Elsevier

Sleep Medicine Reviews

Volume 17, Issue 6, December 2013, Pages 453-464
Sleep Medicine Reviews

Clinical review
Adherence to cognitive behavioral therapy for insomnia: A systematic review

https://doi.org/10.1016/j.smrv.2013.01.001Get rights and content

Summary

Chronic insomnia is a significant public health problem worldwide, and insomnia has considerable personal and social costs associated with serious health conditions, greater healthcare utilization, work absenteeism, and motor-vehicle accidents. Cognitive behavioral therapy for insomnia (CBTI) is an efficacious treatment, yet attrition and suboptimal adherence may diminish its impact. Despite the increasing use of CBTI, surprisingly little attention has been devoted to understanding the role of adherence. This review describes a comprehensive literature search of adherence to CBTI. The search revealed 15 studies that evaluated adherence to CBTI in adults using valid and reliable measures of sleep, and measure of adherence other than study withdrawals. The primary purposes of this review were to 1) synthesize current study characteristics, methodology, adherence rates, contributing factors, and impact on outcomes, 2) discuss measurement issues, and 3) identify future practice and research directions that may lead to improved outcomes. Strong patterns and inconsistencies were identified among the studies, which complicate an evaluation of the role of adherence as a factor and outcome of CBTI success. The importance of standardized adherence and outcome measures is discussed. In light of the importance of adherence to behavior change, this systematic review may better inform future intervention efforts.

Introduction

Chronic insomnia is a public health crisis affecting approximately 10–15% of adults worldwide.1, 2, 3 In addition to the social and financial toll,4 insomnia is associated with serious health conditions,5 greater healthcare utilization,6 work absenteeism,7 and motor-vehicle accidents.8 With accumulating evidence of the effectiveness of cognitive behavioral therapy for insomnia (CBTI),3, 9, 10, *11 adherence to this treatment is a fundamental public health, clinical, and scientific concern.

Little is known about adherence rates and factors related to patients' adherence to CBTI. The lack of attention to adherence to CBTI stands in stark contrast to adherence to treatments for other sleep disorders12 and other medical conditions, which have been the focus of theoretical and empirical research for decades.13 The term compliance, used extensively in the past, has drawn criticism for its emphasis on medical authority and implication that patients are passive recipients of care. In response, the term “adherence” was introduced to call attention to the importance of patient agreement with medical recommendations.14 Adherence is generally referred to as the extent to which a person's behavior coincides with medical or health advice.15, 16 For the purpose of this paper, adherence is defined as persistence in the practice and maintenance of desired health behaviors, and is the result of patient's active participation in and agreement with treatment recommendations.17, 18, 19

Insomnia, characterized by difficulty initiating, maintaining, or obtaining good quality sleep, often occurs in the presence of a medical or psychiatric condition (comorbid insomnia) or may stand alone as a single condition (primary insomnia).1 Growing evidence supports the effectiveness of CBTI for the management of both primary and comorbid insomnia without the associated habituation, and cognitive and psychomotor impairments of pharmacotherapy.*11, 20 CBTI, a multi-component intervention, most often features sleep restriction (SR), stimulus control (SC), sleep hygiene education (SHE), cognitive therapy (CT), and can include relaxation techniques. The specifics of these interventions are discussed in detail elsewhere.9, 21, 22 Based on substantial evidence primarily from randomized controlled trials (RCT), the American Academy of Sleep Medicine has established that combined SR, SC, relaxation training, and CT are efficacious therapies for chronic insomnia.10 Furthermore, CBTI, with and without relaxation therapy, is superior to pharmacological therapy in maintaining treatment gains beyond the completion of treatment.20, 23, 24 RCTs support the efficacy of CBTI under ideal controlled conditions, however, the effectiveness of CBTI in real world situations is less certain.

Adherence to medical treatment is a challenging problem for many clinicians, including behavioral therapists.25 Overall, adherence among patients with chronic conditions is disappointingly low compared to patients with acute medical problems, particularly after several months of therapy. It is not surprising that adherence is suboptimal to treatment of chronic sleep disorders. In a meta-analysis of 569 studies examining adherence to common medical treatments, the average adherence rate was 75% and the mean adherence to sleep-related treatments (65.5%) was the lowest of the disorders studied.25 Most studies reflect poor adherence to positive airway pressure (PAP) treatment for sleep apnea, but also include studies of adherence to behavioral treatment for insomnia. Poor adherence to sleep-related treatments may be due to barriers specific to PAP or to a low relative importance assigned to managing sleep problems in general.

In contrast to the PAP literature, CBTI studies rarely include adherence information. If included, it is often limited to average sessions attended or overall study attrition. Available estimates of withdrawal during CBTI suggest that 14–40% of study participants drop out of individual or group treatment before mid-treatment,26 thus potentially diminishing the opportunity for improvement in insomnia. Dropout rates for internet-based treatment fall within the same range as group or individual CBTI. For example, 17% of adults with chronic insomnia (n = 94) dropped out of weekly internet modules.27 In another study, 33% withdrew before the end of five weekly CBTI online modules.28 Research conducted in natural clinical settings may have even higher dropout rates*29, 30 compared with RCTs, which typically have more rigorous monitoring and homogenous participant samples.*31, 32

Examining the proportion of individuals who discontinue CBTI allows researchers to understand the characteristics of this group compared to treatment completers. Much can also be gained, however, by considering adherence beyond attrition rates, both in terms of factors that shape adherent behavior, and in refining CBTI to reflect the most effective treatment in a range of vulnerable subgroups. To date, previous reviews of CBTI have inadequately addressed the issue of adherence. The goal of this systematic review is to analyze the best available scientific evidence related to CBTI adherence and to identify gaps in the literature. Specifically, we will 1) describe current study characteristics, methodology, adherence rates, contributing factors, and impact on outcomes, 2) discuss measurement issues, and 3) identify future practice and research directions that may lead to improved outcomes.

Section snippets

Search methods and study selection

A systematic review of empirical literature having to do with adherence to CBTI was conducted with assistance from a trained health librarian. Databases included PubMed, PsycInfo and MEDLINE. Search terms included “sleep disorders”, “insomnia”, “cognitive behavioral therapy”, “sleep restriction”, “stimulus control”, “sleep hygiene”, “sleep education”, “relaxation”, “cognitive therapy”, “adherence”, and “compliance” in all applicable combinations. The initial search was inclusive of all

Acknowledgments

This study was funded by the National Institute of Health and National Institute of Nursing Research (1K23NR010587) and the American Nurses Foundation (#2010-049).

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