James M. Trauer, MBBS; Mary Y. Qian, MBBS; Joseph S. Doyle, PhD; Shantha M.W. Rajaratnam, PhD; David Cunnington, MBBS
This article was published online first at www.annals.org on 9 June 2015.
Acknowledgment: The authors thank Kathryn Rough of the Western Hospital and Northern Hospital libraries, who was the chief study librarian and performed the database searches. They also thank the authors of contributing studies who provided additional data and clarification to facilitate this meta-analysis, as well as Dr. Evan Symons, who assessed 1 article and 1 abstract written in German.
Disclosures: Dr. Rajaratnam reports consultancies for VANDA Pharmaceuticals, Philips Respironics, EdanSafe, organizations employing shift workers, the National Transport Commission, The Australian Workers' Union, and Tontine Group; expert testimony for organizations employing shift workers; grants from VANDA Pharmaceuticals, Philips Respironics, and Cephalon; personal fees from VANDA Pharmaceuticals; and equipment from Compumedics, Optalert, Tyco Healthcare, and Philips Lighting outside the submitted work. He also reports that he was 2014 President and board member of the Australasian Sleep Association and Program Leader of the Cooperative Research Centre for Alertness, Safety and Productivity. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-2841.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer.
Reproducible Research Statement:Study protocol: Available at www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42012002863. Statistical code and data set: Available at http://sleephub.com.au/review-of-cognitive-behavioral-therapy-for-insomnia.
Requests for Single Reprints: James M. Trauer, MBBS, Melbourne Sleep Disorders Centre, Suite 508, Level 5, Victoria Parade, East Melbourne, Victoria 3002, Australia.
Current Author Addresses: Drs. Trauer, Qian, and Cunnington: Melbourne Sleep Disorders Centre, Suite 508, Level 5, Victoria Parade, East Melbourne, Victoria 3002, Australia.
Dr. Doyle: The Burnet Institute, 85 Commercial Road, Melbourne, Victoria 3004, Australia.
Dr. Rajaratnam: School of Psychological Sciences, 18 Innovation Walk, Monash University, Wellington Road, Clayton, Victoria 3800, Australia.
Author Contributions: Conception and design: J.M. Trauer, J.S. Doyle, S.M.W. Rajaratnam, D. Cunnington.
Analysis and interpretation of the data: J.M. Trauer, M.Y. Qian, J.S. Doyle, S.M.W. Rajaratnam, D. Cunnington.
Drafting of the article: J.M. Trauer, M.Y. Qian.
Critical revision of the article for important intellectual content: J.M. Trauer, J.S. Doyle, D. Cunnington.
Final approval of the article: J.M. Trauer, M.Y. Qian, J.S. Doyle, S.M.W. Rajaratnam, D. Cunnington.
Statistical expertise: J.M. Trauer, J.S. Doyle.
Administrative, technical, or logistic support: D. Cunnington.
Collection and assembly of data: J.M. Trauer, M.Y. Qian, D. Cunnington.
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. doi: 10.7326/M14-2841
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Published: Ann Intern Med. 2015;163(3):191-204.
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.
To determine the efficacy of CBT-i on diary measures of overnight sleep in adults with chronic insomnia.
Searches of MEDLINE, EMBASE, PsycINFO, CINAHL, the Cochrane Library, and PubMed Clinical Queries from inception to 31 March 2015, supplemented with manual screening.
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.
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%).
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.
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.
CBT-i is an effective treatment for adults with chronic insomnia, with clinically meaningful effect sizes.
None. (PROSPERO registration number: CRD42012002863)
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