Digital CBT for insomnia

1. Introduction

Version followed: multicomponent CBT for insomnia (CBT-I) as described in the European Insomnia Guideline 2023, delivered digitally as in Sleepio (NICE HTG624, formerly MTG70, May 2022; content unchanged at the December 2025 migration) and its US prescription version SleepioRx; Somryst/SHUTi described for comparison. Status checked October 2026.

Digital CBT for insomnia (dCBT-I) is CBT-I, the guideline first-line treatment for chronic insomnia in adults, delivered through a website or app, either fully automated or with some human guidance. It is a delivery format, not a separate therapy: the components are the same as face-to-face CBT-I (see the Domain II CBT-I guide for the full face-to-face protocol). Its model of change: insomnia is kept going by learned arousal in bed, irregular sleep scheduling, time in bed that exceeds sleep ability, and worry or effortful attempts to sleep; behavioural components rebuild sleep pressure and the bed-sleep association, and cognitive components reduce sleep-related arousal and unhelpful beliefs. [source: Riemann et al. 2023, European Insomnia Guideline; NICE HTG624]

For the psychotherapist, two roles are possible: (a) recommending or supervising a digital programme alongside your own work ("care extension", homework support, post-discharge maintenance, as the SleepioRx clinician handout frames it), or (b) using the programme's structure within your own CBT-I. This guide covers the programme as published plus the clinician's support role. [source: APA SleepioRx clinician handout]

Regulatory and access status (as of October 2026):

England (NICE): "Sleepio is recommended as a cost saving option for treating insomnia and insomnia symptoms in primary care" for people who would otherwise be offered sleep hygiene advice or sleeping pills; people at higher risk of other sleep disorders (for example pregnancy or comorbidities) should have a medical assessment before referral; more research is recommended for people eligible for face-to-face CBT-I. Published 20 May 2022 as MTG70; migrated to HTG624 in December 2025 with recommendations unchanged. Access is via GP or social prescriber referral where commissioned, self-referral, or NHS Talking Therapies (formerly IAPT) services; NICE lists a per-person price for users who start session 1. As of October 2026 per NICE HTG624. NICE does not state a CE/UKCA class [uncertain: not verified].
USA (FDA): SleepioRx received FDA 510(k) clearance (reported 15 August 2024) as a prescription digital therapeutic for chronic insomnia/insomnia disorder, as an adjunct to usual care, for patients aged 18 and older, available on the order of a licensed healthcare provider. The consumer Sleepio product states it has not been FDA-cleared for the insomnia disorder indication. CMS created billing codes for FDA-cleared digital mental health treatment devices in the 2025 Medicare Physician Fee Schedule. As of October 2026 per Sleep Review (2024), Big Health clinician pages and the APA SleepioRx clinician handout.
Somryst (USA): a prescription digital therapeutic delivering CBT-I for adults aged 22 and older, originally from Pear Therapeutics. After Pear's 2023 Chapter 11 bankruptcy, Nox Health acquired Somryst (closed June 2023) and planned to offer it via employers, health plans and health systems. Current availability and pathway details as of October 2026 [uncertain: not verified]. [source: Sleep Review 2023]
SHUTi (Sleep Healthy Using the Internet): a fully automated, tailored web programme (University of Virginia origin; listed developer BeHealth Solutions), fee-based, for adults; the content basis for Somryst [uncertain: not verified]. [source: Beacon/ANU listing, last updated 2018]
Guideline position: ACP (2016) recommends CBT-I as initial treatment for chronic insomnia disorder in all adults (strong recommendation, moderate-quality evidence); AASM (2021) makes a strong recommendation for multicomponent CBT-I; the European Insomnia Guideline 2023 recommends CBT-I as first-line for adults of any age, in person or digitally (grade A), prefers guided over fully automated dCBT-I (automated programmes show high dropout), and counts only programmes with at least one pre-registered RCT as evidence-based. [source: Qaseem et al. 2016; AASM 2021; Riemann et al. 2023]

2. Framework

Typical course [source: NICE HTG624; Espie et al. 2012; Beacon SHUTi listing; Riemann et al. 2023]:

Face-to-face CBT-I reference point: usually 4–8 sessions, individual or group, delivered by trained professionals (mainly clinical psychologists), in person, by telehealth or digitally, with or without guidance.
Sleepio: an initial sleep test (questionnaire profile), six weekly interactive sessions led by a virtual therapist ("The Prof"), and a daily sleep diary; designed to be completed in about 6 weeks with 12 months of access. Extras include a library of articles and videos, a moderated online community, and (per NICE) a weekly Q&A facilitated by a clinical psychologist. Optional wearable linking. In the 2012 trial the intervention was six online sessions with an animated therapist and automated web and email support.
SleepioRx: a 90-day prescription programme of video and audio lessons in a mobile app, tailored to symptoms and daily sleep tracking, plus in-the-moment content for getting to sleep.
SHUTi: six sequential cores of about 45–60 minutes, over at least six weeks: (1) introduction and rationale; (2–3) sleep restriction and stimulus control; (4) cognitive restructuring; (5) sleep hygiene; (6) relapse prevention. Diary completion is required to unlock core 2; the system then sets a sleep window algorithmically.

Phases (as a clinician supporting a programme) [synthesis, built on the programme structures above]:

Assessment and suitability (before starting): confirm the insomnia picture, screen for other sleep disorders and for the conditions in which sleep restriction needs medical advice (Section 4, intervention 10). Move on when there are no red flags, or a medical/sleep review has cleared the person.
Baseline (week 1): daily diary only; no schedule changes. Move on when the programme has enough diary nights to calculate a schedule (programmes gate this automatically).
Active behavioural phase (roughly weeks 2–4): sleep restriction or compression plus stimulus control, with weekly schedule adjustment set by the programme from diary data. Expect a temporary rise in sleepiness and fatigue. Move on when sleep is consolidating and the person is managing the schedule safely.
Cognitive and consolidation phase (roughly weeks 4–6): cognitive techniques, relaxation, sleep hygiene review, progressive extension of time in bed.
Relapse prevention and maintenance: a plan for setbacks; booster sessions where gains fade (the European guideline notes boosters may be needed).

Criteria for escalation: no improvement after an adequately completed course, suspected other sleep disorder, large mismatch between perceived and likely sleep, or a safety-critical occupation: route to a medical review or sleep specialist (polysomnography is recommended by the European guideline when other sleep disorders are suspected and for treatment-resistant insomnia). If CBT-I alone has not worked, ACP recommends shared decision-making with the physician about adding short-term medication; this is the prescriber's decision. [source: Riemann et al. 2023; Qaseem et al. 2016]

3. Guiding principles

Digital is a format, not a lesser treatment: guidelines place CBT-I first-line in person or digitally. Practical meaning: offer dCBT-I as a real treatment, not a stopgap. [source: Riemann et al. 2023]
Guided beats unguided: human guidance reduces dropout. Practical meaning: schedule brief check-ins rather than "set and forget". [source: Riemann et al. 2023]
Use only evidence-based programmes: a programme "based on" CBT-I is not the same as one tested in a pre-registered RCT. Practical meaning: check the programme's trial record before recommending it. [source: Riemann et al. 2023]
Screen before restricting sleep: sleep restriction and stimulus control are contraindicated or need medical advice in some conditions. Practical meaning: no programme start without a suitability check. [source: Sleepio suitability page; Riemann et al. 2023; NICE HTG624]
Sleep hygiene alone is not the treatment: AASM suggests against sleep hygiene as a single therapy, and the European guideline warns it can work as a safety behaviour. Practical meaning: treat hygiene as context, never as the whole plan. [source: AASM 2021; Riemann et al. 2023]
The diary drives the treatment: schedules are computed from diary data. Practical meaning: protect diary completion above everything else. [source: Beacon SHUTi listing; NICE HTG624]
The programme sets the schedule, not the therapist improvising: in supported dCBT-I the sleep window comes from the programme's algorithm. Practical meaning: do not hand out your own time-in-bed numbers; if a schedule looks unsafe, pause and refer. [synthesis]
Expect a worse-before-better phase: early sleepiness and fatigue are common. Practical meaning: forewarn, normalise, and monitor safety. [source: Riemann et al. 2023]
Not a crisis service: the programme does not provide crisis support. Practical meaning: your service's risk pathway stays active throughout. [source: Sleepio suitability page]
Medicines stay with the prescriber: programme users should not change medication without their doctor. Practical meaning: route every medication question to the prescriber. [source: Sleepio suitability page; Qaseem et al. 2016]
Fit the format to the person: NICE notes digital access barriers (no internet or device, visual, hearing, cognitive or dexterity impairments, limited English). Practical meaning: assess digital access and offer face-to-face CBT-I where the format does not fit. [source: NICE HTG624]
Adults only for these products: Sleepio and SleepioRx are for ages 18+, Somryst 22+. Practical meaning: do not use them with adolescents; seek age-appropriate care. [source: Sleepio suitability page; APA handout; Sleep Review 2023]

4. Intervention inventory

Part A describes how digital programmes deliver each CBT-I component, at a descriptive level, so you can explain and support it. Part B lists the psychotherapist's own interventions around a programme. Schedules and sleep-window values are set by the programme or the treating clinician's protocol and are deliberately not given here. Example language is illustrative throughout.

Part A. CBT-I components as digital programmes deliver them

A1. Programme orientation and the virtual therapist

Purpose / when: at enrolment; sets the rationale and expectations so the person engages with demanding components.
Steps (as delivered): Sleepio opens with a sleep test that profiles the problem, then weekly sessions guided by a virtual sleep expert ("The Prof") that adapt to the person's diary and answers; content stays available in a library; a moderated community and (per NICE) a weekly psychologist-facilitated Q&A sit alongside. SleepioRx delivers video and audio lessons in an app over 90 days. SHUTi delivers six sequential cores, each unlocked in order. [source: NICE HTG624; Wikipedia, Sleepio; Espie et al. 2012; Big Health clinician page; Beacon SHUTi listing]
Clinician support: ask the person to do session 1 within the week, ideally with you briefly at the start if access is a barrier [synthesis].
Example language (illustrative): "This is a six-week course. Each week there's one session of about the length of a TV episode, and every morning a two-minute sleep diary. The diary is what makes the course work, because it uses your own data to set your plan."
Watch for: not starting session 1 (the main dropout point in automated programmes [uncertain: not verified]); expecting a quick fix (the Sleepio suitability page stresses it is not a "magic bullet"). Working: session 1 done, diary started.

A2. Sleep diary and sleep test

Purpose / when: throughout; baseline and the input for the weekly schedule. The European guideline treats interview, diaries and questionnaires as the core of insomnia evaluation. [source: Riemann et al. 2023]
Steps (as delivered): each morning the person records bedtime, time to fall asleep, night wakings, final waking and rise time, and ratings of sleep quality (SHUTi uses an 11-item diary). The programme calculates summary values such as sleep efficiency and uses them to set and adjust the sleep window. Diary completion gates progression in SHUTi. Sleepio and SleepioRx can also draw on connected trackers, but the European guideline discourages relying on consumer sleep trackers until validated. [source: Beacon SHUTi listing; NICE HTG624; Riemann et al. 2023]
Clinician support: review the diary summary together; teach "estimate, don't clock-watch" [synthesis].
Example language (illustrative): "Fill it in each morning from your best guess. Please don't check the clock in the night to get it exact, because that keeps your brain on alert."
Watch for: clock-watching, perfectionism, gaps that make the schedule unreliable, diary entries that suggest another sleep disorder (loud snoring, gasping, leg discomfort, acting out dreams, irresistible daytime sleep) [synthesis]. Working: near-daily entries; the person starts noticing patterns.

A3. Psychoeducation about sleep

Purpose / when: early; explains sleep drive, the body clock and conditioned arousal, so that restriction and stimulus control make sense. Psychoeducation is usually built into the other components. [source: Riemann et al. 2023]
Steps (as delivered): programme sessions explain how insomnia is maintained and why spending longer in bed backfires; SHUTi core 1 covers rationale. [source: Beacon SHUTi listing]
Clinician support: link the model to the person's own diary and history [synthesis].
Example language (illustrative): "Your sleep drive builds the longer you're awake. Lying in bed for hours spreads sleep thin and teaches your body that bed is a place for being awake."
Watch for: the person treating information as the treatment; health anxiety about lost sleep. Working: the person can explain the rationale in their own words.

A4. Sleep restriction / sleep compression

Purpose / when: the active behavioural core for most people with chronic insomnia; AASM suggests sleep restriction as a single component (conditional) and it is part of strongly recommended multicomponent CBT-I. [source: AASM 2021]
Steps (as delivered, descriptive only): the programme uses baseline diary data to set a fixed window of time in bed closer to the person's actual sleep, with a fixed rise time; it then reviews the diary weekly and extends (or adjusts) the window once sleep is consolidating, by criteria the protocol specifies. Protocols differ in the minimum window they allow. Sleep compression is the gentler variant that narrows time in bed gradually rather than at once [uncertain: not verified in programme documentation]. NICE describes sleep restriction (with the quarter-hour rule) as the challenging part of Sleepio. [source: Riemann et al. 2023; NICE HTG624; Beacon SHUTi listing]
Cautions as sources state: contraindicated in "any kind of epilepsy and conditions that might be aggravated by sleep loss" (European guideline). Sleepio advises consulting a doctor first for bipolar disorder, schizophrenia or other psychotic-spectrum disorders, epilepsy or seizures, untreated sleep apnoea or other sleep-related breathing disorder, high fall risk, or an unstable or degenerative condition that sleep restriction could worsen; to speak to a doctor first with narcolepsy, parasomnias or shift work; not to use sleep restriction where daytime sleepiness could endanger the person or others (examples given include professional drivers, air traffic controllers, heavy-machinery operators, assembly-line workers); to pull over and nap if drowsy at the wheel; to consult a doctor in or after pregnancy, where it sets a pregnancy-specific minimum window. Early weeks bring more sleepiness and fatigue and possibly attention and memory problems, irritability and headaches. [source: Sleepio suitability page; Riemann et al. 2023]
Clinician support: check suitability before the window is set (B1); forewarn about early sleepiness; agree a driving and safety plan; support the person to stick to the window the programme gives; never alter the numbers yourself [synthesis].
Example language (illustrative): "For a few weeks the programme will shorten the time you spend in bed so the sleep you get becomes deeper and more solid. Most people feel more tired at first. While that's happening, let's agree what you'll do if you feel drowsy before driving."
Watch for: excessive daytime sleepiness, near-misses while driving or at work, falls (especially at night), elevated or irritable mood and reduced need for sleep (possible hypomania in someone with bipolar risk [synthesis]), increased seizures, and secret extensions of time in bed that stall progress. Stop and route to the medical clinician if safety signs appear. Working: falling asleep faster, fewer and shorter wakings, window gradually extending.

A5. Stimulus control (including Sleepio's quarter-hour rule)

Purpose / when: to re-link bed with sleep by breaking learned associations with wakefulness; AASM suggests it as a single component (conditional). The European guideline describes it as a set of seven primary instructions. [source: AASM 2021; Riemann et al. 2023]
Steps (as delivered): the commonly taught instructions are to go to bed only when sleepy, use the bed only for sleep (and sex), leave the bed and do something quiet elsewhere when unable to sleep, return only when sleepy, keep a fixed rise time, and avoid daytime napping [uncertain: not verified]. Sleepio delivers the get-up element as the "quarter-hour rule" (named by NICE). Sleepio flags fall risk with this rule for people over 65, on sleep medication, or with physical limitations. [source: NICE HTG624; Sleepio suitability page]
Clinician support: plan in advance where the person will go, what low-light, low-stimulation activity they will do, and how they will move safely in the dark [synthesis].
Example language (illustrative): "If you've been lying awake for what feels like a while, get up and go to the chair you've set up with a dim lamp and a dull book. Come back when you feel sleepy. You don't need to time it."
Watch for: falls, clock-watching to judge the time limit, using the out-of-bed time for screens or work, pain or disability that make getting up hard (Sleepio notes some techniques may need modifying). Working: shorter awake periods in bed; bed starts to feel like a cue for sleep.

A6. Cognitive work

Purpose / when: after the behavioural components have begun; targets worry, racing thoughts, catastrophic beliefs about sleep loss and effort to sleep. The European guideline groups cognitive control, paradoxical intention, imagery training and cognitive restructuring as the "C" component. SleepioRx lists cognitive therapy; SHUTi core 4 is cognitive restructuring. [source: Riemann et al. 2023; APA SleepioRx handout; Beacon SHUTi listing]
Steps (as delivered, descriptive): identifying sleep-related thoughts; testing and re-evaluating beliefs about the consequences of poor sleep; setting aside an earlier time to process the day's concerns (cognitive control); dropping the effort to sleep (paradoxical intention); calming imagery. [source: Riemann et al. 2023]
Clinician support: this is where the therapist adds most value: link sleep beliefs to the person's wider formulation, and help with thoughts the programme's examples do not fit [synthesis].
Example language (illustrative): "What's the thought that shows up at 3 a.m.? ... And what has actually happened on the days after your worst nights?" "Try letting go of the job of falling asleep. Your only task is to rest."
Watch for: rumination that is part of depression or anxiety rather than sleep-specific (treat in therapy too); paradoxical intention misunderstood as staying awake on purpose for hours. Working: less pre-sleep arousal, less catastrophising about the next day.

A7. Relaxation

Purpose / when: for people with high physical or mental arousal at bedtime; AASM suggests relaxation therapy as a single component (conditional). Methods most used: abbreviated progressive muscle relaxation, autogenic training, imagery; none shown superior. Sleepio includes in-the-moment audio for getting to sleep (SleepioRx). [source: AASM 2021; Riemann et al. 2023; Big Health clinician page]
Steps (as delivered): guided audio practised daily at first outside bedtime, then used as part of the wind-down [synthesis on sequencing].
Clinician support: adapt for pain or limited mobility (Sleepio suggests alternatives to muscle tensing); rehearse in session.
Example language (illustrative): "Let's try the relaxation audio together now, so it's familiar before you use it at night."
Watch for: relaxation used as a new effort-to-sleep tool ("it didn't work, I'm still awake"); relaxation-induced anxiety or trauma-related discomfort with body focus [synthesis]. Working: easier wind-down.

A8. Sleep hygiene

Purpose / when: a supporting component only; AASM suggests against sleep hygiene as a single therapy, and the European guideline warns it may act as a safety behaviour. SHUTi core 5. [source: AASM 2021; Riemann et al. 2023; Beacon SHUTi listing]
Steps (as delivered): review caffeine, alcohol, nicotine, exercise timing, bedroom environment and evening light or screen use. [source: NICE HTG624 lists sleep hygiene advice; content specifics uncertain: not verified]
Example language (illustrative): "These habits help around the edges. The main work is still the schedule and getting up when you can't sleep."
Watch for: rigid rules that raise sleep anxiety; hygiene used instead of the core components. Working: fewer obvious disruptors without new rituals.

A9. Relapse prevention and boosters

Purpose / when: final session and after; SHUTi core 6 is relapse prevention; the European guideline notes booster sessions may be needed to refresh gains. Sleepio access continues for 12 months after registration. [source: Beacon SHUTi listing; Riemann et al. 2023; NICE HTG624]
Steps (as delivered): recognise that bad nights will recur; avoid the old responses (extra time in bed, napping, cancelling plans); return to the diary and core rules if a run of poor nights builds. [synthesis on detail]
Example language (illustrative): "A bad week after stress is normal. If it happens, go back to the diary for a week and the get-up rule, and don't sleep in to compensate."
Watch for: relapse around life events, illness, travel or mood episodes. Working: the person can describe their own plan.

Part B. The psychotherapist's interventions around a digital programme

B1. Suitability screening before starting

Purpose / when: before recommending or prescribing-on-referral any dCBT-I; NICE asks for a medical assessment before referral for people at higher risk of other sleep disorders, and Sleepio lists conditions needing a doctor's advice. [source: NICE HTG624; Sleepio suitability page]
Steps: (1) Confirm chronic insomnia complaint and its history. (2) Ask about the Sleepio-listed conditions: bipolar disorder, psychotic disorders, epilepsy or seizures, sleep apnoea or loud snoring with pauses or gasping, narcolepsy or irresistible daytime sleep, parasomnias, shift work, high fall risk, pregnancy or recent pregnancy, unstable or degenerative medical conditions, current sleep medication. (3) Ask about safety-critical driving or work. (4) Check age (18+ for Sleepio/SleepioRx, 22+ for Somryst). (5) Check digital access, literacy, language, sensory and dexterity needs (NICE). (6) If any flag: do not start sleep restriction components; route to the GP, prescriber or sleep service first (B2) and document. [source: Sleepio suitability page; NICE HTG624; Riemann et al. 2023; steps sequenced as synthesis]
Example language (illustrative): "Before we start, I need to check a few things, because one part of the course can make you sleepier for a while, and for some conditions that needs your doctor's okay first."
Watch for: under-reported snoring (ask a bed partner, with consent), hypomanic history not previously diagnosed, people minimising sleepiness at work. Working: a clear documented decision: start, start after medical clearance, or another route.

B2. Referral for medical review or to a sleep specialist

Purpose / when: when another sleep disorder is suspected, insomnia is treatment-resistant, the person works in a safety-critical role, or perceived and likely sleep differ greatly; the European guideline recommends polysomnography when other sleep disorders are suspected and for treatment-resistant insomnia, and suggests screening for obstructive sleep apnoea. CBT-I remains effective in comorbid insomnia and sleep apnoea once apnoea is assessed and managed. [source: Riemann et al. 2023]
Steps: (1) Summarise the concern with diary data. (2) Refer via the GP or the person's physician (or directly where your service allows) to a sleep clinic. (3) Agree whether the programme pauses, continues with only non-restrictive components, or proceeds, as the medical clinician advises. (4) Keep psychological work on sleep-related worry going meanwhile. [synthesis on steps]
Example language (illustrative): "What you've described, the gasping and feeling sleepy behind the wheel, is something a sleep doctor should look at. That doesn't stop us working on the worry about sleep in the meantime."
Watch for: the person feeling dismissed; delays in sleep services. Working: referral made, decision about the programme documented.

B3. Introducing the programme and supporting informed choice

Purpose / when: at the decision point; supports shared decision-making between face-to-face CBT-I, guided dCBT-I and other options. [source: Qaseem et al. 2016 on shared decision-making; Riemann et al. 2023 on guided versus automated formats]
Steps: explain what the programme involves (time commitment, daily diary, early sleepiness), that it is self-help with limited human contact, what data it collects (diary, questionnaires, optional wearable data), that it is not a crisis service, and the alternatives. Encourage the person to read the product's privacy policy and instructions for use; SleepioRx states users should read the instructions for use for full information. [source: APA SleepioRx handout; Sleepio suitability page; privacy content as synthesis]
Data privacy and security [synthesis]: discuss what is stored, who sees it (employer- or insurer-funded access may differ from NHS access), whether wearables share data, and what the person is comfortable with; check your own service's information-governance approval before routinely recommending a product.
Example language (illustrative): "You'd be doing most of this on your phone, on your own schedule. I'll check in with you every couple of weeks. It will ask for your sleep data each day, so it's worth reading how they store it before you sign up."
Watch for: pressure to use the cheapest option where the person needs in-person care; privacy concerns that later cause silent dropout. Working: an informed, owned choice.

B4. Guided support and adherence check-ins

Purpose / when: throughout; guided dCBT-I has better retention than fully automated, which shows dropout above half in some trials. [source: Riemann et al. 2023]
Steps: brief scheduled contacts (phone, video or within therapy sessions): (1) which session is done; (2) diary completion; (3) what was hard; (4) problem-solve one barrier; (5) reinforce the rationale; (6) review safety (sleepiness, driving). Use the SleepioRx framing of homework support when the person is also in therapy for something else. [source: APA SleepioRx handout; check-in content as synthesis]
Example language (illustrative): "You've done three sessions. That's the hardest stretch. What got in the way of the get-up rule this week?"
Watch for: stalled session completion, diary gaps, the person quietly lengthening time in bed. Discuss ambivalence about the programme openly, without pushing. Working: steady progression through sessions.

B5. Monitoring side effects and safety

Purpose / when: especially during the active behavioural weeks, when sleepiness, fatigue, reduced vigilance, attention and memory problems, irritability and headaches are reported. NICE reports very few adverse events and no serious adverse events related to Sleepio; in the UK, problems with medical devices can be reported to the MHRA through the Yellow Card scheme. [source: Riemann et al. 2023; NICE HTG624]
Steps: ask each contact about daytime sleepiness, driving, falls, mood change, and (for people with seizure history cleared to proceed) any change in seizures. If a safety sign appears, advise pausing restrictive components and contact the medical clinician the same day if urgent; document and, where relevant, report via the Yellow Card scheme or the product's reporting route. [synthesis on steps]
Example language (illustrative): "On a scale of how sleepy you've felt in the day, has anything worried you, like nodding off at the wheel or at work?"
Watch for: reduced need for sleep with high energy (possible mood switch [synthesis]), dangerous sleepiness, falls at night. Working: side effects tolerable and fading.

B6. Crisis and safety pathway

Purpose / when: throughout; Sleepio states it does not provide crisis support and directs users to emergency services (for example 999 or A&E in the UK, 911 or 988 in the US) for emergencies or suicidal thoughts. [source: Sleepio suitability page]
Steps: confirm that the person knows how to reach crisis help; keep your usual risk assessment going; where insomnia is part of depression, remember that worsening sleep can accompany worsening mood and needs a risk review rather than only programme troubleshooting. [synthesis on the last point]
Example language (illustrative): "The app can't respond if you're in crisis. If things get very dark, this is who you contact."
Watch for: the person disclosing distress in a community forum instead of to a clinician. Working: a known plan.

B7. Medicines conversations

Purpose / when: many users take hypnotics or other sedating medicines; Sleepio tells users not to change medication or treatment plans without their doctor; ACP leaves medication decisions after unsuccessful CBT-I to shared decision-making with the physician. [source: Sleepio suitability page; Qaseem et al. 2016]
Steps: ask what they take, note interaction with sleepiness and falls risk, and route every question about reducing, stopping or adding medicine to the prescriber. Never advise a change. [synthesis on steps]
Example language (illustrative): "Wanting to come off the sleeping tablets is worth raising with your GP, and they can plan it with you alongside the course."
Watch for: self-directed stopping during the programme. Working: prescriber involved.

B8. Integrating dCBT-I with psychotherapy

Purpose / when: when insomnia co-occurs with depression, anxiety, trauma or other problems you are treating; SleepioRx suggests care extension (programme for insomnia while you treat other conditions), homework support, and discharge support. NICE notes healthcare-professional involvement may benefit people with mental health conditions. [source: APA SleepioRx handout; NICE HTG624]
Steps: decide sequencing with the person (concurrent, before, or after other work) [synthesis]; use programme content as between-session homework; bring sleep-related cognitions into your formulation; for complex presentations or if the programme does not fit, deliver face-to-face CBT-I (see the Domain II CBT-I guide). [synthesis]
Example language (illustrative): "While we keep working on the panic, the app can take care of the sleep schedule, and we'll use part of each session to look at what came up."
Watch for: competing demands overloading the person; nightmares (trauma) needing their own treatment. Working: sleep and the main problem both improving.

B9. After the programme ends

Purpose / when: at completion, at discharge, and at follow-up; supports maintenance and relapse prevention. [source: APA SleepioRx handout (discharge support); Riemann et al. 2023 (boosters)]
Steps: review outcome with the person's diary data or a standard insomnia severity measure your service uses; agree a relapse plan (A9); arrange a follow-up check; if insufficient benefit, consider guided or face-to-face CBT-I, medical review, or sleep-specialist referral (B2). [synthesis on steps]
Example language (illustrative): "Let's look at where you started and where you are now, and write down what you'll do if sleep slips again."
Watch for: partial responders who drop the techniques once sleep improves. Working: maintained gains at follow-up.

5. Handling problems

The sources reviewed give little problem-specific guidance for digital delivery beyond dropout rates, side effects and suitability cautions; most responses below are [synthesis] unless tagged.

Never starts / drops out early: fully automated programmes lose over half of users in some trials and guidance improves retention [source: Riemann et al. 2023]. Response: book a short check-in for the end of week 1; offer to open session 1 together; shrink the ask to "diary only this week". If digital self-help does not suit the person, switch to guided or face-to-face CBT-I. [synthesis]
Won't keep the diary: explain that without it the programme cannot set a safe or useful schedule; simplify to best-guess estimates; link the diary prompt to an existing morning habit. [synthesis]
Refuses or cannot tolerate sleep restriction: validate the fear of tiredness; revisit the rationale with their own diary; discuss with the person whether a gentler compression approach or face-to-face CBT-I with a clinician who can tailor the schedule would suit them better; never set or alter numbers yourself. [synthesis]
Secretly extends time in bed or naps: raise it non-judgementally ("the diary shows ..."); explore what makes the evening or morning hardest; problem-solve a substitute activity for the sleepy evening slot. [synthesis]
Overwhelming daytime sleepiness or a near-miss while driving: this is a safety issue, not resistance. Advise pausing restrictive components, no driving while drowsy (Sleepio: pull over and nap until sleepiness subsides), and contact the medical clinician. [source: Sleepio suitability page; Riemann et al. 2023; response sequence as synthesis]
Mood elevation, reduced need for sleep, or psychotic symptoms during the course: stop restrictive components and contact the psychiatric team or GP urgently; bipolar disorder and psychotic disorders are listed by Sleepio as needing medical advice before starting, and the European guideline urges caution in severe acute mental disorders. [source: Sleepio suitability page; Riemann et al. 2023]
Seizure history surfaces mid-course: the European guideline lists epilepsy as a contraindication to sleep restriction and stimulus control; pause those components and route to the treating physician. [source: Riemann et al. 2023]
Suspected sleep apnoea, narcolepsy or parasomnia: pause behavioural components and refer (B2). [source: Sleepio suitability page; Riemann et al. 2023]
Shift workers: Sleepio advises speaking to a doctor first; standard fixed-schedule rules may not fit rotating shifts, so consider sleep-specialist input. [source: Sleepio suitability page; second clause synthesis]
Falls risk with getting out of bed: older adults, people on sleep medication or with physical limitations: medical advice first (Sleepio); in-session planning of a safe, lit route and an alternative to leaving the bed where appropriate. [source: Sleepio suitability page; planning as synthesis]
"I did everything and it didn't work": check actual adherence from the diary; check for an unrecognised other sleep disorder or a large perception mismatch (refer for polysomnography as the European guideline describes); discuss options with the physician, including ACP's shared decision-making about medication, which is the prescriber's call. [source: Riemann et al. 2023; Qaseem et al. 2016]
Sleep effort and perfectionism (the programme becomes another performance): use cognitive work on effort and control; loosen rules that have become rituals (the European guideline's warning that sleep hygiene can become a safety behaviour). [source: Riemann et al. 2023; response as synthesis]
Rupture: the person feels "fobbed off with an app": acknowledge it; make clear you remain involved; offer face-to-face CBT-I if available. NICE's research recommendation for people eligible for face-to-face CBT-I signals the digital route is not a substitute for everyone. [source: NICE HTG624; response as synthesis]
Privacy worries or employer-funded access: discuss what data are shared and with whom; offer an alternative route if the person is uneasy. [synthesis]
Access barriers (no device, visual, hearing, cognitive or dexterity impairment, limited English): NICE flags these; offer assisted use, a carer's help, or face-to-face CBT-I. [source: NICE HTG624]
Adolescents: Sleepio and SleepioRx are for adults (18+), Somryst for 22+; use age-appropriate assessment and care. [source: Sleepio suitability page; APA handout; Sleep Review 2023]
Product no longer available: product status changes (for example Somryst's transfer from Pear to Nox Health after Pear's bankruptcy). Re-check availability before recommending, and have a fallback (face-to-face or another evidence-based programme). [source: Sleep Review 2023; fallback as synthesis]

Sources

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