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Psychological and Behavioral Interventions for Managing Insomnia Disorder: An Evidence Report for a Clinical Practice Guideline by the American College of PhysiciansPsychological and Behavioral Interventions for Managing Insomnia Disorder

Michelle Brasure, PhD, MSPH, MLIS; Erika Fuchs, MPH, PhD; Roderick MacDonald, MS; Victoria A. Nelson, MSc; Erin Koffel, PhD; Carin M. Olson, MD, MS; Imran S. Khawaja, MD; Susan Diem, MD, MPH; Maureen Carlyle, MPH; Timothy J. Wilt, MD, MPH; Jeannine Ouellette; Mary Butler, PhD; and Robert L. Kane, MD
[+] Article, Author, and Disclosure Information

This article was published at www.annals.org on 3 May 2016.


From University of Minnesota School of Public Health, Minneapolis Veterans Affairs Health Care System, Minnesota Regional Sleep Disorders Center, and University of Minnesota School of Medicine, Minneapolis, Minnesota; Optum, Eden Prairie, Minnesota; and University of Texas Medical Branch, Galveston, Texas.

Acknowledgment: The authors thank the administrative staff at the Minnesota Evidence-based Practice Center for their help and support on this project.

Grant Support: By the Agency for Healthcare Research and Quality (contract HHSA 290-2012-00016-I).

Disclosures: Dr. Brasure reports other fees from Agency for Healthcare Quality and Research during the conduct of the study. Mr. MacDonald reports grants from Agency for Healthcare Quality and Research and personal fees from the American College of Physicians during the conduct of the study. Ms. Nelson reports grants from Agency for Healthcare Research and Quality during the conduct of the study. Dr. Diem reports grants from Agency for Healthcare Research and Quality during the conduct of the study. Authors not named here have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M15-1782.

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 and Johnson & Johnson.

Reproducible Research Statement:Study protocol: Registered at www.crd.york.ac.uk/PROSPERO(CRD42014009908) in May 2014 and published at http://effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productid=1888. Statistical code: Available from Dr. MacDonald (e-mail, Rod.macdonald@va.gov). Data set: Available at http://srdr.ahrq.gov/.

Requests for Single Reprints: Michelle Brasure, PhD, MSPH, MLIS, Division of Health Policy and Management, School of Public Health, MMC 197, Mayo Memorial Building, 420 Delaware Street SE, Minneapolis, MN 55455; e-mail, brasu001@umn.edu.

Current Author Addresses: Dr. Brasure, Ms. Nelson, Ms. Ouellette, and Drs. Butler and Kane: Division of Health Policy and Management, University of Minnesota School of Public Health, MMC 197, Mayo Memorial Building, 420 Delaware Street SE, Minneapolis, MN 55455.

Dr. Fuchs: Center for Interdisciplinary Research in Women's Health, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555-0128.

Mr. MacDonald and Drs. Wilt, Koffel, and Olson: Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN 55417.

Dr. Khawaja: Minnesota Regional Sleep Disorders Center, 701 Park Avenue, G8.220, Minneapolis, MN 55415.

Dr. Diem: Department of Medicine, University of Minnesota School of Medicine, 1100 Washington Avenue S, Minneapolis, MN 55415.

Ms. Carlyle: Optum, Health Economics and Outcomes Research, 11000 Optum Circle, Eden Prairie, MN 55344.

Author Contributions: Conception and design: M.B. Brasure, M. Butler, M.H. Carlyle, E. Koffel, J. Ouellette, T.J. Wilt.

Analysis and interpretation of the data: M.B. Brasure, M. Butler, M.H. Carlyle, S. Diem, I. Khawaja, E. Koffel, R. MacDonald, V.A. Nelson, T.J. Wilt.

Drafting of the article: M.B. Brasure, R.L. Kane, E. Koffel, V.A. Nelson, J. Ouellette.

Critical revision for important intellectual content: M.B. Brasure, S. Diem, I. Khawaja, E. Koffel, C.M. Olson, J. Ouellette, T.J. Wilt.

Final approval of the article: M.B. Brasure, M. Butler, M.H. Carlyle, S.-. Diem, R.L. Kane, I. Khawaja, E. Koffel, R. MacDonald, V.A. Nelson, C.M. Olson, J. Ouellette, T.J. Wilt.

Provision of study materials or patients: M.B. Brasure.

Statistical expertise: M.B. Brasure, R. MacDonald, T.J. Wilt.

Obtaining of funding: M.B. Brasure, R.L. Kane, T.J. Wilt.

Administrative, technical, or logistic support: M.B. Brasure, M. Butler, R.L. Kane, T.J. Wilt.

Collection and assembly of data: M.B. Brasure, M.H. Carlyle, S.-. Diem, R. MacDonald, V.A. Nelson, C.M. Olson, T.J. Wilt.


Ann Intern Med. 2016;165(2):113-124. doi:10.7326/M15-1782
Text Size: A A A

Background: Psychological and behavioral interventions are frequently used for insomnia disorder.

Purpose: To assess benefits and harms of psychological and behavioral interventions for insomnia disorder in adults.

Data Sources: Ovid MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, and PsycINFO through September 2015, supplemented with hand-searching.

Study Selection: Randomized, controlled trials of psychological or behavioral interventions that were published in English and enrolled adults with insomnia disorder lasting 4 or more weeks.

Data Extraction: Data extraction by single investigator confirmed by a second reviewer; dual investigator assessment of risk of bias; consensus determination of strength of evidence.

Data Synthesis: Sixty trials with low to moderate risk of bias compared psychological and behavioral interventions with inactive controls or other psychological and behavioral interventions. Cognitive behavioral therapy for insomnia (CBT-I) improved posttreatment global and most sleep outcomes, often compared with information or waitlist controls (moderate-strength evidence). Use of CBT-I improved several sleep outcomes in older adults (low- to moderate-strength evidence). Multicomponent behavioral therapy improved several sleep outcomes in older adults (low- to moderate-strength evidence). Stimulus control improved 1 or 2 sleep outcomes (low-strength evidence). Evidence for other comparisons and for harms was insufficient to permit conclusions.

Limitations: A wide variety of comparisons limited the ability to pool data. Trials did not always report global outcomes and infrequently conducted remitter or responder analysis. Comparisons were often information or waitlist groups, and publication bias was possible.

Conclusion: Use of CBT-I improves most outcomes compared with inactive controls. Multicomponent behavioral therapy and stimulus control may improve some sleep outcomes. Evidence on other outcomes, comparisons, and long-term efficacy were limited.

Primary Funding Source: Agency for Healthcare Research and Quality. (PROSPERO: CRD42014009908)

Figures

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Appendix Figure 1.

Summary of evidence search and selection.

Intervention type totals do not equal total references because several trials were used in the analysis for 2 different types of interventions. RCT = randomized, controlled trial.

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Figure 1.

CBT-I versus inactive control: remitters.

CBT = cognitive behavioral therapy; CBT-I = cognitive behavioral therapy for insomnia; M-H = Mantel–Haenszel.

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Figure 2.

CBT-I versus inactive control: responders.

CBT = cognitive behavioral therapy; CBT-I = cognitive behavioral therapy for insomnia; M-H = Mantel–Haenszel.

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Figure 3.

CBT-I versus inactive control: posttreatment Insomnia Severity Index.

CBT = cognitive behavioral therapy; CBT-I = cognitive behavioral therapy for insomnia; IV = inverse variance.

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Figure 4.

CBT-I versus inactive control: post-treatment Pittsburgh Sleep Quality Index.

CBT = cognitive behavioral therapy; CBT-I = cognitive behavioral therapy for insomnia; IV = inverse variance.

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