1. Ann Intern Med. 2015 Aug 4;163(3):191-204. doi: 10.7326/M14-2841.

Cognitive Behavioral Therapy for Chronic Insomnia: A Systematic Review and
Meta-analysis.

Trauer JM, Qian MY, Doyle JS, Rajaratnam SM, Cunnington D.

Comment in
    BMJ. 2015;350:h3076.
    Ann Intern Med. 2015 Aug 4;163(3):236-7.
    Evid Based Ment Health. 2016 Feb;19(1):e2.
    Ann Intern Med. 2016 Jan 19;164(2):134-5.
    Ann Intern Med. 2016 Jan 19;164(2):134.

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).

DOI: 10.7326/M14-2841 
PMID: 26054060  [Indexed for MEDLINE]