Discover the most effective components of cognitive behavioral therapy for chronic insomnia, enhancing treatment outcomes and patient care strategies.
Rajesh R. Tampi, MD, MS, DFAPA, DFAAGP, Column Editor
A monthly column dedicated to reviewing the literature and sharing clinical implications.
Chronic insomnia is common and can impair mood, cognition, and quality of life. Although cognitive behavior therapy for insomnia (CBT-I) is the recommended first-line treatment, it is delivered in various formats and includes multiple components. It remains poorly understood which elements of CBT-I are most important. This study aimed to better characterize which CBT-I components are most essential to positive outcomes.
1. Furukawa Y, Sakata M, Yamamoto R, et al.
Funded by the Japan Agency for Medical Research and Development and the Japan Society for the Promotion of Science.
To determine which components and delivery methods of CBT-I are most effective for chronic insomnia by comparing complete CBT-I packages and individual treatment elements using network meta-analysis and component network meta-analysis.
This study was a systematic review and component network meta-analysis (cNMA) of randomized controlled trials (RCTs) that evaluated different parts and formats of CBT-I in adults with chronic insomnia.
Investigators searched PubMed, PsycINFO, the Cochrane Central Register of Controlled Trials, and the World Health Organization clinical trials registry. The first search was performed in May 2022 and updated in July 2023. There were no limits on language, publication date, or publication status, although studies had to include enough detail in English to be evaluated.
1. The study addressed a clinically relevant and underresearched question in determining which specific components of CBT-I lead to positive outcomes.
2. The study included a well-designed component-network meta-analysis with a large sample size and sufficient power to detect statistical differences.
3. The study clearly defined the analyzed components of CBT-I with excellent interrater agreement and drew clinically meaningful conclusions.
1. Components were measured as existing or not existing and could not fully account for overlap.
2. Analysis assumed that the components of CBT-I work independently from one another.
3. Limited trials were available for specific components.
To be included, studies had to involve adults (18+ years) with chronic insomnia. Individuals with medical or psychiatric comorbidities were not excluded. CBT-I was broadly defined to include at least 1 core component, such as sleep restriction, cognitive restructuring, stimulus control, sleep hygiene, relaxation, mindfulness, or paradoxical intention. Trials delivered in different ways, such as in-person, virtual, individual, and group, were included. Study authors also included trials where other therapies (such as medications) were used, if they were equally distributed between groups. Control groups could include wait-lists, sleep hygiene education, placebo, or usual care.
Pairs of reviewers independently screened studies, extracted data, and rated risk of bias. Any disagreements were resolved by discussion or a third reviewer. Interrater reliability was assessed using statistical measures such as Cohen κ and intraclass correlation.
The main outcome was remission after treatment, based on validated self-report scales. If a study did not report remission rates, the authors estimated them using a validated method based on symptom scores. Secondary outcomes included dropout rates and sleep-related measures (eg, sleep efficiency, total sleep time, and sleep latency).
The authors used network meta-analysis to compare full CBT-I treatment packages and component network meta-analysis to assess individual CBT-I elements. They ranked treatments, checked for consistency across studies, and ran sensitivity analyses to test whether results held up when excluding certain kinds of studies (such as those with informal diagnoses or high dropout rates).
The final analyses included 241 trials spanning from 1980 to 2023 and 31,452 participants. Most participants were middle-aged women with comorbidities and moderate insomnia symptoms. The 241 trials had 528 arms, and treatment duration ranged from 1 to 16 weeks.
With psychoeducation as the reference, treatment-level analysis showed that CBT-I has the highest likelihood of remission with an OR of 2.50 (1.93-3.24), followed by behavioral therapy at 2.50 (1.93-3.24), and cognitive therapy at 2.49 (1.59-3.92). Usual treatment, relaxation therapy, and no treatment were not found to be significant; finally, wait-list was found to be detrimental, with an OR of 0.66 (0.52-0.84).
Component-level analysis showed that cognitive restructuring (remission incremental OR [iOR],1.68; 95% CI, 1.28-2.20; P < .01), third-wave components (iOR, 1.49; 95% CI, 1.10-2.03; 0.99 < P < .05), sleep restriction (iOR, 1.49; 95% CI, 1.04-2.13; 0.99 < P < .05), and stimulus control (iOR, 1.43; 95% CI, 1.00-2.05; 0.99 < P < .05) may be beneficial in remission, whereas relaxation (iOR, 0.81; 95% CI, 0.64-1.02; 0.05< P < .01) may be detrimental. The wait-list component was found to have a decrease in remission (iOR, 0.64; 95% CI, 0.47-0.89; P < .01). Finally, an in-person format was the most helpful delivery method (iOR, 1.83; 95% CI, 119-2.81; P < .01).
Sleep restriction was associated with improved time to wake after sleep onset and improved sleep efficiency. Stimulus control was associated with improved sleep latency and improved sleep efficiency.
Finally, comparing the most effective in-person treatment—comprising the 4 beneficial components—with in-person psychoeducation revealed a 33% increase in the remission rate (95% CI, 0.23%-0.43%) in favor of in-person treatment, with a number needed to treat of 3.0 (95% CI, 2.3-4.3).
When interventions for chronic insomnia are compared, CBT-I shows the strongest association with increased remission, followed closely by cognitive therapy and behavioral therapy alone. Component-level analysis identified cognitive restructuring, third-wave techniques, sleep restriction, and stimulus control as beneficial, whereas relaxation techniques were potentially detrimental. Among delivery methods, in-person therapy yielded the best outcomes.
This study identifies which components of CBT-I are most effective in treating chronic insomnia and which are less beneficial. Clinicians can use this information to tailor treatments for better outcomes and apply individual components in smaller settings, especially for patients hesitant to begin full CBT-I.
CBT-I is the most beneficial treatment for chronic insomnia. The components of cognitive restructuring, third-wave components, sleep restriction, and stimulus control seem to be the most important elements when utilizing CBT-I when treating chronic insomnia.
Dr Palakollu is a first-year psychiatry resident at Creighton University in Omaha, Nebraska. Dr Perez Meek is a third-year psychiatry resident at Creighton University. Dr Schuster is a fourth-year psychiatry resident at Creighton University. Dr Mullen is an assistant professor of psychiatry at Saint Louis University School of Medicine in St. Louis, Missouri. Dr Tampi is professor and chair of the Department of Psychiatry at Creighton University School of Medicine and Catholic Health Initiatives Health Behavioral Health Services. He is also an adjunct professor of psychiatry at Yale School of Medicine in New Haven, Connecticut, and a member of the Psychiatric Times editorial board.
Reference
1. Furukawa Y, Sakata M, Yamamoto R, et al.
Receive trusted psychiatric news, expert analysis, and clinical insights — subscribe today to support your practice and your patients.
