It’s 3 a.m. You check the clock and realize sleep is nowhere to be found. After enough nights like this, it’s understandable to wonder: Should I just take something to sleep?
The short answer is sleep medications can help. But when it comes to chronic insomnia, medication and Cognitive Behavioral Therapy for Insomnia (CBT-I) do different things. The evidence helps us understand why that difference matters.
Before we go further, an important clarification: I am a psychotherapist, not a physician or medication prescriber. My work focuses on treating insomnia with CBT-I. The information about medication in this article is educational and based on clinical research and guidelines. Decisions about starting, changing, reducing, or stopping medication should be discussed with the healthcare professional who prescribes it.
So, do sleeping pills work?
Yes, they can. There are different medications used to treat insomnia, and depending on the medication and the individual, they may help you fall asleep faster, stay asleep longer, or both.
This is not an argument against medication. When insomnia becomes chronic, however, it is worth asking another question: What is keeping the insomnia going?
That is where CBT-I comes in.
What started your insomnia may not be what is keeping it going
Insomnia can begin during a period of stress, anxiety, trauma, illness, pain, hormonal changes, grief, or another major life disruption. After several nights of poor sleep, we naturally start trying to compensate. You might go to bed earlier, spend more time in bed, sleep later after a bad night, repeatedly check the clock, cancel plans because you have no energy, or start worrying in the afternoon about whether you’ll sleep that night.
These responses make sense because you’re trying to solve the problem, but some can unintentionally help maintain it. This is explained by the 3P Model of Insomnia, which looks at predisposing, precipitating, and perpetuating factors. If you want to understand this cycle in more detail, you can read my article, Why Does Insomnia Happen? Understanding the 3P Model.
CBT-I focuses particularly on changing the factors that are keeping insomnia going now.
What does CBT-I actually do?
First, CBT-I is not simply sleep hygiene. It isn’t just avoiding caffeine, turning off your phone earlier, or creating a relaxing bedtime routine.
CBT-I is a structured treatment that may include stimulus control to strengthen the connection between bed and sleep; sleep restriction or compression to strengthen sleep drive and consolidate sleep; cognitive strategies to address worry, monitoring, and pressure around sleep; and behavioral interventions and education based on how sleep actually works.
The American Academy of Sleep Medicine (AASM) recommends multicomponent CBT-I for chronic insomnia and suggests that sleep hygiene should not be used as a stand-alone treatment.
What do the studies say about CBT-I vs. medication?
A 2024 systematic review and network meta-analysis examined 13 randomized clinical trials involving 823 adults with chronic insomnia. Long-term remission was evaluated at a median of 24 weeks, with follow-up ranging from 12 to 48 weeks.
The estimated long-term remission rates were:
Medication: 28%
CBT-I: 41%
The odds of long-term remission were 1.82 times higher with CBT-I than with pharmacotherapy. In other words, across these studies, starting with CBT-I showed an advantage over starting with medication when researchers evaluated long-term remission from insomnia.
That does not mean medication does not work, and it does not mean 41% is a guarantee for every person who receives CBT-I. It means that when the results of multiple studies were analyzed together, CBT-I showed better long-term remission outcomes than pharmacotherapy.
This is consistent with clinical guidelines. Both the American Academy of Sleep Medicine and the American College of Physicians recommend CBT-I for chronic insomnia.
CBT-I is not a treatment reserved for when everything else fails. It is a first-line treatment.
Do the benefits actually last?
There is evidence suggesting that they can last for years. In one randomized clinical trial with a 10-year follow-up, improvements after CBT-I remained evident a decade later. Among those who participated in the follow-up, 66% no longer met diagnostic criteria for insomnia at 10 years, compared with 64% at the one-year follow-up.
Even more encouraging, insomnia severity remained substantially improved compared with participants’ scores before treatment. While one study cannot predict exactly how any individual person will respond to CBT-I, these findings show something important: the skills and improvements gained through CBT-I have the potential to last long after treatment ends.
That is one of the goals of CBT-I. You are not only working toward better sleep right now. You are learning how your sleep works, how to respond after a difficult night, and how to recognize patterns that could begin feeding insomnia again. The goal is to leave treatment with tools you can continue using for years to come.
Can I do CBT-I if I take sleep medication?
Yes. Taking sleep medication does not prevent you from participating in CBT-I, and beginning CBT-I does not mean you must stop a medication.
Any decision to start, change, reduce, or stop a medication should be discussed with the healthcare professional who prescribes it. Depending on the medication and your circumstances, a gradual reduction with medical supervision may be necessary.
CBT-I can be part of your treatment even if you currently use medication for sleep.
So, CBT-I or medication?
It does not have to be a competition between therapy and medication. Sleep medications can be appropriate and helpful for some people.
But if you have spent months trying to solve insomnia, perhaps the question is no longer only:
“What can I take to sleep?”
It may also be worth asking:
“What is keeping my insomnia going?”
That is precisely one of the questions we work with in CBT-I.
References
Edinger, J. D., et al. (2021). Behavioral and psychological treatments for chronic insomnia disorder in adults: An American Academy of Sleep Medicine clinical practice guideline. Journal of Clinical Sleep Medicine, 17(2), 255–262.
Furukawa, Y., Sakata, M., Furukawa, T. A., Efthimiou, O., & Perlis, M. (2024). Initial treatment choices for long-term remission of chronic insomnia disorder in adults: A systematic review and network meta-analysis. Psychiatry and Clinical Neurosciences, 78(11), 646–653.
Jernelöv, S., Blom, K., Hentati Isacsson, N., Bjurner, P., Rosén, A., Kraepelien, M., Forsell, E., & Kaldo, V. (2022). Very long-term outcome of cognitive behavioral therapy for insomnia: One- and ten-year follow-up of a randomized controlled trial. Cognitive Behaviour Therapy, 51(1), 72–88.
Qaseem, A., et al. (2016). Management of chronic insomnia disorder in adults: A clinical practice guideline from the American College of Physicians. Annals of Internal Medicine, 165(2), 125–133.
