Cognitive and behavioral therapies in the treatment of insomnia: A meta-analysis
Open accessAbstract
Insomnia is a major public health problem considering its high prevalence, impact on daily life, co-morbidity with other disorders and societal costs. Cognitive behavioral treatment for insomnia (CBTI) is currently considered to be the preferred treatment. However, no meta-analysis exists of all studies using at least one component of CBTI for insomnia, which also uses modern techniques to pool data and to analyze subgroups of patients. We included 87 randomized controlled trials, comparing 118 treatments (3724 patients) to non-treated controls (2579 patients). Overall, the interventions had significant effects on: insomnia severity index (g = 0.98), sleep efficiency (g = 0.71), Pittsburgh sleep quality index (g = 0.65), wake after sleep onset (g = 0.63) and sleep onset latency (SOL; g = 0.57), number of awakenings (g = 0.29) and sleep quality (g = 0.40). The smallest effect was on total sleep time (g = 0.16). Face-to-face treatments of at least four sessions seem to be more effective than self-help interventions or face-to-face interventions with fewer sessions. Otherwise the results seem to be quite robust (similar for patients with or without comorbid disease, younger or older patients, using or not using sleep medication). We conclude that CBTI, either its components or the full package, is effective in the treatment of insomnia.
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“Additionally, there is an unsettled issue of generalizability with respect to CBT-I, because the majority of CBT-I trials were conducted among primarily White highly-educated females.(93) As important, of those trials that report enrollment of racial/ethnic minorities, the sample sizes are often too small for any mean…”
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BackgroundMethodResultInfluentialSleep in the anxiety-related disorders: A meta-analysis of subjective and objective research
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“diaries [11, 19, 21, 22], however relatively few studies collect or report on objective sleep”
BackgroundResultInfluentialEfficacy of cognitive behavioral therapy for insomnia in breast cancer: A meta-analysis
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“Moreover, sub-group analyses of two recent meta-analyses indicated that onsite CBT-I may be superior to self-help CBT-I 15,21 .”
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Self-citationSleep Disturbance as a Potential Modifiable Risk Factor for Alzheimer’s Disease
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BackgroundDoes exercise improve sleep for adults with insomnia? A systematic review with quality appraisal
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Non-pharmacological Approaches for Management of Insomnia
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Effectiveness of Sequential Psychological and Medication Therapies for Insomnia Disorder
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Self-citationBuse, D. C., Rains, J. C., Pavlovic, J. M., Fanning, K. M., Reed, M. L., Adams, A. M., & Lipton, R. B. (2018) · Headache The Journal of Head and Face Pain · doi:10.1111/head.13435 · Cited by 98 · see citing works
“CBTi is the recommended preferred treatment for insomnia;(58) a meta-analysis of 87 randomized controlled trials found CBTi to be useful in patients with and without comorbid disease.(59) Specifically in CM, a small pilot”
BackgroundLorenz, N., Heim, E., Rötger, A., Birrer, E., & Maercker, A. R. A. (2018) · Behavioural and Cognitive Psychotherapy · doi:10.1017/s1352465818000486 · Cited by 90 · see citing works
“Cognitive behavioural therapy for insomnia (CBT-I) is an effective treatment with moderate to large effects on measures of sleep continuity and on subjective insomnia severity in general (Irwin et al., 2006; Morin et al., 2009; Trauer et al., 2015; Van Straten et al., 2017).”
BackgroundWe know CBT-I works, now what?
Muench, A., Vargas, I., Grandner, M. A., Ellis, J. G., Posner, D. A., Bastien, C., Drummond, S. P. A., & Perlis, M. L. (2022) · Faculty Reviews · doi:10.12703/r/11-4 · Cited by 91 · see citing works
Carpi, M., Cianfarani, C., & Vestri, A. (2022) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph19052874 · Cited by 102 · see citing works
“In particular, among the many outcomes considered, CBT-I showed high effectiveness in reducing insomnia symptoms and ameliorating sleep quality measured with the same instruments employed in this study (namely, the ISI and the PSQI) [66], which encompass both specific sleep-related problems and daytime dysfunc-”
MethodTranscutaneous Auricular Vagus Nerve Stimulation for Chronic Insomnia Disorder
Zhang, S., Zhao, Y., Qin, Z., Han, Y., He, J., Zhao, B., Wang, L., Duan, Y., Huo, J., Wang, T., et al. (2024) · JAMA Network Open · doi:10.1001/jamanetworkopen.2024.51217 · Cited by 89 · see citing works
The effect of acceptance and commitment therapy on insomnia and sleep quality: A systematic review
Salari, N., Khazaie, H., Hosseinian-Far, A., Khaledi-Paveh, B., Ghasemi, H., Mohammadi, M., & Shohaimi, S. (2020) · BMC Neurology · doi:10.1186/s12883-020-01883-1 · Cited by 78 · see citing works
Sleep disturbance and the long-term impact of early adversity
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van der Zweerde, T., Lancee, J., Slottje, P., Bosmans, J. E., Someren, E. J. W. V., & van Straten, A. (2020) · Psychotherapy and Psychosomatics · doi:10.1159/000505600 · Cited by 76 · see citing works
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Sweetman, A., Lack, L. C., McEvoy, R. D., Antic, N. A., Smith, S. S., Chai‐Coetzer, C. L., Douglas, J. A., O’Grady, A., Dunn, N., Robinson, J., et al. (2020) · ERJ Open Research · doi:10.1183/23120541.00161-2020 · Cited by 74 · see citing works
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Morin, C. M. (2020) · Expert Review of Medical Devices · doi:10.1080/17434440.2020.1852929 · Cited by 66 · see citing works
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Prevention of internalizing disorders and suicide via adolescent sleep interventions
Blake, M. J., & Allen, N. B. (2019) · Current Opinion in Psychology · doi:10.1016/j.copsyc.2019.08.027 · Cited by 66 · see citing works
Blake, M. J., Snoep, L., Raniti, M. B., Schwartz, O., Waloszek, J. M., Simmons, J. G., Murray, G., Blake, L. M., Landau, E. R., Dahl, R. E., et al. (2017) · Behaviour Research and Therapy · doi:10.1016/j.brat.2017.10.006 · Cited by 65 · see citing works
Digital Delivery of Cognitive Behavioral Therapy for Insomnia
Luik, A. I., van der Zweerde, T., van Straten, A., & Lancee, J. (2019) · Current Psychiatry Reports · doi:10.1007/s11920-019-1041-0 · Cited by 69 · see citing works
Self-citationMurri, M. B., Caruso, R., Ounalli, H., Zerbinati, L., Berretti, E., Costa, S., Recla, E., Folesani, F., Kissane, D. W., Nanni, M. G., et al. (2020) · Journal of Affective Disorders · doi:10.1016/j.jad.2020.06.074 · Cited by 68 · see citing works
Sleep Well and Recover Faster with Less Pain—A Narrative Review on Sleep in the Perioperative Period
Sipilä, R. M., & Kalso, E. A. (2021) · Journal of Clinical Medicine · doi:10.3390/jcm10092000 · Cited by 67 · see citing works
“If time allows and the sleep problem is severe, cognitive behavioral therapy for insomnia (CBT-I) is considered the first-line intervention [100,101].”
BackgroundBrupbacher, G., Gerger, H., Zander-Schellenberg, T., Straus, D., Porschke, H., Gerber, M., von Känel, R., & Schmidt-Trucksäss, A. (2021) · Sleep Medicine Reviews · doi:10.1016/j.smrv.2021.101452 · Cited by 64 · see citing works
Kallestad, H., Scott, J. L., Vedaa, Ø., Lydersen, S., Vethe, D., Morken, G., Stiles, T. C., Sivertsen, B., & Langsrud, K. (2020) · SLEEP · doi:10.1093/sleep/zsab185 · Cited by 64 · see citing works
“The lack of a third arm with a control group prohibits strong conclusions about the effects of each of the interventions, but there was a significant reduction in scores on all measures from baseline to follow-up for both interventions, and previous research has demonstrated that both FtF CBT-I and dCBT-I is effective…”
ResultSweetman, A., Putland, S., Lack, L. C., McEvoy, R. D., Adams, R., Grunstein, R. R., Stocks, N., Kaambwa, B., Ryswyk, E. V., Gordon, C. J., et al. (2020) · Sleep Medicine Reviews · doi:10.1016/j.smrv.2020.101404 · Cited by 65 · see citing works
Ó’Caoimh, R., Mannion, H., Sezgin, D., O’Donovan, M. R., Liew, A., & Molloy, D. W. (2019) · Maturitas · doi:10.1016/j.maturitas.2019.06.007 · Cited by 66 · see citing works
Maurer, L., Espie, C., Omlin, X., Reid, M. J., Sharman, R., Gavriloff, D., Emsley, R., & Kyle, S. (2020) · Sleep · doi:10.1093/sleep/zsaa096 · Cited by 47 · see citing works
Takaesu, Y., Utsumi, T., Okajima, I., Shimura, A., Kotorii, N., Kuriyama, K., Yamashita, H., Suzuki, M., Watanabe, N., & Mishima, K. (2019) · Sleep Medicine Reviews · doi:10.1016/j.smrv.2019.101214 · Cited by 57 · see citing works
Sleep-Related Disorders in Neurology and Psychiatry
Rémi, J., Pollmächer, T., Spiegelhalder, K., Trenkwalder, C., & Young, P. (2019) · Deutsches Ärzteblatt international · doi:10.3238/arztebl.2019.0681 · Cited by 59 · see citing works
Denis, D., Eley, T. C., Rijsdijk, F. V., Zavos, H. M. S., Keers, R., Espie, C. A., Luik, A. I., Badini, I., Derveeuw, S., Hodsoll, J. P., et al. (2019) · Sleep Medicine · doi:10.1016/j.sleep.2019.10.007 · Cited by 57 · see citing works
Fitrianie, S., Horsch, C., Beun, R. J., Griffioen-Both, F., & Brinkman, W.-P. (2021) · Journal of Medical Systems · doi:10.1007/s10916-021-01785-w · Cited by 57 · see citing works
Blake, M. J., Schwartz, O., Waloszek, J. M., Raniti, M. B., Simmons, J. G., Murray, G., Blake, L. M., Dahl, R. E., Bootzin, R. R., McMakin, D. L., et al. (2017) · SLEEP · doi:10.1093/sleep/zsx061 · Cited by 57 · see citing works
Blake, M. J., Blake, L. M., Schwartz, O., Raniti, M. B., Waloszek, J. M., Murray, G., Simmons, J. G., Landau, E. R., Dahl, R. E., McMakin, D. L., et al. (2017) · Journal of Child Psychology and Psychiatry · doi:10.1111/jcpp.12842 · Cited by 57 · see citing works
Hypnosis intervention effects on sleep outcomes: a systematic review
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Bramoweth, A. D., Lederer, L. G., Youk, A. O., Germain, A., & Chinman, M. (2020) · Behavior Therapy · doi:10.1016/j.beth.2020.02.002 · Cited by 57 · see citing works
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Saruhanjan, K., Zarski, A., Bauer, T., Baumeister, H., Cuijpers, P. J., Spiegelhalder, K., Auerbach, R. P., Kessler, R. C., Bruffaerts, R., Karyotaki, E., et al. (2020) · Journal of Sleep Research · doi:10.1111/jsr.13097 · Cited by 60 · see citing works
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Behrendt, D., Ebert, D. D., Spiegelhalder, K., & Lehr, D. (2020) · Journal of Medical Internet Research · doi:10.2196/13346 · Cited by 52 · see citing works
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Digital Cognitive Behavioral Therapy for Insomnia in Women With Chronic Migraines
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Prescription Drugs Used in Insomnia
Dujardin, S., Pijpers, A., & Pevernagie, D. (2020) · Sleep Medicine Clinics · doi:10.1016/j.jsmc.2020.02.002 · Cited by 49 · see citing works
Christensen, K. A., & Short, N. A. (2021) · International Journal of Eating Disorders · doi:10.1002/eat.23498 · Cited by 49 · see citing works
“For example, CBT for Insomnia (CBT-I) demonstrates strong evidence for reducing insomnia symptoms and maintaining treatment gains (van der Zweerde et al., 2019; van Straten et al., 2018).”
BackgroundJansson‐Fröjmark, M., & Norell‐Clarke, A. (2018) · Sleep Medicine Reviews · doi:10.1016/j.smrv.2018.05.001 · Cited by 49 · see citing works
Zhang, X., Sun, Y., Ye, S., Huang, Q., Zheng, R., Li, Z., Yu, F., Zhao, C., Zhang, M., Zhao, G., et al. (2024) · Journal of Clinical Sleep Medicine · doi:10.5664/jcsm.11326 · Cited by 51 · see citing works
“66 A previous study found that the use of cognitive behavioral therapy for insomnia in patients with chronic HF combined with insomnia can alleviate insomnia symptoms, fatigue, excessive daytime sleepiness, and improved 6-minute walk distance, which has important prognostic implications for…”
Hwang, J., Lee, G. E., Woo, J. H., Kim, S. M., & Kwon, J. Y. (2025) · npj Digital Medicine · doi:10.1038/s41746-025-01514-4 · Cited by 50 · see citing works
“Thispatternhasbeendocumentedinpriormeta-analysesondCBT-Ieffects onsleepbyZachariaeetal.,Tsaietal.,Dengetal.,andLeeetal.,aswellasin traditionalCBT-Istudies 25,27,37,38,70 .”
Perini, F., Wong, K. F., Lin, J., Hassirim, Z., Ong, J. L., Lo, J. C.-Y., Ong, J. C., Doshi, K., & Lim, J. (2021) · Psychological Medicine · doi:10.1017/s0033291721002476 · Cited by 47 · see citing works
“Although we did not compare directly MBTI with a CBT-I, the current frontline treatment for primary insomnia, our trial showed that the effect size of the reduction in ISI scores is comparable to those seen in studies of CBT-I (van Straten et al., 2018).”
ResultInfluentialProspective Analyses of Cytokine Mediation of Sleep and Survival in the Context of Advanced Cancer
Steel, J. L., Terhorst, L. A., Collins, K. P., Geller, D. A., Yoram Vodovotz, B., Kim, J. E., Krane, A., Antoni, M. H., Marsh, J. W., Burke, L. E., et al. (2018) · Psychosomatic Medicine · doi:10.1097/psy.0000000000000579 · Cited by 46 · see citing works
The Treatment of Sleep Dysfunction in Neurodegenerative Disorders
Voysey, Z. J., Barker, R. A., & Lázár, A. S. (2020) · Neurotherapeutics · doi:10.1007/s13311-020-00959-7 · Cited by 47 · see citing works
Tsai, H.-J., Yang, A. C., Zhu, J.-D., Hsu, Y.-Y., Hsu, T.-F., & Tsai, S.-J. (2022) · Journal of Personalized Medicine · doi:10.3390/jpm12030481 · Cited by 45 · see citing works
Jernelöv, S., Larsson, Y., Llenas, M., Nasri, B., & Kaldo, V. (2019) · BMC Psychiatry · doi:10.1186/s12888-019-2216-2 · Cited by 45 · see citing works
Jernelöv, S., Blom, K., Isacsson, N. H., Bjurner, P., Rosén, A., Kraepelien, M., Forsell, E., & Kaldo, V. (2022) · Cognitive Behaviour Therapy · doi:10.1080/16506073.2021.2009019 · Cited by 41 · see citing works
“…al., 2018; Wu et al., 2015), and CBT-i is indeed effective whether the treatment is delivered face-to-face, one-on-one, as grouptherapy, as internet-delivered programs, or as self-help (Koffel et al., 2015; Seyffert et al., 2016; Van Straten et al., 2018; Ye et al., 2015; Zachariae et al., 2016).”
BackgroundInfluentialZhang, Y., Ren, R., Yang, L., Zhang, H., Shi, Y., Shi, J., Sanford, L. D., Lü, L., Vitiello, M. V., & Tang, X. (2022) · Sleep Medicine Reviews · doi:10.1016/j.smrv.2022.101687 · Cited by 43 · see citing works
- Authors
- van Straten, A., van der Zweerde, T., Kleiboer, A., Cuijpers, P., Morin, C. M., & Lancee, J.
- Affiliations
- Amsterdam Public Health (NL)
- Université Laval (CA)
- University of Amsterdam (NL)
- Venue
- Sleep Medicine Reviews
- Publisher
- Elsevier BV
- Published
- 2018-04
- Volume
- 38
- Pages
- 3-16
- ISSN
- 1087-0792 (ISSN-L)
- OpenAlex
- W2587695521
- Semantic Scholar
- 6c1b6f5159447dbff310c8cee6eabea911bf3c07
- Cited by
- 676
- References
- 158
- Citations by year
- 2026: 55 · 2025: 100 · 2024: 90 · 2023: 79 · 2022: 79 · 2021: 77 · 2020: 89 · 2019: 58 · 2018: 34 · 2017: 14 · 2016: 1
- FWCI
- 8.49
- Type
- journal article
- Language
- en
- Open access
- green
- research.vu.nl
- Licence
- Locations
- Sleep Medicine Reviews (publishedVersion)
- PubMed (publishedVersion)
- UvA-DARE (University of Amsterdam) (publishedVersion)
- Pure Amsterdam UMC (publishedVersion)
- Amsterdam UMC (VU Amsterdam) - Institutional Repository (publishedVersion)
- VU Research Portal (publishedVersion, other-oa)
- Data Archiving and Networked Services (DANS) (submittedVersion)
- Data Archiving and Networked Services (DANS) (submittedVersion, other-oa)
- Topics
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Sleep and related disorders
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Health Sciences › Medicine › Physiology › Obstructive Sleep Apnea Research
- Keywords
- insomnia, cognitive behavioral therapy for insomnia, sleep efficiency, sleep quality, sleep latency, wake after sleep onset, number of awakenings, total sleep time, self-help intervention, number of treatment sessions, comorbid diseases, sleep medication use
- MeSH terms
- Humans, Sleep Initiation and Maintenance Disorders, Cognitive Behavioral Therapy, Randomized Controlled Trials as Topic
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