Cited by 528Sleep and related disordersObstructive Sleep Apnea ResearchAnxiety, Depression, Psychometrics, Treatment, Cognitive Processes

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Cognitive Behavioral Therapy for Insomnia Comorbid With Psychiatric and Medical Conditions: A Meta-analysis

Wu, Jade Q., Appleman, Erica R., Salazar, Robert D., Ong, Jason C.·2015·JAMA Internal Medicine

DOI 10.1001/jamainternmed.2015.3006

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Abstract

IMPORTANCE: Cognitive behavioral therapy for insomnia (CBT-I) is the most prominent nonpharmacologic treatment for insomnia disorders. Although meta-analyses have examined primary insomnia, less is known about the comparative efficacy of CBT-I on comorbid insomnia. OBJECTIVE: To examine the efficacy of CBT-I for insomnia comorbid with psychiatric and/or medical conditions for (1) remission from insomnia; (2) self-reported sleep efficiency, sleep onset latency, wake after sleep onset, total sleep time, and subjective sleep quality; and (3) comorbid symptoms. DATA SOURCES: A systematic search was conducted on June 2, 2014, through PubMed, PsycINFO, the Cochrane Library, and manual searches. Search terms included (1) CBT-I or CBT or cognitive behavioral [and its variations] or behavioral therapy [and its variations] or behavioral sleep medicine or stimulus control or sleep restriction or relaxation therapy or relaxation training or progressive muscle relaxation or paradoxical intention; and (2) insomnia or sleep disturbance. STUDY SELECTION: Studies were included if they were randomized clinical trials with at least one CBT-I arm and had an adult population meeting diagnostic criteria for insomnia as well as a concomitant condition. Inclusion in final analyses (37 studies) was based on consensus between 3 authors' independent screenings. DATA EXTRACTION AND SYNTHESIS: Data were independently extracted by 2 authors and pooled using a random-effects model. Study quality was independently evaluated by 2 authors using the Cochrane risk of bias assessment tool. MAIN OUTCOMES AND MEASURES: A priori main outcomes (ie, clinical sleep and comorbid outcomes) were derived from sleep diary and other self-report measures. RESULTS: At posttreatment evaluation, 36.0% of patients who received CBT-I were in remission from insomnia compared with 16.9% of those in control or comparison conditions (pooled odds ratio, 3.28; 95% CI, 2.30-4.68; P < .001). Pretreatment and posttreatment controlled effect sizes were medium to large for most sleep parameters (sleep efficiency: Hedges g = 0.91 [95% CI, 0.74 to 1.08]; sleep onset latency: Hedges g = 0.80 [95% CI, 0.60 to 1.00]; wake after sleep onset: Hedges g = 0.68; sleep quality: Hedges g = 0.84; all P < .001), except total sleep time. Comorbid outcomes yielded a small effect size (Hedges g = 0.39 [95% CI, 0.60-0.98]; P < .001); improvements were greater in psychiatric than in medical populations (Hedges g = 0.20 [95% CI, 0.09-0.30]; χ2 test for interaction = 12.30; P < .001). CONCLUSIONS AND RELEVANCE: Cognitive behavioral therapy for insomnia is efficacious for improving insomnia symptoms and sleep parameters for patients with comorbid insomnia. A small to medium positive effect was found across comorbid outcomes, with larger effects on psychiatric conditions compared with medical conditions. Large-scale studies with more rigorous designs to reduce detection and performance bias are needed to improve the quality of the evidence.

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“Cognitive Behavioral Therapy for Insomnia (CBT-I; a behavioral treatment that addresses the cognitive, physiological, and behavioral maintaining factors of insomnia) is the recommended first line of treatment for sleep issues [48] and has been demonstrated to be effective in college students [49], as well as in popula…”
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A Pilot Randomized Controlled Trial (RCT) of Acceptance and Commitment Therapy Versus Cognitive Behavioral Therapy for Chronic Insomnia
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Hypnotic drug risks of mortality, infection, depression, and cancer: but lack of benefit
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“Adjunctive CBT-I [159,240,323–325 ,326”
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“Meta-analyses have shown that CBT-I improves sleep among patients with chronic pain(16, 17) and there is some indication that CBT-I improves pain outcomes.”
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Krakow, B. J., McIver, N. D., Ulibarri, V. A., Krakow, J., & Schrader, R. M. (2019) · EClinicalMedicine · doi:10.1016/j.eclinm.2019.06.011 · Cited by 24
Understanding fatigue in adults with visual impairment: A path analysis study of sociodemographic, psychological and health-related factors
Schakel, W., Bode, C., van de Ven, P. M., van der Aa, H. P. A., Hulshof, C. T. J., van Rens, G. H. M. B., & van Nispen, R. M. A. (2019) · PLoS ONE · doi:10.1371/journal.pone.0224340 · Cited by 24
“Psychological interventions such as cognitive behavioral therapy (CBT) are effective treatment options for depression [50], although the evidence is less convincing in the field of low vision [51].”
Background
Primary care provider evaluation and management of insomnia
Sun, J., McPhillips, M., Chen, K.-C., Zang, Y., Li, J., Oehlke, J., Brewster, G. S., & Gooneratne, N. S. (2021) · Journal of Clinical Sleep Medicine · doi:10.5664/jcsm.9154 · Cited by 27
“47 Unlike CBT-I, hypnotic medications for insomnia can be associated with several disadvantages, including adverse effects, drug-drug interactions, habituation, and dependency.”
Modified Cognitive Behavioral Therapy for Insomnia in Depressed Adolescents: A Pilot Study
Conroy, D. A., Czopp, A., Dore‐Stites, D., Dopp, R. R., Armitage, R., Hoban, T. F., & Arnedt, J. T. (2017) · Behavioral Sleep Medicine · doi:10.1080/15402002.2017.1299737 · Cited by 24
Sleep is a modifiable determinant of health: Implications and opportunities for health psychology
Kyle, S. D., & Henry, A. L. (2017) · British Journal of Health Psychology · doi:10.1111/bjhp.12251 · Cited by 24
Genetic and Environmental Contributions to Sleep Quality and Low Back Pain: A Population-Based Twin Study
Pinheiro, M. B., Morosoli, J. J., Ferreira, M. L., Madrid‐Valero, J. J., Refshauge, K. M., Ferreira, P. H., & Ordoñana, J. R. (2017) · Psychosomatic Medicine · doi:10.1097/psy.0000000000000548 · Cited by 24
“For instance, interventions proven to be effective in improving sleep quality, such as cognitive behavioral therapy (57,58), would have the potential to also improve pain in patients experiencing sleep problems and low back pain.”
Background
Novel Treatment Based on Acceptance and Commitment Therapy Versus Cognitive Behavioral Therapy for Insomnia: A Randomized Comparative Effectiveness Trial in Women Veterans
Martin, J. L., Carlson, G. C., Kelly, M. R., Song, Y., Mitchell, M. N., Josephson, K. R., McGowan, S. K., Culver, N. C., Kay, M. A., Erickson, A. J., et al. (2023) · Journal of Consulting and Clinical Psychology · doi:10.1037/ccp0000836 · Cited by 23
Efficacy of cognitive behavioral therapy for comorbid insomnia: a meta-analysis
Okajima, I., & Inoue, Y. (2017) · Sleep and Biological Rhythms · doi:10.1007/s41105-017-0124-8 · Cited by 24
A Drosophila model of sleep restriction therapy for insomnia
Belfer, S. J., Bashaw, A. G., Perlis, M. L., & Kayser, M. S. (2019) · Molecular Psychiatry · doi:10.1038/s41380-019-0376-6 · Cited by 25
Examination of night eating and loss-of-control eating following bariatric surgery
Ivezaj, V., Lawson, J. L., Lydecker, J. A., Duffy, A. J., & Grilo, C. M. (2021) · Eating and Weight Disorders - Studies on Anorexia Bulimia and Obesity · doi:10.1007/s40519-021-01156-x · Cited by 23
Mindfulness as an Adjunct or Alternative to CBT-I
Ong, J. C., & Kalmbach, D. A. (2023) · Sleep Medicine Clinics · doi:10.1016/j.jsmc.2022.09.002 · Cited by 23
Comorbid insomnia and sleep apnea: a prevalent but overlooked disorder
Brock, M. S., & Mysliwiec, V. (2018) · Sleep And Breathing · doi:10.1007/s11325-018-1628-4 · Cited by 23
“In a metaanalysis of CBTi in comorbid medical and psychiatric disorders, only 36% of patients were in remission after treatment [15].”
Background
Delphi consensus recommendations for the management of chronic insomnia in Canada
Morin, C. M., Khullar, A., Robillard, R., Désautels, A., Mak, M. S. B., Dang‐Vu, T. T., Chow, W., Habert, J., Lessard, S., Alima, L., et al. (2024) · Sleep Medicine · doi:10.1016/j.sleep.2024.09.038 · Cited by 28
An evaluation of cognitive behavioral therapy for insomnia: A systematic review and application of Tolin’s Criteria for empirically supported treatments.
Boness, C. L., Hershenberg, R., Kaye, J. L., Mackintosh, M., Grasso, D. J., Noser, A. E., & Raffa, S. D. (2020) · Clinical Psychology Science and Practice · doi:10.1111/cpsp.12348 · Cited by 31
Residual symptoms of PTSD following Sertraline plus enhanced medication management, Sertraline plus PE, and PE plus placebo
Tripp, J. C., Norman, S. B., Kim, H. M., Venners, M. R., Martis, B., Simon, N. M., Stein, M. B., Allard, C. B., & Rauch, S. A. M. (2020) · Psychiatry Research · doi:10.1016/j.psychres.2020.113279 · Cited by 22
Efficacy of Face-to-Face Delivered Cognitive Behavioral Therapy in Improving Health Status of Patients With Insomnia: A Meta-Analysis
Xu, D., Cardell, E., Broadley, S., & Sun, J. (2021) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2021.798453 · Cited by 27
“Also, the effect of face-to-face CBT was more significant when the patients had co-morbid psychiatric diseases or taking drugs such as hypnotics and antidepressants, which was consistent with the findings in previous study (67).”
Result
Insomnia and Early Incident Atrial Fibrillation: A 16‐Year Cohort Study of Younger Men and Women Veterans
Gaffey, A. E., Rosman, L., Lampert, R. J., Yaggi, H. K., Haskell, S. G., Brandt, C., Enriquez, A. D., Mazzella, A. J., Skanderson, M., & Burg, M. M. (2023) · Journal of the American Heart Association · doi:10.1161/jaha.123.030331 · Cited by 22
Residual Insomnia and Nightmares Postintervention Symptom Reduction Among Veterans Receiving Treatment for Comorbid PTSD and Depressive Symptoms
López, C. M., Lancaster, C. L., Wilkerson, A. K., Grös, D. F., Ruggiero, K. J., & Acierno, R. E. (2019) · Behavior Therapy · doi:10.1016/j.beth.2019.01.006 · Cited by 24
Cognitive Behavioral Therapies for Insomnia and Hypnotic Medications
Cheung, J. M. Y., Ji, X., & Morin, C. M. (2019) · Sleep Medicine Clinics · doi:10.1016/j.jsmc.2019.01.006 · Cited by 25
Does cognitive-behavioural therapy improve sleep outcomes in individuals with traumatic brain injury: a scoping review
Ludwig, R. L., Vaduvathiriyan, P., & Siengsukon, C. F. (2020) · Brain Injury · doi:10.1080/02699052.2020.1831070 · Cited by 22
Effectivity of (Personalized) Cognitive Behavioral Therapy for Insomnia in Mental Health Populations and the Elderly: An Overview
Mijnster, T., Boersma, G. J., Meijer, E., & Lancel, M. (2022) · Journal of Personalized Medicine · doi:10.3390/jpm12071070 · Cited by 24
“Consistent with previous reports [16,84,89,166], our overview indicates that CBT-I is efficient in reducing insomnia symptoms across different mental health populations.”
Result
Advancing cognitive behaviour therapy for older adults with comorbid insomnia and depression
Sadler, P., McLaren, S., Klein, B., & Jenkins, M. (2017) · Cognitive Behaviour Therapy · doi:10.1080/16506073.2017.1359206 · Cited by 21
“Several recent studies have shown CBT-I produced similar benefits for adults and older adults with primary insomnia and insomnia that was associated with a mixture of psychiatric disorders (Edinger et al., 2009; Irwin et al., 2006; Wu et al., 2015).”
Background
Pain inconsistency and sleep in mid to late-life: the role of depression
Ravyts, S. G., Dzierzewski, J. M., Grah, S. C., Buman, M. P., Aiken‐Morgan, A. T., Giacobb, P. R., Roberts, B. L., Marsiske, M., & McCrae, C. S. (2018) · Aging & Mental Health · doi:10.1080/13607863.2018.1481929 · Cited by 21
Light-enhanced cognitive behavioural therapy for sleep and fatigue: study protocol for a randomised controlled trial during chemotherapy for breast cancer
Bean, H. R., Stafford, L., Little, R., Diggens, J., Ftanou, M., Alexander, M., Francis, P. A., Bei, B., & Wiley, J. F. (2020) · Trials · doi:10.1186/s13063-020-4196-4 · Cited by 22
Sleep and Suicide in Older Adults: An Opportunity for Intervention
Bishop, T. M., Simons, K. V., King, D. A., & Pigeon, W. R. (2016) · Clinical Therapeutics · doi:10.1016/j.clinthera.2016.09.015 · Cited by 21
A Pilot Randomized Controlled Trial to Assess Feasibility and Treatment Effect of a Web-Based Delivered Cognitive Behavioral Therapy for Insomnia Program in Individuals with Multiple Sclerosis
Siengsukon, C. F., Beck, E. S., & Drerup, M. L. (2020) · International Journal of MS Care · doi:10.7224/1537-2073.2019-122 · Cited by 20
Cognitive behavioral therapy for insomnia to reduce cannabis use: Results from a pilot randomized controlled trial
Arnedt, J. T., Conroy, D. A., Stewart, H. J., Yeagley, E. E., Bowyer, G. E., Bohnert, K. M., & Ilgen, M. A. (2023) · Drug and Alcohol Dependence · doi:10.1016/j.drugalcdep.2023.109835 · Cited by 22
Clinical Sleep–Wake Disorders II: Focus on Insomnia and Circadian Rhythm Sleep Disorders
Spiegelhalder, K., Nissen, C., & Riemann, D. W. (2017) · Handbook of experimental pharmacology · doi:10.1007/164_2017_40 · Cited by 20
Adapting Brief CBT-I for Depressed Adolescents: A Case Illustration of the Sleeping Better Program
Orchard, F., Pass, L., Chessell, C., Moody, A., Ellis, J. G., & Reynolds, S. A. (2019) · Cognitive and Behavioral Practice · doi:10.1016/j.cbpra.2019.07.010 · Cited by 20
Treatment of chronic primary sleep onset insomnia with Kundalini yoga: a randomized controlled trial with active sleep hygiene comparison
Khalsa, S. B. S., & Goldstein, M. R. (2021) · Journal of Clinical Sleep Medicine · doi:10.5664/jcsm.9320 · Cited by 23
“Full CBT-I treatments have been the most widely researched treatment modality, with demonstrable efficacy and effectiveness across a variety of primary and comorbid clinical presentations, 42 – 49 albeit requiring relatively high amount of time and provider training to administer.”
Tailoring cognitive behavioural therapy for insomnia across contexts, conditions, and individuals: What do we know, where do we go?
Crowther, M. E., Saunders, W. J., Sletten, T. L., Drummond, S. P. A., & Bei, B. (2023) · Journal of Sleep Research · doi:10.1111/jsr.14023 · Cited by 19
“Further, co-existing physical and mental health conditions could influence the presentation of insomnia (Wu et al., 2015; Zhou et al., 2020).”
Background
Understanding the Relationships Between Sleep Quality and Depression and Anxiety in Neurotrauma: A Scoping Review
Saravanan, K., Downey, L. A., Sawyer, A., Jackson, M. L., Berlowitz, D. J., & Graco, M. (2023) · Journal of Neurotrauma · doi:10.1089/neu.2023.0033 · Cited by 21
Apport de la pleine conscience dans les thérapies cognitives et comportementales de l’insomnie
Vanhuffel, H., Rey, M. F., Lambert, I., Fonséca, D. D., & Bat‐Pitault, F. (2017) · L Encéphale · doi:10.1016/j.encep.2016.12.001 · Cited by 22
Fear of sleep and sleep quality mediate the relationship between trauma exposure and suicide attempt in adolescents
King, C. D., Joyce, V. W., Nash, C. C., Buonopane, R. J., Black, J. M., Zuromski, K. L., & Millner, A. J. (2021) · Journal of Psychiatric Research · doi:10.1016/j.jpsychires.2021.01.026 · Cited by 20
Nighttime heart rate predicts response to depression treatment in patients with coronary heart disease
Carney, R. M., Freedland, K. E., Steinmeyer, B. C., Rubin, E. H., Stein, P. K., & Rich, M. W. (2016) · Journal of Affective Disorders · doi:10.1016/j.jad.2016.04.051 · Cited by 19
“A meta-analysis of CBT interventions for insomnia in patients with other psychiatric or medical disorders found that it was associated with greater than three-fold likelihood of remission compared to control conditions (Wu et al., 2015).”
Background
Psychological Interventions for Late-Life Insomnia: Current and Emerging Science
Dzierzewski, J. M., Griffin, S. C., Ravyts, S. G., & Rybarczyk, B. D. (2018) · Current Sleep Medicine Reports · doi:10.1007/s40675-018-0129-0 · Cited by 20
Examining Sleep Disturbance Among Sheltered and Unsheltered Transition Age Youth Experiencing Homelessness
Redline, B., Semborski, S., Madden, D. R., Rhoades, H., & Henwood, B. F. (2021) · Medical Care · doi:10.1097/mlr.0000000000001410 · Cited by 18
A step-by-step model for a brief behavioural treatment for insomnia in Australian general practice
Sweetman, A., Zwar, N. A., Grivell, N., Lovato, N., & Lack, L. C. (2021) · Australian Journal of General Practice · doi:10.31128/ajgp-04-20-5391 · Cited by 19
Pediatric sleep and pain: etiologies, consequences, and clinical considerations
Morris, E. E., Howell, M. J., Pickup, E., Iber, C., & Wang, S. G. (2022) · Journal of Clinical Sleep Medicine · doi:10.5664/jcsm.10008 · Cited by 18
Depression as a Mediator and Social Participation as a Moderator in the Bidirectional Relationship Between Sleep Disorders and Pain: Dynamic Cohort Study
Fan, S., Wang, Q., Zheng, F., Wu, Y., Yu, T., Wang, Y., Zhang, X., & Zhang, D. (2023) · JMIR Public Health and Surveillance · doi:10.2196/48032 · Cited by 21
Cognitive behavioral therapy for insomnia in veterans with gulf war illness: Results from a randomized controlled trial
Chao, L. L., Kanady, J. C., Crocker, N., Straus, L. D., Hlavin, J., Metzler, T. J., Maguen, S., & Neylan, T. C. (2021) · Life Sciences · doi:10.1016/j.lfs.2021.119147 · Cited by 17
Acceptance-Based Behavioural Treatment for Insomnia in Chronic Pain: A Clinical Pilot Study
Zetterqvist, V., Grudin, R., Rickardsson, J., Wicksell, R. K., & Holmström, L. (2018) · Journal of Contextual Behavioral Science · doi:10.1016/j.jcbs.2018.07.003 · Cited by 17
Efficacy of brief behavioural therapy for insomnia in older adults with chronic insomnia: a systematic review and meta-analysis from randomised trials
Chen, Y., Lu, T., Ku, E., Chen, C.-T., Fang, C., Lai, P.-C., & Liu, C.-H. (2023) · Age and Ageing · doi:10.1093/ageing/afac333 · Cited by 20
Deconstructing Chronic Low Back Pain in the Older Adult—Step by Step Evidence and Expert-Based Recommendations for Evaluation and Treatment: Part VII: Insomnia
Bramoweth, A. D., Renqvist, J. G., Germain, A., Buysse, D. J., Gentili, A., Kochersberger, G. G., Rodríguez, E., Rossi, M. I., & Weiner, D. K. (2016) · Pain Medicine · doi:10.1093/pm/pnw063 · Cited by 17

Authors: Wu, J. Q., Appleman, E. R., Salazar, R. D., & Ong, J. C.
Affiliations: Boston University (US)
Rush University Medical Center (US)
ORCID: Wu, Jade Q.
Appleman, Erica R.
Ong, Jason C.
Venue: JAMA Internal Medicine
Publisher: American Medical Association (AMA)
Published: 2015-09-01
Volume: 175
Issue: 9
Pages: 1461
ISSN: 2168-6106 (ISSN-L)
DOI: 10.1001/jamainternmed.2015.3006
OpenAlex: W1574691271
Cited by: 527
References: 65
Citations by year: 2026: 34 · 2025: 45 · 2024: 38 · 2023: 55 · 2022: 65 · 2021: 60 · 2020: 51 · 2019: 48 · 2018: 44 · 2017: 46 · 2016: 32 · 2015: 7
FWCI: 64.76
Type: journal article
Language: en
Open access: closed
Locations: JAMA Internal Medicine (publishedVersion)
PubMed (publishedVersion)
Topics: Social Sciences › Psychology › Experimental and Cognitive Psychology › Sleep and related disorders
Health Sciences › Medicine › Physiology (medical) › Obstructive Sleep Apnea Research
Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
Keywords: cognitive behavioral therapy for insomnia, insomnia comorbidity, psychiatric comorbidity, comorbidities, insomnia remission, sleep efficiency, sleep latency, wake after sleep onset, subjective sleep quality, sleep restriction, stimulus control, relaxation training, paradoxical intention, risk of bias
MeSH terms: Mental Disorders, Humans, Sleep Initiation and Maintenance Disorders, Sleep, Cognitive Behavioral Therapy, Treatment Outcome

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Cognitive Behavioral Therapy for Insomnia Comorbid With Psychiatric and Medical Conditions: A Meta-analysis

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