Clinical ReviewCognitive and behavioral therapies in the treatment of insomnia: A meta-analysis
Introduction
Insomnia is a major public health problem. The prevalence of insomnia, which may be characterized by difficulty initiating or maintaining sleep, with significant distress and impairments of daytime functioning, is high: about a third of the population suffers from insomnia symptoms, and about 10% fulfills the criteria for a sleep disorder [1], [2]. Insomnia has a high burden of disease, which impacts daily life in different domains [3], [4] and often persists for many years [5]. The societal costs are substantial: poor sleepers cost society about ten times as much as good sleepers [6]. These societal costs are due to increased health care consumption but especially caused by reduced work productivity and increased work absenteeism [6], [7].
In addition, insomnia is strongly associated with other somatic and mental health problems as well as with an increased mortality rate [8], [9], [10]. Most notable is the association with cardiovascular diseases [11], [12], [13] and with depression [14], [15], [16]. The nature of these associations is still not clear but it has been suggested that hyperarousal and the chronic activation of stress responses is a possible pathway between insomnia, depression and cardiac disease [13]. There are also indications that insomnia is a mediator in the increased mortality rates after depression [17].
Treatment of insomnia is highly desirable, mostly to decrease the burden of insomnia itself. But it might also contribute to a decrease of the associated somatic and mental health problems such as depression and cardiovascular risk.
Several meta-analyses have shown that benzodiazepine-receptor agonists are effective in enhancing sleep in the short run, but with risks of negative side effects and limited evidence for their long-term efficacy [18], [19], [20]. Various non-pharmacological treatments have been developed as alternatives. These non-pharmacological treatments can be classified as educational (psycho-education, sleep hygiene), behavioral (relaxation, sleep restriction, stimulus control, paradoxical intention) or cognitive (identifying and challenging dysfunctional thoughts and excessive worries about sleep; [21], [22], [23], [24], [25], [26]). Since the 1990s it has become popular to offer these non-pharmacological treatments in (various) combinations. These combinations are usually referred to as cognitive behavioral therapy for insomnia (CBTI).
Several excellent (systematic) reviews and meta-analyses have been written on CBTI; they conclude that CBTI is effective [27], [28], [29], [30], [31], ∗[32], [33] in primary [34] and comorbid ∗[35], ∗[36] insomnia and CBTI is at least as effective as pharmacotherapy ∗[37], ∗[38]. As a result, the American College of Physicians recently recommended CBTI as the initial treatment for all adults with insomnia [39]. Even though some of these reviews pooled the data of individual studies [e.g., [28], [29], ∗[35]], to our knowledge, no recent meta-analysis exists that includes all CBTI studies and that uses modern techniques to pool data and to analyze the subgroups of patients which might benefit most from CBTI.
The aim of this meta-analysis is to quantify the effects of educational, behavioral and cognitive therapies for insomnia, based on all available randomized controlled trials, and to perform subgroup analysis as a function of several potential moderators (e.g., comorbidity, sleep medication, year of publication) of treatment outcomes.
Section snippets
Search strategy
We carried out a comprehensive literature search in PubMed, PsycINFO, EMBASE and the Cochrane central register of controlled trials. We combined terms indicative of insomnia (e.g., insomnia, sleep disorders, sleep initiation and maintenance disorders) with those of psychological treatment (e.g., psychotherapy, cognitive therapy, behavior therapy). For example for PsycINFO we used (DE=(“sleep disorders” or “insomnia”)) and (DE=(“psychotherapy” or “behavior therapy” or “cognitive behavior
Selection of studies
The titles and abstracts of 1727 references were screened (after removal of 290 duplicates). We excluded 1503 references and retrieved full-text papers of the remaining 224 references. A total of 137 papers did not fulfill our inclusion criteria (Fig. 1). We included 87 papers on RCTs in which (a component of) CBTI was examined in comparison to a non-treatment control group [45–131]. Some studies had more than two arms and examined different active interventions in comparison to a control. Of
Discussion
In this meta-analysis on 87 studies with 118 comparisons we examined the effects of educational, behavioral and/or cognitive treatments for insomnia. The overall effects were large on insomnia severity (ISI; g = 0.98), sleep efficiency (SE; g = 0.71), the Pittsburgh sleep quality Index (PSQI; g = 0.65), wake after sleep onset (WASO; g = 0.63) and sleep onset latency (SOL; g = 0.57). Small to moderate effect sizes were observed for number of awakenings (NWAK; g = 0.28) and sleep quality (SQ; g
Conflicts of interest
Prof. Van Straten, Ms van der Zweerde, dr. Kleiboer, prof. Cuijpers and dr. Lancee, declare that they have no competing interests. Prof. Morin has served as a consultant for Merck, Valeant, and Novartis and received research support from Novartis. We did not receive any financial support to write this meta-analysis.
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