Guided digital cognitive-behavioral therapy for insomnia

OBJECTIVE: Insomnia is common in anxiety, posttraumatic stress disorder (PTSD), and borderline personality disorder (BPD), but cognitive-behavioral therapy for insomnia (CBT-I) is understudied in these conditions. We evaluated the (cost-)effectiveness of CBT-I in adults with insomnia and symptoms of anxiety, PTSD, or BPD.

METHOD: A total of 157 adults with insomnia and symptoms of anxiety, PTSD, or BPD were randomized to guided digital CBT-I or sleep diary control. Assessments at baseline, 2-month posttreatment, and 8-month follow-up included insomnia severity (Insomnia Severity Index), mental health symptoms, sleep diary measures, and positive health. Cost-effectiveness (Insomnia Severity Index-based) and cost-utility (quality-adjusted life years-based) were analyzed from a societal perspective.

RESULTS: At posttreatment, CBT-I produced large reductions in insomnia severity versus control (d = -1.04; p < .001) and small effects on symptoms of anxiety and BPD (ds = -0.28; -0.36) but not of PTSD. At follow-up, effects on insomnia severity remained large (d = -0.98; p < .001), but effects on anxiety and BPD were no longer significant. Most sleep diary measures showed small-to-moderate improvements; positive health changes were minimal. CBT-I did not significantly reduce societal costs (-€826, 95% CI [-3,797, 2,144]) but showed a 94% probability of cost-effectiveness at €450 per Insomnia Severity Index point and 71% at €20,000 per quality-adjusted life year.

CONCLUSIONS: CBT-I is a (cost-)effective treatment for insomnia with co-occurring anxiety, PTSD, or BPD symptoms, although effects on anxiety and BPD are small, and none were found for PTSD. These findings support integrating CBT-I into routine care, potentially alongside targeted interventions for co-occurring psychological distress. (PsycInfo Database Record (c) 2026 APA, all rights reserved).