Cited by 199Sleep and related disordersPsychotherapy Techniques and ApplicationsAnxiety, Depression, Psychometrics, Treatment, Cognitive Processes

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Adherence to cognitive behavioral therapy for insomnia: A systematic review

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Matthews, Ellyn E., Arnedt, J. Todd, McCarthy, Michaela S., Cuddihy, Leisha J., Aloia, Mark S.·2013·Sleep Medicine Reviews

DOI 10.1016/j.smrv.2013.01.001PMC PMC3720832

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Abstract

Chronic insomnia is a significant public health problem worldwide, and insomnia has considerable personal and social costs associated with serious health conditions, greater healthcare utilization, work absenteeism, and motor-vehicle accidents. Cognitive behavioral therapy for insomnia (CBTI) is an efficacious treatment, yet attrition and suboptimal adherence may diminish its impact. Despite the increasing use of CBTI, surprisingly little attention has been devoted to understanding the role of adherence. This review describes a comprehensive literature search of adherence to CBTI. The search revealed 15 studies that evaluated adherence to CBTI in adults using valid and reliable measures of sleep, and measure of adherence other than study withdrawals. The primary purposes of this review were to 1) synthesize current study characteristics, methodology, adherence rates, contributing factors, and impact on outcomes, 2) discuss measurement issues, and 3) identify future practice and research directions that may lead to improved outcomes. Strong patterns and inconsistencies were identified among the studies, which complicate an evaluation of the role of adherence as a factor and outcome of CBTI success. The importance of standardized adherence and outcome measures is discussed. In light of the importance of adherence to behavior change, this systematic review may better inform future intervention efforts.

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“Sleep disorders, such as sleep insufﬁciency or impaired sleep quality, can be treated us-ing various behavioral techniques [3–5] or via pharmacological intervention [6,7].”
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Background
A Feasibility Study of Group-Delivered Behavioral Interventions for Insomnia Among Breast Cancer Survivors: Comparing Cognitive Behavioral Therapy for Insomnia and a Mind–Body Intervention
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Experiences of group-based cognitive behavioural therapy for insomnia among patients with rheumatoid arthritis: a qualitative study
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“Several of these treatment-related factors have been poorly studied in the context of CBT-I due to factors such as a lack of well-defined approaches to assess the factors, a few published trials, and issues with small sample sizes (Agnew et al., 2021; Condon et al., 2021; Matthews et al., 2013).”
Effectiveness and safety of fire-needle moxibustion on insomnia
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“However, few well-trained therapists and poor compliance limited its clinical practice.([11,12]) Pharmacotherapy also plays an important part in the treatment of insomnia.”
Background
Pain-related beliefs about sleep as a predictor of insomnia symptoms and treatment acceptability
Ravyts, S. G., Perez, E., & Dzierzewski, J. M. (2022) · Sleep Medicine · doi:10.1016/j.sleep.2022.05.008 · Cited by 6
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“A challenge also remains when making non-drug therapies available and easily accessible to patients to improve adherence [90,91], highlighting the need for other approaches, such as vestibular stimulation.”
Background
The efficacy and safety of repetitive transcranial magnetic stimulation for comorbid chronic low back pain and insomnia: A randomized, double-blind, sham-controlled pilot trial
Chang, J. R., Sun, E. R., Jin, M., Lin, L. G., Li, S. X., Lee, J. L., Huang, F. F., Kwan, R. L., Zheng, D. K. Y., Samartzis, D., et al. (2025) · Journal of Pain · doi:10.1016/j.jpain.2025.106180 · Cited by 7
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“Cognitive-behavioral therapy as a CID treatment has demonstrable clinical efficacy but suffers from low accessibility and adherence [4,15–18].”
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Effectiveness and safety of electroacupuncture for insomnia
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Management of Chronic Insomnia Using Cognitive Behavior Therapy for Insomnia (CBT-I) During COVID-19 Pandemic: Does One Shoe Fit All?
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“, sleep hygiene, stimulus control technique (SCT) and cognitive restructuring are difficult to be measured objectively [44].”
BackgroundMethodResultInfluential
Efficacy of Multicomponent CBT‐I and Its Single Components
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“There have been many reports that behavioral cognitive therapy, as an emerging ﬁ eld, can stably and effectively improve comorbid insomnia in various diseases, but this method requires much manpower and resources and cannot bene ﬁ t most patients (14).”
White matter alterations in heart-kidney imbalance insomnia and Jiao-Tai-Wan treatment: A diffusion-tensor imaging study
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“However, poor adherence may diminish its therapeutic effect (Matthews et al. 2013).”
Background
Plant-based dietary patterns and risk of insomnia: a prospective study
Gan, Z. H., Chiu, T. H. T., Lin, C., Lin, M., & Kuo, P. (2023) · European Journal of Clinical Nutrition · doi:10.1038/s41430-023-01380-x · Cited by 4
“Cognitive behavioral therapy (CBT) is effective, but problems of accessibility, adherence, and cost limit its use [9].”
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Zheng, Y., Qin, Y., Lyu, Y., Li, L., Ya, C., & Yao, Z. (2021) · Medicine · doi:10.1097/md.0000000000028046 · Cited by 4
“Unfortunately, there are currently few relevant studies and no gold standard for evaluating adherence with CBT-I or its brief model.([22,47,48]) To evaluate the adherence of participants, our team devised the BBT-I adherence questionnaire based on the contents of sleep restriction and stimulus control, which focuses o…”
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BackgroundMethod
Secondary psychiatric care patients’ experiences of internet CBT for insomnia – a qualitative study
Sidén, F. N., & Spak, F. (2022) · BMC Psychology · doi:10.1186/s40359-022-00943-0 · Cited by 4
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“See Supplementary File S1 for full inclusion/exclusion criteria.”
Method
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Yoga as the “Next Wave” of Therapeutic Modalities For Treatment of Insomnia
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Chen, J., Lu, L., Xu, N., Chen, J., Fan, Y., Feng, F., Qin, X., & Kui, Y. (2018) · Medicine · doi:10.1097/md.0000000000012060 · Cited by 3
CBT‐I Assessment Instruments
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GABA Probiotic Lactiplantibacillus plantarum Lp815 Improves Sleep, Anxiety and Increases Urinary GABA: a Randomized, Double-Blind, Placebo-Controlled StudyPreprint
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“Treatment attrition has not been consistently reported in previous clinical studies of CBT-I CBT-I [ 64, Knowledge about the importance of the respective components of CBT-I, such as stimulus control and cognitive restructuring, is limited [66].”
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“Predicting user adherence is essential for enhancing treatment delivery and healthcare utilization, with predictors including demographic variables, sleep-related questionnaires, diary-derived sleep variables, health and psychological variables, and attitudes toward treatment [16–18].”
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Li, Z., Wang, Q. J., Xu, J., Song, Q., Ling, X., Gao, Y., & Lei, J. (2023) · PLoS ONE · doi:10.1371/journal.pone.0282614 · Cited by 2
“However, despite the evidence that CBT-I is effective, CBT-I has not been widely used due to limited access to well-trained providers and poor adherence to the recommended treatment [22].”
Background
Identifying predictors of the amount of veteran participation in cognitive behavioral therapy for insomnia in the Veterans Affairs health care system.
Tighe, C. A., Berlin, G. S., Boland, E. M., Miller, K. E., & Bramoweth, A. D. (2023) · Psychological Services · doi:10.1037/ser0000818 · Cited by 2
Effectiveness of Cognitive Behavioural Therapy to Improve Sleep Outcomes in Patients with Schizophrenia: A Systematic Review of Randomised Control Trials
Khalid, M. A. (2022) · Open Journal of Social Sciences · doi:10.4236/jss.2022.105018 · Cited by 2
“However, variations in sample size, CBTI components, therapy sessions, and adherence are likely to be found equally in both delivery modes (Matthews et al., 2013; Ye et al., 2016) and pose severe validity threats.”
Background
Efficacy of dexmedetomidine with cognitive behavioral therapy for treating chronic insomnia related to conditioned arousal: a randomized controlled trial
Li, X., Jiang, X., Liu, Y., Lang, Y., Ye, Y., Lin, L., Liu, J., & Zhang, Y. (2015) · Sleep and Biological Rhythms · doi:10.1007/s41105-015-0025-7 · Cited by 2
“Ellyn performed a systematic retrospective study in 2013 and found that the demographic and psychological characteristics of the patients were not related to the patients’ compliance and that gender and education level were not important factors [24].”
Method
Tratamiento del insomnio
González, M. A. Á. M., & Ortuño, F. (2016) · Medicine - Programa de Formación Médica Continuada Acreditado · doi:10.1016/j.med.2016.12.005 · Cited by 2
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Lei, H., Xu, G., Zepeng, W., Ling, Z., & Fan-rong, L. (2024) · PubMed Central · doi:10.19852/j.cnki.jtcm.20240408.002 · Cited by 1
Duration of insomnia and success expectancy predict treatment outcome of iCBT for insomnia
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“Many authors link success expectancy with better adherence, known to be an important mediator of the eﬀect of iCBT-I (Matthews et al., 2013; Horsch et al., 2015).”
The Effect of Single‐Component Sleep Restriction Therapy for Insomnia in Adults: A Meta‐Analysis of Randomised Controlled Trials
Wei, J., Yang, F., Li, C., Xiaofang, D., & Liu, Y. (2025) · Journal of Sleep Research · doi:10.1111/jsr.70200 · Cited by 1
“Firstly, as the most potent element of CBT-I, SRT directly restricts time- in-bed to actual sleep duration (Matthews et al. 2013), it produces controlled sleep deprivation that (a) enhances homeostatic sleep drive, (b) reduces nocturnal arousal through improved sleep efficiency and (c) stabilises…”
Predictors and moderators of treatment outcomes from cognitive behavioural interventions for insomnia in adults: A systematic review
Smith, M. L., Oldenhof, E., Byrne, J. E. M., McNeill, I. M., Sweetman, A., & Staiger, P. K. (2026) · Sleep Medicine Reviews · doi:10.1016/j.smrv.2026.102269 · Cited by 1
The glymphatic system in chronic pain: putative mechanisms and prospective therapeutic strategies
Zhang, H., Li, X., You, X., & Wu, J. (2026) · Anesthesiology and Perioperative Science · doi:10.1007/s44254-026-00180-3 · Cited by 2
“Sleep optimization: Putative pain–sleep–glymphatic system vicious cycle [20], but implementation is hindered by patient compliance [127].”
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Carlson, G. E., Zeidler, M. R., & Martin, J. L. (2022) · Respiratory medicine · doi:10.1007/978-3-030-93739-3_13 · Cited by 1
Factors associated with significant improvement in cancer-related fatigue after completing cognitive behavioral therapy for insomnia in cancer survivors
Greeley, K. M., Rash, J. A., Tulk, J., Savard, J., Seal, M., Urquhart, R., Thoms, J., Laing, K. E., Fawcett, E. J., & Garland, S. N. (2025) · Supportive Care in Cancer · doi:10.1007/s00520-025-09482-x · Cited by 1
“Adherence to these components ranges from 40 to 70% in the general population [46].”
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Authors: Matthews, E. E., Arnedt, J. T., McCarthy, M. S., Cuddihy, L. J., & Aloia, M. S.
Affiliations: University of Colorado Denver (US)
University of Michigan (US)
Pine Rest Christian Mental Health Services (US)
National Jewish Health (US)
ORCID: Arnedt, J. Todd
McCarthy, Michaela S.
Cuddihy, Leisha J.
Aloia, Mark S.
Venue: Sleep Medicine Reviews
Publisher: Elsevier BV
Published: 2013-12
Volume: 17
Issue: 6
Pages: 453-464
ISSN: 1087-0792 (ISSN-L)
DOI: 10.1016/j.smrv.2013.01.001
PMC: PMC3720832
OpenAlex: W2018449766
Cited by: 199
References: 76
Citations by year: 2026: 17 · 2025: 11 · 2024: 27 · 2023: 26 · 2022: 22 · 2021: 15 · 2020: 15 · 2019: 13 · 2018: 8 · 2017: 19 · 2016: 4 · 2015: 13 · 2014: 9
FWCI: 1.44
Type: journal article
Language: en
Open access: green
www.ncbi.nlm.nih.gov
Licence: www.elsevier.com/tdm/userlicense/1.0/ (tdm)
Locations: Sleep Medicine Reviews (publishedVersion)
PubMed (publishedVersion)
PubMed Central (acceptedVersion)
Funders: National Institute of Health
National Institute of Nursing Research (1K23NR010587, #2010-049)
American Nurses Foundation
Topics: Social Sciences › Psychology › Experimental and Cognitive Psychology › Sleep and related disorders
Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
Keywords: cognitive behavioral therapy for insomnia, medication adherence, chronic insomnia, attrition, adherence measurement, behavior change, sleep outcomes, standardized outcome measures
MeSH terms: Adult, Humans, Sleep Initiation and Maintenance Disorders, Patient Compliance, Cognitive Behavioral Therapy

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