When to Refer for CBT-I: A Guide for Primary Care and Sleep Medicine Clinicians
Last reviewed: 10/20/2026
Reviewed by: Dr. Kiesa Kelly
Chronic insomnia shows up in almost every clinic, often as a side note at the end of a visit about something else. The guidelines are clear about what comes first. What is less clear, in a busy practice, is which patients to refer for CBT-I, what has to be checked before they go, and what you should expect to hear back.
This guide is written for primary care clinicians, sleep medicine physicians, and the nurse practitioners and physician assistants who work alongside them. It focuses on the referral decision itself. If you are ready to refer now, our referral page for clinicians has the practical steps.
In this article, you'll learn:
Why a CBT-I referral is the first-line treatment decision, not a fallback
Which insomnia presentations to refer, including with a hypnotic, sleep apnea or a psychiatric condition
What to screen for before referral, and what to flag
What to send, and what you get back
How CBT-I fits alongside a hypnotic taper you are leading
The short version: Refer adults with chronic insomnia for CBT-I as the first treatment, whether or not they take a sleep medication and whether or not depression, anxiety, pain or PTSD come with it. In our clinical judgment, suspected sleep apnea or another sleep disorder is evaluated first or alongside. ScienceWorks delivers CBT-I by secure telehealth and in person in Nashville, and shares progress with you once your patient signs a release.
The short answer: guidelines put CBT-I first, so the referral is the treatment decision
The American College of Physicians recommends that all adults with chronic insomnia disorder receive CBT-I as the initial treatment, a strong recommendation based on moderate-quality evidence, and it wrote that guideline for all clinicians [1]. The American Academy of Sleep Medicine makes a strong recommendation for multicomponent CBT-I [2]. The 2023 European Insomnia Guideline calls CBT-I the first-line treatment for chronic insomnia in adults of any age, including patients with comorbidities, delivered in person or digitally [3].
So for most patients with chronic insomnia, the referral is not what you do after something else fails. It is the treatment decision.
Three misconceptions tend to delay that referral.
Misconception 1: "Start with sleep hygiene, and refer if that doesn't work." The AASM suggests clinicians not use sleep hygiene as a single-component therapy for chronic insomnia [2]. A 2024 component network meta-analysis of 241 trials found sleep hygiene education was not an essential component, while sleep restriction and stimulus control were among the components associated with remission [4]. A handout is a reasonable thing to give while the referral is arranged. It is not a substitute.
Misconception 2: "Treat the depression, pain or PTSD first, and the sleep will follow." CBT-I was studied, and is recommended, for patients with and without comorbid conditions [2,3]. In a meta-analysis of 37 randomized trials in people with insomnia alongside psychiatric or medical conditions, 36.0% of those who received CBT-I were in remission from insomnia after treatment, compared with 16.9% in comparison conditions [5]. Insomnia that travels with another condition is still insomnia, and it can be treated alongside. If you have not already measured mood or anxiety, the PHQ-9 depression screener and the GAD-7 anxiety screener are validated brief measures that give you and the CBT-I clinician a shared starting point [6,7].
Misconception 3: "A patient on a hypnotic isn't a candidate until they're off it." The AASM's 2026 guideline suggests CBT-I plus medication over medication alone when treatment starts, and its authors extend that reasoning to adding CBT-I to an existing medication [8]. In our clinical experience, CBT-I often makes a later taper easier to attempt, and the taper stays with you.
🛏️ Key takeaway: CBT-I is the guideline-recommended first treatment for chronic insomnia, including in patients who take a hypnotic or have a psychiatric or medical condition. The referral is the treatment decision.
Which patients to refer
Chronic insomnia disorder, with or without hypnotic use
The core group is adults with chronic insomnia disorder, whatever they have already tried. That includes patients who have taken a prescription sleep aid for years. ACP recommends CBT-I as the initial treatment for all adults with chronic insomnia disorder [1]. The AASM's 2026 combination-treatment guideline studied starting CBT-I and medication together. It notes that it did not directly address adding CBT-I to an existing medication, although its authors write that the findings may be extrapolated to that situation [8].
Picture a 61-year-old patient who has taken a nightly hypnotic for six years. She asks for a refill and, almost as an afterthought, says she would like to need it less. She falls asleep fine on the medication but wakes at 3 a.m. most nights and lies awake. She has no snoring history, no daytime sleepiness beyond feeling unrefreshed, and no psychiatric history. This is a straightforward CBT-I referral. You keep prescribing as you judge best, and if she later wants to reduce the dose, the taper plan is yours, with CBT-I alongside it.
Insomnia alongside sleep apnea
Insomnia and obstructive sleep apnea commonly co-occur [9]. In a randomized trial of 145 adults with moderate-to-severe obstructive sleep apnea and comorbid insomnia, four sessions of CBT-I before starting CPAP led to 61 more minutes of average nightly CPAP use and greater improvement in insomnia severity, though sleep outcomes and daytime impairment did not differ between groups at six months [9]. The authors concluded that patients with sleep apnea should be evaluated for co-occurring insomnia and considered for CBT-I before starting CPAP [9].
CBT-I does not treat the apnea. It works alongside sleep medicine care. Patients often ask whether they can do CBT-I while already using CPAP, and our post on CBT-I after a sleep study answers that from the patient's side.
Insomnia with depression, anxiety, chronic pain or PTSD
In our clinical experience, these patients are often held back from referral, although the evidence supports treating their insomnia directly. The meta-analysis above found small to medium improvements in the comorbid conditions too, larger for psychiatric than for medical conditions [5].
Consider a 38-year-old veteran with PTSD who is in trauma-focused therapy and whose nightmares are slowly easing. His sleep onset has not improved. He lies awake for an hour or more most nights, watching the clock, and has started napping in the afternoon. His trauma therapist and you both assumed the insomnia would resolve as the PTSD did. A year later it has not. In our clinical experience, a patient like this is a good CBT-I candidate, coordinated with his trauma therapist rather than delayed until trauma therapy ends. A PCL-5 score, from a widely used self-report measure of PTSD symptoms [10], in the referral lets everyone track the PTSD side while the Insomnia Severity Index tracks sleep.
🔗 Key takeaway: Refer insomnia that comes with apnea, depression, anxiety, pain or PTSD. CBT-I runs alongside treatment for the other condition rather than waiting for it to finish.
Screen first: what to rule out or treat before referral
In our clinical judgment, most patients need no special workup before referral beyond what you already know about them. A few findings change the order of care or how CBT-I is delivered. The AASM notes that the main undesirable effects of CBT-I, such as daytime fatigue and sleepiness, are largely limited to the early stages and typically resolve by the end of treatment, and that sleep restriction may be contraindicated in some groups [2].
Signs of a breathing-related or other sleep disorder: in our clinical judgment, evaluate first or alongside; polysomnography when another sleep disorder is suspected [3].
History of, or predisposition to, mania or hypomania: flag it in the referral; sleep restriction may be contraindicated [2].
Poorly controlled seizure disorder: flag it in the referral; sleep restriction may be contraindicated [2].
Driving or heavy-machinery work: flag it in the referral; sleep restriction may be contraindicated [2].
Active suicidal thoughts or acute crisis: address safety first (988 or 911); in our clinical judgment, CBT-I follows stabilization.
Insomnia that has not responded to treatment: consider polysomnography to look for another sleep disorder [3].
The patient-facing version of this, including the red flags that change a patient's first stop, lives in our guide to what kind of doctor treats insomnia. It is also a good article to share with your patient.
⚠️ Key takeaway: In our clinical judgment, suspected sleep apnea or another sleep disorder is evaluated first or alongside. Flag mania risk, poorly controlled seizures and safety-sensitive jobs, because they change how sleep restriction is used.
What to send with the referral
A short, specific referral saves the most time. In our practice, these are the items that change what happens in the first session:
The reason for referral and how long the insomnia has lasted
Any sleep study result, in-lab or home, with the diagnosis and current treatment
The current medication list, including any hypnotic or sedating medication, the dose and who prescribes it
Relevant history: bipolar disorder, any seizure disorder (especially if poorly controlled), substance use, and any safety-sensitive occupation
Any measurement you already have: a sleep diary, an Insomnia Severity Index score, a PHQ-9 or GAD-7
Send nothing by email or web form. Once your patient signs a release, we arrange a secure exchange.
What your patient will do in CBT-I
CBT-I is a structured, time-limited treatment. Your patient keeps a daily sleep diary, often in a standardized format such as the Consensus Sleep Diary [11]. Over the following weeks, they work on stimulus control, which re-links the bed with sleep; sleep restriction, which sets a temporary sleep window from diary data and widens it as sleep consolidates; and cognitive work on the beliefs and worry that keep sleep effortful [4]. Our overview of how CBT-I works and who it helps is written for patients and is a good primer to share.
Our clinicians deliver CBT-I by secure telehealth and in person at our Nashville office. In a randomized noninferiority trial of 65 adults, CBT-I delivered by telemedicine was not inferior to face-to-face delivery on insomnia severity [12]. The 2023 European guideline recommends CBT-I delivered in person or through digital programs [3]; the telemedicine trial is what speaks to video sessions.
What you get back, and when
The most useful thing you can get back is a repeated, standardized measure, not a general impression. The Insomnia Severity Index (ISI) is a seven-item questionnaire with excellent internal consistency. In one validation study, a score of 10 best identified insomnia cases in a community sample, and a drop of about 8 points was associated with moderate improvement as rated by an independent assessor [13].
With your patient's written permission, we share:
At intake: the ISI score, a summary of the sleep pattern from the diary, and anything that changes the plan, such as a finding that suggests another sleep disorder
During and at the end of treatment: the ISI trend, diary trends, and any recommendation that concerns you, such as a patient ready to discuss a dose reduction with you
If anything suggests a sleep disorder that CBT-I does not treat, we tell you and recommend a sleep medicine evaluation.
📈 Key takeaway: Ask for ISI scores at intake and across treatment. A drop of about 8 points tracked moderate improvement in validation research, which gives you something concrete to act on.
When your patient is tapering a hypnotic
If your patient wants to come off a sleep medication, the taper is your decision, and CBT-I supports it. We do not prescribe, change doses or set taper schedules. What CBT-I adds is a way to rebuild the sleep pattern while the dose comes down, and a measured record of how sleep is holding up. Our post on coming off sleep medication with CBT-I support explains to patients how the two fit together, and is a good one to share.
Questions to ask any CBT-I provider before you refer
Whether you refer to us or elsewhere, these questions help you judge the fit:
Training: Is the clinician trained in CBT-I or behavioral sleep medicine?
Content: Is it full multicomponent CBT-I, including sleep restriction and stimulus control, rather than sleep hygiene advice?
Measurement: How is progress measured, and what will you share with me?
Coordination: How do you work with me on a hypnotic taper or with a sleep physician on apnea treatment?
Safety: How do you adjust sleep restriction for patients with mania risk, seizures or safety-sensitive jobs?
A simple way to decide
If an adult has chronic insomnia and nothing on the screen-first list applies, refer for CBT-I now. If they take a hypnotic, refer anyway and keep the medication decisions with you. If there are signs of sleep apnea or another sleep disorder, start or continue the sleep medicine workup and refer for CBT-I alongside it. If mania risk, a seizure disorder or a safety-sensitive job is in the picture, refer and flag it. If the patient is in crisis, address safety first.
🧭 Key takeaway: For most adults with chronic insomnia, the answer is to refer now. The screen-first list changes the order or the method, rarely the decision.
Conclusion
The guidelines have settled the first-line question. What remains for the referring clinician is a short screen, a specific referral and a way to measure progress. Refer the patient with chronic insomnia, flag what changes how sleep restriction is used, keep the medication decisions where they belong, and ask for numbers back.
Your patient can book a free phone consultation (or text 931-223-1095) and mention you. No referral or prior authorization is needed. Please don't send health information by email or web form; once your patient signs a release, we arrange a secure exchange.
Frequently Asked Questions
What should I include when I refer a patient for CBT-I?
Include the reason for referral, any sleep study result, the current medication list with any hypnotic or sedating medication and who prescribes it, and anything that changes how sleep restriction is used, such as a history of mania, a seizure disorder (especially if poorly controlled) or a safety-sensitive job. A sleep diary or an Insomnia Severity Index score helps if you have one. Send health information only through a secure channel after your patient signs a release.
How will I know whether CBT-I is helping my patient?
Ask for a repeated, standardized measure rather than a general impression. The Insomnia Severity Index is a short questionnaire that is sensitive to treatment change: in one validation study, a drop of about 8 points matched moderate improvement rated by an independent assessor. With your patient's permission, we share scores from intake and from across treatment, along with diary trends.
Should insomnia medication be started at the same time as CBT-I?
Usually not as a default. A 2026 American Academy of Sleep Medicine guideline suggests CBT-I plus medication over medication alone, but suggests against starting both together over CBT-I alone. Both are conditional recommendations based on low-certainty evidence, and patients who most value faster early gains in sleep time may reasonably choose the combination. The prescribing decision stays with you; we do not prescribe.
About the Author
Dr. Kiesa Kelly is a clinical psychologist and the founder of ScienceWorks Behavioral Healthcare, with more than 20 years of experience in psychological assessment and evidence-based treatment. Her graduate cognitive-behavioral therapy practicum was completed at The Chicago Medical School Anxiety Disorders Clinic, and she also completed adult individual psychotherapy training at the University of Wisconsin-Madison Psychiatric Institute and Clinics.
Dr. Kelly earned her PhD in clinical psychology, with a concentration in neuropsychology, from Rosalind Franklin University of Medicine and Science. She completed practica, internship and an NIH-funded postdoctoral fellowship at the University of Chicago, the University of Wisconsin, the University of Florida and Vanderbilt University. She is a psychologist, not a physician, and does not prescribe medication.
References
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Disclaimer
This article is for informational and educational purposes only. It is not a substitute for professional clinical judgment and does not create a clinician-patient relationship. ScienceWorks does not prescribe medication; medication and taper decisions stay with the prescribing clinician. ScienceWorks is not an emergency service. If a patient is in crisis or at risk of harming themselves, call or text 988, or call 911 in an emergency.