CBT-I is the first-line treatment for chronic insomnia in every major guideline, and most people with insomnia are never offered it. That is not because it does not work. It is a supply problem, an awareness problem and a payment problem, and the sleep medicine field has described all three in its own words.
Three reasons it is hard to get
1. There are not enough specialists
In a 2024 report from an American Academy of Sleep Medicine stakeholder summit, the authors put it bluntly: "fewer than 350 board-certified behavioral sleep specialists cannot possibly care for the millions of adults with insomnia."
The problem is also geographic. A 2016 study that counted behavioral sleep medicine providers more broadly than board certification found 659 in the US. More than half were concentrated in twelve states, four states had none at all, and 105 of the 167 US cities with populations over 150,000 had none. That count is from 2016, so treat it as a snapshot rather than today's number.
If you live outside a major medical center, there may simply be no one nearby to see.
2. Many doctors do not know to offer it
Most people raise insomnia first with a primary care provider. In a survey of primary care providers in the Veterans Health Administration, only 10% reported a good understanding and use of CBT-I, and 43% did not know it was available in their own facility.
When a doctor does not know CBT-I exists locally, or has nowhere to refer you, the appointment ends with a prescription or sleep hygiene advice. That is not bad faith; it is the only option on the table. How to raise CBT-I with your doctor.
