The Role of Acceptance and Commitment Therapy in Insomnia Treatment

This discussion follows an updated meta-analysis by Barroso and colleagues, which pooled randomized controlled trials examining the efficacy of ACT for insomnia. Meta-analyses are considered high-quality evidence as they consolidate data from multiple independent trials, providing a clearer picture of the treatment's effectiveness. The significance of this publication is noted because prior ACT studies exhibited mixed results, with some demonstrating substantial benefits and others showing negligible effects.

Understanding CBT-I's structure helps clarify this debate. CBT-I is a multi-faceted approach, centering on stimulus control and sleep restriction therapy, which aim to re-associate sleep with the bed and consolidate sleep time. Other components include cognitive restructuring, relaxation training, and sleep hygiene education. Research, including a 2019 meta-analysis by van der Zweerde and colleagues, indicates that these strategies produce lasting results, making CBT-I the recommended first-line treatment for chronic insomnia by the American College of Physicians and the European Sleep Research Society.

Conversely, ACT addresses the psychological aspects of insomnia differently. It encourages patients to accept anxious thoughts about sleep instead of attempting to suppress them, aiming to reduce the hyperarousal that exacerbates sleeplessness. This mechanism raises questions about ACT's effectiveness compared to traditional CBT-I approaches.

Ballesio's letter supports the integration of ACT within CBT-I rather than suggesting it should replace existing methods. A randomized controlled pilot trial by Hertenstein and colleagues in 2024 found that combining ACT with sleep-scheduling components was feasible and indicated potential benefits on sleep and psychological measures.

The relevance of this integration is underscored by the fact that insomnia often coexists with various psychiatric and medical conditions. Meta-analyses, including a 2015 study in JAMA Internal Medicine by Wu and colleagues, reveal that CBT-I can improve sleep for individuals with such comorbidities. Recent findings indicate that CBT-I can also yield long-term improvements in depressive symptoms, emphasizing the broader mental health benefits of addressing insomnia.

A biological perspective is also vital in considering ACT's role. A 2023 meta-analysis by He and colleagues explored CBT-I in patients with a short sleep duration phenotype often associated with heightened physiological arousal. Acceptance-based strategies, targeting broader arousal factors rather than merely sleep-related beliefs, may be particularly beneficial for this group.

Practical considerations around treatment accessibility further complicate the conversation. A 2025 commentary in the journal Sleep argues for the delivery of CBT-I by a diverse range of healthcare providers, due to a significant disparity between patient demand and available therapists. This modular model allows for acceptance strategies to be integrated into established protocols, potentially expanding treatment access through various delivery formats.

However, the evidence for ACT as a standalone treatment remains inconclusive. Ballesio acknowledges that the updated meta-analysis reflects a tempered enthusiasm for ACT, and there remains a scarcity of comparative trials directly evaluating ACT against standard CBT-I protocols. The main takeaway from the letter is the call for precision in research—the focus should shift from questioning whether ACT is effective to understanding for whom it works best and in combination with what elements.

For patients, the essential takeaway is that while the conversation around ACT is evolving, CBT-I continues to be the foremost evidence-based treatment for insomnia, offering longer-lasting effects compared to many pharmacological options without the risks of dependency. This letter urges a framework that maintains effective behavioral techniques while allowing for flexibility, integrating ACT when appropriate to enhance treatment outcomes. As the field advances toward larger comparative trials and personalized treatment strategies, discussions surrounding ACT aim to refine, rather than challenge, existing insomnia care protocols.