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Cited by 78Sleep and related disordersSubstance Abuse Treatment and OutcomesObstructive Sleep Apnea Research

Insomnia treatment in the context of alcohol use disorder: A systematic review and meta-analysis

Open access
Miller, Mary Beth, Donahue, Marissa L., Carey, Kate B., Scott-Sheldon, Lori A.J.·2017·Drug and Alcohol Dependence
DOI 10.1016/j.drugalcdep.2017.09.029PMC PMC5683932
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Abstract

Purpose To determine the efficacy of behavioral and pharmacological interventions for insomnia among individuals with alcohol use disorder (AUD).Procedures Comprehensive literature searches of psychological, medical, and educational databases were conducted through October 2016. Eligible studies evaluated the efficacy of an insomnia intervention, included a comparison condition, sampled individuals with AUD and either insomnia disorder or complaints of insomnia, assessed sleep-related outcomes, and provided relevant statistics to calculate between-group effect sizes. Effect sizes were estimated for sleep quality, days of alcohol abstinence, and symptoms of depression. Type of intervention (behavioral versus pharmacological) was tested as a moderator of intervention efficacy.Main findings Nine studies met eligibility criteria and were included in the final review and meta-analysis. Random-effects models indicated that intervention participants reported greater improvements in sleep quality (d+=0.62, 95% CI=0.28, 0.97) and symptoms of depression (d+=0.52, 95% CI=0.06, 0.98) than control participants. Participants reported significantly greater improvements in sleep quality in response to behavioral (d+=1.20, 95% CI=0.70, 1.70) as opposed to pharmacological (d+=0.43, 95% CI=0.19, 0.67) interventions. Behavioral (d+=0.74, 95% CI=0.31, 1.18) and pharmacological (d+=0.08, 95% CI=-0.64, 0.78) interventions did not have significantly different effects on depressive symptoms. Neither behavioral nor pharmacological interventions improved rates of alcohol abstinence.Conclusions Insomnia interventions improve sleep quality and reduce symptoms of depression among individuals with comorbid AUD. Given the methodological weaknesses of studies reviewed, additional research is needed to determine the efficacy of insomnia treatment in improving rates of alcohol relapse within this population.

Verified 2026-10-10 · 1 reference not checked yet

AI snapshot

Written from the paper’s full text.

TL;DR

This systematic review and meta-analysis found that insomnia interventions improved sleep quality and depressive symptoms among individuals with alcohol use disorder, with behavioral interventions showing larger sleep-quality effects than pharmacological ones. Neither intervention type improved rates of alcohol abstinence.

Key findings

  • Across 9 studies and 410 participants, insomnia interventions produced greater improvements in sleep quality than control conditions (d+ = 0.62, 95% CI = 0.28, 0.97).
  • Behavioral interventions improved sleep quality more than pharmacological interventions (behavioral d+ = 1.20, 95% CI = 0.70, 1.70; pharmacological d+ = 0.43, 95% CI = 0.19, 0.67).
  • Intervention participants showed greater reductions in depressive symptoms than controls (d+ = 0.52, 95% CI = 0.06, 0.98), with no statistically significant difference between behavioral and pharmacological interventions.
  • Neither behavioral nor pharmacological interventions improved alcohol abstinence (overall d+ = 0.09, 95% CI = −0.49, 0.68).

Methods

  • Systematic review and meta-analysis following PRISMA guidelines, with comprehensive database searches through October 2016.
  • Eligible studies evaluated an insomnia intervention, included a comparison condition, sampled individuals with AUD and insomnia disorder or insomnia complaints, assessed sleep-related outcomes, and provided statistics for between-group effect sizes.
  • Nine studies met criteria; random-effects models estimated effects for sleep quality, days of alcohol abstinence, and depressive symptoms, and intervention type (behavioral vs. pharmacological) was tested as a moderator.

Limitations

  • The paper states that definitions of insomnia varied across studies, samples were not necessarily seeking or engaged in alcohol treatment, and three out of four participants were men, limiting generalizability.
  • The paper states methodological weaknesses: 8 of 9 trials had fewer than 30 participants per group at first follow-up, attrition and missing data were inconsistently handled, 5 of 9 studies were limited to post-intervention outcomes, and only 6 studies provided outcome data for both sleep quality and alcohol abstinence.
  • The paper states publication bias could not be assessed because fewer than 10 studies were included; the text also makes evident that abstinence analyses were heterogeneous (I² = 79) and based on limited trials.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1016/j.drugalcdep.2017.09.029

Cites

68 of 69 references verified0 citation errors · 0 not checkable

Statistics

Claims the paper makes

0 of 31 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    Intervention type did not significantly moderate alcohol abstinence outcomes (behavioral d+ = 0.24, 95% CI = -0.74, 1.23; pharmacological d+ = 0.00, 95% CI = -0.77, 0.78; Q = 0.14, p = .71).

    “Intervention type did not significantly moderate treatment outcomes (behavioral d+ = 0.24, 95% CI = −0.74, 1.23; pharmacological d+ = 0.00, 95% CI = −0.77, 0.78; Q [1] = 0.14, p = .71).”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The different sleep quality and depression measures used across included studies are sufficiently comparable to be pooled into single effect sizes.
    • Rests on an assumption: The different comparison conditions across included studies (assessment-only, matched content/time, placebo, active medication) are sufficiently equivalent to serve as controls in pooled analyses.
  • Findingown data

    The proportion of methodological quality criteria met was not a significant predictor of sleep quality (B = -0.48, p = .64).

    “The proportion of methodological quality criteria achieved (see Table 1) was not a significant predictor of sleep quality (B = −0.48, p = .64), alcohol abstinence (B = −1.68, p = .18), or depressive symptoms (B = −2.95, p = .21).”
    Quote in the paperNot a substantial claim
  • Findingown data

    Sleep quality outcomes did not reject the null hypothesis of homogeneity (Q[7] = 12.82, p = .08; I2 = 45).

    “however, we failed to reject the null hypothesis of homogeneity (Q [7] = 12.82, p = .08; I2 = 45, 95% uncertainty limits = 0, 76).”
    Quote in the paperNot a substantial claim
  • Findingown data

    The proportion of methodological quality criteria met was not a significant predictor of depressive symptoms (B = -2.95, p = .21).

    “The proportion of methodological quality criteria achieved (see Table 1) was not a significant predictor of sleep quality (B = −0.48, p = .64), alcohol abstinence (B = −1.68, p = .18), or depressive symptoms (B = −2.95, p = .21).”
    Quote in the paperNot a substantial claim
  • Findingown data

    The studies satisfied a mean of 62% (SD = 0.18; range = 31-88%) of the methodological quality criteria.

    “The studies satisfied a mean of 62% (SD = 0.18; range = 31–88%) of the methodological quality criteria.”
    Quote in the paperNot a substantial claim
  • The quote only partly states this claim. 1
  • Classified as probably not a substantial claim. 11
  • May combine two claims. 16

  • The quote only partly states this claim.

    Findingown data

    Neither behavioral nor pharmacological interventions improved rates of alcohol abstinence (pooled d+ = 0.09, 95% CI = -0.49, 0.68).

    “Neither behavioral nor pharmacological interventions improved rates of alcohol abstinence.”
    • Also stated in: § 3.4. Summary of Effects · plain
      “There were no between-group differences in rates of abstinence (d+ = 0.09; 95% CI = −0.49, 0.68).”
    • Also stated in: § 4. Discussion · plain
      “Neither behavioral nor pharmacological interventions improved rates of alcohol abstinence within this population.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The different sleep quality and depression measures used across included studies are sufficiently comparable to be pooled into single effect sizes.
    • Rests on an assumption: The different comparison conditions across included studies (assessment-only, matched content/time, placebo, active medication) are sufficiently equivalent to serve as controls in pooled analyses.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingnone given

    Among the behavioral treatments available, CBT-I was the primary intervention investigated.

    “Of the behavioral treatments available, CBT-I was the primary intervention investigated.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingcitation

    CBT-I reduced symptoms of depression among individuals with comorbid AUD, with effect sizes ranging from small to large.

    “Consistent with previous studies (Clarke et al., 2015; Manber et al., 2008), CBT-I reduced symptoms of depression among individuals with comorbid AUD, with effect sizes ranging from small to large.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingreasoning

    Both behavioral and pharmacological interventions improved sleep quality among individuals with alcohol use disorder (AUD).

    “Both behavioral and pharmacological interventions improved sleep quality among individuals with AUD.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingreasoning

    CBT-I was highly effective in improving sleep quality among individuals with comorbid AUD, with all available studies indicating large effects.

    “CBT-I was highly effective in improving sleep quality among individuals with comorbid AUD, with all available studies indicating large effects.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Some trials included AUD participants who complained of sleep disturbance and others required that participants meet diagnostic criteria for both AUD and insomnia disorder.

    “Definitions of ‘insomnia’ varied considerably across studies; some trials included AUD participants who complained of sleep disturbance and others required that participants meet diagnostic criteria for both AUD and insomnia disorder.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    All studies used appropriate statistical analyses for between-group differences.

    “Finally, all studies used appropriate statistical analyses for between-group differences”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductown data

    Two trained reviewers independently extracted data from each article.

    “Two trained reviewers independently extracted data regarding study information (e.g., publication year and source), sample characteristics (e.g., sample size, age), design and measurement specifics (e.g., recruitment method, number of follow-ups), length and content of the intervention (e.g., behavioral or pharmacological, inclusion of sleep education), and overall methodological quality from each”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    Interrater reliability was moderate for categorical variables (81% agreement; mean Cohen's k = 0.71) and strong for continuous variables (average intraclass correlation coefficient = 0.89).

    “For categorical variables, raters agreed on 81% of judgments (mean Cohen’s k = 0.71, indicating a moderate agreement; Landis and Koch, 1977). For continuous variables, raters were in strong agreement (average intraclass correlation coefficient = 0.89).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Landis and Koch, 1977 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    Publication bias could not be assessed because fewer than 10 studies were included in the meta-analysis.

    “Publication bias could not be assessed due to the limited number of studies included in the meta-analysis (i.e., <10 studies; Lau et al., 2006).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Lau et al., 2006 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Recent reviews have summarized clinical manifestations, etiology, assessment, and treatment of insomnia in AUD, but none have quantified the impact of various insomnia treatments on sleep- and alcohol-related outcomes.

    “Recent reviews have summarized the clinical manifestations, etiology, assessment, and treatment of insomnia in the context of AUD (Brooks and Wallen, 2014; Brower, 2015; Chakravorty, Chaudhary, et al., 2016). However, none have quantified the impact of various insomnia treatments on sleep- and alcohol-related outcomes.”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites Brooks and Wallen, 2014

      Not checked in the free run.

    • cites Brower, 2015 source

      Not checked in the free run.

    • cites Chakravorty, Chaudhary, et al., 2016

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    In the context of alcohol treatment, insomnia symptoms precede and predict relapse to alcohol use.

    “Moreover, in the context of alcohol treatment, insomnia symptoms have been shown to precede and predict relapse to alcohol use (Brower et al., 2001; Malcolm et al., 2007; Smith et al., 2014).”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites Brower et al., 2001 source

      Not checked in the free run.

    • cites Malcolm et al., 2007

      Not checked in the free run.

    • cites Smith et al., 2014 source

      Not checked in the free run.

  • May combine two claims.

    Interpretationown data

    Insomnia interventions improve sleep quality and reduce symptoms of depression among individuals with comorbid AUD.

    “Insomnia interventions improve sleep quality and reduce symptoms of depression among individuals with comorbid AUD.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The different sleep quality and depression measures used across included studies are sufficiently comparable to be pooled into single effect sizes.
    • Rests on an assumption: The different comparison conditions across included studies (assessment-only, matched content/time, placebo, active medication) are sufficiently equivalent to serve as controls in pooled analyses.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    This systematic review and meta-analysis was prepared using PRISMA guidelines.

    “This systematic review and meta-analysis was prepared using guidelines outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA; Moher et al., 2009).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Moher et al., 2009 source

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning

    It is unclear to what extent the variation in insomnia definitions impacted outcomes, as participants in all studies reported sleep disturbances above the clinical screening cut-off for insomnia.

    “It is unclear to what extent this impacted outcomes, as participants in all studies reported sleep disturbances above the clinical screening cut-off for insomnia.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    There is strong evidence for the efficacy of insomnia interventions in improving sleep quality among individuals with AUD, but data regarding secondary benefits such as reduced alcohol relapse were limited.

    “Collectively, there is strong evidence for the efficacy of insomnia interventions in improving sleep quality among individuals with AUD; however, data regarding the secondary benefits of such interventions (e.g., reduced rates of alcohol relapse) were limited.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The different sleep quality and depression measures used across included studies are sufficiently comparable to be pooled into single effect sizes.
    • Rests on an assumption: The different comparison conditions across included studies (assessment-only, matched content/time, placebo, active medication) are sufficiently equivalent to serve as controls in pooled analyses.

  • May combine two claims.

    Premisecitation

    Rates of alcohol relapse may be higher among those in earlier recovery (2 to 4 weeks after detoxification), which is a time of prevalent sleep disturbance.

    “Rates of alcohol relapse may be higher among those in earlier recovery (2 to 4 weeks after detoxification), which is a time of prevalent sleep disturbance (Chakravorty, Chaudhary, et al., 2016).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Chakravorty, Chaudhary, et al., 2016

      Not checked in the free run.

  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    Behavioral treatments may be preferable to medication in the context of AUD because they are longer-lasting and theoretically may break the cycle of using substances to manage distress.

    “Behavioral treatments may be preferable to medication in the context of AUD because they are longer-lasting and, theoretically, may break the cycle of using substances to manage distress (Brower, 2015).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Brower, 2015 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

    Study design and conductreasoning

    We could be more confident in conclusions regarding the efficacy of insomnia treatment within this population if samples were more consistent across studies.

    “However, we could be more confident in conclusions regarding the efficacy of insomnia treatment within this population if samples were more consistent across studies.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    In Friedmann and colleagues (2008), the sample consisted of recently detoxified patients, only 25% of whom had engaged in formal substance use treatment by one-month follow-up.

    “However, their sample also consisted of recently detoxified patients, only 25% of whom had engaged in formal substance use treatment by one-month follow-up.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Friedmann et al., 2008 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    In a previous meta-analytic review, relaxation, cognitive-behavioral, and strictly behavioral interventions all demonstrated robust effects on sleep quality and symptoms of insomnia among middle-aged and older adults.

    “This conclusion is consistent with the results of a previous meta-analytic review, in which relaxation, cognitive-behavioral, and strictly behavioral interventions all demonstrated robust effects on sleep quality and symptoms of insomnia among middle-aged and older adults; however, cognitive behavioral techniques were needed to improve sleep efficiency (Irwin et al., 2006).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Irwin et al., 2006 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Insomnia symptoms are common among individuals with AUD, with rates as high as 74% among those actively drinking, 69% during early recovery, and 50% after four weeks of sobriety.

    “Insomnia symptoms are common among individuals with alcohol use disorder (AUD), with rates as high as 74% among those who are actively drinking, 69% during early recovery, and 50% after four weeks of sobriety (Brower et al., 2001; Chaudhary et al., 2015; Kolla et al., 2014).”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites Brower et al., 2001 source

      Not checked in the free run.

    • cites Chaudhary et al., 2015 source

      Not checked in the free run.

    • cites Kolla et al., 2014 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The prevalence of depressive symptoms among patients with AUD is high.

    “Given the prevalence of depressive symptoms among patients with AUD (SAMHSA, 2016) and the promise of these findings, additional studies examining the impact of CBT-I on psychiatric outcomes among patients with AUD are warranted.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites SAMHSA, 2016

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Rates of AUD tend to be higher among men.

    “While rates of AUD tend to be higher among men (Goldstein et al., 2015), rates of AUD are increasing among women (Han et al., 2017) and the prevalence of insomnia tends to be higher among women (Ford et al., 2015).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Goldstein et al., 2015 source

      Not checked in the free run.

  • May combine two claims.

    Interpretationown data

    Both behavioral and pharmacological insomnia interventions improved sleep quality and depressive symptoms among individuals with comorbid AUD, although improvements were stronger for behavioral interventions.

    “Both behavioral and pharmacological insomnia interventions improved sleep quality and depressive symptoms among individuals with comorbid AUD, although improvements were stronger for behavioral interventions.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The different sleep quality and depression measures used across included studies are sufficiently comparable to be pooled into single effect sizes.
    • Rests on an assumption: The different comparison conditions across included studies (assessment-only, matched content/time, placebo, active medication) are sufficiently equivalent to serve as controls in pooled analyses.

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationnone given

    Findings from this systematic review and meta-analysis fill a gap in the literature by quantifying the impact of various insomnia treatments on sleep- and alcohol-related outcomes.

    “Findings from this systematic review and meta-analysis fill a gap in the literature by quantifying the impact of various insomnia treatments on sleep- and alcohol-related outcomes.”
    Quote in the paperNot a substantial claim
26 of 26

  • The paper relies on this without support.

    The different sleep quality and depression measures used across included studies are sufficiently comparable to be pooled into single effect sizes.

    “Sleep quality was measured in one study using the daily sleep diary, in one study using an unpublished measure, in two studies using the Sleep Problems Questionnaire (Jenkins et al., 1988), in three studies using the Pittsburgh Sleep Quality Index (Buysse et al., 1989), and in three studies using the Insomnia Severity Index (Morin et al., 2011) (see Table 1).”

  • The paper relies on this without support.

    The different comparison conditions across included studies (assessment-only, matched content/time, placebo, active medication) are sufficiently equivalent to serve as controls in pooled analyses.

    “Of the four behavioral intervention trials, two implemented a comparison condition that was matched for both content and time; the other two utilized assessment-only controls. Of the five pharmacological trials, four utilized a time-matched placebo and one (Karam-Hage and Brower, 2003) used trazodone as an active medication comparison.”

  • The paper relies on this without support.

    The co-occurrence of insomnia and AUD is prevalent and costly.

    “The co-occurrence of insomnia and AUD is both prevalent and costly.”
3 of 3

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  • ConsistentQ(1) = 2.44reported p = .118 · recomputed p = .118

    “QB (1) = 2.44, p = .118”

1 of 1

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Authors
Miller, M. B., Donahue, M. L., Carey, K. B., & Scott-Sheldon, L. A. J.
Affiliations
  • Brown University (US)
  • Miriam Hospital (US)
Corresponding author
Miller, Mary Beth
ORCID
Venue
Drug and Alcohol Dependence
Publisher
Elsevier BV
Published
2017-12
Volume
181
Pages
200-207
ISSN
0376-8716 (ISSN-L)
DOI
10.1016/j.drugalcdep.2017.09.029
PMC
PMC5683932
OpenAlex
W2765515288
Cited by
78
References
68
Citations by year
2026: 5 · 2025: 14 · 2024: 10 · 2023: 8 · 2022: 10 · 2021: 11 · 2020: 9 · 2019: 5 · 2018: 6
FWCI
0.86
Type
journal article
Language
en
Open access
Licence
Locations
  • Drug and Alcohol Dependence (publishedVersion)
  • PubMed (publishedVersion)
  • Europe PMC (PubMed Central) (acceptedVersion)
  • PubMed Central (acceptedVersion)
Funders
  • National Center for Complementary and Integrative Health (R01-AT008815)
  • National Institute on Alcohol Abuse and Alcoholism (T32-AA007459)
Topics
  • Social Sciences › Psychology › Experimental and Cognitive Psychology › Sleep and related disorders
  • Health Sciences › Medicine › Epidemiology › Substance Abuse Treatment and Outcomes
  • Health Sciences › Medicine › Physiology › Obstructive Sleep Apnea Research
Keywords
insomnia, alcoholism, insomnia treatment, sleep quality, depression, behavioral interventions, pharmacological interventions, alcohol abstinence, comorbidities, alcohol relapse
MeSH terms
Sleep Aids, Pharmaceutical, Adult, Alcoholism, Behavior Therapy, Depression, Female, Humans, Sleep Initiation and Maintenance Disorders, Male, Middle Aged, Sleep, Treatment Outcome

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