Cognitive Behavioral Therapy for Chronic Insomnia: A Systematic Review and Meta-analysis
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Abstract
Background:
Because psychological approaches are likely to produce sustained benefits without the risk for tolerance or adverse effects associated with pharmacologic approaches, cognitive behavioral therapy for insomnia (CBT-i) is now commonly recommended as first-line treatment for chronic insomnia.
Purpose:
To determine the efficacy of CBT-i on diary measures of overnight sleep in adults with chronic insomnia.
Data Sources:
Searches of MEDLINE, EMBASE, PsycINFO, CINAHL, the Cochrane Library, and PubMed Clinical Queries from inception to 31 March 2015, supplemented with manual screening.
Study Selection:
Randomized, controlled trials assessing the efficacy of face-to-face, multimodal CBT-i compared with inactive comparators on overnight sleep in adults with chronic insomnia. Studies of insomnia comorbid with medical, sleep, or psychiatric disorders were excluded.
Data Extraction:
Study characteristics, quality, and data were assessed independently by 2 reviewers. Main outcome measures were sleep onset latency (SOL), wake after sleep onset (WASO), total sleep time (TST), and sleep efficiency (SE%).
Data Synthesis:
Among 292 citations and 91 full-text articles reviewed, 20 studies (1162 participants [64% female; mean age, 56 years]) were included. Approaches to CBT-i incorporated at least 3 of the following: cognitive therapy, stimulus control, sleep restriction, sleep hygiene, and relaxation. At the posttreatment time point, SOL improved by 19.03 (95% CI, 14.12 to 23.93) minutes, WASO improved by 26.00 (CI, 15.48 to 36.52) minutes, TST improved by 7.61 (CI, −0.51 to 15.74) minutes, and SE% improved by 9.91% (CI, 8.09% to 11.73%). Changes seemed to be sustained at later time points. No adverse outcomes were reported.
Limitation:
Narrow inclusion criteria limited applicability to patients with comorbid insomnia and other sleep problems, and accuracy of estimates at later time points was less clear.
Conclusion:
CBT-i is an effective treatment for adults with chronic insomnia, with clinically meaningful effect sizes.
Primary Funding Source:
None. (PROSPERO registration number: CRD42012002863)
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References
1.
American Psychiatric Association. DSM-IV: Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Pr; 1994.
2.
Morin CM, LeBlanc M, Daley M, Gregoire JP, Mérette C. Epidemiology of insomnia: prevalence, self-help treatments, consultations, and determinants of help-seeking behaviors. Sleep Med. 2006;7:123-30. [PMID: 16459140]
3.
Ohayon MM. Epidemiology of insomnia: what we know and what we still need to learn. Sleep Med Rev. 2002;6:97-111. [PMID: 12531146]
4.
Ohayon MM, Reynolds CF 3rd. Epidemiological and clinical relevance of insomnia diagnosis algorithms according to the DSM-IV and the International Classification of Sleep Disorders (ICSD). Sleep Med. 2009;10:952-60. [PMID: 19748312] doi: 10.1016/j.sleep.2009.07.008
5.
Ohayon MM. Prevalence of DSM-IV diagnostic criteria of insomnia: distinguishing insomnia related to mental disorders from sleep disorders. J Psychiatr Res. 1997;31:333-46. [PMID: 9306291]
6.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013.
7.
Chang PP, Ford DE, Mead LA, Cooper-Patrick L, Klag MJ. Insomnia in young men and subsequent depression. The Johns Hopkins Precursors Study. Am J Epidemiol. 1997;146:105-14. [PMID: 9230772]
8.
Fernandez ME, Lopez SM, Cazaux A, Cambursano VH, Cortes JR. [Insomnia: prevalence in Cordoba city hospital]. Rev Fac Cien Med Univ Nac Cordoba. 2012;69:191-6. [PMID: 23751785]
9.
Vgontzas AN, Liao D, Bixler EO, Chrousos GP, Vela-Bueno A. Insomnia with objective short sleep duration is associated with a high risk for hypertension. Sleep. 2009;32:491-7. [PMID: 19413143]
10.
Vgontzas AN, Liao D, Pejovic S, Calhoun S, Karataraki M, Bixler EO. Insomnia with objective short sleep duration is associated with type 2 diabetes: a population-based study. Diabetes Care. 2009;32:1980-5. [PMID: 19641160] doi: 10.2337/dc09-0284
11.
Smith MT, Haythornthwaite JA. How do sleep disturbance and chronic pain inter-relate? Insights from the longitudinal and cognitive-behavioral clinical trials literature. Sleep Med Rev. 2004;8:119-32. [PMID: 15033151]
12.
Daley M, Morin CM, LeBlanc M, Grégoire JP, Savard J, Baillargeon L. Insomnia and its relationship to health-care utilization, work absenteeism, productivity and accidents. Sleep Med. 2009;10:427-38. [PMID: 18753000] doi: 10.1016/j.sleep.2008.04.005
13.
Taylor DJ, Lichstein KL, Durrence HH, Reidel BW, Bush AJ. Epidemiology of insomnia, depression, and anxiety. Sleep. 2005;28:1457-64. [PMID: 16335332]
14.
Roth T, Jaeger S, Jin R, Kalsekar A, Stang PE, Kessler RC. Sleep problems, comorbid mental disorders, and role functioning in the national comorbidity survey replication. Biol Psychiatry. 2006;60:1364-71. [PMID: 16952333]
15.
Breslau N, Roth T, Rosenthal L, Andreski P. Sleep disturbance and psychiatric disorders: a longitudinal epidemiological study of young adults. Biol Psychiatry. 1996;39:411-8. [PMID: 8679786]
16.
Roth T, Drake C. Defining insomnia: the role of quantitative criteria [Editorial]. Sleep. 2006;29:424-5. [PMID: 16676773]
17.
Daley M, Morin CM, LeBlanc M, Grégoire JP, Savard J. The economic burden of insomnia: direct and indirect costs for individuals with insomnia syndrome, insomnia symptoms, and good sleepers. Sleep. 2009;32:55-64. [PMID: 19189779]
18.
Kripke DF, Langer RD, Kline LE. Hypnotics' association with mortality or cancer: a matched cohort study. BMJ Open. 2012;2:e000850. [PMID: 22371848] doi: 10.1136/bmjopen-2012-000850
19.
International Narcotics Control Board. Psychotropic Substances: Statistics for 2013. New York: United Nations; 2014.
20.
Charles J, Harrison C, Britt H. Insomnia. Aust Fam Physician. 2009;38:283. [PMID: 19458795]
21.
Hermes ED, Sernyak M, Rosenheck R. Use of second-generation antipsychotic agents for sleep and sedation: a provider survey. Sleep. 2013;36:597-600. [PMID: 23565006] doi: 10.5665/sleep.2554
22.
Anderson SL, Vande Griend JP. Quetiapine for insomnia: a review of the literature. Am J Health Syst Pharm. 2014;71:394-402. [PMID: 24534594] doi: 10.2146/ajhp130221
23.
Morin CM, Bootzin RR, Buysse DJ, Edinger JD, Espie CA, Lichstein KL. Psychological and behavioral treatment of insomnia: update of the recent evidence (1998–2004). Sleep. 2006;29:1398-414. [PMID: 17162986]
24.
Vincent N, Lionberg C. Treatment preference and patient satisfaction in chronic insomnia. Sleep. 2001;24:411-7. [PMID: 11403525]
25.
Harvey AG, Bélanger L, Talbot L, Eidelman P, Beaulieu-Bonneau S, Fortier-Brochu É, et al. Comparative efficacy of behavior therapy, cognitive therapy, and cognitive behavior therapy for chronic insomnia: a randomized controlled trial. J Consult Clin Psychol. 2014;82:670-83. [PMID: 24865869] doi: 10.1037/a0036606
26.
Montgomery P, Dennis J. Cognitive behavioural interventions for sleep problems in adults aged 60+. Cochrane Database Syst Rev. 2003:CD003161. [PMID: 12535460]
27.
Morin CM, Culbert JP, Schwartz SM. Nonpharmacological interventions for insomnia: a meta-analysis of treatment efficacy. Am J Psychiatry. 1994;151:1172-80. [PMID: 8037252]
28.
Okajima I, Komada Y, Inoue Y. A meta-analysis on the treatment effectiveness of cognitive behavioral therapy for primary insomnia. Sleep Biol Rhythms. 2011;9:24-34.
29.
Murtagh DR, Greenwood KM. Identifying effective psychological treatments for insomnia: a meta-analysis. J Consult Clin Psychol. 1995;63:79-89. [PMID: 7896994]
30.
Trauer J, Cunnington D, Rajaratnam S, Qian M, Doyle J. Cognitive behavioural therapy for insomnia, a systematic review and meta-analysis. PROSPERO International Prospective Register of Systematic Reviews. 2012.
31.
Morin CM, Benca R. Chronic insomnia. Lancet. 2012;379:1129-41. [PMID: 22265700] doi: 10.1016/S0140-6736(11)60750-2
32.
Cochrane Collaboration. The Cochrane Collaboration's Tool for Assessing Risk of Bias. 2011. Accessed at http://ohg.cochrane.org/sites/ohg.cochrane.org/files/uploads/Risk of bias assessment tool.pdf on 20 May 2015.
33.
Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ. 2003;327:557-60. [PMID: 12958120]
34.
Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. BMJ. 1997;315:629-34. [PMID: 9310563]
35.
Fernando A 3rd, Arroll B, Falloon K. A double-blind randomised controlled study of a brief intervention of bedtime restriction for adult patients with primary insomnia. J Prim Health Care. 2013;5:5-10. [PMID: 23457689]
36.
Edinger JD, Wohlgemuth WK, Radtke RA, Coffman CJ, Carney CE. Dose-response effects of cognitive-behavioral insomnia therapy: a randomized clinical trial. Sleep. 2007;30:203-12. [PMID: 17326546]
37.
Altena E, Van Der Werf YD, Strijers RL, Van Someren EJ. Sleep loss affects vigilance: effects of chronic insomnia and sleep therapy. J Sleep Res. 2008;17:335-43. [PMID: 18844819] doi: 10.1111/j.1365-2869.2008.00671.x
38.
Bothelius K, Kyhle K, Espie CA, Broman JE. Manual-guided cognitive-behavioural therapy for insomnia delivered by ordinary primary care personnel in general medical practice: a randomized controlled effectiveness trial. J Sleep Res. 2013;22:688-96. [PMID: 23859625] doi: 10.1111/jsr.12067
39.
Buysse DJ, Germain A, Moul DE, Franzen PL, Brar LK, Fletcher ME, et al. Efficacy of brief behavioral treatment for chronic insomnia in older adults. Arch Intern Med. 2011;171:887-95. [PMID: 21263078] doi: 10.1001/archinternmed.2010.535
40.
Edinger JD, Wohlgemuth WK, Radtke RA, Marsh GR, Quillian RE. Cognitive behavioral therapy for treatment of chronic primary insomnia: a randomized controlled trial. JAMA. 2001;285:1856-64. [PMID: 11308399]
41.
Edinger JD, Sampson WS. A primary care “friendly” cognitive behavioral insomnia therapy. Sleep. 2003;26:177-82. [PMID: 12683477]
42.
Edinger JD, Olsen MK, Stechuchak KM, Means MK, Lineberger MD, Kirby A, et al. Cognitive behavioral therapy for patients with primary insomnia or insomnia associated predominantly with mixed psychiatric disorders: a randomized clinical trial. Sleep. 2009;32:499-510. [PMID: 19413144]
43.
Espie CA, Inglis SJ, Tessier S, Harvey L. The clinical effectiveness of cognitive behaviour therapy for chronic insomnia: implementation and evaluation of a sleep clinic in general medical practice. Behav Res Ther. 2001;39:45-60. [PMID: 11125723]
44.
Espie CA, MacMahon KM, Kelly HL, Broomfield NM, Douglas NJ, Engleman HM, et al. Randomized clinical effectiveness trial of nurse-administered small-group cognitive behavior therapy for persistent insomnia in general practice. Sleep. 2007;30:574-84. [PMID: 17552372]
45.
Guilleminault C, Palombini L, Poyares D, Chowdhuri S. Chronic insomnia, premenopausal women and sleep disordered breathing: part 2. Comparison of nondrug treatment trials in normal breathing and UARS post-menopausal women complaining of chronic insomnia. J Psychosom Res. 2002;53:617-23. [PMID: 12127180]
46.
Jacobs GD, Pace-Schott EF, Stickgold R, Otto MW. Cognitive behavior therapy and pharmacotherapy for insomnia: a randomized controlled trial and direct comparison. Arch Intern Med. 2004;164:1888-96. [PMID: 15451764]
47.
Lovato N, Lack L, Wright H, Kennaway DJ. Evaluation of a brief treatment program of cognitive behavior therapy for insomnia in older adults. Sleep. 2014;37:117-26. [PMID: 24470701] doi: 10.5665/sleep.3320
48.
McCrae CS, McGovern R, Lukefahr R, Stripling AM. Research Evaluating Brief Behavioral Sleep Treatments for Rural Elderly (RESTORE): a preliminary examination of effectiveness. Am J Geriatr Psychiatry. 2007;15:979-82. [PMID: 17974868]
49.
Morin CM, Kowatch RA, Barry T, Walton E. Cognitive-behavior therapy for late-life insomnia. J Consult Clin Psychol. 1993;61:137-46. [PMID: 8450099]
50.
Morin CM, Colecchi C, Stone J, Sood R, Brink D. Behavioral and pharmacological therapies for late-life insomnia: a randomized controlled trial. JAMA. 1999;281:991-9. [PMID: 10086433]
51.
Sivertsen B, Omvik S, Pallesen S, Bjorvatn B, Havik OE, Kvale G, et al. Cognitive behavioral therapy vs zopiclone for treatment of chronic primary insomnia in older adults: a randomized controlled trial. JAMA. 2006;295:2851-8. [PMID: 16804151]
52.
Soeffing JP, Lichstein KL, Nau SD, McCrae CS, Wilson NM, Aguillard RN, et al. Psychological treatment of insomnia in hypnotic-dependant older adults. Sleep Med. 2008;9:165-71. [PMID: 17644419]
53.
Taylor DJ, Zimmerman MR, Gardner CE, Williams JM, Grieser EA, Tatum JI, et al. A pilot randomized controlled trial of the effects of cognitive-behavioral therapy for insomnia on sleep and daytime functioning in college students. Behav Ther. 2014;45:376-89. [PMID: 24680232] doi: 10.1016/j.beth.2013.12.010
54.
Waters WF, Hurry MJ, Binks PG, Carney CE, Lajos LE, Fuller KH, et al. Behavioral and hypnotic treatments for insomnia subtypes. Behav Sleep Med. 2003;1:81-101. [PMID: 15600131]
55.
Wu R, Bao J, Zhang C, Deng J, Long C. Comparison of sleep condition and sleep-related psychological activity after cognitive-behavior and pharmacological therapy for chronic insomnia. Psychother Psychosom. 2006;75:220-8. [PMID: 16785771]
56.
Structured clinical interview for DSM-III-R (SCID). Washington, DC: American Psychiatric Pr; 1990.
57.
Diagnostic and Statistical Manual of Mental Disorders, Text Revision (DSM-IV-TR). 4th ed. Washington, DC: American Psychiatric Assoc; 1997.
58.
International Classification of Sleep Disorders (ICSD): Diagnostic and Coding Manual. Rochester, MN: American Sleep Disorders Assoc; 1990.
59.
The International Classification of Sleep Disorders. 2nd ed. Westchester, IL: American Academy of Sleep Medicine; 2005.
60.
Edinger JD, Bonnet MH, Bootzin RR, Doghramji K, Dorsey CM, Espie CA, et al; American Academy of Sleep Medicine Work Group. Derivation of research diagnostic criteria for insomnia: report of an American Academy of Sleep Medicine Work Group. Sleep. 2004;27:1567-96. [PMID: 15683149]
61.
Spielman AJ, Saskin P, Thorpy MJ. Treatment of chronic insomnia by restriction of time in bed. Sleep. 1987;10:45-56. [PMID: 3563247]
62.
Buysse DJ, Reynolds CF 3rd, Monk TH, Berman SR, Kupfer DJ. The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Res. 1989;28:193-213. [PMID: 2748771]
63.
Morin CM, Stone J, Trinkle D, Mercer J, Remsberg S. Dysfunctional beliefs and attitudes about sleep among older adults with and without insomnia complaints. Psychol Aging. 1993;8:463-7. [PMID: 8216967]
64.
Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression. Arch Gen Psychiatry. 1961;4:561-71. [PMID: 13688369]
65.
Johns MW. A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep. 1991;14:540-5. [PMID: 1798888]
66.
Bastien CH, Vallières A, Morin CM. Validation of the Insomnia Severity Index as an outcome measure for insomnia research. Sleep Med. 2001;2:297-307. [PMID: 11438246]
67.
McNair D, Lorr M, Droppleman L. Profile of Mood States. San Diego: Educational and Industrial Testing Service; 1971.
68.
Ware JE Jr, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care. 1992;30:473-83. [PMID: 1593914]
69.
Lacks P. Behavioral Treatment for Persistent Insomnia. New York: Pergamon Pr; 1987.
70.
Spielberger C, Gorsuch R, Lushene R. Manual for the State-Trait Anxiety Inventory. Palo Alto, CA: Consulting Psychologists Pr; 1970.
71.
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;25:559-92. [PMID: 15970367]
72.
Taylor DJ, Pruiksma KE. Cognitive and behavioural therapy for insomnia (CBT-I) in psychiatric populations: a systematic review. Int Rev Psychiatry. 2014;26:205-13. [PMID: 24892895] doi: 10.3109/09540261.2014.902808
73.
Ashworth DK, Sletten TL, Junge M, Simpson K, Clarke D, Cunnington D, et al. A randomized controlled trial of cognitive behavioral therapy for insomnia: an effective treatment for comorbid insomnia and depression. J Couns Psychol. 2015;62:115-23. [PMID: 25867693] doi: 10.1037/cou0000059
74.
Morin CM, Espie CA. Insomnia: A Clinical Guide to Assessment and Treatment. New York: Kluwer Academic/Plenum; 2003.
75.
Edinger JD, Carney CE. Overcoming Insomnia: A Cognitive-Behavioral Therapy Approach. Therapist Guide. New York: Oxford Univ Pr; 2008.
76.
Arnedt JT, Cuddihy L, Swanson LM, Pickett S, Aikens J, Chervin RD. Randomized controlled trial of telephone-delivered cognitive behavioral therapy for chronic insomnia. Sleep. 2013;36:353-62. [PMID: 23450712] doi: 10.5665/sleep.2448
77.
Espie CA, Kyle SD, Williams C, Ong JC, Douglas NJ, Hames P, et al. A randomized, placebo-controlled trial of online cognitive behavioral therapy for chronic insomnia disorder delivered via an automated media-rich web application. Sleep. 2012;35:769-81. [PMID: 22654196] doi: 10.5665/sleep.1872
78.
Cunnington D, Junge MF, Fernando AT. Insomnia: prevalence, consequences and effective treatment. Med J Aust. 2013;199:S36-40. [PMID: 24138364]
79.
Vallières A, Ivers H, Bastien CH, Beaulieu-Bonneau S, Morin CM. Variability and predictability in sleep patterns of chronic insomniacs. J Sleep Res. 2005;14:447-53. [PMID: 16364146]
80.
Buysse DJ, Thompson W, Scott J, Franzen PL, Germain A, Hall M, et al. Daytime symptoms in primary insomnia: a prospective analysis using ecological momentary assessment. Sleep Med. 2007;8:198-208. [PMID: 17368098]
81.
Gu NY, Botteman MF, Ji X, Bell CF, Carter JA, van Hout B. Mapping of the Insomnia Severity Index and other sleep measures to EuroQol EQ-5D health state utilities. Health Qual Life Outcomes. 2011;9:119. [PMID: 22208861] doi: 10.1186/1477-7525-9-119
82.
Bonnet MH, Arand DL. EEG arousal norms by age. J Clin Sleep Med. 2007;3:271-4. [PMID: 17561594]
83.
Walsleben JA, Kapur VK, Newman AB, Shahar E, Bootzin RR, Rosenberg CE, et al. Sleep and reported daytime sleepiness in normal subjects: the Sleep Heart Health Study. Sleep. 2004;27:293-8. [PMID: 15124725]
84.
Smith MT, Perlis ML, Park A, Smith MS, Pennington J, Giles DE, et al. Comparative meta-analysis of pharmacotherapy and behavior therapy for persistent insomnia. Am J Psychiatry. 2002;159:5-11. [PMID: 11772681]
85.
De Niet GJ, Tiemens BG, Kloos MW, Hutschemaekers GJ. Review of systematic reviews about the efficacy of non-pharmacological interventions to improve sleep quality in insomnia. Int J Evid Based Healthc. 2009;7:233-42. [PMID: 21631864] doi: 10.1111/j.1744-1609.2009.00142.x
86.
Hofmann SG, Asnaani A, Vonk IJ, Sawyer AT, Fang A. The efficacy of cognitive behavioral therapy: a review of meta-analyses. Cognit Ther Res. 2012;36:427-440. [PMID: 23459093]
87.
Meltzer LJ, Mindell JA. Systematic review and meta-analysis of behavioral interventions for pediatric insomnia. J Pediatr Psychol. 2014;39:932-48. [PMID: 24947271] doi: 10.1093/jpepsy/jsu041
88.
Belleville G, Cousineau H, Levrier K, St-Pierre-Delorme MÈ. Meta-analytic review of the impact of cognitive-behavior therapy for insomnia on concomitant anxiety. Clin Psychol Rev. 2011;31:638-52. [PMID: 21482322] doi: 10.1016/j.cpr.2011.02.004
89.
Cheng SK, Dizon J. Computerised cognitive behavioural therapy for insomnia: a systematic review and meta-analysis. Psychother Psychosom. 2012;81:206-16. [PMID: 22585048] doi: 10.1159/000335379
90.
Koffel EA, Koffel JB, Gehrman PR. A meta-analysis of group cognitive behavioral therapy for insomnia. Sleep Med Rev. 2015;19:6-16. [PMID: 24931811] doi: 10.1016/j.smrv.2014.05.001
91.
Pallesen S, Nordhus IH, Kvale G. Nonpharmacological interventions for insomnia in older adults: a meta-analysis of treatment efficacy. Psychotherapy (Chic). 1998;35:472-82.
92.
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;25:3-14. [PMID: 16448292]
93.
Rybarczyk B, Lopez M, Benson R, Alsten C, Stepanski E. Efficacy of two behavioral treatment programs for comorbid geriatric insomnia. Psychol Aging. 2002;17:288-98. [PMID: 12061413]
94.
Mimeault V, Morin CM. Self-help treatment for insomnia: bibliotherapy with and without professional guidance. J Consult Clin Psychol. 1999;67:511-9. [PMID: 10450621]
95.
Ström L, Pettersson R, Andersson G. Internet-based treatment for insomnia: a controlled evaluation. J Consult Clin Psychol. 2004;72:113-20. [PMID: 14756620]
96.
Perlis ML, Smith MT, Orff H, Enright T, Nowakowski S, Jungquist C, et al. The effects of modafinil and cognitive behavior therapy on sleep continuity in patients with primary insomnia. Sleep. 2004;27:715-25. [PMID: 15283007]
97.
Jansson M, Linton SJ. Cognitive-behavioral group therapy as an early intervention for insomnia: a randomized controlled trial. J Occup Rehabil. 2005;15:177-90. [PMID: 15844675]
98.
Nowell PD, Mazumdar S, Buysse DJ, Dew MA, Reynolds CF 3rd, Kupfer DJ. Benzodiazepines and zolpidem for chronic insomnia: a meta-analysis of treatment efficacy. JAMA. 1997;278:2170-7. [PMID: 9417012]
99.
Huedo-Medina TB, Kirsch I, Middlemass J, Klonizakis M, Siriwardena AN. Effectiveness of non-benzodiazepine hypnotics in treatment of adult insomnia: meta-analysis of data submitted to the Food and Drug Administration. BMJ. 2012;345:e8343. [PMID: 23248080] doi: 10.1136/bmj.e8343
100.
Hoque R, Chesson AL Jr. Zolpidem-induced sleepwalking, sleep related eating disorder, and sleep-driving: fluorine-18-flourodeoxyglucose positron emission tomography analysis, and a literature review of other unexpected clinical effects of zolpidem. J Clin Sleep Med. 2009;5:471-6. [PMID: 19961034]
101.
Zammit G. Comparative tolerability of newer agents for insomnia. Drug Saf. 2009;32:735-48. [PMID: 19670914] doi: 10.2165/11312920-000000000-00000
102.
Kales A, Manfredi RL, Vgontzas AN, Bixler EO, Vela-Bueno A, Fee EC. Rebound insomnia after only brief and intermittent use of rapidly eliminated benzodiazepines. Clin Pharmacol Ther. 1991;49:468-76. [PMID: 2015735]
103.
Janson C, Lindberg E, Gislason T, Elmasry A, Boman G. Insomnia in men-a 10-year prospective population based study. Sleep. 2001;24:425-30. [PMID: 11403527]
104.
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;4:487-504. [PMID: 18853708]
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Published In
Annals of Internal Medicine
Volume 163 • Number 3 • 4 August 2015
Pages: 191 - 204
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Published online: 4 August 2015
Published in issue: 4 August 2015
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© 2015 American College of Physicians.
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Cognitive Behavioral Therapy for Chronic Insomnia: A Systematic Review and Meta-analysis. Ann Intern Med.2015;163:191-204. [Epub 4 August 2015]. doi:10.7326/M14-2841
Cognitive Behavioral Therapy for Chronic Insomnia: A Systematic Review and Meta-analysis. Ann Intern Med.2015;163:191-204. [Epub 4 August 2015]. doi:10.7326/M14-2841
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Author's Response
In relation to insomnia definition and duration, the terms that we accepted as indicating chronic insomnia are listed in the Supplemental Appendix and Table 1 presents the texts referenced by individual studies for their definitions. The two studies with insomnia definitions listed as “author-defined” required a duration of one month (Waters) and six months (Lovato), and both DSM-IV and RDC criteria require a duration of at least one month (1, 2). Therefore, the minimum duration of insomnia required for entry into any of the studies of our review would have been one month. Nine of the studies reported a mean duration of insomnia among participants, which ranged from 9.5 to 14.3 months, with the exception of the one study which did not contribute data to pooled estimates (Guilleminault), for which the duration was 4.1 months.
Publication bias and loss to follow up are universal concerns in meta-analyses of clinical trials. Our search strategy returned a number of trial protocols, including studies currently underway and yet to report results. We also found no statistical evidence of publication bias. Risk of bias due to incomplete follow up is presented in Table 2 and our approach to assessing this domain is described in the Study Quality section of the manuscript. Only one study had greater than 10% loss to follow up at post-treatment (14% of the treatment cohort) and did not describe a statistical technique to account for these drop outs (Espie 2001), although risk was unclear for a further three.
As van den Noort and colleagues also point out, our results at late follow up did not achieve statistical significance using a Knapp-Hartung method for random effect meta-analyses. Although we believe this statistical approach is the most appropriate approach and accords with Annals policy, it is not as commonly used as the standard Laird-Dersimonian method (3). Under the Laird-Dersimonian approach, all outcomes except SOL (i.e. TST, SE% and WASO) were statistically significant at both early and late follow up, but borderline using the Knapp-Hartung method. Moreover, as the point estimates for outcomes remained virtually unchanged over time, we believe our findings are consistent with patients maintaining their skills over time and that the wording “seems to be well-maintained” is justified. Our statement that CBT-i “results in significant alleviation of symptoms” refers to the statistically significant secondary outcome results at post-treatment.
James M Trauer and David Cunnington
1. Diagnostic and statistical manual for mental disorders, text revision (DSM-IV-TR). 4th ed. ed. Washington, DC: American Psychiatric Association; 1997.
2. Edinger JD, Bonnet MH, Bootzin RR, Doghramji K, Dorsey CM, Espie CA, et al. Derivation of research diagnostic criteria for insomnia: report of an American Academy of Sleep Medicine Work Group. Sleep. 2004;27:1567-96.
3. Cornell JE, Mulrow CD, Localio R, Stack CB, Meibohm AR, Guallar E, et al. Random-effects meta-analysis of inconsistent effects: a time for change. Ann Intern Med. 2014;160:267-70.
Efficacy of Cognitive Behavioral Therapy in the Treatment of Chronic Insomnia
Although we agree with Trauer et al. (1) and Morin (2) that cognitive behavioral therapy seems to be a promising treatment for chronic insomnia, there are three issues that did not receive enough attention, therefore, the conclusions that were drawn by Trauer and colleagues (1) are premature. First, Trauer et al. (1) do not give any information on how “chronic” was defined in their meta-analysis and whether those studies included in their study, use the same criterion for chronic insomnia?
Secondly, there is a bias in the data because, naturally, only published studies are included in the present meta-analysis, leading to higher efficacy scores, because studies that do not find any significant (positive) results probably will not get published. This over-estimation of treatment efficacy is a common problem in meta-analyses (3) and can be better accounted for by including all collected data of registered clinical trials instead of only the published ones (3). However, even more important, with respect to the bias in their data, how did the studies, included in the present meta-analysis; deal with drop-out? This is particularly of importance, because previous research has revealed that cognitive behavioral therapy suffers from high drop-out rates, up to even 34% (4, 5).
Finally, Trauer et al. (1) state that “Its efficacy seems to be well-maintained over time and results in significant alleviation of symptoms” (on page 201). However, if we take a closer look at their data (see page 197-200), we see that they base their statement solely on either 4 or 5 studies at early follow-up and on either 3 or 4 studies at late follow-up, which is a very low number of studies, and even more astonishing is the fact that the authors on the same page state “the improvements at the late follow-up time point were also not statistically significant”. Therefore, to date, it is simply too premature to claim that its efficacy seems to be well-maintained over time; more future studies on the long-term effects of cognitive behavioral therapy in chronic insomnia are required.
Conflict of interest
The authors report no conflict of interest.
References
1. Trauer JM, Qian MY, Doyle JS, Rajaratnam SM, Cunnington D. Cognitive behavioral therapy for chronic insomnia: A systematic review and meta-analysis. Ann Intern Med. 2015;163:191-204. [PMID: 26054060] doi:10.7326/M14-2841
2. Morin CM. Cognitive behavioral therapy for chronic insomnia: State of the science versus current clinical practices. Ann Intern Med. 2015;163:236-7. [PMID: 26052868] doi:10.7326/M15-1246
3. Schmucker C, Bluemle A, Briel M, Portalupi S, Lang B, Motschall E, et al. A protocol for a systematic review on the impact of unpublished studies and studies published in the gray