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Cited by 393Sleep and related disordersAnxiety, Depression, Psychometrics, Treatment, Cognitive ProcessesPsychotherapy Techniques and Applications

Cognitive behavioral therapy for insomnia in patients with mental disorders and comorbid insomnia: A systematic review and meta-analysis

Open access
Hertenstein, Elisabeth, Trinca, Ersilia, Wunderlin, Marina, Schneider, Carlotta L., Züst, Marc A., Fehér, Kristoffer D., Su, Tanja, Straten, Annemieke v. +7 more·2022·Sleep Medicine Reviews
DOI 10.1016/j.smrv.2022.101597
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Abstract

Almost 70% of patients with mental disorders report sleep difficulties and 30% fulfill the criteria for insomnia disorder. Cognitive behavioral therapy for insomnia (CBT-I) is the first-line treatment for insomnia according to current treatment guidelines. Despite this circumstance, insomnia is frequently treated only pharmacologically especially in patients with mental disorders. The aim of the present meta-analysis was to quantify the effects of CBT-I in patients with mental disorders and comorbid insomnia on two outcome parameters: the severity of insomnia and mental health. The databases PubMed, CINHAL (Ebsco) und PsycINFO (Ovid) were searched for randomized controlled trials on adult patients with comorbid insomnia and any mental disorder comparing CBT-I to placebo, waitlist or treatment as usual using self-rating questionnaires as outcomes for either insomnia or mental health or both. The search resulted in 1994 records after duplicate removal of which 22 fulfilled the inclusion criteria and were included for the meta-analysis. The comorbidities were depression (eight studies, 491 patients), post-traumatic stress disorder (PTSD, four studies, 216 patients), alcohol dependency (three studies, 79 patients), bipolar disorder (one study, 58 patients), psychosis (one study, 50 patients) and mixed comorbidities within one study (five studies, 189 patients). The effect sizes for the reduction of insomnia severity post treatment were 0.5 (confidence interval, CI, 0.3-0.8) for patients with depression, 1.5 (CI 1.0-1.9) for patients with PTSD, 1.4 (CI 0.9-1.9) for patients with alcohol dependency, 1.2 (CI 0.8-1.7) for patients with psychosis/bipolar disorder, and 0.8 (CI 0.1-1.6) for patients with mixed comorbidities. Effect sizes for the reduction of insomnia severity were moderate to large at follow-up. Regarding the effects on comorbid symptom severity, effect sizes directly after treatment were 0.5 (CI 0.1-0.8) for depression, 1.3 (CI 0.6-1.9) for PTSD, 0.9 (CI 0.3-1.4) for alcohol dependency in only one study, 0.3 (CI -0.1 - 0.7, insignificant) for psychosis/bipolar, and 0.8 (CI 0.1-1.5) for mixed comorbidities. There were no significant effects on comorbid symptoms at follow-up. Together, these significant, stable medium to large effects indicate that CBT-I is an effective treatment for patients with insomnia and a comorbid mental disorder, especially depression, PTSD and alcohol dependency. CBT-I is also an effective add-on treatment with the aim of improving mental health in patients with depression, PTSD, and symptom severity in outpatients with mixed diagnoses. Thus, in patients with mental disorders and comorbid insomnia, given the many side effects of medication, CBT-I should be considered as a first-line treatment.

AI snapshot

Written from the paper’s full text.

TL;DR

This systematic review and meta-analysis of 22 RCTs found that CBT-I is effective for insomnia in patients with comorbid mental disorders, with large post-treatment reductions in insomnia severity and moderate improvements in mental health. Effects were strongest for depression, PTSD, and alcohol dependency, but mental-health effects were generally not significant at follow-up.

Key findings

  • Across 22 RCTs, CBT-I reduced insomnia severity versus control post-treatment (Hedges’ g 1.0, CI 0.7–1.2) and at first follow-up (g 0.8, CI 0.4–1.2); mental health improved post-treatment (g 0.7, CI 0.4–0.9) and at first follow-up (g 0.5, CI 0.2–0.7).
  • Post-treatment insomnia severity effect sizes by subgroup were: depression 0.5 (CI 0.3–0.8), PTSD 1.5 (CI 1.0–1.9), alcohol dependency 1.4 (CI 0.9–1.9), psychosis/bipolar 1.2 (CI 0.8–1.7), and mixed comorbidities 0.8 (CI 0.1–1.6).
  • Post-treatment mental-health effect sizes were: depression 0.5 (CI 0.1–0.8), PTSD 1.3 (CI 0.6–1.9), alcohol dependency 0.9 (CI 0.3–1.4) in only one study, psychosis/bipolar 0.3 (CI −0.1–0.7, insignificant), and mixed comorbidities 0.8 (CI 0.1–1.5); no significant effects on comorbid symptoms at follow-up.
  • Risk of bias was low for 5 studies, high for 4, and moderate for 13; Egger tests were significant for insomnia and comorbidity post-treatment, indicating potential publication bias.

Methods

  • Systematic review and meta-analysis conducted per MOOSE and PRISMA, registered with PROSPERO (CRD42021249929); PubMed, CINAHL, and PsycINFO were searched through October 2021, yielding 1994 records after duplicate removal and 22 included RCTs.
  • Inclusion required adults ≥18 years with insomnia and a mental disorder diagnosed by DSM/ICD/ICSD or validated questionnaire cutoff, CBT-I containing sleep restriction or stimulus control, a control condition of no treatment/placebo/waitlist/TAU, and validated self-rating outcomes for insomnia and/or mental health.
  • Random-effects meta-analysis used R package Metafor; Hedges’ g compared post-treatment and first follow-up means between CBT-I and control; I² assessed heterogeneity; Cochrane Risk of Bias Tool and funnel plots/Egger tests were used.

Limitations

  • Stated: most included trials had short follow-up periods, mostly one follow-up 3–6 months after treatment; 16 of 22 studies had sample sizes ≤50; potential publication bias was indicated; three studies used a quality-of-life measure instead of a specific psychiatric measure; many trials were in specialist research settings with selected samples; risk-of-bias ratings for all but two studies were performed by only one rater; only six of 22 studies reported adverse events; several comorbidities remain under-researched.
  • Evident from the text: heterogeneity was high in the total sample (I² over 50% at both time points and both outcomes), and some subgroup analyses relied on very few studies (e.g., one study each for bipolar disorder and psychosis, and only one study for alcohol dependency mental-health outcome).

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

Integrity signals

Registry

Crossref · 10.1016/j.smrv.2022.101597

Cites

67 of 67 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 34 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    Improvement of insomnia symptoms is associated with improved mental health, as shown in the present work.

    “and, as shown in the present work, improvement of insomnia symptoms is associated with improved mental health.”
    Quote in the paperSubstantial claim
  • Findingnone given

    CBT-I reduces the severity of the comorbid disorder with a medium effect size in patients with mental disorders and comorbid insomnia.

    “2) CBT-I reduces insomnia severity (large effect size) and the severity of the comorbid disorder (medium effect size).”
    Quote in the paperSubstantial claim
  • Findingown data

    Almost half of the sample of primary studies consisted of patients with depression.

    “Almost half of our sample of primary studies consisted of patients with depression.”
    Quote in the paperNot a substantial claim
  • Findingown data

    Egger tests were non-significant for insomnia and comorbidity at follow-up.

    “Egger tests were non-significant (p > 0.1) for insomnia and comorbidity at follow-up.”
    Quote in the paperNot a substantial claim
  • Findingown data

    Most included trials had relatively short follow-up periods.

    “Most included trials had relatively short follow-up periods.”
    Quote in the paperSubstantial claim
  • Classified as probably not a substantial claim. 17
  • May combine two claims. 31

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

    Findingown data

    The search resulted in 1994 records after duplicate removal, of which 22 fulfilled the inclusion criteria and were included in the meta-analysis.

    “The search resulted in 1994 records after duplicate removal of which 22 fulfilled the inclusion criteria and were included for the meta-analysis.”
    • Also stated in: § Study flow · plain
      “The search resulted in 1994 hits after duplicate removal.We included n ¼ 22 primary RCTs into the meta-analysis.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The included studies comprised depression (8 studies, 491 patients), PTSD (4 studies, 216 patients), alcohol dependency (3 studies, 79 patients), bipolar disorder (1 study, 58 patients), psychosis (1 study, 50 patients), and mixed comorbidities (5 studies, 189 patients).

    “The comorbidities were depression (eight studies, 491 patients), post-traumatic stress disorder (PTSD, four studies, 216 patients), alcohol dependency (three studies, 79 patients), bipolar disorder (one study, 58 patients), psychosis (one study, 50 patients) and mixed comorbidities within one study (five studies, 189 patients).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    For mental health post-treatment, the effect was significant with a large effect size for alcohol dependency, mixed comorbidity, and PTSD; significant with a moderate effect size for depression; and non-significant for psychosis/bipolar.

    “For mental health post treatment, the effect was significant with a large effect size for alcohol dependency, mixed comorbidity, and PTSD.The effect was significant with a moderate effect size for depression and non-significant for psychosis/bipolar.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    CBT-I produces large effect sizes for reducing insomnia severity both directly after treatment and at first follow-up, and moderate effect sizes for improving mental health post-treatment.

    “We found large effect sizes for the reduction of the severity of insomnia both directly after treatment and at first follow-up (3e6 mo after end of treatment for most studies) and moderate effect sizes for the improvement of mental health post-treatment.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The Egger test was significant for insomnia and for comorbidity post-treatment, indicating potential publication bias.

    “The Egger test was significant for insomnia and for comorbidity post treatment, indicating potential publication bias (insomnia: t ¼ 2.59, df ¼ 20, p ¼ 0.017; comorbidity: t ¼ 3.92, df ¼ 18, p ¼ 0.001).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingnone given

    The majority of studies provided only one follow-up assessment, mostly three to six months after the end of treatment.

    “The majority of studies provided only one follow-up assessment, mostly three to six months after the end of treatment.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Significant improvement of alcohol dependency, depression, mixed comorbidity and PTSD, but not psychosis and bipolar disorder, was observed directly after treatment, but not at follow-up.

    “More specifically, a significant improvement of alcohol dependency, depression, mixed comorbidity and PTSD, but not psychosis and bipolar disorder was observed directly after treatment, but not at follow-up.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    For insomnia severity at follow-up, the effect was significant with a large effect size for alcohol dependency, depression, and psychosis/bipolar, but insignificant for the mixed subgroup.

    “For the severity of insomnia at follow-up, the effect was significant with a large effect size for alcohol dependency, depression, and psychosis/bipolar, but insignificant for the mixed subgroup.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    With three primary studies each, the meta-analysis indicates that CBT-I is effective in patients with PTSD and alcohol dependency.

    “With three primary studies each, our metaanalysis indicates that CBT-I is effective in those with PTSD and alcohol dependency.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    For mental health at follow-up, the effect was not significant for any subgroup and effect sizes were small to moderate.

    “For mental health at follow-up, the effect was not significant for any subgroup and effect sizes were small to moderate.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Six out of 22 studies reported on adverse events related to CBT-I, and all six stated that no adverse events related to the intervention had been observed.

    “Six out of 22 studies reported on adverse events related to CBT-I.All of these six state that no adverse events related to the intervention had been observed.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Heterogeneity was still significant within the depression subgroup and within the mixed subgroup.

    “Heterogeneity was still significant within the depression subgroup and within the mixed subgroup (Figs.2e5).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    The overall risk of bias was low for five studies, high for four studies, and moderate for the remaining 13 studies.

    “The overall risk of bias was low for five studies, high for four studies and moderate for remaining 13 studies.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingreasoning

    Important sources of risk of bias in the primary studies were missing data due to dropouts and the fact that true blinding is often not possible in psychotherapy studies.

    “Important sources of risk of bias in the primary studies were missing data due to dropouts throughout the pre-post-follow-up designs and the fact that true blinding is often not possible in psychotherapy studies, constituting a risk of bias concerning the measurement of the outcome.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingcitation

    Serious adverse events (suicide attempts and violent incidents) were reported by Freeman et al. in patients with psychosis and Sheaves et al. in psychiatric inpatients, and all were considered unrelated to the study intervention.

    “Serious adverse events were reported by Freeman et al. in patients with psychosis [44] and Sheaves et al. in psychiatric inpatients [45].The events were suicide attempts and violent incidents.All serious adverse events were considered unrelated to the study intervention.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [44] Freeman, 2015, Efficacy of cognitive behavioural therapy for sleep improvement in patients with persistent delusions and hallucinations (BEST): a prospective, assessor-blind, randomised controlled pilot trial, Lancet Psychiatry source

      Not checked in the free run.

    • cites [45] Sheaves, 2018, Stabilising sleep for patients admitted at acute crisis to a psychiatric hospital (OWLS): an assessor-blind pilot randomised controlled trial, Psychol Med source

      Not checked in the free run.

  • May combine two claims.

    Findingown data

    Only one RCT each fulfilling the inclusion criteria has been conducted with patients suffering from bipolar disorder and psychosis.

    “Only one RCT each fulfilling our inclusion criteria has been conducted with patients suffering from bipolar disorder and psychosis.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    For insomnia severity post-treatment, the effect was significant with a large effect size in alcohol dependency, mixed comorbidity, psychosis/bipolar, and PTSD, and significant with a moderate effect size for depression.

    “For the severity of insomnia post treatment, the effect was significant with a large effect size in alcohol dependency, mixed comorbidity, psychosis/bipolar, and PTSD and significant with a moderate effect size for depression.”
    Quote in the paperSubstantial claim

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

    Study design and conductown data

    The Cochrane Risk of Bias Tool was used to estimate risk of bias in the included studies.

    “The Cochrane Risk of Bias Tool (RoB) was used to estimate the risk of bias in the included studies.”
    Quote in the paperNot a substantial claim

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

    Study design and conductcitation

    The literature review and meta-analysis was conducted in accordance with MOOSE and PRISMA reporting recommendations.

    “This literature review and meta-analysis has been conducted in accordance with the recommendations of reporting for metaanalyses of observational studies in epidemiology (MOOSE) and the PRISMA statement for reporting systematic reviews and metaanalyses of studies that evaluate health care interventions [20,21].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [20] Liberati, 2009, The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration, J Clin Epidemiol source

      Not checked in the free run.

    • cites [21] Stroup, 2000, Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis of Observational Studies in Epidemiology (MOOSE) group, JAMA source

      Not checked in the free run.

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

    Study design and conductnone given

    Studies were reviewed by two independent raters, and discrepancies were discussed and solved in consensus with the co-authors.

    “Studies were reviewed by two independent raters.Discrepancies were discussed and solved in consensus with the co-authors.”
    Quote in the paperNot a substantial claim

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

    Premisecitation

    Gee et al. concluded that non-pharmacological treatment for insomnia is effective for reducing insomnia and has moderate to large effects on depression, especially in clinical populations.

    “Focusing on comorbid depression and insomnia in their meta-analysis, Gee et al. concluded that non-pharmacological treatment for insomnia is effective not only for the reduction of insomnia, but has moderate to large effects on depression especially in clinical populations [18].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [18] Gee, 2019, The effect of non-pharmacological sleep interventions on depression symptoms: a meta-analysis of randomised controlled trials, Sleep Med Rev source

      Not checked in the free run.

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

    Study design and conductnone given

    The meta-analysis was registered with PROSPERO under registration number CRD42021249929.

    “This meta-analysis has been registered with PROSPERO with the registration number CRD42021249929.”
    Quote in the paperNot a substantial claim

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

    Premisecitation

    Wu et al.'s meta-analysis found that CBT-I was more effective for patients with mental comorbidity compared to medical comorbidity.

    “In their meta-analysis, Wu and colleagues found that CBT-I was more effective for patients with mental comorbidity compared to medical comorbidity [17].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [17] Wu, 2015, Cognitive behavioral therapy for insomnia comorbid with psychiatric and medical conditions: a meta-analysis, JAMA Intern Med source

      Not checked in the free run.

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

    Premisecitation

    CBT-I is the first-line treatment for chronic insomnia in adults according to current guidelines.

    “The results of our meta-analysis are in line with current guidelines recommending CBT-I as the first-line treatment for chronic insomnia in adults [59e62]”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites 59e62

      Not checked in the free run.

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

    Premisecitation

    A recent meta-analysis concluded that sleep improvement after different non-pharmacological treatments for insomnia is causally related to improvements in mental health.

    “A recent meta-analysis concluded that sleep improvement after different non-pharmacological treatments for insomnia is causally related to improvements in mental health [19].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [19] Scott, 2021, Improving sleep quality leads to better mental health: a meta-analysis of randomised controlled trials, Sleep Med Rev source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Patients with comorbid insomnia, compared to those with a mental disorder without insomnia, have a more adverse course of the mental disorder and lower general treatment efficacy.

    “Patients with comorbid insomnia, compared to those suffering from a mental disorder without insomnia, are characterized by a more adverse course of the mental disorder and lower general treatment efficacy [1].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [1] Seow, 2018, Evaluating DSM-5 insomnia disorder and the treatment of sleep problems in a psychiatric population, J Clin Sleep Med source

      Not checked in the free run.

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

    Study design and conductcitation

    Visual inspection of funnel plots and Egger's tests were used to estimate publication bias.

    “Visual inspection of funnel plots and Egger's tests were used to estimate publication bias [34].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [34] Egger, 1997, Meta-analysis: principles and procedures, BMJ source

      Not checked in the free run.

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

    Premisecitation

    The Insomnia Severity Index is a well-known, validated questionnaire that is sensitive to change.

    “The Insomnia Severity Index (ISI) was chosen as a measure of insomnia severity if available because it is a well-known, validated questionnaire that is sensitive to change [28].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [28] Bastien, 2001, Validation of the Insomnia Severity Index as an outcome measure for insomnia research, Sleep Med source

      Not checked in the free run.

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

    Premisecitation

    CBT-I is feasible and effective when delivered via the internet.

    “CBT-I is also feasible and effective when delivered via the internet [11].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [11] Seyffert, 2016, Internet-delivered cognitive behavioral therapy to treat insomnia: a systematic review and meta-analysis, PLoS One source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisecitation

    Absence of insomnia after successful antidepressant treatment is a predictor for restoration of a normal level of functioning.

    “Absence of insomnia after successful antidepressant treatment is a predictor for the restoration of a normal level of functioning [6].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [6] Carney, 2011, Residual sleep beliefs and sleep disturbance following cognitive behavioral therapy for major depression, Depress Anxiety source

      Not checked in the free run.

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

    Study design and conductnone given

    Risk of bias ratings were performed by ET and TS supervised by EH, and inconsistencies were discussed and agreed upon among the authors.

    “Risk of bias ratings were performed by ET and TS supervised by EH.Inconsistencies were discussed and agreed upon among the authors.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Insomnia often persists despite successful antidepressant treatment and increases the risk of relapse into depression.

    “Research, however, has demonstrated that on the contrary, insomnia often persists despite successful antidepressant treatment and increases the risk of a relapse into depression [6].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [6] Carney, 2011, Residual sleep beliefs and sleep disturbance following cognitive behavioral therapy for major depression, Depress Anxiety source

      Not checked in the free run.

  • May combine two claims.

    Interpretationown data

    In patients with a mental disorder and comorbid insomnia, CBT-I is significantly more effective than control conditions both for reducing insomnia and improving mental health.

    “This meta-analysis found that in patients with a mental disorder and comorbid insomnia, CBT-I is significantly more effective than control conditions both for the reduction of insomnia and the improvement of mental health.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Premisecitation

    Chronic stress can lead to depression.

    “Since chronic stress can lead to depression, stress induced by constant worry about sleep may play a role in the development of depression [70e73].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [70e73]

      Not checked in the free run.

  • May combine two claims.

    Study design and conductown data

    Risk of bias ratings for all but two studies were performed by only one rater, potentially causing biased results.

    “A further limitation of our study is that risk of bias ratings for all but two studies were performed by only one rater, potentially causing biased results.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Interpretationnone given

    Depression, post-traumatic stress disorder and alcohol dependency are the comorbid disorders with the best evidence base for CBT-I.

    “3) Depression, post-traumatic stress disorder and alcohol dependency are the comorbid disorders with the best evidence base for CBT-I.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    CBT-I in addition to psychotherapeutic or pharmacological state-of-the-art treatment of the mental disorder results in better, long-lasting effects for both insomnia and the course of the mental disorder.

    “Here, CBT-I in addition to psychotherapeutic or pharmacological state-of-the-art treatment of the mental disorder results in better, long-lasting effects for both insomnia and the course of the mental disorder.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data

    The results replicate Wu et al.'s finding that CBT-I is effective for patients with comorbid depression, and extend their findings by demonstrating it is also effective for patients with PTSD, alcohol dependency, mixed comorbidities and potentially bipolar disorder and psychosis.

    “In general, we replicate their finding that CBT-I is effective for patients with comorbid depression, and extend their findings by demonstrating that it is also effective for patients with PTSD, alcohol dependency, mixed comorbidities and potentially bipolar disorder and psychosis.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [17] Wu, 2015, Cognitive behavioral therapy for insomnia comorbid with psychiatric and medical conditions: a meta-analysis, JAMA Intern Med source

      Not checked in the free run.

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

    Interpretationreasoning

    There is a heightened need for research into the efficacy of CBT-I for patients with insomnia and previously under-researched patient groups.

    “This indicates a heightened need for research into the efficacy of CBT-I for patients with insomnia and previously under-researched patient groups.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationcitation

    In this meta-analysis, effect sizes for insomnia severity in patients with comorbidity were moderate to large and comparable to those found in patients with primary insomnia.

    “In this meta-analysis, the effect sizes for insomnia severity in patients with comorbidity were moderate to large and therefore comparable to those found in patients with primary insomnia [9].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [9] Trauer, 2015, Cognitive behavioral therapy for chronic insomnia: a systematic review and meta-analysis, Ann Intern Med source

      Not checked in the free run.

  • May combine two claims.

    Interpretationown data

    CBT-I also has the potential to reduce the symptoms of alcohol dependency and PTSD, but not those of bipolar disorder and psychosis.

    “We extend the findings of the Gee et al. meta-analysis by demonstrating that CBT-I also has the potential to reduce the symptoms of alcohol dependency and PTSD, but not those of bipolar disorder and psychosis.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Insomnia is a predictor for de novo onset of depression and increases the risk for the onset of anxiety disorders and substance dependency.

    “In addition, insomnia is not only a predictor for de novo onset of depression, but also increases the risk for the onset of anxiety disorders and substance dependency [3].”
    • Also stated in: § Discussion · boosted
      “Together, quantitative evidence demonstrates that insomnia is a risk factor for the de novo onset of mental disorders [3]”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [3] Hertenstein, 2019, Insomnia as a predictor of mental disorders: a systematic review and meta-analysis, Sleep Med Rev source

      Not checked in the free run.

42 of 42

  • The paper relies on this without support.

    Control conditions receiving no treatment, placebo, waitlist, or treatment as usual without specific sleep treatment are valid comparators for estimating CBT-I efficacy.

    “Each study had to include a control group receiving no treatment, placebo, waitlist or treatment as usual without specific sleep treatment.”

  • The paper relies on this without support.

    Pooling heterogeneous mental health outcome measures across different mental disorders yields a meaningful overall effect estimate.

    “The outcome measure for mental health were heterogeneous due to the heterogeneity of the mental disorders themselves and due to different instruments chosen to assess the same mental disorder in the individual primary studies.”

  • The paper relies on this without support.

    The included primary studies' self-rating questionnaires validly measure the severity of insomnia and mental disorders.

    “The severity of insomnia and the mental disorder had to be assessed with validated self-rating questionnaires (not sleep diaries only).”

  • The authors state this as an assumption.

    There is a distribution of true effect sizes rather than a single true effect size.

    “Assuming that there is a distribution of true effect sizes rather than a single true effect size, a random-effects model was selected for meta-analytic pooling of the primary studies as recommended by Borenstein et al. [30].”

  • The paper relies on this without support.

    Diagnoses of insomnia and mental disorders based on DSM, ICD, ICSD, or validated self-rating questionnaire cutoffs are valid.

    “Diagnosis of insomnia and the mental disorder had to be based on a version of DSM (DSM III or higher) or ICD or the International Classification of sleep disorders (ICSD) for insomnia or an abnormal score, exceeding the cutoff for pathology, in a validated self-rating questionnaire.”

  • The paper relies on this without support.

    The included studies' treatment packages labeled CBT-I are sufficiently similar to pool.

    “Twenty out of 22 studies investigated a treatment package including behavioral treatment, cognitive restructuring and relaxation.The two remaining studies used brief behavioral treatment including only behavioral treatment components (sleep restriction and stimulus control) [39,40].”

  • The paper relies on this without support.

    Hallmarks of insomnia are subjective sleep disturbances and dysfunctional thoughts and attitudes about sleep.

    “Hallmarks of insomnia are subjective sleep disturbances and dysfunctional thoughts and attitudes about sleep.”
7 of 7

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • The 6-week iMAP protocols in sleep, exercise, diet, or social connection were grounded in evidence-based intervention protocols for these lifestyle domains in depression.

    “Description of each 6-week iMAP in either sleep/ exercise/ diet/ social connection domain is provided in Supplementary Methods section S.5 and is grounded in evidence-based intervention protocols in these lifestyle domains in the context of depression [5, 6, 8, 11, 16, 68–70].”

    From Personalized machine learning guided intervention for optimizing lifestyle behaviors in depression: a pilot study (2026) · cites this paper as [16]

  • Reduced heart-rate variability relates to impaired stress regulation during bedtime; lower pre-sleep HRV is associated with greater cognitive and somatic arousal, longer sleep-onset latency, and poorer overall sleep quality in insomnia and high-stress populations.

    “Autonomic indicators such as reduced heart-rate variability (HRV) have also been found to relate to impaired stress regulation during bedtime, where lower pre-sleep HRV is associated with greater cognitive and somatic arousal, longer sleep-onset latency, and poorer overall sleep quality in both insomnia and high-stress populations [31,32].”

    From Pre-Sleep Anxiety: Mechanisms and Therapeutic Approaches in Clinical Practice. (2026) · cites this paper as [31]

    Split into 2 atoms — 0 confirmed, 0 partially supported, 0 disputed, 0 misattributed, 2 unverifiable. Expand the claim to see per-atom verdicts.

    Experimental — accuracy not yet measured

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Conflicting counts of PTSD studies

    Minor

    The study description counts four PTSD studies, but the discussion says there were three.

  • PTSD follow-up subgroup is reported as both nonsignificant and significant

    Minor

    The results say no mental-health subgroup had a significant follow-up effect, while the displayed PTSD follow-up subgroup test reports p = 0.016.

2 of 2

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Authors
Hertenstein, E., Trinca, E., Wunderlin, M., Schneider, C. L., Züst, M. A., Fehér, K. D., Su, T., Straten, A. V., Berger, T., Baglioni, C., Johann, A., Spiegelhalder, K., Riemann, D., Feige, B., & Nissen, C.
Affiliations
  • University of Bern (CH)
  • GGZ inGeest (NL)
  • Amsterdam Public Health (NL)
  • University of Freiburg (DE)
Corresponding author
Hertenstein, Elisabeth
ORCID
Venue
Sleep Medicine Reviews
Publisher
Elsevier BV
Published
2022-04
Volume
62
Pages
101597
ISSN
1087-0792 (ISSN-L)
DOI
10.1016/j.smrv.2022.101597
OpenAlex
W4211223218
Semantic Scholar
7550b85b43f19cd95ac0de10aec873e16b237242
Cited by
391
References
67
Citations by year
2026: 82 · 2025: 153 · 2024: 84 · 2023: 63 · 2022: 9
FWCI
11.30
Type
journal article
Language
en
Open access
Licence
Locations
  • Sleep Medicine Reviews (publishedVersion, cc-by-nc-nd)
  • PubMed (publishedVersion)
  • Amsterdam UMC (VU Amsterdam) - Institutional Repository (publishedVersion, other-oa)
  • VU Research Portal (publishedVersion, other-oa)
  • Bern Open Repository and Information System (University of Bern) (submittedVersion, cc-by-nc-nd)
  • Pure Amsterdam UMC (submittedVersion, cc-by)
  • Data Archiving and Networked Services (DANS) (submittedVersion, other-oa)
  • Open Access CRIS of the University of Bern
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
  • Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
Keywords
cognitive behavioral therapy for insomnia, insomnia, mental illness, comorbid insomnia, depression, post-traumatic stress disorder, alcohol dependency, bipolar disorder, psychosis, insomnia severity, mental health, non-pharmacological treatment, treatment discontinuation, treatment acceptability
MeSH terms
Adult, Humans, Sleep Initiation and Maintenance Disorders, Stress Disorders, Post-Traumatic, Comorbidity, Cognitive Behavioral Therapy, Treatment Outcome

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-09.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-09.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

What counts as a claim ›How we measure confidence ›How we check this ›

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