“CBT-I works better than sleeping pills for long-term insomnia.”
CBT-I (cognitive behavioral therapy for insomnia) works better than sleeping pills over the long run, and major guidelines recommend it as the first treatment for long-term insomnia.
If you have long-term insomnia, CBT-I is the treatment most likely to keep working after it ends, and it avoids the side effects of pills. Sleeping pills still have a place, mainly as a short-term option when CBT-I is not enough or not available.
Ask a clinician about CBT-I from a trained provider or a validated program. If you take a sleeping pill now, keep taking it as prescribed until you have talked with your prescriber.
Safety note: Early in treatment, CBT-I can cause daytime tiredness and sleepiness, irritability and trouble concentrating, which usually fade by the end of treatment. The sleep-restriction part may not be safe without close supervision for people who drive or run heavy machinery for work, people prone to mania (such as with bipolar disorder) and people with poorly controlled seizures. Sleeping pills carry their own risks, including next-day drowsiness, dependence and withdrawal, and falls.
Talk to a healthcare professional if: your insomnia has lasted three months or more, you feel very impaired during the day or drowsy while driving, you may have sleep apnea, you have severe mood symptoms or possible bipolar disorder, or you want to stop or change a sleep medicine.
Head-to-head trials and major guidelines agree that CBT-I gives longer-lasting results than sleeping pills, and the newest review of those trials rated the long-term evidence high in certainty. Confidence is moderate, not strong, because there are only a small number of these trials, they followed people for a year at most, and in the short term the two treatments are closer to even.
CBT-I (cognitive behavioral therapy for insomnia) works better than sleeping pills over the long run, and major guidelines recommend it as the first treatment for long-term insomnia. In a 2024 review that pooled the trials with long-term follow-up, about 41 in 100 people who started with CBT-I were free of insomnia 3 to 12 months later, compared with about 28 in 100 who started with pills.
"Better" here means results that last longer after treatment ends, fewer people quitting, and no pill side effects. In the short term, the two are closer: in the 2024 review, CBT-I did as well as or better than pills on most sleep measures, but people taking pills slept about 20 minutes longer at the end of treatment. An earlier review of five head-to-head trials found the same pattern, with CBT-I ahead over the long term (low to moderate quality evidence) and pills possibly ahead in the short term (very low quality evidence). The trials followed people for 12 to 48 weeks, so results over several years are less certain, and people who join therapy trials may be more motivated than average.
The American College of Physicians recommends CBT-I as the first treatment for all adults with chronic insomnia (strong recommendation, moderate-quality evidence), with medicine added only after a shared decision if CBT-I alone has not worked. The 2023 European insomnia guideline recommends CBT-I as the first treatment for adults of any age, including people with other health conditions, and says sleeping pills can be offered for short-term use, up to 4 weeks, when CBT-I is not enough. The American Academy of Sleep Medicine gives CBT-I a strong recommendation, the only behavioral treatment to receive one, and says it is generally regarded as the treatment of choice.
- Qaseem A, Kansagara D, Forciea MA, Cooke M, Denberg TD; Clinical Guidelines Committee of the American College of Physicians. Management of Chronic Insomnia Disorder in Adults: A Clinical Practice Guideline From the American College of Physicians. Annals of Internal Medicine. 2016;165(2):125-133. DOI: 10.7326/M15-2175. PMID: 27136449
- Riemann D, Espie CA, Altena E, Arnardottir ES, Baglioni C, Bassetti CLA, et al. The European Insomnia Guideline: An update on the diagnosis and treatment of insomnia 2023. Journal of Sleep Research. 2023;32(6):e14035. DOI: 10.1111/jsr.14035. PMID: 38016484
- Edinger JD, Arnedt JT, Bertisch SM, Carney CE, Harrington JJ, Lichstein KL, Sateia MJ, Troxel WM, Zhou ES, Kazmi U, Heald JL, Martin JL. Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine clinical practice guideline. Journal of Clinical Sleep Medicine. 2021;17(2):255-262. DOI: 10.5664/jcsm.8986. PMID: 33164742. PMCID: PMC7853203
- Mitchell MD, Gehrman P, Perlis M, Umscheid CA. Comparative effectiveness of cognitive behavioral therapy for insomnia: a systematic review. BMC Family Practice. 2012;13:40. DOI: 10.1186/1471-2296-13-40. PMID: 22631616. PMCID: PMC3481424
- Furukawa Y, Sakata M, Furukawa TA, Efthimiou O, Perlis M. Initial treatment choices for long-term remission of chronic insomnia disorder in adults: a systematic review and network meta-analysis. Psychiatry and Clinical Neurosciences. 2024;78(11):646-653. DOI: 10.1111/pcn.13730. PMID: 39188094. PMCID: PMC11804918