CATR: Which patients are the best candidates for cognitive behavioral therapy for insomnia (CBT-i)?
Dr. Arnedt: CBT-i is a first-line treatment for anyone with chronic insomnia. Technically, that is defined as difficulty falling or staying asleep, or both, occurring three or more nights per week for at least three months and causing daytime impairment. But practically, it can be used for anyone with consistently poor sleep. Its efficacy is supported by multiple randomized controlled trials in people with and without comorbid health conditions, including substance use disorders (SUDs). In head-to-head comparisons with sleeping medications, CBT-i has been shown to be similarly effective during treatment, but its benefits are better sustained over the longer term (Morin CM and Buysse DJ, New Engl J Med 2024;391(3):247–258). The downside is that CBT-i requires more effort than taking medication. People have to implement strategies, adjust them over time, and remain patient because it takes longer to work. The best candidates are motivated and ready to change their behavior around sleep and challenge strongly held beliefs about sleep.

CATR: You mentioned that CBT-i can be useful for patients with SUDs. Tell us more about that.
Dr. Arnedt: Insomnia and SUDs are highly comorbid; as many as two-thirds to three-quarters of patients actively using substances or in early recovery have clinically significant insomnia (Miller MB et al, Drug Alcohol Depend 2017;181:200–207; Chekani F et al, Subst Use Misuse 2026:1–12). Patients with both insomnia and SUDs tend to have more comorbidities, worse substance use, and less engagement in their treatment. Among people who do achieve abstinence, insomnia is associated with a higher risk of relapse. The good news is that studies show CBT-i is effective in patients with SUDs. The research, which has mostly been done with alcohol use disorder (AUD), shows that it is well tolerated, improves sleep, and decreases daytime symptoms (Turkmen C et al, Sleep Med Rev 2025;80:102049).

CATR: Do sleep improvements translate to improvements in substance use?
Dr. Arnedt: It’s a plausible argument; better sleep can improve mood, thinking, and judgment, which may help people make better decisions around substances. But overall, the evidence is mixed. Several randomized trials have found reductions in substance use with CBT-i compared to controls, but the difference has not risen to statistical significance in every study (Turkmen et al, 2025).

CATR: Most of our readers know how CBT works generally. How are these principles adapted to insomnia treatment?
Dr. Arnedt: CBT-i has the same two-pronged structure as other CBT approaches: cognitive strategies and behavioral strategies. The working model of chronic insomnia is that it’s often triggered acutely by a life stressor, such as a medical illness, or a period of heavy substance use. But what perpetuates the insomnia is not the inciting event—it’s the compensatory thoughts and behaviors that develop afterwards. CBT-i directly targets these behaviors and cognitions.

CATR: Tell us about some cognitive strategies.
Dr. Arnedt: Cognitive strategies address thoughts that can interfere with sleep. We all experience these from time to time. You lie in bed and get anxious because you’re not falling asleep fast enough. You start thinking, “I won’t be able to function tomorrow if I don’t fall asleep right now.” That’s not a frame of mind that is going to help you fall asleep. The strategy here is to recognize this as an example of the common cognitive distortion we call catastrophic thinking. You can work with your patient to reframe these extreme thoughts: Will they really not be able to function at all? Is that reality-based? You can help them conclude that people function after a night of poor sleep all the time. Maybe they’ll be a little tired, but one night of poor sleep is not the end of the world. Another cognitive distortion is overvaluing the importance of one night of poor sleep. Your patient may think of that night as definitive proof that their insomnia is much worse than it may in fact be. Of course, the reality is that night-to-night variability is normal. Your role as the therapist is to challenge that distorted belief, normalize a sleepless night from time to time, and refocus the patient’s attention on overall sleep trends.

CATR: What about the behavioral strategies?
Dr. Arnedt: Behavioral strategies aim to change unhelpful sleep-related behaviors. Many people do activities other than sleep in bed, such as watching TV, talking on the phone, or eating meals, so the bed becomes associated with stimulating or anxiety-producing activities rather than just sleep. Stimulus control is one useful strategy that aims to reassociate the bed only with sleep. Another is sleep restriction, which temporarily reduces time in bed to increase sleepiness and consolidate nighttime sleep. It’s counterintuitive that better sleep can come from purposefully sleeping less, but in practice this can be a powerful tool.

CATR: Are there other strategies that you use in CBT-i?
Dr. Arnedt: There are several techniques that serve as important adjuncts to the cognitive and behavioral strategies we discussed. Basic sleep hygiene psychoeducation is important but should not be used alone. Mindfulness and relaxation training can help as well.

CATR: What does a typical course of treatment look like?
Dr. Arnedt: A full course is 4–8 sessions, 30–60 minutes each, delivered individually or in groups. Sessions are highly structured: We set an agenda, review homework, discuss progress and challenges, troubleshoot those challenges, introduce a new behavioral or cognitive concept, summarize it, and assign homework for the coming week. Homework tends to be prescriptive around sleep schedules (when to go to bed, when to get up, what to do when unable to sleep), and patients might keep records of automatic thoughts to discuss in session. Like all CBT, treatment is iterative: Make a plan, evaluate implementation, fine-tune, add a component, and adjust course as needed.

CATR: How do you know if a course adjustment is necessary? How do you monitor progress?
Dr. Arnedt: Perhaps the most important component of homework is keeping a regular sleep diary, which is a critical tool for telling us how the treatment is working. And we assess the patient’s subjective report of sleep quality and quantity, and their daytime symptoms like fatigue, sleepiness, or cognitive difficulties. We also use validated measures, the most common being the Insomnia Severity Index (ISI). I recommend administering it at intake and every follow-up. It uses validated criteria for identifying clinically significant insomnia as well as monitoring treatment response and remission (www.tinyurl.com/29bvb98f).

CATR: How should CBT-i be tailored for patients with SUD?
Dr. Arnedt: Timing and pacing matter. Sleep may be disrupted during early recovery, particularly during acute withdrawal, so I recommend being conservative with CBT-i in that period. Engage patients with sleep diaries and perhaps sleep hygiene strategies, but hold off on core CBT strategies. As a rule of thumb, wait a month for withdrawal effects to dissipate before implementing CBT-i. Cognitive restructuring should also explicitly address SUD-specific beliefs, since cognitive distortions can build up around substance use and sleep, especially with long-standing SUD or significant substance-related sleep disturbance. For example, a patient may say, “I’ll never be able to sleep without a drink or a pill,” or conversely, “If I can’t sleep, I’ll go back to drinking or using substances.” These distorted thoughts should be addressed directly in session.

CATR: Can CBT-i be integrated into other forms of SUD treatment?
Dr. Arnedt: Absolutely. It can be combined with psychotherapy or medication approaches. It shares the skills-based, homework-driven structure of CBT for SUDs and pairs well with motivational interviewing, particularly when patients are ambivalent about behavioral change. Improving sleep may also help patients engage more effectively in the rest of treatment by supporting clearer thinking and better mood.

CATR: How do sleep medications fit into CBT-i?
Dr. Arnedt: CBT-i can be used whether someone is taking sleep medication or not, although the general goal is to reduce reliance on medication and develop other strategies for managing sleep. In fact, evidence shows that unlike medications, CBT-i is a durable treatment, meaning the benefits of treatment outlast the treatment course itself (Perlis ML et al, Lancet 2022;400(10357):1047–1060). If medication is being used, I recommend stabilizing it before embarking on treatment. It’s going to be difficult to track progress if sleep medications are being changed along the way. Decide ahead of time which days the patient will take their medication and at what dose. Once that’s stable, you can embark on CBT-i. It’s important to acknowledge that CBT-i, unlike medication, does not work instantly. Set that expectation at the outset. Many patients may use medication early in treatment, and once they’ve seen some benefit and gotten through the protocol, then the medication can be slowly tapered off while maintaining the CBT-i strategies. I recommend keeping a sleep diary during this period as well; it may reveal opportunities for a CBT-i “refresher.”

“It’s important to acknowledge that CBT-i, unlike medication, does not work instantly. Set that expectation at the outset.” - J. Todd Arnedt, PhD

CATR: Are there particular considerations for patients receiving medications for SUDs?
Dr. Arnedt: Methadone and buprenorphine can affect sleep architecture, including slow-wave and REM sleep, and patients on these medications, especially early on, may report fragmented or poor-quality sleep (Rosen IM et al, J Clin Sleep Med 2019;15(11):1671–1673). Setting expectations ahead of time can help with medication adherence. You could say something like: “Sleep issues are common early in recovery. The important thing is that you stick with treatment as best you can. Nothing will be better for your sleep, and your safety for that matter, than continuing to not use substances.” Gabapentin is sometimes used off label in AUD and may have modest sleep-promoting effects, improving sleep during early abstinence (Mason BJ et al, JAMA Intern Med 2014;174(1):70–77). However, we are increasingly aware of gabapentin’s misuse potential, so caution is warranted.

CATR: How can clinicians without CBT-i training incorporate these principles into their practice?
Dr. Arnedt: You don’t need to be a behavioral sleep medicine specialist to bring value around sleep. A simple first step is to incorporate the ISI into routine SUD care. If your patient has clinically significant insomnia, recommend basic evidence-based behavioral strategies: Maintain a consistent wake time, get out of bed if unable to sleep after 20–30 minutes, and reserve the bed for sleep only. You can also help patients identify unhelpful cognitions about sleep and substance use and intervene on those. This is especially important for patients with SUD. We know that poor sleep can be a trigger for relapse—acknowledge this with your patient and develop a plan for when they have a bad night. Maybe they get out of bed and take a warm shower, read a book, or listen to some relaxing music. Walk them through what they might do other than using substances. And if these strategies aren’t enough, you can always refer them to a CBT-i provider.

CATR: That would be great, but CBT-i providers can be difficult to find.
Dr. Arnedt: That’s true, and that’s where digital platforms can be useful. Sleepio and SHUTi (now Somryst) are fully automated self-contained apps that can deliver a course of treatment without face-to-face sessions. The length of a treatment is comparable to traditional CBT-i and consists of highly structured sessions. Sleepio is not available directly to consumers but can be accessed through many employer health plans. Somryst is accessible to the public, though it requires a prescription. There are two other apps that I recommend, both of which were developed at the VA. One is another stand-alone app called Insomnia Coach. The other, called CBT-i Coach, is designed to be used alongside a therapist.

CATR: What is the evidence behind digital platforms? How do they compare to traditional face-to-face sessions?
Dr. Arnedt: Sleepio and Somryst are the most rigorously studied. The two VA apps use similar principles but have only been evaluated on the level of pilot and feasibility studies. But the evidence is very promising. Studies have repeatedly found that digital platforms produce meaningful and durable improvements, though there is some evidence that dropout rates are higher for digital platforms and that therapist involvement improves outcomes (Chan WS et al, JMIR Mental Health 2024;11:e51716).

CATR: Are there other resources you recommend?
Dr. Arnedt: For patients, there’s Quiet Your Mind and Get to Sleep, which has chapters and practical exercises (Carney C and Manber R. Quiet Your Mind and Get to Sleep: Solutions to Insomnia for Those With Depression, Anxiety, or Chronic Pain. Oakland, CA: New Harbinger Publications; 2009); and Overcoming Insomnia, a workbook-style resource (Espie C. Overcoming Insomnia: A Self-Help Guide Using Cognitive Behavioural Techniques. London, UK: Robinson; 2006). The National Sleep Foundation has accessible patient information about CBT-i and other evidence-based insomnia treatments (www.tinyurl.com/4zr7tmez). For clinicians, Cognitive Behavioral Treatment of Insomnia offers a prescriptive, step-by-step approach to implementing CBT-i (Perlis ML et al. Cognitive Behavioral Treatment of Insomnia: A Session-by-Session Guide. New York, NY: Springer; 2008). The Society of Behavioral Sleep Medicine maintains a list of CBT-i providers and clinician resources (www.tinyurl.com/3zxhv282), and the American Academy of Sleep Medicine publishes useful practice guidelines for treatment beyond strict CBT-i (www.tinyurl.com/54ptjpkn).

CATR: Thank you for your time, Dr. Arnedt.