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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Background
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Impulsivity mediates the relationship between sleep quality and interpersonal functioning: a cross-sectional study in a sample of university students
Farrell, B. J., Emmerton, R. W., Camilleri, C., & Sammut, S. (2024) · Sleep Science and Practice · doi:10.1186/s41606-024-00113-8 · Cited by 10
“…which are utilized in behavioral interventions, such as cognitive behavioral therapy for insomnia (CBT-I), which have been shown to be more effective in assisting individuals suffering from sleep issues such as insomnia in the long-term (Schlarb et al., 2018; Trauer et al., 2015; Wu et al., 2015).”
Background
Efficacy of online mindfulness for the treatment of insomnia in pregnancy: A randomized clinical trial
Wi, D., Lee, R. Y., & Kantrowitz‐Gordon, I. (2025) · PLoS ONE · doi:10.1371/journal.pone.0322931 · Cited by 9
Evidence-Based Psychotherapy in Primary Care
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Cognitive-Behavioral Therapy for Insomnia (CBT-I)
Bennett, D. S. (2020) · Springer eBooks · doi:10.1007/978-3-030-44447-1_3 · Cited by 9
The Management of Prodromal Symptoms of Bipolar Disorder: Available Options and Future Perspectives
Favero, E. D., Montemagni, C., Bozzatello, P., Brasso, C., Riccardi, C., & Rocca, P. (2021) · Medicina · doi:10.3390/medicina57060545 · Cited by 11
The Experience of Insomnia in Patients With Schizophrenic Disorder: A Qualitative Study
Batalla-Martín, D., Martorell‐Poveda, M., Eraso, Á. G. B., Garijo, E. M., Serratosa, A. D.-C., Pérez, J. V., Escobar, M. M., & López‐Ruiz, M. (2022) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2021.805601 · Cited by 11
“Cognitive-behavioural therapy has shown statistically significant results in the treatment of insomnia (79) and in treating patients with comorbidities of both mental and organic diseases (80).”
Do better nights lead to better days? Guided internet-based cognitive behavioral therapy for insomnia in people suffering from a range of mental health problems: Protocol of a pragmatic randomized clinical trial
Reesen, J. E., van der Zweerde, T., Batelaan, N. M., Fris, E., Hoogendoorn, A. W., Ikelaar, S. L. C., Lakbila‐Kamal, O., Lancee, J., Leerssen, J., van Marle, H. J. F., et al. (2023) · Contemporary Clinical Trials · doi:10.1016/j.cct.2023.107122 · Cited by 9
EMPOWERED trial: protocol for a randomised control trial of digitally supported, highly personalised and measurement-based care to improve functional outcomes in young people with mood disorders
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Management of Insomnia in Patients with Alcohol Use Disorder
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Perspective: Cognitive Behavioral Therapy for Insomnia Is a Promising Intervention for Mild Traumatic Brain Injury
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Anxiety, depressive and insomnia symptoms among patients with depression: a network perspective
Luo, X. G., Fang, L., Du, S., Zeng, S., Zheng, S., & Zhang, B. (2025) · BMC Psychology · doi:10.1186/s40359-025-02826-6 · Cited by 9
Effects of cognitive-behavioral therapy for insomnia compared with controls among cancer survivors: a systematic review and meta-analysis of randomized trials
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Examining Sleep Quality Following Sleeve Gastrectomy Among Patients with Loss-of-Control Eating
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Brief Cognitive Behavioral Therapy for Insomnia in Parkinson's Disease: A Case Series Study 1
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Sex Differences in the Associations Between Chronic Diseases and Insomnia Symptoms Among Older Adults in India
Muhammad, T., Das, M., Jana, A., & Lee, S. (2024) · Nature and Science of Sleep · doi:10.2147/nss.s456025 · Cited by 8
Who Is Seeking Help for Sleep? A Clinical Profile of Patients in a Sleep Psychology Clinic
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Investigating Sleep Disturbance and Its Correlates Among Formerly Homeless Adults in Permanent Supportive Housing
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Treatment feasibility and preliminary evaluation of group-delivered cognitive behavioral therapy for insomnia adapted for patients with bipolar and related disorders: A pragmatic within-group study
Jernelöv, S., Killgren, J., Ledin, L., & Kaldo, V. (2021) · Journal of Affective Disorders Reports · doi:10.1016/j.jadr.2021.100293 · Cited by 9
Poor Subjective Sleep Quality Among Patients with Cancer and Comorbid Depression: An Opportunity to Inform Screening and Intervention
Price, S. N., Hamann, H. A., Halaby, L., Trejo, J. I., Corella, F., & Weihs, K. L. (2022) · Behavioral Sleep Medicine · doi:10.1080/15402002.2022.2033243 · Cited by 8
“Although no studies to date specifically focus on treating insomnia in patients with both cancer and depression, a meta-analysis of CBT-I for various clinical populations (medical or psychiatric diagnoses) found CBT-I efficacious for both cancer and mood disorder populations (Wu et al., 2015).”
Background
Effectiveness of change from suvorexant to lemborexant drug in the treatment of sleep disorders
Okino, K., Suzuki, H., Kondo, S., Tomioka, H., Tokumasu, T., Yamada, H., Iwanami, A., & Inamoto, A. (2022) · Psychogeriatrics · doi:10.1111/psyg.12858 · Cited by 8
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Special Considerations in the Adaptation of Cognitive Behavioral Therapy for Insomnia With Active-Duty U.S. Army Personnel
Pruiksma, K. E., Fina, B. A., Dietch, J. R., Dondanville, K. A., Williams, J. M., Wright, E. C., Molino, A. T. C., Hall‐Clark, B. N., Nicholson, K. L., Peterson, A. L., et al. (2018) · Cognitive and Behavioral Practice · doi:10.1016/j.cbpra.2017.12.007 · Cited by 9
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Internet-based cognitive behavioural therapy for insomnia comorbid with chronic benign pain – A randomized controlled trial
Bothelius, K., Jernelöv, S., Kaldo, V., Lu, C., Stråle, M.-M., & Jansson‐Fröjmark, M. (2024) · Internet Interventions · doi:10.1016/j.invent.2024.100781 · Cited by 8
“Cognitive behavioural therapy for insomnia, CBT-i (Morin et al., 2006), has been demonstrated to be effective in treating comorbid insomnia (Geiger-Brown et al., 2015; Wu et al., 2015; Zhou et al., 2020; Hertenstein et al., 2022; Blom et al., 2024).”
Background
Remission, treatment response, and treatment adherence across the delivery methods of cognitive behavioral therapy for insomnia: A systematic review and meta-analysis of randomized controlled trials
Takano, Y., Okajima, I., Osao, M., Ibata, R., Machida, N., Higami, K., Takagi, S., & Inoue, Y. (2025) · Sleep Medicine Reviews · doi:10.1016/j.smrv.2025.102204 · Cited by 9
Effects of non-pharmacological interventions on sleep quality in older adults: a systematic review and network meta-analysis of randomized controlled trials
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“This may be attributed to our study focus on strictly defined geriatric populations ( ≥ 60 years) and the incorporation of mindfulness techniques in CBT-I + , which may enhance anxiety management—a common comorbidity in insomnia [79].”
Effects of schedule exercise therapy on chronic insomnia
Liao, Y., Huang, F., Ni, X., Ke, H.-Y., Tian, Y., Yu, M., Jin, G., & Chen, G. (2022) · Medicine · doi:10.1097/md.0000000000030792 · Cited by 7
“[17-21] Clinical research has demonstrated that CBT-I can be a safe and effective treatment option for patients with CID with various medical and psychiatric comorbidities, including chronic pain, fibromyalgia, breast cancer, and vasomotor symptoms in perimenopausal women.[13,22-26] However, CBT-I is underutilized in…”
Background
A Pilot Nurse-Administered CBT Intervention for Insomnia in Patients with Schizophrenic Disorder: A Randomized Clinical Effectiveness Trial
Batalla-Martín, D., Martorell‐Poveda, M., Eraso, Á. G. B., Gordo, A. M., Lleal, H. B., Melendez, R., Girona, R. Q., & López‐Ruiz, M. (2023) · Journal of Clinical Medicine · doi:10.3390/jcm12196147 · Cited by 7
“CBT has also shown statistically signiﬁcant results in the treatment of insomnia [20,21] and in the treatment of patients with organic and mental health pathologies [22].”
From guidelines to bedside - insomnia treatment practices in South Korea: a nationwide cohort study
Moon, D. U., Piao, Z., Lee, D. H., & Han, E. (2024) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2024.1453550 · Cited by 10
“This observation is consistent with previous research, which has shown that the adoption of CBT-I in routine practice is limited despite its proven ef ﬁ cacy (24, 26, 32).”
Result
Suvorexant in the Treatment of Difficulty Falling and Staying Asleep (Insomnia)
Berger, A. A., Sottosanti, E., Winnick, A. A., Keefe, J., Gilbert, E., Hasoon, J. J., Thase, M. E., Kaye, A. D., Viswanath, O., & Urits, I. (2025) · Psychopharmacology Bulletin · doi:10.64719/pb.4429 · Cited by 8
Efficacy of a digital cognitive behavioral therapy for insomnia in people with low back pain: a feasibility randomized co-twin and singleton-controlled trial
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Solving insomnia electronically: Sleep treatment for asthma (SIESTA): A study protocol for a randomized controlled trial
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“CBT-I implemented in medical and psychiatric populations with comorbid insomnia has been shown to improve insomnia severity and general measures of mood, fatigue, and quality of life [22,23].”
Background
A Practical Application Primer on Cognitive Behavioral Therapy for Insomnia for Medical Residents
Chernyak, Y. (2019) · MedEdPORTAL · doi:10.15766/mep_2374-8265.10862 · Cited by 9
Treating co-morbid insomnia and social anxiety disorder with sequential CBT protocols: a single-case experimental study
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“A meta-analysis found that 36% of patients with insomnia and co-morbid psychiatric or medical disorders receiving CBT for insomnia (CBT-I) reached remission, and the effect sizes for most symptoms and sleep parameters varied between medium and large (Wu et al., 2015).”
BackgroundResult
Effectiveness of Cognitive Behavioural Therapy for Insomnia (CBT‐I) in Individuals With Neurodevelopmental Conditions: A Systematic Review
Cullen, M., McCrory, S., Hooman, G., Coyle, M., & Fleming, L. (2025) · Journal of Sleep Research · doi:10.1111/jsr.70058 · Cited by 5
“Given the vast evidence based on the usefulness of CBT-I in neurotypical populations (Trauer et al. 2015), including those with psychiatric and medical co-morbidities (Hertenstein et al. 2022; Scott et al. 2021; Wu et al. 2015; Zhou et al. 2020), large and consistent findings were expected.”
Combination treatment for chronic insomnia disorder in adults: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment
Buysse, D. J., Arnedt, J. T., Buenaver, L. F., Chang, J. L., Fernández‐Mendoza, J., Patel, S. I., Zhou, E. S., Falck-Ytter, Y. T., Hyer, S., Kazmi, U., et al. (2026) · Journal of Clinical Sleep Medicine · doi:10.1007/s44470-025-00039-7 · Cited by 6
“Be conducted with patients presenting with co-morbidities [32] such as depression [77], pain [78, 79], substance misuse [80], or sleep apnea [81].”
Cognitive behavioral therapy for insomnia treatment attrition in patients with weekly nightmares
Hamilton, N. A., Russell, J. A., Youngren, W. A., Gallegos, A. M., Crean, H. F., Cerulli, C., Bishop, T. M., Hamadah, K., Schulte, M., Pigeon, W. R., et al. (2023) · Journal of Clinical Sleep Medicine · doi:10.5664/jcsm.10710 · Cited by 7

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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