Try Cognitive Behavioral Therapy for Insomnia First

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Although there is reason for optimism about some of the newer medications for insomnia (orexin antagonists) that are coming to market, it remains true that sleeping medications are not the right answer for many people with insomnia. Cognitive behavioral therapy for insomnia (CBTi) has several advantages as an initial treatment.

Cognitive Behavioral Therapy for Insomnia First

We have been writing about the value of cognitive behavioral therapy for insomnia CBTi for several years because of the evidence that it is at least as effective as sleep medications, has fewer adverse effects and more durable outcomes (therapy lasts after you stop it, medications don’t). And the experts seem to agree with us.

Results from a New Study

A study published in 2020 suggests that there is another reason for focusing on CBTi as the first line treatment for insomnia.

Patients with insomnia were randomized to receive treatment initially with either behavior therapy for insomnia or a sleep medication (see picture below for the design of the study and results).

There was a tendency for those who were randomized to receive behavior therapy initially to have a more robust response, with fewer adverse effects, but the difference was not great and probably not clinically relevant.

Taking a Sleeping Medication First Leads to Worse Long Term Outcomes

What really distinguished the outcomes between the two groups was how the patients who failed the initial treatment (either medication or therapy) did when they were switched to an alternative treatment.

There was a robust response in the group who had failed behavior therapy and were switched to either a sleep medication or cognitive therapy.

But those who initially received sleep medications and did not respond had almost no response to behavior therapy or an alternative sleep medication (trazodone).

Therapy first patients and medication first patients equivalent initially but therapy first patients overall much better response.
Therapy First patients did better because those who did not respond had options whereas medication first patients did not respond to therapy (or a different medication).

The chart below shows the details of response after the first round treatment and response, in those who did not improve significantly with the first round treatment, to the second round.

Avoiding Sedating Medications for Anxiety and Insomnia

This was similar to our experience with a medication that was introduced many years ago as an alternative treatment to benzodiazepines for patients with generalized anxiety: buspirone or BuSpar.

The medication worked roughly as well for people with generalized anxiety as sedating medications such as Ativan.

However, anyone who had first received treatment with a sedating anti-anxiety medication did much less well when treated with buspirone.

In other words, medications such as benzodiazepines should be reserved for people who have failed to respond other treatments for anxiety or insomnia.


Morin CM, Edinger JD, Beaulieu-Bonneau S, et al. Effectiveness of Sequential Psychological and Medication Therapies for Insomnia Disorder: A Randomized Clinical Trial. JAMA Psychiatry. Published online July 08, 2020. doi:10.1001/jamapsychiatry.2020.1767

For more information

New Insomnia Guidelines