What is CBT-I and why is it better than sleeping pills?

CBT-I (cognitive behavioural therapy for insomnia) is a structured 5-8 session programme combining sleep restriction, stimulus control, cognitive restructuring, relaxation and sleep hygiene. It addresses the perpetuating factors of chronic insomnia — the conditioned arousal, sleep anxiety and dysfunctional sleep beliefs that maintain the problem. Evidence: CBT-I equals sleep medications short-term and is significantly superior long-term (benefits persist after treatment ends; medications lose benefit when stopped). AASM, ACP and NICE all recommend CBT-I as first-line for chronic insomnia disorder.

What are the risks of long-term Z-drugs?

Z-drugs (zopiclone, zolpidem, zaleplon) prescribed beyond 2-4 weeks: tolerance (dose escalation needed); psychological and physiological dependence; next-day cognitive impairment and psychomotor slowing (driving impairment); falls and hip fractures in elderly; complex sleep behaviours (sleepwalking, sleep-driving, sleep-eating — FDA black box warning for zolpidem); possible dementia association in long-term users (observational). Deprescribing: requires very gradual taper — abrupt cessation causes severe rebound insomnia and anxiety.

What sleep medications are safest for long-term use?

No sleep medication is truly designed for long-term use — CBT-I is preferred. When medication is needed longer-term: DORAs (lemborexant, suvorexant) have the best long-term safety profile — no physiological dependence; no complex sleep behaviours; approved for chronic insomnia. Low-dose doxepin (Silenor 3-6mg): FDA-approved for sleep maintenance; antihistamine mechanism at this dose; less dependence risk than Z-drugs. Melatonin: very safe long-term but modest efficacy for most insomnia.

Does alcohol help sleep?

Alcohol shortens sleep onset but seriously disrupts sleep quality: suppresses REM sleep (first half of night); causes rebound wakefulness (second half); worsens snoring and sleep apnoea; increases early awakening as blood alcohol falls. Regular alcohol as a sleep aid leads to tolerance and dependence. Not a safe or effective sleep aid — and insomnia improves with alcohol cessation (after initial 2-4 week worsening).

How does GMJ News cover sleep and CBT-I?

GMJ News covers AASM/ACP CBT-I first-line recommendation, sleep restriction therapy, stimulus control, Z-drug risks, DORA pharmacology, melatonin as a chronobiotic, digital CBT-I evidence, sleep architecture, orexin system, caffeine pharmacokinetics, alcohol disruption of REM, and benzodiazepine deprescribing protocol. Directly relevant to PHIG's NCD programme and GMJ Academy occupational health curricula.

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Sleep Hygiene and CBT-I

GMJ News knowledge hub · last reviewed September 2026 · Georgian Medical Journal

Summary Statistics Glossary GMJ news FAQ Documents Organizations Research

Chronic insomnia disorder — difficulty initiating or maintaining sleep associated with daytime impairment, occurring ≥3 nights/week for ≥3 months — affects approximately 10-15% of adults chronically (with up to 30-35% having transient insomnia symptoms), causes profound impact on health, productivity and quality of life, and has a highly effective non-pharmacological treatment in CBT-I (cognitive behavioural therapy for insomnia) that is recommended as first-line therapy over sleep medications by the American Academy of Sleep Medicine (AASM), the American College of Physicians and NICE — yet remains profoundly underutilised while Z-drugs (zopiclone, zolpidem) — associated with tolerance, dependence, falls and cognitive impairment — continue to be overprescribed (WHO). Digital CBT-I (dCBT-I — apps such as Sleepio and SHUTi, validated in randomised trials) is making the gold-standard treatment scalable, while a new class of sleep medications — dual orexin receptor antagonists (DORAs) such as lemborexant and suvorexant — provide a safer pharmacological alternative to Z-drugs with no dependence risk and a lower next-day sedation burden.

Key messages

CBT-I is first-line over sleep medication — AASM, ACP and NICE recommend

The American Academy of Sleep Medicine (AASM), American College of Physicians (ACP) and NICE all recommend CBT-I (cognitive behavioural therapy for insomnia) as first-line treatment for chronic insomnia disorder — superior to pharmacotherapy in long-term outcomes without tolerance, dependence or cognitive side effects.

Sleep restriction — the most counterintuitive and most effective CBT-I component

Sleep restriction: temporarily restricts time in bed (TIB) to match actual sleep time (e.g. sleeping 5h → TIB set to 5.5h). Builds sleep pressure, consolidates fragmented sleep, resets the homeostatic drive. When sleep efficiency >85%, TIB extended by 15 minutes/week. Often produces rapid, durable improvement — more effective than any sleeping pill.

Z-drugs — maximum 2-4 weeks — not for chronic insomnia

Z-drugs (zopiclone, zolpidem, zaleplon): GABA-A modulators; effective short-term sleep initiation. Risks: tolerance; psychological dependence; next-day impairment; falls and hip fractures in elderly; complex sleep behaviours (FDA black box warning — sleepwalking, sleep-driving). NICE: maximum 2-4 weeks; avoid in elderly; not first-line for chronic insomnia.

Dual orexin receptor antagonists (DORAs) — a safer pharmacological option

Suvorexant (Belsomra, FDA 2014) and lemborexant (Dayvigo, FDA 2020) block wake-promoting orexin signals. Advantages over Z-drugs: no physiological dependence; no complex sleep behaviours; lower next-day sedation. Approved for chronic insomnia — a safer pharmacological choice when medication is needed.

Stimulus control — breaking the bedroom-wakefulness conditioned response

Stimulus control re-establishes the bed as a cue for sleep: use the bed only for sleep and sex; if not asleep within approximately 20 minutes, get up and do a calm activity until sleepy; maintain a fixed wake time every day regardless of sleep quality. Breaks conditioned arousal (bed associated with anxiety) — rebuilding the sleep-bed association.

Melatonin — a chronobiotic, not a sleeping pill

Melatonin signals darkness/nighttime to the circadian system — it is NOT a sedative. Best evidence: circadian rhythm disorders (jet lag; shift work; delayed sleep phase). Modest evidence for sleep onset in adults ≥55 (prolonged-release melatonin, Circadin — EU licensed). Substantially less effective than CBT-I for chronic insomnia disorder. Alcohol disrupts sleep architecture — suppresses REM, causes rebound wakefulness; not a safe sleep aid.

Key statistics

10-15%

of adults have chronic insomnia disorder; 30-35% have insomnia symptoms

AASM/Cochrane

AASM + ACP

both recommend CBT-I as first-line for chronic insomnia over pharmacotherapy

AASM 2021/ACP 2016

Max 2-4 weeks

Z-drug prescription duration per NICE — not for chronic insomnia

NICE

FDA 2020

lemborexant (Dayvigo) — latest DORA for chronic insomnia; no dependence risk

FDA 2020

5-7 hours

caffeine half-life — 4pm coffee still 50% active at 9pm

Pharmacology

>85%

sleep efficiency target before extending time in bed in sleep restriction

CBT-I protocol

Insomnia treatment — sustained outcomes at 6-12 months (Cochrane/AASM)

Source: Cochrane/AASM. CBT-I superiority is most pronounced long-term; pharmacotherapy effects largely lost when stopped.

Glossary of key terms

CBT-I components
AASMCBT-I (5-8 sessions): (1) Sleep restriction — TIB restricted to actual sleep time, builds homeostatic sleep pressure. (2) Stimulus control — bed = sleep only; get up if not asleep in 20 mins; fixed wake time. (3) Sleep hygiene — caffeine, alcohol, screen, temperature. (4) Cognitive restructuring — challenging dysfunctional beliefs ("I need 8 hours", "I'll be useless tomorrow"). (5) Relaxation — progressive muscle relaxation, diaphragmatic breathing. Delivered face-to-face or via validated digital programmes (Sleepio, SHUTi, Somryst — FDA De Novo 2020).

Orexin-DORA mechanism
NeuropharmacologyOrexin (hypocretin) neuropeptides from the lateral hypothalamus maintain wakefulness by activating monoaminergic arousal systems. Dual orexin receptor antagonists (DORAs) block both OX1R and OX2R — suppressing wake drive and allowing sleep to occur physiologically. Fundamentally different from GABA-A enhancement (benzodiazepines, Z-drugs): does not cause disinhibition, amnesia or complex behaviours. Narcolepsy (loss of orexin neurons) proves orexin's central wake-promoting role.

Sleep hygiene principles
Evidence/ClinicalFixed wake time (most important — anchors the circadian clock). Caffeine: half-life 5-7 hours — avoid after 2pm. Alcohol: fragments sleep architecture (disrupts REM, rebound awakening, worsens insomnia). Blue light/screens: suppresses melatonin 1-3 hours — dim screens or use blue-light filter 60 minutes before bed. Bedroom: cool (18-19°C), dark, quiet. Exercise: regular aerobic exercise improves sleep quality (avoid vigorous within 2-3 hours of bedtime). Sleep hygiene is necessary but insufficient as a standalone treatment for chronic insomnia disorder.

Benzodiazepine and Z-drug deprescribing
NICE/PHEApproximately 1 in 4 adults over 65 takes a benzodiazepine or Z-drug — the most common cause of preventable falls. Abrupt withdrawal causes rebound insomnia, anxiety, seizures. Gradual taper: reduce by 10-25% every 2-4 weeks; convert to long-acting benzodiazepine (diazepam) before taper; simultaneously implement CBT-I (most effective combination). PHE 2019: Z-drugs + benzodiazepines are the single biggest pharmacological driver of falls in the elderly.

Digital CBT-I
NHS/NICENICE recognises digital CBT-I as effective. NHS England 2022: recommends digital CBT-I as first-line digital health technology for insomnia. Key programmes: Sleepio (UK — NHS eligible); SHUTi (USA); Somryst (FDA De Novo authorised 2020 — first prescription digital therapeutic for insomnia). Espie et al. (JAMA Psychiatry 2012): digital CBT-I significantly superior to placebo for sleep onset latency, total sleep time and efficiency.

Melatonin use and timing
ChronobiologyMelatonin 0.5-5mg at destination bedtime: reduces jet lag severity (especially eastward travel). Delayed sleep phase disorder: low dose 0.5-1mg, 5-6 hours before desired bedtime (advances the circadian clock). EU: prolonged-release melatonin (Circadin 2mg) licensed for primary insomnia in adults ≥55 (modest evidence, short-term). For chronic insomnia disorder without circadian disruption: evidence is very weak — substantially inferior to CBT-I.