbidities were excluded. Meta-­
analyses that have examined differential efficacy by comorbid-
ity and age have done so as secondary analyses, pooling results
891
from studies designed to answer questions of efficacy relative
to control treatment rather than comparative efficacy among
subgroups of patients. Knowing how specific patient-­ level
attributes relate to outcomes is important as it could inform
further refinement of CBT-­I to tailor it to specific patient
presentations. One promising approach is to conduct pooled
patient level meta-­analyses. At the time of this writing, efforts
to pool individual patient data to address this important ques-
tion are underway.21
Meta-­analyses have concluded that CBT-­I is also effec-
tive across treatment modalities22 and for specific modali-
ties.23–25 Among self-­ help interventions, internet-­ delivered
treatments are increasing in popularity and are effective.26,27
A meta-­analysis of an internet CBT-­I conducted by Zacharie
and colleagues27 identified higher dropout rates as a predic-
tor of smaller effect sizes. This finding highlights the impor-
tance of identifying and addressing factors that can increase
patient engagement in self-­ help CBT-­ I. There is already
some evidence that internet-­based interventions that offer a
higher intensity of support produce larger effect sizes com-
pared to those with low or no support interventions.23,27–29
Researchers have also compared the efficacy of different
delivery methods, with some meta-­analyses suggesting that
individual treatment is more effective than group or self-­help
treatments.13,22 Although efficacy across treatment modali-
ties provides further support for the robust nature of CBT-­I,
the range of observed effect sizes based on delivery method
has led to increased interest in development and testing of
stepped-­care models of insomnia treatment delivery to most
effectively and efficiently deliver treatment resources to help
the largest number of patients in need (see Dissemination and
Implementation section.) 
EFFECTIVENESS: IMPACT ON OTHER SYMPTOMS
Increasingly, studies examining the efficacy of CBT-­I also
examined it effectiveness, that is, the effects of CBT-­I on
symptoms beyond insomnia and sleep. Some of these effec-
tiveness studies have specifically selected individuals with
comorbidities or with specific symptoms (e.g., those with
elevated depression scores but not meeting formal diagnos-
tic criteria for major depression) and examined the impact of
CBT-­I on the target comorbid disorder or symptom sever-
ity. Other effectiveness studies have examined the impact of
CBT-­I on nonsleep outcomes in general samples of individu-
als with insomnia. To follow, we review the literature on the
effectiveness of CBT-­I on the following outcomes: depression,
anxiety, pain, fatigue, and quality of life. In addition, because
multiple professional and medical organizations, including the
American Academy of Sleep Medicine, encourage minimiz-
ing the use of hypnotic medications,30,31 we also discuss the
effects of CBT-­I on hypnotic medication use.
Depression Symptom Severity
Three meta-­analyses have concluded that behavioral and cog-
nitive behavioral interventions for adults with insomnia lead
to decreases in depressive symptom severity.32,33 Whereas
pretreatment to posttreatment effect sizes for improvement
in depression symptom severity in these meta-­analyses are
moderate to large,33 effect sizes relative to a control condition
are small to medium.32,34 When considering treatment type
(behavioral vs. cognitive behavioral) and modality (self-­help,
892 PART II • Section 11  Insomnia
group, and individual), only individual CBT-­I (i.e., individu-
ally provided treatment that included cognitive and behav-
ioral treatment for insomnia) was associated with greater
improvement in depressive symptoms compared with con-
trol conditions.32 However, studies of self-­help CBT-­I that
were included in this analysis consisted of a mix of digital
and other self-­help modalities and did not include two very
large digital CBT-­I studies.35,36 This is particularly important,
given increase in availability of digital CBT-­I. These two large
studies reported small to moderate effects of digital CBT-­I on
depression symptom severity.
Many of the analyzed studies in these three meta-­analyses
excluded participants that met, or were likely to meet, diag-
nostic criteria for a depressive disorder. As a result, it is pos-
sible that the effects of CBT-­I alone on depression severity
among individuals with meaningful depressive symptoms is
smaller than these meta-­analyses suggest. Moreover, these
three meta-­analyses focused on the effects on depression of
CBT-­I alone, rather than as an adjunct to an antidepressant
intervention. Two RCTs of patients with comorbid insomnia
and depression diagnoses provided CBT-­I (or a control inter-
vention for insomnia) plus a depression intervention. Both
studies found that there was no additive effect of CBT-­I on
depressive symptom severity.17,18 Nonetheless, in one of these
studies, Manber and colleagues18 found that improvements in
insomnia severity over the first 6 weeks of insomnia treatment
mediated the remission from depression over the entire 12-­
week treatment period; in other words, early change in insom-
nia severity symptoms predicted depression remission in the
CBT-­I but not in the control treatment arm.
The large heterogeneity in samples and study designs
among studies on the effects of CBT-­I on depressive symp-
toms precludes definitive conclusions. The results do, however,
point to three directions for further research that could have
clinically meaningful implications. The first pertains to the
potential utility of CBT-­I for the prevention of depression
among those at risk for depressive disorder. Two recent pre-
vention studies that used digital CBT-­I suggest that this may
indeed be a promising approach,35,37,38 particularly among
those with low depression severity at baseline and hence at
risk for developing a depressive disorder. The second direc-
tion for future research is to identify attributes of patients with
dual diagnoses of insomnia and depression who are particu-
larly likely to experience additive benefit from incorporating
CBT-­I into their depression management. For example, Asar-
now and colleagues39 identified greater eveningness tenden-
cies as one such characteristic.9 Specifically, they found that
individuals with co-­occurring depression and insomnia who
had a stronger evening tendency had better depression out-
comes if assigned to CBT-­I plus an antidepressant medication
condition compared with the control insomnia intervention
plus an antidepressant medication condition. The third clini-
cally meaningful direction for future research is to focus on
ways to enhance depression outcomes among patients with
dual insomnia-­depression diagnoses. For example, findings
from a recent study conducted by Kalmbach and colleagues40
suggest that the cognitive component of CBT-­I might be par-
ticularly important for reducing depressive symptoms.  CBT-­I alone or in combination with behavioral pain interven-
Anxiety Symptom Severity
A 2011 meta-­analysis identified 50 controlled and uncon-
trolled studies of CBT-­I that included measures of anxiety
and anxiety-­related constructs (e.g., perceived stress).41 This
analysis found that effect sizes for in-­person CBT-­I on anxi-
ety and related symptoms were small for comparisons between
treatment and control conditions (20 studies) and moderate
for pretreatment to posttreatment (within-­subject) compari-
sons (30 studies). Of interest, studies that integrated a hyp-
notic withdrawal component into the CBT-­I protocol had
a near-­zero effect size for anxiety outcomes. This intriguing
finding suggests that additional attention to anxiety might
enhance the effectiveness of CBT-­ I protocols that target
hypnotic-­dependent patients and include a hypnotic taper
component (see Chapter 100 for more detailed discussion).
The results of this meta-­analysis have limited generalizability
for those with comorbid anxiety disorder because only 4 stud-
ies in this large meta-­analysis had samples with dual diagnoses
of insomnia and anxiety disorders.41 A more recent meta-­
analysis of 8 RCTs that evaluated change in anxiety symptom
severity with CBT-­I found a low effect size for comparisons
between CBT-­I and control conditions26; similarly, none of
the included studies focused on patients with a comorbid
anxiety disorder. In contrast, a 2016 meta-­analysis focused
exclusively on the effects of psychological treatments for
improving sleep among individuals with posttraumatic stress
disorder (PTSD) symptoms or syndrome42 found a moderate
effect size on PTSD symptoms. However, it is difficult to tease
out the impact of CBT-­I alone on PTSD symptoms because
only 3 of the 8 studies used CBT-­I as a monotherapy; the rest
included interventions that targeted nightmares, either alone
or in combination with CBT-­I. Taken together, there seems to
be a small effect size of CBT-­I on anxiety symptoms among
individuals without comorbid anxiety disorder and paucity of
research on the effects of CBT-­I on anxiety symptoms among
individuals with diagnoses of comorbid insomnia and anxiety
disorders 
Pain
CBT-­I protocols that do not directly address pain have been
tested in a variety of pain conditions. In a meta-­analysis of six
such studies among those with pain-­related conditions, Tang
and colleagues12 (2015) found a small effect size on pain. Sim-
ilarly, in a meta-­analysis of four studies on group-­delivered
CBT-­I protocols that did not include a target pain interven-
tion, Koffel and colleagues24 (2015) found a small effect size
for pain improvement among adults with insomnia, although
participants were not specifically selected to also have a pain
condition. A 2019 review considered the evidence to date
about the potential benefits of CBT-­I in the management of
pain conditions.43 This review included several studies pub-
lished after 2015 and have similarly concluded that “the effect
sizes for pain reduction after behavioral sleep interventions
are modest and variable but comparable or even superior to
those of psychological therapies for pain.” Three small stud-
ies and a more recent larger RCT tested hybrid interventions
that simultaneously address sleep and pain among those with
pain conditions and suggest that this hybrid approach could
be beneficial for the management of chronic pain.44–46 There
is also convergence of evidence that the beneficial effects of
tions on pain outcomes are greater at 3-­to 6-­months follow-
­up than at posttreatment.47,48 Given that insufficient sleep is
particularly relevant to the pain experience,49 it is possible that
the lag in benefits is related to the fact that total sleep duration
 Chapter 96  Behavioral Treatment II: Efficacy, Effectiveness, and Dissemination
often continues to increase after CBT-­I is completed, likely
due to patients continued use of cognitive-­behavioral com-
ponents (i.e., maintenance) after the initial treatment phase.3
It is therefore important that future research on the effects
on CBT-­I on pain include long-­term follow-­up and consider
and evaluate treatment protocols that include a maintenance
treatment phase.  improve sleep.58 In contrast, recent data suggest that digital
Fatigue
Fatigue is a frequent complaint of individuals with insom-
nia disorders and therefore an important outcome to assess.
Fatigue is not a well-­defined construct among both patients
and researchers. One of the challenges for synthesizing the
literature on the impact of CBT-­I on fatigue is that the
construct of fatigue is multidimensional and not uniformly
defined in research. As a result, different studies likely mea-
sure different aspects of fatigue. Regardless, studies that
have focused on populations known to have high levels of
fatigue, such as cancer patients, generally find improvement
in fatigue after CBT-­I. A meta-­analysis of CBT-­I among
those with pain-­related conditions (cancer and fibromyalgia)
found a moderate overall effect size for reduction in fatigue
posttreatment (six studies) and at 3-­to 12-­month follow-
­up (three studies). Only two of the six studies included in
this meta-­analysis had a treatment component that specifi-
cally addressed fatigue,12 suggesting that CBT-­I alone could
help reduce fatigue in these populations. The available RCTs
of CBT-­I among patients with other medical comorbidi-
ties, such as patients on peritoneal dialysis and hemodialy-
sis50 and with COPD,51 also found improvements in fatigue
levels after CBT-­I, as did a recent trial among those with
menopausal symptoms.52 The effects of CBT-­I on fatigue
in mixed samples of patients with varying levels of fatigue
at baseline are less clear. A network meta-­analysis, which
included samples with and without comorbidities and vary-
ing levels of fatigue at baseline, found a moderate effect size
for fatigue after individually delivered CBT-­I; however, after
examining heterogeneity among studies, the meta-­analysis
concluded that there were no significant effects on fatigue.32
A few studies published after this meta-­analysis reported
fatigue improvements after internet-­ delivered CBT-­ I36,53
and therapist-­delivered CBT-­I.54 Many studies on the
effects of CBT-­I on fatigue did not report having a fatigue-­
specific treatment component; however, because concerns
about next-­day fatigue are often identified by patients with
insomnia as an obstacle to implementing time-­in-­bed restric-
tion, it is likely that even therapists who implement strictly
behavioral protocols end up addressing fatigue. It is possible
that adding a component that explicitly addresses fatigue to
general CBT-­I protocols, as previously done in a study in
CBT-­I among cancer patients (e.g., Savard and colleagues55),
could further enhance fatigue outcomes. Explicitly address-
ing fatigue could also enhance adherence to the behavioral
components of CBT-­I, which in turn may strengthen efficacy
for CBT-­I on insomnia symptoms.  tions,63 it will be important for future research in this area
Quality of Life
Quality of life is an important outcome in insomnia because
chronic insomnia is one of the top contributors to reduced
quality of life.56 It is therefore surprising that quality of life
has been understudied as an outcome after CBT-­ I. One
meta-­analysis of RCTs of CBT-­I suggest it is associated with
893
statistically significant improvements in measures of global
quality of life.57 The improvements in quality of life seen
with CBT-­I may be more modest among those with comor-
bid mental health conditions.14 There also is some evidence
for delivery-­specific effects; for instance, telephone-­delivered
CBT-­I did not improve quality of life, even though it did
CBT-­I improves sleep-­related quality of life, that is, aspects
of quality of life that patients believe are impaired by poor
sleep.36 Taken together, although available data are limited,
CBT-­I appears to improve quality of life, but the size of the
effects may be variable depending on domain-­specific quality
of life, coexisting conditions, and method of CBT-­I delivery. 
Hypnotic Use
CBT-­I protocols that do not directly target hypnotic reduc-
tion seem to significantly reduce hypnotic medication use,
nonetheless. One of the earliest studies to demonstrate that
CBT-­I leads to reduction in hypnotic medication use was
based on data from a series of 100 patients in a university-­
based sleep center who received CBT-­I.59 In this study the
number of habitual users of sleep medication decreased by
54% posttreatment. Subsequent controlled studies have
similarly shown that, without therapists’ explicit attention
to discontinuing medication, close to half of habitual users
decreased their hypnotic medication by half of their base-
line use after CBT-­I, compared to only 17% of those receiv-
ing usual care.60 Several additional studies have examined
the effect of CBT-­I protocols that have included a targeted
medication taper component (e.g., information about taper
and encouragement to include discontinuation or tapering
as a treatment goal). A 2019 meta-­analysis of eight stud-
ies examined the effects of adding CBT-­I to a schedule for
gradual taper of medication on hypnotic medication use.61 It
concluded that the addition of CBT-­I leads to greater reduc-
tion in hypnotic use than gradual medication taper alone in
the short (<3 months) but not long term (12 months). Studies
in this meta-­analysis were heterogeneous with respect to the
extent to which the CBT-­I protocol provided targeted atten-
tion to support the taper. The studies were also heterogeneous
with respect to representation of frequency and chronicity
of hypnotic use in the sample. Not included in this meta-­
analysis is an RCT of internet-­based CBT-­I, conducted in
a sample in which about half the participants took hypnotic
medications at baseline. After treatment and during a 3-­year
follow-­up, roughly a quarter of those assigned to CBT-­I were
using sleep medications; at the 3-­year follow-­up, the differ-
ence between CBT-­I and control conditions was statistically
significant and clinically meaningful (29% vs. 47%9). In clini-
cal practice, many behavioral medicine specialists integrate
into CBT-­I strategies to help patients reduce or eliminate
hypnotic use, often collaborating with prescribing physicians
regarding the specific taper schedule.62 Given increasing pro-
fessional guidelines to minimize the use of hypnotic medica-
to identify patient factors that predict spontaneous reduction
in hypnotic use after CBT-­I alone. It will also be important
to formalize and refine strategies to encourage and facilitate
successful hypnotic taper among those who are less likely to
do so with standard CBT-­I alone. Chapter 100 of this book
includes additional discussion of hypnotic discontinuation
protocols. 
894 PART II • Section 11  Insomnia
DISSEMINATION AND IMPLEMENTATION
Limited access to CBT-­I is a major barrier to its wide-­scale
implementation as a first-­ line treatment of insomnia and
ergo to the successful implementation of the insomnia treat-
ment guidelines made by multiple professional organizations.
Efforts to overcome this limitation have included training of
providers and the development of new models for deliver-
ing CBT-­I that promote greater and better access to trained
CBT-­I providers and use of digital technology. These efforts
are discussed as follows.
Dissemination via Provider Training
The traditional paths for training treatment providers to
deliver CBT-­I has been through graduate programs and/or
postdoctoral fellowships within the psychology discipline.
These training paths involve courses on general principles of
CBT and on sleep science and sleep disorders. Although the
majority of psychology graduate programs and psychiatry resi-
dencies offer training in CBT for a variety of mental health
disorders, few offer specialty training in CBT-­I. In response
to high demand for CBT-­I services, the Veterans Health
Administration has developed a CBT-­I training program for
licensed mental health providers from different professional
disciplines. This 4-­month training program provides a model
for increasing the ranks of licensed clinicians who can effec-
tively provide CBT-­I. In the past 10 years it has trained 900
Veterans Affairs (VA) mental health providers nationwide
to deliver CBT-­I. In addition to a didactic portion, which
included learning about sleep architecture, sleep regulation,
and common sleep disorders, training involves experiential
learning, both through role-­plays and ongoing expert consul-
tation and feedback on sampled work throughout the training
period. Expert consultation and feedback in this initiative aim
to optimize competency and promote continued use of CBT-­I.
Although the VA training uses a traditional six-­session proto-
col, a case-­conceptualization–driven approach guides thera-
pists on how to adapt and tailor the protocol to patients with
complex presentations, who often experience insomnia in the
context of comorbid medical and mental disorders. Tailoring
includes guidelines for selecting which components of CBT-­I
to emphasize and in what order to present them based on the
case-­conceptualization framework. Consultants (expert-­level
providers in CBT-­I involved in the training program) also
listen to recorded sessions and use a program-­developed com-
petency rating form, which, unlike standard fidelity checklists,
rates the level of competency in delivering each of the CBT-­I
treatment components, not merely whether these components
are present or absent.
Program evaluation of this VA training program pro-
vides evidence on real-­world effectiveness of CBT-­I, exam-
ining patient outcomes, therapists’ fidelity, and the extent to
which those trained continue to use CBT-­I.64,65 To promote
sustainable impact, the VA CBT-­I training initiative devel-
oped a mechanism for identifying and training outstanding
high-­utilization graduates to become consultants and trainers
themselves. This allows the training program to keep growing
in scope and amplifies its impact. As a result, CBT-­I is now
available to veterans seen in a wide range of practice settings,
including general and specialty mental health clinics, primary
care, and those in residential and home-­based care. To enhance
the reach of CBT-­I, the program also developed supplemental
training to deliver CBT-­I in a group format, which is available
to those who have already obtained competency and became
experienced practitioners of individual CBT-­I. 
Implementation Models
Currently, the most prevalent model for delivering CBT-­I is
individual face-­to-­face therapy by specialty-­trained providers,
usually mental health professionals. However, there are many
barriers for patients to engage in CBT-­I within the currently
prevailing model. One of these barriers is the need to travel to
the provider’s office. This is a challenge for patients with lim-
ited mobility and for those who live in communities that do
not have qualified providers nearby. Telemedicine helps miti-
gate this barrier to access to therapist-­led CBT, allowing ther-
apists to use secure video conferencing technology to deliver
CBT-­I. Eliminating the need to travel to the therapist’s office
also minimizes the time off from work and reduces child care
burden for patients. Digital CBT-­I, such as online-­or app-­
based programs, also addresses these barriers and additionally
reduces potential stigma and embarrassment about seeking
mental health care, eliminates waiting time for therapy, and
offers flexibility in pace of treatment. However, as reviewed ear-
lier and in Chapter 97, although digital CBT-­I programs are
effective, there is also evidence that they are less effective than
therapist-­delivered treatment. There are also barriers for use of
digital CBT-­I, such as patient preferences and proficiency and
comfort with digital technology. Some individuals may do bet-
ter with hybrid models that provide some human guidance and
encouragement while they are using a digital program. Indeed,
there is evidence from one meta-­analysis that a higher degree
of support leads to greater efficacy of digital interventions.27
Examples of low level of support include automated text mes-
sages; examples of higher level of support include access to
brief phone consultation with a provider. Additional ways to
increase support within hybrid models include supplementing
digital CBT-­I with short visits with a provider (professional
or paraprofessional) and use of a chatbot (or virtual coach).
Hybrid models can also be used in clinical settings to promote
patient engagement and adherence to treatment recommenda-
tions offered in the course of digital CBT-­I.
Stepped-­care implementation models combine digital and
therapist delivery but do so sequentially rather than concomi-
tantly. One approach is to provide digital CBT first and then
offer therapist-­ delivered CBT-­ I to those whose insomnia
does not remit. Another approach is to triage patients into
digital or therapist-­delivered CBT-­I at the first step of care,
based on their clinical presentations, and then offer therapist-­
led CBT-­I to those who have not sufficiently benefited from
digital CBT-­I. Testing of this model is currently underway
(NCT03532282). Regardless of implementation model, real-­
life implementations will need to take into account patient
preferences. The COVID-19 pandemic of 2020-2021 has
accelerated acceptance of newer modes of CBT-I delivery.66
As CBT-­I becomes more widely disseminated using the
variety of delivery modes and implementation strategies, it
will be important to understand how to best optimize its effec-
tiveness in real-­world settings. Some important unanswered
effectiveness questions include the following: What are the
best methods to ensure therapists’ fidelity to CBT-­I treat-
ment in the field? How is patients’ engagement best promoted
in real-­world clinical settings rather than within the context
of a research setting? How do financial considerations, such
 Chapter 96  Behavioral Treatment II: Efficacy, Effectiveness, and Dissemination
as health insurance coverage for online interventions, factor
into the use of CBTI-­I in the community? What resources
do physicians need to support their patients’ engagement in
CBT-­I? Future large-­scale pragmatic trials can answer these
and related questions and examine the efficacy of CBT-­I in
real-­world settings.  somnia reduce repetitive negative thinking and sleep-related worry beliefs?
SUMMARY
The evidence reviewed in this chapter indicates that CBT-­I
is highly effective treatment in diverse patient populations,
including those with comorbid conditions and across the life
span. At the end of treatment, patients typically experience
improvements in insomnia and sleep outcomes, except for
total sleep time. The benefits are durable long after treatment
ends, and total sleep duration tends to increase over time.
CBT-­I also has modest benefits on some outcomes beyond
sleep, such as quality of life, mood, pain, and fatigue, as well
as reduction in hypnotic medications use. Digital CBT-­I has
vastly increased access to CBT-­I; however, recent data sug-
gests that it may be less effective than therapist-­led treat-
ment. Stepped-­care models that triage patients to digital or
therapist-­led CBT-­I have the potential for increasing access
to CBT-­I in a manner that could optimize patient care and
available resources.
CLINICAL PEARLS
• A fter completing cognitive behavioral therapy for
insomnia (CBT-­I), patients are expected to experience
reduction in insomnia severity and meaningful
improvements in sleep outcomes, except for total sleep
time, for which improvements are expected to gradually
increase after treatment ends.
• CBT-­I is an effective treatment for patients with
insomnia, including those with a range of comorbid
conditions, and also might have value in management
of some symptoms of the comorbid conditions.
• Individuals receiving CBT-­I may also experience modest
benefits in some other life domains, such as quality of
life, mood, pain, and fatigue.
• Access to CBT-­I can be enhanced with telehealth, web-­
based CBT-­I programs, and combinations of technology-­
assisted therapy options. Stepped-­care models that
triage people to digital or therapist-­led CBT-­I might
increase access to CBT-­I in a manner that could optimize
patient care and available resources. These efforts may
facilitate integration of behavioral sleep medicine /CBT-­I
in accredited sleep centers.
895
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A systematic review and meta-analysis. Sleep Med Rev. 2021;55:101378.
Espie CA, Emsley R, Kyle SD, et  al. Effect of digital cognitive behavioral
therapy for insomnia on health, psychological well-­ being, and sleep-­
related quality of life: a randomized clinical trial. JAMA Psychiatry.
2019;76(1):21–30.
Gee B, Orchard F, Clarke E, Joy A, Clarke T, Reynolds S. The effect of non-­
pharmacological sleep interventions on depression symptoms: a meta-­
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Manber R, Carney C. Treatment Plans and Interventions for Insomnia: A Case
Formulation Approach. New York: Guilford Press; 2015.
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 Chapter 96  Behavioral Treatment II: Efficacy, Effectiveness, and Dissemination
REVIEW QUESTIONS
1. During a routine prenatal visit, a 32-­year-­old pregnant
woman tells the obstetrician that she has trouble sleeping.
The obstetrician tells her that this is normal and nothing
can be done. The obstetrician further advises against using
sleep medications and suggests she uses a pregnancy pillow
to make her more comfortable. Was the obstetrician cor-
rect?
A. Yes. It is normal to have sleep disruptions during preg-
nancy, and it is not a good idea to take sleep medications
during pregnancy.
B. Yes. The pregnancy pillow will likely resolve her prob-
lems sleeping.
C. No. If the woman has insomnia disorder, then she could
benefit from cognitive behavioral therapy for insomnia
(CBTI).
D. Yes. Although CBTI is safer than sleep medications, it
does not have proven efficacy during pregnancy
2. A 58-­year-­old, recently divorced, man has difficulty staying
asleep. On most nights he wakes up in the middle of the
night and is awake for 1 to 2 hours. When he finally falls
back asleep, his sleep is light. He lost his job as a software
engineer during a company layoff about a year ago and has
not been able to find another job. He was prescribed an
antidepressant medication that has helped reduce some
of his depressive symptoms, but he continues to experi-
ence poor sleep, low energy, and poor concentration. What
would be the best approach to help him improve his sleep?
A. He should focus on treating his depression because a
better treatment of depression will also improve his
problems with sleep.
B. He should continue treating his depression and also
engage in CBTI.
C. He should not consider CBTI because it is not likely to
help him, given his current depression.
D. He should stop taking the antidepressant medication
and try CBTI.
895.e3
3. A 67-­year-­old woman with insomnia lives in a rural town,
a 4-­hour drive from the nearest therapist who offers CBTI.
What empirically supported treatment options does she
have?
A. She can try a digital CBTI or a self-­help book.
B. She can check if the nearest therapist offers therapy via
telemedicine.
C. Her only option is to ask her doctor to prescribe a hyp-
notic medication.
D. A and B.
4. A 48-­year-­old man has suffered from insomnia for more
than 10 years. He is taking a hypnotic medication, as
needed, as originally prescribed. He really would prefer not
to take any medication. Every night he tries to fall asleep
on his own but ends up taking the medication after about
an hour of trying. He has tried to stop taking it entirely but
gives up after a few nights with no medication. Can CBTI
help this patient discontinue his use of this hypnotic medi-
cation?
A. Yes. CBTI is effective for people who are taking hyp-
notic medications, and many are able to discontinue use
of hypnotic medications.
B. No. He should first discontinue the medication and
then try CBTI.
C. Yes. He can benefit from CBTI alone or in combination
with a gradual taper.
D. A and C.
895.e4 PART II • Section 11  Insomnia

ANSWERS 3. D. Self-­help CBTI, including digital treatment options,

1. C. There is empirical support for CBTI among pregnant
women. If this woman has insomnia disorder, regardless
of the presence of pregnancy-­related sleep disruptions, she
could benefit from CBTI.
2. B. CBTI has proven efficacy among patients with ele-
vated depression symptom severity, including those taking
antidepressant medications. CBTI could help this man
improve his sleep.
and CBTI offered via telemedicine have empirical support.
4. D. Research has demonstrated that people with insomnia
who take a prescribed hypnotic medication and wish to
discontinue it can achieve their goal by engaging in CBTI
alone or in combination with a supported plan to help
gradually reduce medication use.
Chapter
97 Behavioral Treatment III: Digital
and Telehealth Approaches
Øystein Vedaa; Katherine E. Miller; Philip R. Gehrman
Chapter Highlights
• D espite the demonstrated efficacy of cognitive
behavioral therapy for insomnia, many
patients do not have access to face-­to-­face
treatment. There has been a surge of interest
in technological means of treatment delivery,
including internet, mobile, and telehealth
approaches.
• Internet treatment delivery has a strong
evidence base demonstrating efficacy when
compared to control conditions. Available data
on mobile and telehealth delivery indicate that
INTRODUCTION
The costs of offering cognitive behavioral therapy for insom-
nia (CBT-­I) and lack of trained clinicians have so far pre-
vented sufficient dissemination of the treatment to the broad
population of people with insomnia. The standard means of
delivery of CBT-­I is face-­to-­face, individual therapy with a
sleep specialist, but this is also the most resource intensive and
limited in availability. Alternative treatment delivery models
have therefore been proposed, including brief face-­ to-­face
interventions,1 delivery in a group therapy format,2 and tele-
phone consultations,3 among others. These are delivery mod-
els that may increase service efficiency and help reach more
people with effective treatment for chronic insomnia but still
require considerable resources. During the COVID pandemic,
when face to face CBTi sessions were not possible, telehealth
approaches were often explored (see Chapter 213).
Since the mid-­1990s there has been a steady increase in
the use of technological means for delivering cognitive behav-
ioral therapy (CBT) for mental health problems and medical
conditions (i.e., conditions in which behavior is a compo-
nent). In particular, many solutions have been developed to
deliver CBT through digital platforms or over the internet.
The highly structured nature of CBT makes it especially suit-
able for a manual-­and algorithm-­based delivery. In the lit-
erature, the conceptual apparatus for describing this type of
technological innovation in the delivery of CBT has not yet
established itself: some refer to internet CBT, electronic CBT,
computerized CBT, or digital CBT.4 The U.S. Food and Drug
Administration (FDA) seems to have accepted the term digi-
tal, in which digital CBT can be categorized as a digital thera-
peutic, within the subset of digital health.5
896
these modalities are associated with clinically
important improvements in insomnia severity as
well.
• There is a lack of evidence directly comparing
technological means to face-­to-­face delivery, so
it is not clear if there is a loss in the magnitude of
improvements. There is also a need to determine
which modalities are best suited for particular
patient populations (e.g., pregnancy). This
is likely to be an area of increased growth in
coming years.
In recent review studies, a distinction has been made between
three levels of delivering digital CBT (Figure 97.1).4,6 First, in
supportive digital CBT, the digital content often has a more
simplistic nature and serves a purely supportive function in
conjunction with the face-­ to-­
face expert therapy. Second, in
therapist-­guided digital CBT, the therapeutic content is com-
municated and sequenced primarily through the technological
platform that also may incorporate some degree of automation,
to which the therapist only has a supportive function. Third, fully
automated or self-­guided digital CBT typically involves more
sophisticated algorithm-­based delivery of the therapeutic con-
tent, which often uses interactive and tailoring features for better
user engagement and experience, but without any support from a
clinician. Important differences between these digital CBT deliv-
ery levels include the amount of clinician time they require and
the level of automatization they provide, which in turn also indi-
cate the expected costs and the scalability of the delivery modes.
The goal of this chapter is to review the burgeoning area of
research on technological means of delivering CBT-­I. The focus is
on internet, mobile, and telehealth approaches to treatment deliv-
ery, although other technological solutions have been proposed. 
DELIVERY OVER THE INTERNET
The success of internet-­based (i.e., digital) interventions for
mental health problems has been demonstrated in more than
200 trials over the past two decades. A recent review of new
meta-­analyses found moderate to large average effect size
improvements on panic disorder, social anxiety disorder, gen-
eral anxiety disorder, posttraumatic stress disorder (PTSD),
and major depression, with digital CBT interventions.7 The
 Chapter 97  Behavioral Treatment III: Digital and Telehealth Approaches
Supportive
digital CBT-I
Therapist-guided
digital CBT-I
Fully automated
digital CBT-I
Figure 97.1  Three levels of delivering digital cognitive behavioral therapy.
first randomized controlled trial (RCT) that demonstrated
the effects of internet therapy for insomnia was published
by Ström and colleagues in 2004, in which written self-­help
material was made available to participants through a web-
page.8 Since then, online adaptations of CBT-­I have become
increasingly interactive and personalized, which seems to have
enhanced the effect size improvements with such interven-
tions (see the reviews by Ritterband and colleagues9 and Espie
and colleagues10).
Digital CBT-­I programs are usually designed to mimic
face-­to-­face CBT-­I11 in terms of content and form. Typically,
they consist of six weekly sessions that cover the basic topics of
CBT-­I, including sleep restriction, stimulus control, cognitive
restructuring, relaxation strategies, sleep hygiene, and relapse
prevention.
In one recent well-­conducted RCT, more than 300 adults
with insomnia were recruited from the general population
and given access to either fully automated digital CBT-­I or
a webpage containing information about sleep hygiene. The
authors found that use of digital CBT-­I was associated with
reductions in insomnia severity and improvements in sleep-­
wake patterns (assessed via online sleep diaries).12 Other large,
well-­conducted trials have demonstrated the efficacy of fully
automated digital CBT-­I on reductions in depressive symp-
toms,13 improved functional health, psychological well-­being,
and sleep-­related quality of life.14 Further, in a sample of more
than 3000 students, use of digital CBT-­I was associated with
significantly greater reductions in symptoms of paranoia and
hallucinations, compared with usual care.15 These findings are
in line with those of several meta-­analyses on the effects of
digital CBT-­I (including trials on both therapist-­guided and
self-­guided interventions), with the overall conclusion that the
interventions lead to significant and sustained improvements
on daytime and nighttime symptoms of insomnia, with a mag-
nitude that is comparable to that typically obtained with tra-
ditional face-­to-­face treatment.16-­18 Number needed to treat
(NNT) is a measure of how many participants need to receive
the intervention for one individual to respond or recover. The
most recent meta-­ analysis of digital CBT-­ I calculated an
897
The digital content has a more
simplistic nature and serves a purely
supportive function in conjunction
with the face-to-face expert therapy
The therapeutic content is
communicated and sequenced
primarily through the technological
platform, to which the therapist only
has a supportive function
Sophisticated algorithm-based
delivery of the therapeutic content,
which often utilizes interactive and
tailoring features, but without any
support from a clinician
average NNT of 2.2 for insomnia severity, based on treatment
response or estimates from effect sizes.17 This is comparable to
the NNT reported in studies using in-­person CBT-­I, which
in one RCT was 3.2 for cases of recovery on insomnia sever-
ity,19 and in another RCT was 2.4 for participants who no
longer met the criteria for insomnia disorder.1
A number of studies have demonstrated a high rate of
comorbid medical or mental health conditions with chronic
insomnia.20-­22 RCTs have so far found meaningful improve-
ments in insomnia severity among participants with comorbid
medical or mental health conditions.12 Furthermore, in par-
ticipants with comorbid depressive disorder, it is fairly well
documented that digital CBT-­I not only reduces complaints
of sleep problems but also reduces depressive symptomatol-
ogy.13,23 Digital CBT‐I has also been demonstrated as a viable
intervention for cancer survivors experiencing insomnia,24,25
for individuals with Parkinson disease and comorbid insom-
nia,26 and for individuals with comorbid pain and insomnia.27
In a recent RCT of digital CBT-­I for pregnant women with
insomnia, it was found that insomnia severity and sleep qual-
ity, as well as symptom severity of depression and anxiety,
improved after the intervention period when compared with
standard of care.28
The question often raised in the discussion of internet
delivery of CBT is whether there is value in the addition of
therapist support. This is an important question because a dig-
ital intervention without therapist support would be preferred
over an intervention that requires therapist support, given
that they are equally effective, as dissemination of the former
would be easier and associated with lower costs. Whether the
effects of an intervention changes as a factor of the level of
support could also have implications for how digital inter-
ventions are implemented, for example, in the context of a
stepped care model.29 There is some evidence to suggest that
therapist support is needed to gain the full potential of digi-
tal interventions (see, for example, the report by Andersson
and Cuijpers30). However, few studies have compared digital
interventions with and without therapist support in controlled
study designs. It is also reasonable to expect that the effects of
898 PART II • Section 11  Insomnia
unguided, fully automated interventions will vary depending
on the condition that is being treated.31 A meta-­analysis of
both supported and self-­guided digital CBT-­I demonstrated
larger improvements for insomnia severity and sleep efficiency
in studies with a higher degree of therapist support.17 Thera-
pist support can come in many forms; including face-­to-­face
sessions, videoconferences with a therapist, telephone sessions,
and email correspondence, among others. One RCT on dig-
ital CBT-­I demonstrated an added effect of email support,
in which 59% of participants in the support condition met
the insomnia severity index criteria for response at 6-­month
follow-­up, compared to 32% in the no-­support condition.32
The support condition in that study consisted of emails aimed
at reminding and motivating the participants, advice on par-
ticipants sleep scheduling (confer sleep restriction), as well as
support aimed at clearing up common misconceptions’ intrin-
sic to the insomnia disorder. An average of 40 minutes of sup-
port was added to the digital CBT-­I intervention, which may
indicate a significant potential for reducing costs compared
to the traditional six to eight sessions in face-­to-­face treat-
ment. There are also studies that have demonstrated improved
adherence to target behaviors in insomnia treatment through
support by means of automated reminders.33 However, there
is potential for further development of personalized auto-
mated support in digital CBT-­I, in the form of tailor-­made
feedback and encouragement to increase user engagement and
adherence to the intervention.
Although meta-­analyses indicate that digital CBT-­I leads
to improved sleep and daytime functioning with effect sizes
comparable to those typically obtained with face-­to-­face treat-
ment,17,18 there are very few trials that have directly compared
automated digital interventions with face-­to-­face treatment.
One trial compared guided digital CBT-­I with individual
face-­to-­face CBT-­I (n = 30 in each group) and demonstrated
superior effects of face-­ to-­face treatment on reduction of
insomnia symptoms and improved sleep-­wake patterns.34 In
another noninferiority trial, fully automated digital CBT-­I
was compared with face-­to-­face treatment (n ≈ 50 in each
group) and demonstrated superior effects of the face-­to-­face
approach in terms of reducing insomnia severity at 9-­week
follow-­up.35 In particular, 52% of participants in the face-­to-­
face group were in remission at 9-­week follow-­up, compared to
18% in the digital CBT-­I group, which represent a statistically
and clinically significant 34% difference in the proportion of
participants in remission. However, the difference in insomnia
severity between the groups at 6-­month follow-­up did not dif-
fer significantly from the noninferiority margin. In both of the
previously mentioned trials, guided and fully automated digi-
tal CBT-­I were associated with large effect size improvements
on insomnia symptoms among participants.34,35 Although the
limited data available suggest some advantage for face-­to-­face
over digital in the short term, additional research is needed
to clarify the effect of fully automated digital CBT-­I com-
pared to face-­to-­face CBT-­I on sleep and functional health
outcomes.
It is reasonable to expect that digital CBT-­I will not be
suitable for everyone. Self-­help solutions such as internet-­
based or digital programs should be organized in the larger
context of a stepped care approach.20 This would ensure that
those who do not benefit from such interventions, or for other
reasons are believed to have an unacceptable risk of unde-
sirable effects of fully automated programs, are provided a
suitable alternative intervention.29 Indeed, one study indicated
that introducing a stepped care pathway in routine practice at
a behavioral medicine sleep clinic, with fully automated digital
CBT-­I as the entry level intervention, increased service effi-
ciency by 69%.36 RCTs are needed to evaluate the efficacy of
such stepped care CBT-­I approaches. Further, in a proof-­of-­
concept study, Forsell and colleagues37 investigated the use-
fulness of an adaptive treatment strategy in therapist-­guided
digital CBT-­I in an RCT, in which treatment intensity was
increased for participants deemed to be at risk of failing to
respond to treatment. Increased treatment intensity entailed
telephone support, printed materials via regular mail, and/
or increased text message reminders. The adaptive treatment
strategy increased treatment effects for at-­risk patients and
reduced the number of failed treatments, compared to a con-
trol group that received standard of care.37 The authors argued
that adaptive treatment strategies may be an important step in
moving from stepped care into accelerated care to minimize
the duration of patient suffering and time spent in unhelp-
ful low-­intensity interventions. Adaptive treatment strategies
should be further developed in terms of identifying both the
effective outcome prediction algorithms and the appropriate
components of added treatment intensity. 
MOBILE DELIVERY OF COGNITIVE BEHAVIORAL
THERAPY FOR INSOMNIA
With mounting evidence for the efficacy of digitally deliv-
ered CBT-­I4,38 and the ubiquity of smartphone use,39 mobile
health applications (apps) could serve as another route in the
stepped care model to increase access to evidence-­based inter-
ventions for insomnia.40,41 As smartphones are typically car-
ried on the person and rarely turned off, apps offer convenient,
private access to treatment, allowing patients to take advan-
tage of opportunities to engage with content when they may
not otherwise do so (e.g., in public). Although there are some
available apps built on evidence-­based principles for improv-
ing insomnia symptoms, not all available apps, particularly
free apps, are created equal. Yu and colleagues42 conducted a
review of freely available smartphone apps for insomnia and
found that few of these apps use evidence-­based principles to
help users practice the behavioral and cognitive skills shown
to best manage insomnia. In addition to potential quality con-
trol issues with app content, few of the available programs
have been formally tested in research studies.43 This lack of
validation and rigorous testing potentially puts users at risk
for receiving an app-­generated treatment plan that is based
on inaccurate or invalid data. Therefore it may be important
for providers to review an app before suggesting it to their
patients. In this section, we highlight the available apps using
evidence-­ based cognitive-­behavioral principles for treating
insomnia and the current state of their efficacy.
As described previously, digitally delivered treatments vary
based on the level of clinician involvement, level of automa-
tization, costs, and scalability. Similar to internet-­delivered
treatment options, available apps fall into these categories or
as companions to other digital platforms (Table 97.1). The
first category includes mobile apps that augment in-­person
CBT-­I, typically as a resource for patients to store sleep diary
entries, track treatment progress, review educational materials,
and practice relaxation strategies outside of session. Poten-
tial advantages of these apps are to increase accessibility of
 Chapter 97  Behavioral Treatment III: Digital and Telehealth Approaches 899

Table 97.1 Examples of Mobile Apps Delivering Insomnia Treatment by Category

Outcome, Feasibility,
Example Apps Description Intended User Usability, or Case Studies
Support Face-­to-­Face Treatment
CBT-­i Coach Used in conjunction with face-­to-­face Individuals with insomnia Reilly, Robinson47;
CBT-­I Koffel, Kuhn46;
Babson, Ramo44
Win-­Win aSleep [WWaS] Used in conjunction with face-­to-­face Older adults with insomnia Chen, Hung45
CBT-­I
Guided Programs with Clinical Support
interactive Resilience Bidirectional exchange of data to Patients with sleep disorders Pulantara, Parmanto48;
Enhancing Sleep Tactics clinician portal for delivery of a under provider care. Pulantara, Parmanto49
(iREST) just-­in-­time adaptive intervention Focus on military populations
based on brief behavioral therapy for
insomnia
Companion App to Web-­Based Program
Sleepio Companion app to fully automated Adults with insomnia See studies noted in internet-­
subscription-­based CBT-­I web symptoms delivered section
program
Fully Automated
SleepRate A fully automated, subscription-­based Individuals with sleep Eyal and Baharav51 (abstract
CBT-­I program difficulties supplement);
Baharav and Niejadlik55
(abstract supplement)
Night Owl: Sleep Coach Fully automated delivery of a 56-­day Individuals with insomnia Harbison, Cole52 (abstract
CBT-­I program symptoms supplement)
Sleep Ninja Fully automated delivery of a 6-­week Adolescents with insomnia or Werner-­Seidler, Wong56
CBT-­I informed program sleep disturbance
SleepCare (commercial Fully automated delivery of a 6-­to Adults with insomnia Horsch, Lancee54; Horsch,
version called Lyla Coach) 7-­week Spruit57
CBT-­I program

materials and improve adherence to recommendations. These
apps are found to be user friendly and perceived as helpful44;
however, they may need further tailoring for use by older
adults.45 A small RCT comparing CBT-­I alone to CBT-­I
with the addition of an app (CBT-­i Coach) found that app
users consistently used the app as intended, and integration
of the app into treatment did not compromise the therapy.46
Although a nonsignificant finding, there also was a large effect
for app use being related to better adherence to therapist rec-
ommendations. More recently, Reilly and colleagues47 pub-
lished outcomes of a pilot trial assessing the use of CBT-­I
Coach as a self-­management tool for insomnia in veterans.
Although originally intended to be used in conjunction with
provider-­delivered CBT-­I, this study used the app with a self-­
management guide that instructed the participant on what
materials to review or features to use from the app during each
week of the 6-­week intervention. Significant improvements in
insomnia severity and overall sleep quality and sleep-­related
functioning were reported by those who completed treatment,
suggesting that this app could be used to manage insom-
nia without the aid of a therapist, thereby reducing clinical
resources.
The second category includes mobile apps that inter-
face with a clinician portal from where clinicians can review
patient data and send individualized recommendations, such
as sleep restriction and stimulus control prescriptions, to the
patient’s app. This category reduces the need for in-­person
appointments while simultaneously providing clinician moni-
toring. An example of this type of system is the interactive
Resilience Enhancing Sleep Tactics (iREST) platform.48,49 A
usability study of this platform found that participants rated
the platform as easy to use and learn, and participants used
the app daily to record their sleep.49 Results from an open
pilot investigation of iREST in a sample of military person-
nel and veterans with sleep disturbance revealed a significant
reduction in self-­reported insomnia symptoms from pre-­to
postintervention along with improvements in depression, anx-
iety, and PTSD symptoms.48 Notably, the treatment response
and remission rates observed in this study were comparable to
those found in other trials of provider-­delivered CBT-­I.
Along the continuum of accessibility, the third category
of mobile interventions includes fully automated models that
do not require clinician input. Apps within this category may
stand alone (e.g., Sleeprate, Sleep Ninja) or serve as a com-
panion to internet-­ based CBT-­ I programs (e.g., Sleepio).
Typically, these programs are structured to guide the user
through modules and daily tasks and to provide recommen-
dations based on sleep diary entries or other user input. This
category of apps has no clinical oversight but has the advan-
tage of reaching diverse individuals who may not otherwise
900 PART II • Section 11  Insomnia
have access to treatment (i.e., individuals living in rural loca-
tions, shift workers). These types of apps are viewed favorably
in feasibility studies50 and results from pre-­to postinterven-
tion show improvements in sleep outcomes (see the reviews by
Eyal and Baharav,51 Harbison and colleagues,52 and Kang and
colleagues53). Horsch and colleagues54 were among the first to
conduct an RCT investigating a fully automated app deliver-
ing CBT-­I (SleepCare, recently transformed to a commercial
version called “Lyla Coach”). They found significant interac-
tion effects in favor of the app compared to the waitlist condi-
tion for improving the main outcomes of insomnia severity
and sleep efficiency in adults with mild insomnia symptoms.
Together, the outcomes from these pilot investigations support
the applicability of using automated app-­delivered insomnia
treatment and show promise in benefitting users.
Although the past few years have seen a rise in published
studies on app-­based programs for sleep disturbances, most
research on app-­only programs remains in the pilot or fea-
sibility stage. The exception is the evidence for the internet-­
delivered programs, described in the previous section, that can
also be offered through an app (e.g., Sleepio or Shuti, now
called Somyrst). Additional trials are needed to ensure the
efficacy and safety of fully automated apps in diverse patient
populations.  group. However, patient preferences were stronger for web-­
TELEHEALTH DELIVERY OF COGNITIVE
BEHAVIORAL THERAPY FOR INSOMNIA
Widespread implementation of CBT-­I is limited by the lack
of clinicians who are trained in this treatment.58 Although
increasing the number of certified providers is critical, addi-
tional strategies to increase access to care, particularly for
patients in more rural locations where providers are particu-
larly scarce, is paramount. One means of increasing access to
CBT-­I is to use telemedicine, defined as “the use of electronic
communications and information technology to provide and
support health care when distance separates the provider from
the patient.”59 Although there are several types of telehealth,
CBT-­ I delivery fits into clinical video telehealth (CVT),
in which video technology is used to connect the patient
and provider, as opposed to face-­to-­face treatment. CVT is
increasingly used to provide mental health services remotely,
known as telemental health. Studies have examined the feasi-
bility of medical management via video teleconferencing (e.g.,
see the reports by Nieves and colleagues60 and Himle and
colleagues61), and several noninferiority studies on telemen-
tal health have demonstrated comparable outcomes to that of
in-­person treatment.62-­64 Because of the consistency of results
across mental health conditions and types of treatment, there
is now a general consensus that telemental health treatment is
not inferior to in-­person treatment, resulting in a move away
from further head-­to-­head studies. Although it may be argued
that this type of global statement is premature, it represents
the thinking of many in the field. Few studies, however, have
addressed the telemedicine delivery of an intervention tar-
geted to chronic insomnia.
The first published study of CVT delivery of insomnia
treatment was a small, uncontrolled pilot study of CBT for
combined insomnia and depression.65 As such it was not
specifically CBT-­I. Adults age 50 and above with insomnia
and depression were recruited from rural primary care clin-
ics. Treatment was delivered using Skype and consisted of 10,
50-­minute weekly sessions. Eighteen patients were enrolled in
treatment, but only five completed the study because of sev-
eral factors. There were improvements in both insomnia and
depression posttreatment. The working alliance was also rated
as being comparable to face-­to-­face therapy. A subsequent
study65a reported on the results of a larger trial of 40 partici-
pants randomized to receive combined CBT for insomnia and
depression or a usual care condition. CBT treatment led to
significant improvements in both insomnia and depression
compared to usual care at posttreatment and 3-­month follow-
­up. Similar results were found in an uncontrolled case series of
group CBT-­I delivered by CVT in a general veteran popula-
tion.66 These studies demonstrate the CBT delivered by CVT
is associated with significant improvements and highlights the
potential of using technology to reach patients in rural set-
tings, where access to health care providers may be limited.
An important next question is how the efficacy of CBT-­I
delivered by CVT compares to other modalities of treatment
delivery. Holmqvist and colleagues conducted a clinical trial
in which 73 adults with insomnia were randomized to tele-
health or web-­based CBT-­I.67 Both treatment groups dem-
onstrated significant improvements in insomnia severity, with
some evidence of larger effects in the telehealth treatment
based delivery given the greater convenience of this format.
A final study compared group CBT-­I delivered by CVT to
face-­to-­face treatment for veterans with PTSD in a random-
ized, noninferiority trial.68 This study is the only one thus far
to formally test whether telehealth delivery of treatment is
inferior to face-­to-­face treatment. Although only preliminary
results of the trial have been reported, they suggest that there
is not a loss of treatment efficacy in using CVT to deliver care.
This finding is consistent with a growing body of evidence
that clinical services can be delivered using video telehealth
technology without a loss of effectiveness for patients with
insomnia65,67 and other disorders.62,64
In summary, telehealth delivery of CBT-­I is a means of
increasing access to evidence-­based treatment for insomnia by
reducing barriers such as a lack of trained providers in many
locations. Patients and providers can increasingly feel confi-
dent that they can use these technologies without sacrific-
ing clinical improvement. It would be helpful to have more
controlled trials comparing telehealth CBT-­I to in-­person
treatment, although as stated previously, the telemental health
field as a whole is moving away from these studies. Future
studies should also examine whether certain individuals
are more suited for this modality than others. For example,
patient preferences may be an important determinant success
in each approach. Also, there may be ways to use the telehealth
technology to modify the delivery and/or content of CBT-­I
components.
 SUMMARY
Given the high prevalence of insomnia, there has been a tre-
mendous growth in the interest of using technology to deliver
CBT-­I to address the limited availability and scalability of
face-­to-­face treatment. Internet, mobile, and telehealth tech-
nologies have received the most attention, although there are
other means of using technology to deliver care. Evidence
suggests that treatment delivered via these means is efficacious
and effective in numerous RCTs. What is less certain is how
 Chapter 97  Behavioral Treatment III: Digital and Telehealth Approaches
these modalities stack up against face-­to-­face treatment, as
there have been few direct comparisons. The limited evidence
suggests that technological delivery is only slightly less effec-
tive, or even not inferior, compared to in-­person treatment.
The advantages of increased access to care may outweigh any
disadvantages in terms of reduced efficacy, particularly in the
context of stepped care approaches. However, much more
work is to be done. In parallel to determining which tech-
nological treatments “work,” it is important to determine for
whom so that individuals can be matched to the type of inter-
vention from which they are most likely to benefit. Digital
delivery of CBT-­I has a bright future ahead and will help to
increase the accessibility of proven treatments to match the
number of patients in need.
CLINICAL PEARL
The demand for CBT-­I outweighs the availability of trained
providers. Technology-­delivered CBT-­I, via internet platforms,
mobile devices, or CVT, is a means of increasing access to treat-
ment and may serve as an important tool in the stepped care
pathway. Technological means of treatment delivery may also
reduce costs of treatment, although this has not been directly
tested. There are not yet sufficient data to guide treatment
decisions of which patients would most benefit from each
approach, so selection of modality should be made in discus-
sion with patients. Although still burgeoning, evidence indi-
cates that treatment delivered via these means is efficacious
and effective for improving insomnia severity. If their patients
express openness to technology, providers may consider incor-
porating digitally delivered CBT-­I in their treatment plan.
901
SELECTED READINGS
Espie CA, Emsley R, Kyle SD, et  al. Effect of digital cognitive behavioral
therapy for insomnia on health, psychological well-­being, and sleep-­related
quality of life: a randomized clinical trial. JAMA Psychiatry. 2019;76:21–30.
Gehrman P, Bellamy SL, Medvedeva E, et al. Telehealth delivery of group
CBT-­I is non-­inferior to in-­person treatment in veterans with PTSD.
Sleep. 2018;41(Suppl):A141–A142.
Holmqvist M, Vincent N, Walsh K. Web-­vs. telehealth-­based delivery of
cognitive behavioral therapy for insomnia: a randomized controlled trial.
Sleep Med. 2014;15(2):187–195.
Horsch CHG, Lancee J, Griffioen-­Both F, et  al. Mobile Phone-­delivered
cognitive behavioral therapy for insomnia: a randomized waitlist con-
trolled trial. J Med Internet Res. 2017;19(4):e70.
Hsieh C, Rezayat T, Zeidler MR. Telemedicine and the management of in-
somnia. Sleep Med Clin. 2020;15(3):383–390.
Kallestad H, Langsrud K, Vedaa Ø, Stiles T, Vethe D, Lydersen S, et al. 0371
A randomized noninferiority trial comparing cognitive behavior therapy
for insomnia (cbt-­i) delivered by a therapist or via a fully automated online
treatment program. Sleep. 2018;41(suppl 1):A142–A.
Koffel E, Bramoweth AD, Ulmer CS. Increasing access to and utilization of
cognitive behavioral therapy for insomnia (CBT-­I): a narrative review. J
Gen Intern Med. 2018;33(6):955–962.
Lancee J, van Straten A, Morina N, Kaldo V, Kamphuis JH. Guided online
or face-­to-­face cognitive behavioral treatment for insomnia: a randomized
wait-­list controlled trial. Sleep. 2016;39:183–191.
Luik AI, Kyle SD, Espie CA. Digital Cognitive Behavioral Therapy
(dCBT) for insomnia: a state-­of-­the-­science review. Curr Sleep Med Rep.
2017;3:48–56.
Luik AI, van der Zweerde T, van Straten A, Lancee J. Digital delivery of cog-
nitive behavioral therapy for insomnia. Curr Psychiatry Rep. 2019;21:50.
Ritterband LM, Thorndike FP, Ingersoll KS, et al. Effect of a web-­based cog-
nitive behavior therapy for insomnia intervention with 1-­year follow-­up:
a randomized clinical trial. JAMA Psychiatry. 2017;74:68–75.
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 Chapter 97  Behavioral Treatment III: Digital and Telehealth Approaches 901.e3

REVIEW QUESTIONS 4. Which conclusion(s) can be drawn about the efficacy of

technological means to deliver CBT-­I?
1. What is one advantage that was found for using a mobile A. They are equally efficacious but less efficacious than in-­
app in conjunction with face-­to-­face CBT-­I? person treatment.
A. Greater adherence to therapist recommendations B. Efficacy of these modalities is comparable or somewhat
B. Greater symptom improvements when using the app less effective than in-­person treatment, although few
C. Less likely to miss appointments studies have conducted direct head-­to-­head compari-
D. Greater reduction in caffeine consumption sons.
C. In-­person treatment is the only efficacious option.
2. A patient lives a long distance from any available CBT-­I D. All options are equally efficacious.
provider. What might guide the selection of offering treat-
ment via telehealth versus having them use a digital ther-
apy program?
A. Patient preferences
B. Comfort with using technology on their own
C. W hether there are providers located in their state
D. These are all factors to consider

3. What is the nature of the provider’s involvement in digital

CBT-­I?
A. Providers have no involvement in this treatment modal-
ity.
B. Providers remotely monitor patient progress in digital
CBT-­I.
C. There can be a range of provider involvement in digital
CBT-­I.
D. Patients receive digital CBT-­I with a provider present.
901.e4 PART II • Section 11  Insomnia

ANSWERS 3. C. The use of digital delivery is on a continuum, ranging

from fully automated (i.e., no provider involvement) to
1. A. Integration of an app into provider-­delivered CBT-­I therapist guided or supportive (i.e., a provider is involved
has not been shown to lead to better or worse symptom in the process).
outcomes. However, one study found that those using an
app were more likely to adhere to therapist recommenda- 4. B. Very few trials have directly compared the efficacy of
tions than those in the face-­to-­face only group. different treatment approaches, but the results thus far sug-
gest minimal or small loss of efficacy.
2. D. The modality that a patient prefers should be taken into
consideration. An individual who is less comfortable with
technology may need more assistance than what is typically
available for digital therapy programs. Finally, a telehealth
provider would likely need to be licensed in the state where
the patient resides to be able to provide services.