FAQs for Cognitive Behavioral Therapy for Insomnia (CBT-I)

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Before Starting CBT-I

1. My patient’s sleep problems seem to stem from poor sleep hygiene.  Would CBT-I be helpful for them?

2. Should I treat mental health co-morbidities such as depression, anxiety, or PTSD before providing CBT-I?

3. Can I use CBT-I if I suspect my patient has another sleep disorder, such as circadian rhythm disorder, shift work, restless leg syndrome, nightmares, or obstructive sleep apnea?

4. I was referred a patient who reports getting very little sleep, wakes up unrefreshed, and is tired during the day.  How do I tell the difference between Insomnia Disorder and insufficient sleep?

5. Are there any contraindications for CBT-I?

6. Should patients stop taking sleep medication before starting the CBT-I protocol? 

Sleep Log Challenges
7. Do I include napping in sleep log scoring?

8. Do I include time out of bed when engaging in stimulus control during middle-of-the-night awakenings as part of the scored ‘TIB’ from the sleep log?

9. How do I handle a patient who refuses to complete a sleep log, or insists on using a device like a fitness tracker instead of completing a log?

10. If a patient reports excessive caffeine, alcohol, or other substance use, should that be addressed before stimulus control and sleep restriction?

11. Can a patient get in bed before our scheduled bedtime if they are sleepy earlier?

12. My patient could only come up with stimulating activities to do when out of the bed awake. How should I respond?

13. How do I respond when my patient has difficulty keeping the scheduled wake time consistently?

14. My patient regularly awakens before our scheduled wake time in the mornings. Can we shift the sleep schedule to match that earlier time?

15. How do I adjust my patient’s sleep schedule after setting it for the first time?

During the Protocol
16. My patient is midway through the CBT-I protocol, so why is sleep efficiency still low?

17. What should I do if I suspect my patient is getting more sleep or having less fragmentation than the sleep log shows?

18. If CBT-I has significantly improved a patient’s sleep before Session 8, is it alright to discontinue the protocol early?

Other
19. Do you have a manual to provide group CBT-I?

20. My recently referred patient is considering or has already started an intervention for sleep that I have never heard about (e.g., neurofeedback).  What should I tell my patient to help him/her decide to pursue this treatment or try CBT-I?

Before Starting CBT-I

1. My patient’s sleep problems seem to stem from poor sleep hygiene.  Would CBT-I be helpful for them?
Answer: For some patients, difficulty sleeping can be attributed to a specific source, such as a noisy bed partner or uncomfortable mattress.  In these cases, targeting the problem directly can help.  However, patients with sleep problems generally have multiple contributing factors, particularly if the insomnia has become chronic.  That means it is unlikely that simply targeting sleep hygiene will be helpful, and indeed, research demonstrates that for patients who have Insomnia Disorder, even if they have poor sleep hygiene, sleep hygiene interventions alone are ineffective.  Unless your patient has an easily identifiable single source of sleep problems or sleep problems are acute, CBT-I is recommended.
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2. Should I treat mental health co-morbidities such as depression, anxiety, or PTSD before providing CBT-I?
Answer: Insomnia is often comorbid with other conditions.   There is no conclusive research evidence to suggest that one condition should be treated before another.  Treatment order should instead be guided by the patient’s preference and your case conceptualization.  Often, a patient will express a preference for which condition they wish to address first or which type of treatment they are most willing to consider.  Considering that patient buy-in is an important factor in the success of any treatment, patient preference may be sufficient when choosing treatment order.  In the absence of patient preference, consider which condition seems to be causing the patient the most distress currently (either symptomatically or functionally).  
Resources: VIDEO: CDP Presents: Chickens & Eggs - Treatment Order in Cases of Co-Morbid PTSD and Insomnia
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3. Can I use CBT-I if I suspect my patient has another sleep disorder, such as circadian rhythm disorder, shift work, restless leg syndrome, nightmares, or obstructive sleep apnea?
Answer: This is a complicated question because patients suffering with other sleep disorders may have also developed bad habits that perpetuate insomnia.  However, in the case of comorbid sleep disorders, treating insomnia alone generally will not address the other problems.  If you suspect the presence of a comorbid sleep disorder, the first and most important step is to conduct a thorough sleep assessment utilizing the sleep interview and other measures such as the STOP.   Conditions such as obstructive sleep apnea and restless leg syndrome require referral to a sleep specialist.  Once addressed, CBT-I may then be initiated.  If you do not have experience treating shift work or circadian rhythm disorder, you should consider a referral to a sleep clinic or pursue additional training/consultation.  Nightmare frequency and severity MAY improve through CBTI but may require additional treatment with medication or IRT. 
Resources: Insomnia Treatment Tools 
Upcoming training events
CBTI Consultation Call info
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4. I was referred a patient who reports getting very little sleep, wakes up unrefreshed, and is tired during the day.  How do I tell the difference between Insomnia Disorder and insufficient sleep?
Answer: Both patients who experience insomnia and insufficient sleep share the common symptom of daytime fatigue, and have daytime functional impairment.  Confusingly, both have reduced total sleep times.  However, the difference between the two is sleep ability vs. sleep opportunity.  Patients with insufficient sleep lack opportunity, not ability.  On a sleep log, a pattern of both reduced sleep time with low total time in bed is visible, resulting in a high sleep efficiency.  Patient with insomnia lack ability, despite often spending excessive time in bed.  On a sleep log, look for a pattern of increased time in bed relative to total sleep time, resulting in a low sleep efficiency.
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5. Are there any contraindications for CBT-I?
Answer: The contraindications for CBT-I generally stem from the sleep deprivation aspect inherent in the sleep restriction technique.  These include epilepsy, bipolar disorders, and those at high risk for falls.  Sleep restriction can also exacerbate symptoms for those with untreated disorders of excessive sleepiness and with parasomnias.  Note that other aspects of CBT-I do not share those contraindications, such that the protocol could potentially be modified to exclude sleep restriction; in these instances, providers would still want to monitor patients closely and be mindful of sleep deprivation from any other source.
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6. Should patients stop taking sleep medication before starting the CBT-I protocol? 
Answer: Preferences for discontinuing sleep medication prior to CBT-I vary by provider.  In the absence of definitive guidance, some considerations follow for you to decide what works best for your practice.  Reasons cited for requiring patients to be off sleep medication include obtaining an accurate baseline sleep log, eliminating a possible ceiling effect of improvement from CBT-I (i.e., if medication is already improving sleep, additional benefits of CBT-I may not be as noticeable), and allowing for patients to attribute treatment gains to CBT-I instead of discounting them as from medication.  Alternatively, allowing patients to initiate CBT-I without discontinuing medication may increase referrals willing to engage.  If patients then discontinue medication during CBT-I, they can experience any rebound insomnia symptoms while receiving support and encouragement to maintain behavioral changes and, consequently, learn that periodic nights of worsened sleep can be managed with CBT-I strategies.  Whichever approach patients take, discontinuing sleep medication should only be done under the guidance of the prescribing provider.
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Sleep Log Challenges
7. Do I include napping in sleep log scoring?
Answer: While napping can be averaged across the week using sleep log data, napping is not included in time in bed (TIB) or total sleep time (TST) calculations.  This is because the goal of CBT-I is consolidation of sleep and re-associating sleep to the bed during the major sleep period, and napping occurs outside of the major sleep period.
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8. Do I include time out of bed when engaging in stimulus control during middle-of-the-night awakenings as part of the scored ‘TIB’ from the sleep log?
Answer: Although technically getting out of bed during the night is not “time spent in bed,” for the purposes of sleep titration, subject matter experts recommend it be included in TIB calculation.  Essentially, TIB serves as a measure of sleep opportunity, so while time spent out of bed during awakenings is clearly not in bed, it still represents a time during which the goal is to be sleeping; that is, time that is a missed sleep opportunity.  Thus, TIB is determined as the difference between the first time the patient got in bed and the last time the patient got out of bed.  If time allows, you can score the log with and without this time included in TIB to demonstrate the change in sleep efficiency with stimulus control.
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9. How do I handle a patient who refuses to complete a sleep log, or insists on using a device like a fitness tracker instead of completing a log?
Answer: Sleep logs are an integral part of CBT-I.  There are several versions to choose from, including several pen-and-paper versions and a phone app version inside CBT-I Coach.  At a bare minimum, the patient could even develop a log of their own, such as in Excel, on notecards, or in a calendar, as long as it includes the information needed to derive basic sleep parameters (total sleep time, sleep onset latency, etc.) and identify patterns.  Sometimes problem-solving or enhancing motivation can help.  Otherwise, without a sleep log, critical components of CBT-I cannot be implemented, and therefore CBT-I cannot be conducted.  Although fitness trackers provide interesting information, they do not provide the same information as the sleep log (including subjective perception of sleep estimates, other behaviors) and have identified concerns regarding validity/accuracy; as such, they do not replace the role of sleep log in CBTI.
Resources: Visual sleep log
CBTI Coach Smartphone App (iOS) (or CBTI Coach Smartphone App (Android)
VIDEO: ‘Using the CBTI Coach App’
CBTI Coach App blog
VIDEO: Stimulus Control
VIDEO: Sleep Restriction

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10. If a patient reports excessive caffeine, alcohol, or other substance use, should that be addressed before stimulus control and sleep restriction?
Answer: It depends.  If the substance use is the sole, direct cause of sleep problems, that could potentially be addressed right away.  However, by the time a patient meets criteria for Insomnia Disorder, there are multiple contributing factors such that continuing with the protocol as-is makes sense.  Additional considerations include the potential impact on rapport and willingness to then subsequently engage in stimulus control and sleep restriction.  For cases of Alcohol Use Disorder in particular, the consensus from the field is to not delay sleep treatment in favor of alcohol use treatment (e.g,. to provide concurrent, not sequential, treatment).
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11. Can a patient get in bed before our scheduled bedtime if they are sleepy earlier?
Answer: No.  Recall that ‘chasing sleep’ (otherwise known as sleep extension) contributed to the development of chronic insomnia in the first place, so getting in bed early would counteract the patient’s stimulus control and sleep restriction efforts.  Specifically, getting in bed too early decreases homeostatic sleep drive for later in the night and creates inconsistency in the sleep-wake rhythm.
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12. My patient could only come up with stimulating activities to do when out of the bed awake. How should I respond?
Answer: On one hand, the goal of engaging in relaxing activities when out of the bed awake allows the patient to notice sooner when feelings of sleepiness occur and may in fact increase the likelihood of feeling sleepy by minimizing hyperarousal.  On the other hand, the primary rationale for getting out of bed is to break the association between the bed and wakefulness, so any activity that the patient will actually get out of bed for arguably serves that purpose.  So while it is preferable for the patient to choose relaxing activities, and providers can help suggest these (either verbally or via handout), if a patient will only agree to a stimulating activity, the worst case scenario is that the patient will be unable to return to sleep that night and build homeostatic sleep pressure for the next night.
Resources: ‘Things to Do When You are Awake’ (Requires Provider Portal log-in)
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13. How do I respond when my patient has difficulty keeping the scheduled wake time consistently?
Answer: A consistent wake time is key to both building sleep drive and to setting the circadian rhythm.  Thus, it is important to help patients problem-solve any difficulty with this early on and to regularly monitor and reinforce this issue.  Strategies vary by individual patient preference but could include use of a different or multiple alarms, a ‘reward’ for getting out of bed, leaving a phone message for the provider, or even enlisting the aid of a significant other.  If a patient is repeatedly unwilling to maintain a consistent wake time, and is not improving, it is worth revisiting whether the timing is right for CBT-I.
Resources: VIDEO: ‘Behavioral Strategies for Adherence’
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14. My patient regularly awakens before our scheduled wake time in the mornings. Can we shift the sleep schedule to match that earlier time?
Answer: Yes, if a patient is regularly awakening early, this suggests an earlier wake time would make sense.  Patients can gradually shift back the recommended bedtime-waketime schedule in 15-minute increments.  For example, if the schedule is initially set at 0030-00630 but the patient wakes up regularly at 0545, the patient could successively move to 0015-0615, then 0000-0600, then 1145-0545, by shifting nightly across three nights.  Once the schedule is set and the patient engages consistently with maintained sleep efficiency, further sleep titration can proceed.
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15. How do I adjust my patient’s sleep schedule after setting it for the first time?
Answer: The main guide for adjusting the sleep schedule is sleep efficiency.  With that in mind, when sleep efficiency is 85-90% or higher, patients can increase time in bed by 15-30 minutes.  When sleep efficiency is 80-85%, the same sleep schedule should be maintained.  When sleep efficiency drops below 80%, patients should decrease time in bed by 15-30 minutes.  However, there are often cases where more specific guidelines might be helpful, such as in the first few weeks of sleep restriction when sleep efficiency may be so low it is still below 80% after improving.  For these reasons, consider giving the Sleep Need Questionnaire (SNQ) after setting the initial schedule; with the SNQ, combining score plus sleep efficiency allows for fine-tuned adjustments, such as knowing whether to increase by 15 or by 30 minutes.
Resources: ‘Sleep Need Questionnaire’ (Requires Provider Portal log-in)
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During the Protocol
16. My patient is midway through the CBT-I protocol, so why is sleep efficiency still low?
Sleep efficiency in CBT-I starts low, with the expectation of a gradual overall rise over time.  By definition, sleep efficiency reflects the amount of time spent in bed asleep compared to amount of time spent in bed awake.  Therefore, the fastest way to increase sleep efficiency is to simply cut out time in bed awake, which is in essence stimulus control.  This means if a patient’s sleep efficiency is still low, the patient is spending too much time in bed awake.  This may be due to noncompliance or to having been prescribed a too lengthy sleep schedule (for example, the time in bed may have been expanded prematurely).  In these cases, it is helpful to assess more closely whether the patient is following all recommendations and to consider reducing time in bed.
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17. What should I do if I suspect my patient is getting more sleep or having less fragmentation than the sleep log shows?
Answer: An aspect of insomnia for many patients is misinterpreting light sleep as wake, as well as overestimating time spent awake.  For most patients, this does not impact the CBT-I protocol, and providers should use the patient’s reported sleep log parameters as-is.  In some cases --  particularly cases where the patient’s report of sleep quantity or quality has not improved and the patient endorses adherence to recommendation --  it can be helpful to discuss this possibility with patients.  An additional measurement of sleep might be helpful, such as actigraphy.
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18. If CBT-I has significantly improved a patient’s sleep before Session 8, is it alright to discontinue the protocol early?
Answer: Yes, if the patient is improved and both patient and provider feel it is appropriate to discontinue treatment. Patients will likely need to continue adjusting the sleep schedule on their own which works well, since a goal of CBT-I is for patients to learn to manage their own sleep-related behavior.  Note that there are many different CBT-I protocols, with varying length and amount of sessions, ranging from as few as two to eight plus.
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Other
19. Do you have a manual to provide group CBT-I?
Answer: Yes!  Our manual has recently been updated and is available to providers who have attended any of CDP’s workshops on the provider portal.  Log in, and in the Members Area under the ‘Member Resources’ heading, select ‘Provider Resources & EBP Tools.’  Next, select the CBTI option.  The manual is located there along with a set of slides to accompany the first session.
Resources: ‘CDP Insomnia Group Manual’ (requires Provider Portal log-in)
‘Insomnia Group Session 1’ (requires Provider Portal log-in)
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20. My recently referred patient is considering or has already started an intervention for sleep that I have never heard about (e.g., neurofeedback).  What should I tell my patient to help him/her decide to pursue this treatment or try CBT-I?
Answer: CBT-I is highly effective, in general and with a variety of co-morbidities.  CBT-I is the gold standard of treatment for chronic insomnia, the first-line treatment endorsed by multiple medical associations, with decades of peer-reviewed research supporting the techniques.  There are very few contraindications to CBT-I, notably a history of seizures and possibly bipolar disorder.  In other words, the main reason not to use CBT-I is when someone doesn't have insomnia!  It makes sense to try the treatment that has the most evidence across the widest population first.  If a patient has already started another intervention, CBT-I may still be helpful afterwards, although it is not recommended concurrently.
Resources: AASM CPGs on CBTI as first line 
ACP position on CBTI as first line 
NIH recommendation
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