Cognitive Behavioral Therapy for Insomnia Comorbid With Psychiatric and Medical Conditions: A Meta-analysis | Psychiatry and Behavioral Health | JAMA Internal Medicine | JAMA Network
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Morgenthaler  T, Kramer  M, Alessi  C,  et al; American Academy of Sleep Medicine.  Practice parameters for the psychological and behavioral treatment of insomnia: an update: an American Academy Of Sleep Medicine report.  Sleep. 2006;29(11):1415-1419.PubMedGoogle Scholar
Schutte-Rodin  S, Broch  L, Buysse  D, Dorsey  C, Sateia  M.  Clinical guideline for the evaluation and management of chronic insomnia in adults.  J Clin Sleep Med. 2008;4(5):487-504.PubMedGoogle Scholar
Morin  CM, Culbert  JP, Schwartz  SM.  Nonpharmacological interventions for insomnia: a meta-analysis of treatment efficacy.  Am J Psychiatry. 1994;151(8):1172-1180.PubMedGoogle ScholarCrossref
Murtagh  DRR, Greenwood  KM.  Identifying effective psychological treatments for insomnia: a meta-analysis.  J Consult Clin Psychol. 1995;63(1):79-89.PubMedGoogle ScholarCrossref
Irwin  MR, Cole  JC, Nicassio  PM.  Comparative meta-analysis of behavioral interventions for insomnia and their efficacy in middle-aged adults and in older adults 55+ years of age.  Health Psychol. 2006;25(1):3-14.PubMedGoogle ScholarCrossref
Okajima  I, Komada  Y, Inoue  Y.  A meta-analysis on the treatment effectiveness of cognitive behavioral therapy for primary insomnia.  Sleep Biol Rhythms. 2011;9(1):24-34.Google ScholarCrossref
Koffel  EA, Koffel  JB, Gehrman  PR.  A meta-analysis of group cognitive behavioral therapy for insomnia.  Sleep Med Rev. 2015;19(2):6-16.PubMedGoogle ScholarCrossref
Smith  MT, Perlis  ML, Park  A,  et al.  Comparative meta-analysis of pharmacotherapy and behavior therapy for persistent insomnia.  Am J Psychiatry. 2002;159(1):5-11.PubMedGoogle ScholarCrossref
Lichstein  KL, Wilson  NM, Johnson  CT.  Psychological treatment of secondary insomnia.  Psychol Aging. 2000;15(2):232-240.PubMedGoogle ScholarCrossref
Sánchez-Ortuño  MM, Edinger  JD.  Cognitive-behavioral therapy for the management of insomnia comorbid with mental disorders.  Curr Psychiatry Rep. 2012;14(5):519-528.PubMedGoogle ScholarCrossref
Taylor  DJ, Pruiksma  KE.  Cognitive and behavioural therapy for insomnia (CBT-I) in psychiatric populations: a systematic review.  Int Rev Psychiatry. 2014;26(2):205-213.PubMedGoogle ScholarCrossref
Smith  MT, Huang  MI, Manber  R.  Cognitive behavior therapy for chronic insomnia occurring within the context of medical and psychiatric disorders.  Clin Psychol Rev. 2005;25(5):559-592.PubMedGoogle ScholarCrossref
Buysse  DJ, Ancoli-Israel  S, Edinger  JD, Lichstein  KL, Morin  CM.  Recommendations for a standard research assessment of insomnia.  Sleep. 2006;29(9):1155-1173.PubMedGoogle Scholar
Morin  CM, Belleville  G, Bélanger  L, Ivers  H.  The Insomnia Severity Index: psychometric indicators to detect insomnia cases and evaluate treatment response.  Sleep. 2011;34(5):601-608.PubMedGoogle Scholar
Buysse  DJ, Reynolds  CF  III, Monk  TH, Berman  SR, Kupfer  DJ.  The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research.  Psychiatry Res. 1989;28(2):193-213.PubMedGoogle ScholarCrossref
Hedges  LV.  Statistical Methodology in Meta-analysis. Princeton, NJ: ERIC Clearinghouse; 1982.
Moses  LE, Mosteller  F, Buehler  JH.  Comparing results of large clinical trials to those of meta-analyses.  Stat Med. 2002;21(6):793-800.PubMedGoogle ScholarCrossref
Rosenthal  R.  Meta-analytic Procedures for Social Research. Newbury Park, CA: Sage Publications; 1991.
Cohen  J.  Statistical Power Analysis for the Behavioral Sciences.2nd ed. London, England: Routledge Academic; 2013.
Rosenthal  R, Rubin  DB.  [Selection models and the file drawer problem]: comment: assumptions and procedures in the file drawer problem.  Stat Sci. 1988;3(1):120-125.Google ScholarCrossref
Duval  S, Tweedie  R.  Trim and fill: A simple funnel-plot–based method of testing and adjusting for publication bias in meta-analysis.  Biometrics. 2000;56(2):455-463.PubMedGoogle ScholarCrossref
Higgins  JPT, Altman  DG, Gøtzsche  PC,  et al; Cochrane Bias Methods Group; Cochrane Statistical Methods Group.  The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials.  BMJ. 2011;343:d5928. doi:10.1136/bmj.d5928.PubMedGoogle ScholarCrossref
Borenstein  M, Hedges  L, Higgins  J, Rothstein  H.  Comprehensive Meta-Analysis, Version 2. Englewood, NJ: Biostat; 2005:104.
Pigeon  WR, Moynihan  J, Matteson-Rusby  S,  et al.  Comparative effectiveness of CBT interventions for co-morbid chronic pain & insomnia: a pilot study.  Behav Res Ther. 2012;50(11):685-689.PubMedGoogle ScholarCrossref
Arnedt  JT, Conroy  DA, Armitage  R, Brower  KJ.  Cognitive-behavioral therapy for insomnia in alcohol dependent patients: a randomized controlled pilot trial.  Behav Res Ther. 2011;49(4):227-233.PubMedGoogle ScholarCrossref
Currie  SR, Clark  S, Hodgins  DC, El-Guebaly  N.  Randomized controlled trial of brief cognitive-behavioural interventions for insomnia in recovering alcoholics.  Addiction. 2004;99(9):1121-1132.PubMedGoogle ScholarCrossref
Edinger  JD, Olsen  MK, Stechuchak  KM,  et al.  Cognitive behavioral therapy for patients with primary insomnia or insomnia associated predominantly with mixed psychiatric disorders: a randomized clinical trial.  Sleep. 2009;32(4):499-510.PubMedGoogle Scholar
Manber  R, Edinger  JD, Gress  JL, San Pedro-Salcedo  MG, Kuo  TF, Kalista  T.  Cognitive behavioral therapy for insomnia enhances depression outcome in patients with comorbid major depressive disorder and insomnia.  Sleep. 2008;31(4):489-495.PubMedGoogle Scholar
Margolies  SO, Rybarczyk  B, Vrana  SR, Leszczyszyn  DJ, Lynch  J.  Efficacy of a cognitive-behavioral treatment for insomnia and nightmares in Afghanistan and Iraq veterans with PTSD.  J Clin Psychol. 2013;69(10):1026-1042.PubMedGoogle ScholarCrossref
Morgan  K, Dixon  S, Mathers  N, Thompson  J, Tomeny  M.  Psychological treatment for insomnia in the regulation of long-term hypnotic drug use.  Health Technol Assess. 2004;8(8):iii-iv, 1-68.PubMedGoogle ScholarCrossref
Talbot  LS, Maguen  S, Metzler  TJ,  et al.  Cognitive behavioral therapy for insomnia in posttraumatic stress disorder: a randomized controlled trial.  Sleep. 2014;37(2):327-341.PubMedGoogle Scholar
Ulmer  CS, Edinger  JD, Calhoun  PS.  A multi-component cognitive-behavioral intervention for sleep disturbance in veterans with PTSD: a pilot study.  J Clin Sleep Med. 2011;7(1):57-68.PubMedGoogle Scholar
Wagley  JN, Rybarczyk  B, Nay  WT, Danish  S, Lund  HG.  Effectiveness of abbreviated CBT for insomnia in psychiatric outpatients: sleep and depression outcomes.  J Clin Psychol. 2013;69(10):1043-1055.PubMedGoogle ScholarCrossref
Watanabe  N, Furukawa  TA, Shimodera  S,  et al.  Brief behavioral therapy for refractory insomnia in residual depression: an assessor-blind, randomized controlled trial.  J Clin Psychiatry. 2011;72(12):1651-1658.PubMedGoogle ScholarCrossref
Currie  SR, Wilson  KG, Pontefract  AJ, deLaplante  L.  Cognitive-behavioral treatment of insomnia secondary to chronic pain.  J Consult Clin Psychol. 2000;68(3):407-416.PubMedGoogle ScholarCrossref
Chen  H-Y, Cheng  I-C, Pan  Y-J,  et al.  Cognitive-behavioral therapy for sleep disturbance decreases inflammatory cytokines and oxidative stress in hemodialysis patients.  Kidney Int. 2011;80(4):415-422.PubMedGoogle ScholarCrossref
Dirksen  SR, Epstein  DR.  Efficacy of an insomnia intervention on fatigue, mood and quality of life in breast cancer survivors.  J Adv Nurs. 2008;61(6):664-675.PubMedGoogle ScholarCrossref
Edinger  JD, Fins  AI, Sullivan  RJ, Marsh  GR, Dailey  DS, Young  M.  Comparison of cognitive-behavioral therapy and clonazepam for treating periodic limb movement disorder.  Sleep. 1996;19(5):442-444.PubMedGoogle Scholar
Edinger  JD, Wohlgemuth  WK, Krystal  AD, Rice  JR.  Behavioral insomnia therapy for fibromyalgia patients: a randomized clinical trial.  Arch Intern Med. 2005;165(21):2527-2535.PubMedGoogle ScholarCrossref
Epstein  DR, Dirksen  SR.  Randomized trial of a cognitive-behavioral intervention for insomnia in breast cancer survivors.  Oncol Nurs Forum. 2007;34(5):E51-E59.PubMedGoogle ScholarCrossref
Espie  CA, Fleming  L, Cassidy  J,  et al.  Randomized controlled clinical effectiveness trial of cognitive behavior therapy compared with treatment as usual for persistent insomnia in patients with cancer.  J Clin Oncol. 2008;26(28):4651-4658.PubMedGoogle ScholarCrossref
Fiorentino  L, McQuaid  JR, Liu  L,  et al.  Individual cognitive behavioral therapy for insomnia in breast cancer survivors: a randomized controlled crossover pilot study.  Nat Sci Sleep. 2009;2010:1-8.PubMedGoogle ScholarCrossref
Garland  SN, Carlson  LE, Stephens  AJ, Antle  MC, Samuels  C, Campbell  TS.  Mindfulness-based stress reduction compared with cognitive behavioral therapy for the treatment of insomnia comorbid with cancer: a randomized, partially blinded, noninferiority trial.  J Clin Oncol. 2014;32(5):449-457.PubMedGoogle ScholarCrossref
Guilleminault  C, Davis  K, Huynh  NT.  Prospective randomized study of patients with insomnia and mild sleep disordered breathing.  Sleep. 2008;31(11):1527-1533.PubMedGoogle Scholar
Jansson-Fröjmark  M, Linton  SJ, Flink  IK, Granberg  S, Danermark  B, Norell-Clarke  A.  Cognitive-behavioral therapy for insomnia co-morbid with hearing impairment: a randomized controlled trial.  J Clin Psychol Med Settings. 2012;19(2):224-234.PubMedGoogle ScholarCrossref
Jungquist  CR, O’Brien  C, Matteson-Rusby  S,  et al.  The efficacy of cognitive-behavioral therapy for insomnia in patients with chronic pain.  Sleep Med. 2010;11(3):302-309.PubMedGoogle ScholarCrossref
Kapella  MC, Herdegen  JJ, Perlis  ML,  et al.  Cognitive behavioral therapy for insomnia comorbid with COPD is feasible with preliminary evidence of positive sleep and fatigue effects.  Int J Chron Obstruct Pulmon Dis. 2011;6:625-635.PubMedGoogle ScholarCrossref
Martínez  MP, Miró  E, Sánchez  AI,  et al.  Cognitive-behavioral therapy for insomnia and sleep hygiene in fibromyalgia: a randomized controlled trial.  J Behav Med. 2014;37(4):683-697.PubMedGoogle ScholarCrossref
Matthews  EE, Berger  AM, Schmiege  SJ,  et al.  Cognitive behavioral therapy for insomnia outcomes in women after primary breast cancer treatment: a randomized, controlled trial.  Oncol Nurs Forum. 2014;41(3):241-253.PubMedGoogle ScholarCrossref
Miró  E, Lupiáñez  J, Martínez  MP,  et al.  Cognitive-behavioral therapy for insomnia improves attentional function in fibromyalgia syndrome: a pilot, randomized controlled trial.  J Health Psychol. 2011;16(5):770-782.PubMedGoogle ScholarCrossref
Morgan  K, Gregory  P, Tomeny  M, David  BM, Gascoigne  C.  Self-help treatment for insomnia symptoms associated with chronic conditions in older adults: a randomized controlled trial.  J Am Geriatr Soc. 2012;60(10):1803-1810.PubMedGoogle ScholarCrossref
Ritterband  LM, Bailey  ET, Thorndike  FP, Lord  HR, Farrell-Carnahan  L, Baum  LD.  Initial evaluation of an Internet intervention to improve the sleep of cancer survivors with insomnia.  Psychooncology. 2012;21(7):695-705.PubMedGoogle ScholarCrossref
Rios Romenets  S, Creti  L, Fichten  C,  et al.  Doxepin and cognitive behavioural therapy for insomnia in patients with Parkinson’s disease—a randomized study.  Parkinsonism Relat Disord. 2013;19(7):670-675.PubMedGoogle ScholarCrossref
Rybarczyk  B, Lopez  M, Benson  R, Alsten  C, Stepanski  E.  Efficacy of two behavioral treatment programs for comorbid geriatric insomnia.  Psychol Aging. 2002;17(2):288-298.PubMedGoogle ScholarCrossref
Rybarczyk  B, Stepanski  E, Fogg  L, Lopez  M, Barry  P, Davis  A.  A placebo-controlled test of cognitive-behavioral therapy for comorbid insomnia in older adults.  J Consult Clin Psychol. 2005;73(6):1164-1174.PubMedGoogle ScholarCrossref
Savard  J, Simard  S, Ivers  H, Morin  CM.  Randomized study on the efficacy of cognitive-behavioral therapy for insomnia secondary to breast cancer, part I: sleep and psychological effects.  J Clin Oncol. 2005;23(25):6083-6096.PubMedGoogle ScholarCrossref
Tang  NKY, Goodchild  CE, Salkovskis  PM.  Hybrid cognitive-behaviour therapy for individuals with insomnia and chronic pain: a pilot randomised controlled trial.  Behav Res Ther. 2012;50(12):814-821.PubMedGoogle ScholarCrossref
Vitiello  MV, McCurry  SM, Shortreed  SM,  et al.  Cognitive-behavioral treatment for comorbid insomnia and osteoarthritis pain in primary care: the lifestyles randomized controlled trial.  J Am Geriatr Soc. 2013;61(6):947-956.PubMedGoogle ScholarCrossref
Messer  SB, Wampold  BE.  Let’s face facts: common factors are more potent than specific therapy ingredients.  Clin Psychol Sci Pract. 2006;9(1):21-25.Google ScholarCrossref
Hofmann  SG, Smits  JA.  Cognitive-behavioral therapy for adult anxiety disorders: a meta-analysis of randomized placebo-controlled trials.  J Clin Psychiatry. 2008;69(4):621-632.PubMedGoogle ScholarCrossref
Butler  AC, Chapman  JE, Forman  EM, Beck  AT.  The empirical status of cognitive-behavioral therapy: a review of meta-analyses.  Clin Psychol Rev. 2006;26(1):17-31.PubMedGoogle ScholarCrossref
Hofmann  SG, Wu  JQ, Boettcher  H.  Effect of cognitive-behavioral therapy for anxiety disorders on quality of life: a meta-analysis.  J Consult Clin Psychol. 2014;82(3):375-391.PubMedGoogle ScholarCrossref
Carney  CE, Buysse  DJ, Ancoli-Israel  S,  et al.  The consensus sleep diary: standardizing prospective sleep self-monitoring.  Sleep. 2012;35(2):287-302.PubMedGoogle Scholar
Shochat  T, Umphress  J, Israel  AG, Ancoli-Israel  S.  Insomnia in primary care patients.  Sleep. 1999;22(suppl 2):S359-S365.PubMedGoogle Scholar
Mitchell  MD, Gehrman  P, Perlis  M, Umscheid  CA.  Comparative effectiveness of cognitive behavioral therapy for insomnia: a systematic review.  BMC Fam Pract. 2012;13(1):40.PubMedGoogle ScholarCrossref
Buysse  DJ, Germain  A, Moul  DE,  et al.  Efficacy of brief behavioral treatment for chronic insomnia in older adults.  Arch Intern Med. 2011;171(10):887-895.PubMedGoogle ScholarCrossref
Original Investigation
September 2015

Cognitive Behavioral Therapy for Insomnia Comorbid With Psychiatric and Medical Conditions: A Meta-analysis

Author Affiliations
  • 1Department of Psychological and Brain Sciences, Boston University, Boston, Massachusetts
  • 2Sleep Disorders Service and Research Center, Department of Behavioral Sciences, Rush University Medical Center, Chicago, Illinois
JAMA Intern Med. 2015;175(9):1461-1472. doi:10.1001/jamainternmed.2015.3006

Importance  Cognitive behavioral therapy for insomnia (CBT-I) is the most prominent nonpharmacologic treatment for insomnia disorders. Although meta-analyses have examined primary insomnia, less is known about the comparative efficacy of CBT-I on comorbid insomnia.

Objective  To examine the efficacy of CBT-I for insomnia comorbid with psychiatric and/or medical conditions for (1) remission from insomnia; (2) self-reported sleep efficiency, sleep onset latency, wake after sleep onset, total sleep time, and subjective sleep quality; and (3) comorbid symptoms.

Data Sources  A systematic search was conducted on June 2, 2014, through PubMed, PsycINFO, the Cochrane Library, and manual searches. Search terms included (1) CBT-I or CBT or cognitive behavioral [and its variations] or behavioral therapy [and its variations] or behavioral sleep medicine or stimulus control or sleep restriction or relaxation therapy or relaxation training or progressive muscle relaxation or paradoxical intention; and (2) insomnia or sleep disturbance.

Study Selection  Studies were included if they were randomized clinical trials with at least one CBT-I arm and had an adult population meeting diagnostic criteria for insomnia as well as a concomitant condition. Inclusion in final analyses (37 studies) was based on consensus between 3 authors’ independent screenings.

Data Extraction and Synthesis  Data were independently extracted by 2 authors and pooled using a random-effects model. Study quality was independently evaluated by 2 authors using the Cochrane risk of bias assessment tool.

Main Outcomes and Measures  A priori main outcomes (ie, clinical sleep and comorbid outcomes) were derived from sleep diary and other self-report measures.

Results  At posttreatment evaluation, 36.0% of patients who received CBT-I were in remission from insomnia compared with 16.9% of those in control or comparison conditions (pooled odds ratio, 3.28; 95% CI, 2.30-4.68; P < .001). Pretreatment and posttreatment controlled effect sizes were medium to large for most sleep parameters (sleep efficiency: Hedges g = 0.91 [95% CI, 0.74 to 1.08]; sleep onset latency: Hedges g = 0.80 [95% CI, 0.60 to 1.00]; wake after sleep onset: Hedges g = 0.68; sleep quality: Hedges g = 0.84; all P < .001), except total sleep time. Comorbid outcomes yielded a small effect size (Hedges g = 0.39 [95% CI, 0.60-0.98]; P < .001); improvements were greater in psychiatric than in medical populations (Hedges g = 0.20 [95% CI, 0.09-0.30]; χ2 test for interaction = 12.30; P < .001).

Conclusions and Relevance  Cognitive behavioral therapy for insomnia is efficacious for improving insomnia symptoms and sleep parameters for patients with comorbid insomnia. A small to medium positive effect was found across comorbid outcomes, with larger effects on psychiatric conditions compared with medical conditions. Large-scale studies with more rigorous designs to reduce detection and performance bias are needed to improve the quality of the evidence.