OBJECTIVES: Insomnia is a prevalent and costly condition in the United States, responsible for over USD$100 billion in annual spending. Recent guideline changes have established cognitive behavioral therapy for insomnia (CBT-I) as first-line treatment for insomnia. Despite this, the most prevalent treatment for insomnia remains benzodiazepine-receptor agonists referred to as “z-drugs.” The objective of this study was to compare the cost-effectiveness of CBT-I, z-drugs, and no treatment to inform payers, policymakers, providers and others about the value provided by these treatments.

METHODS: A Markov model of elderly insomnia patients receiving treatment with CBT-I, Z-drugs, or no treatment (NT) was developed. Parameter values were derived from established literature. An incremental cost-effectiveness ratio (ICER) evaluated at a willingness-to-pay threshold of USD$100,000 per QALY. Costs were from the U.S. healthcare sector perspective. A time horizon of 15 years with a cycle length of 6 weeks was chosen to reflect a typical CBT-I treatment cycle. One-way and probabilistic sensitivity analyses were conducted.

RESULTS: CBT-I resulted in larger incremental costs (CBT-I vs. Z-drugs: $2,666; CBT-I vs. NT: $2,987) and QALY gains (CBT-I vs. Z-drugs: 0.22; CBT-I vs. NT: 0.12) in our base case scenario. The ICER (INMB) was estimated to be $22,333/QALY ($9,270) for CBT-I vs. Z-drugs and $13,651/QALY ($18,282) for CBT-I vs. NT. Results were robust to probabilistic sensitivity analyses, confirming that CBT-I is the most cost-effective option as thresholds surpass $25,000/QALY.

CONCLUSIONS: CBT-I is a cost-effective treatment option for insomnia but remains underutilized in the elderly population. Policy makers may consider investments in CBT-I provider training to improve availability and uptake among elderly patients in the United States.