Clinical Question

How effective is cognitive behavior therapy (CBT) for patients with chronic insomnia?

Bottom Line

A five-component approach to changing patients' beliefs and behaviors surrounding sleep is effective, at least in the short term, in getting persons to fall asleep and stay asleep, although total sleep time is not increased. The interventions are not difficult, and many are part of typical sleep hygiene practice. (Level of Evidence = 1a –)

Synopsis

Although medication is the primary treatment of chronic insomnia, CBT has been extensively studied as well. To determine its effectiveness, these researchers searched five databases, including the Cochrane Library, and identified 20 studies of 1,162 patients. The CBT used in these studies comprised at least three of five components (see below) and was compared with inactive treatments. Two investigators independently determined the eligibility of studies, extracted the data, and evaluated for risk of bias. There was no evidence of publication bias, although the study qualities were not high (because most studies were not or could not be masked). There was significant heterogeneity among some of the results, especially for outcomes for which there were limited data. Compared with inactive treatments, onset of sleep was 19 minutes earlier, on average, at the end of the treatment period. Minutes spent awake after first falling asleep were significantly fewer (by an average 26 minutes) at the end of treatment. However, overall sleep time did not increase significantly with treatment. Some, but not all, studies found a benefit that persisted after completion of therapy.

Components of CBT for insomnia:

1. Cognitive therapy: aimed at dysfunctional beliefs and attitudes toward sleep and insomnia

2. Stimulus control: avoiding nonsleep activities in the bedroom

3. Sleep restriction: limiting time in bed to match perceived sleep duration to assure that more than 85% of time spent in bed was spent sleeping

4. Sleep hygiene: typical measures of sleep scheduling and alcohol, caffeine, and nicotine intake

5. Relaxation techniques: meditation, mindfulness, and so forth

Study design: Meta-analysis (randomized controlled trials)

Funding source: Self-funded or unfunded

Setting: Various (meta-analysis)

Reference: TrauerJMQianMYDoyleJSRajaratnamSMCunningtonDCognitive behavioral therapy for chronic insomnia: a systematic review and meta-analysis. Ann Intern Med2015; 163( 3): 191– 204.