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Cognitive behavioral therapy for insomnia in patients with mental disorders and comorbid insomnia: A systematic review and meta-analysis
Open accessAbstract
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.
Overview
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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).
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29 Not checked yet · 29 Own result · 10 Own interpretation · 6 Own method · 6 No basis given
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“and, as shown in the present work, improvement of insomnia symptoms is associated with improved mental health.”
§ Cognitive behavioral therapy for insomnia in patients with mental disorders and comorbid insomnia: A systematic review and meta-analysis > Discussion
boostedcorrelational- Asserted: passes — The authors put it forward as true.
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The paper states this without a source or data behind it here, so there is nothing to check it against. The quote shows it is in the paper.
In the paper
“2) CBT-I reduces insomnia severity (large effect size) and the severity of the comorbid disorder (medium effect size).”
§ Cognitive behavioral therapy for insomnia in patients with mental disorders and comorbid insomnia: A systematic review and meta-analysis > Discussion
plaindirect- Asserted: passes — The authors put it forward as true.
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In the paper
“Almost half of our sample of primary studies consisted of patients with depression.”
§ Cognitive behavioral therapy for insomnia in patients with mental disorders and comorbid insomnia: A systematic review and meta-analysis > Discussion
plain- Asserted: passes — The authors put it forward as true.
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A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Egger tests were non-significant (p > 0.1) for insomnia and comorbidity at follow-up.”
§ Cognitive behavioral therapy for insomnia in patients with mental disorders and comorbid insomnia: A systematic review and meta-analysis > Publication bias
plain- Asserted: passes — The authors put it forward as true.
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A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Most included trials had relatively short follow-up periods.”
§ Cognitive behavioral therapy for insomnia in patients with mental disorders and comorbid insomnia: A systematic review and meta-analysis > Discussion
plain- Asserted: passes — The authors put it forward as true.
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In the paper
“Apart from one study in patients with depression [1] that was insignificant, the effects of the studies using abbreviated treatment versions had similar effect sizes compared to those using longer treatment periods.”
§ Cognitive behavioral therapy for insomnia in patients with mental disorders and comorbid insomnia: A systematic review and meta-analysis > Discussion
What the sources say
- Not checked yetcites [1] Seow, 2018, Evaluating DSM-5 insomnia disorder and the treatment of sleep problems in a psychiatric population, J Clin Sleep Med source
plain- Asserted: passes — The authors put it forward as true.
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In the paper
“All the named studies with adaptations had good effects.”
§ Cognitive behavioral therapy for insomnia in patients with mental disorders and comorbid insomnia: A systematic review and meta-analysis > Discussion
plaindirect- Asserted: passes — The authors put it forward as true.
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A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Twenty out of 22 primary studies conducted a form of CBT-I including the components education, behavioral treatment (sleep restriction and/or stimulus control), relaxation and cognitive therapy.”
§ Cognitive behavioral therapy for insomnia in patients with mental disorders and comorbid insomnia: A systematic review and meta-analysis > Discussion
plain- Asserted: passes — The authors put it forward as true.
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In the paper
“For the severity of insomnia post treatment, we found a large effect favoring CBT-I (Hedges' g 1.0, CI 0.7e1.2).”
§ Cognitive behavioral therapy for insomnia in patients with mental disorders and comorbid insomnia: A systematic review and meta-analysis > Main results
plaindirect- Asserted: passes — The authors put it forward as true.
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In the paper
“In addition, the funnel plots and the Egger tests indicated potential publication bias.”
§ Cognitive behavioral therapy for insomnia in patients with mental disorders and comorbid insomnia: A systematic review and meta-analysis > Discussion
hedgedcorrelational- Asserted: passes — The authors put it forward as true.
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- Probably not a substantial claim. 17
- It may state two separate claims as one. 31
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“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.”
§ Cognitive behavioral therapy for insomnia in patients with mental disorders and comorbid insomnia: A systematic review and meta-analysis > Abstract
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Probably not a substantial claim. It may state two separate claims as one.
- Also stated in: § Study flow · plain
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“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).”
§ Cognitive behavioral therapy for insomnia in patients with mental disorders and comorbid insomnia: A systematic review and meta-analysis > Abstract
plainn = 491- Asserted: passes — The authors put it forward as true.
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- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
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It may state two separate claims as one.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“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.”
§ Cognitive behavioral therapy for insomnia in patients with mental disorders and comorbid insomnia: A systematic review and meta-analysis > Main results
plaindirect- Asserted: passes — The authors put it forward as true.
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It may state two separate claims as one.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“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.”
§ Cognitive behavioral therapy for insomnia in patients with mental disorders and comorbid insomnia: A systematic review and meta-analysis > Discussion
plaindirect- Asserted: passes — The authors put it forward as true.
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It may state two separate claims as one.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“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).”
§ Cognitive behavioral therapy for insomnia in patients with mental disorders and comorbid insomnia: A systematic review and meta-analysis > Publication bias
hedgedcorrelational- Asserted: passes — The authors put it forward as true.
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The paper states this without a source or data behind it here, so there is nothing to check it against. The quote shows it is in the paper.
In the paper
“The majority of studies provided only one follow-up assessment, mostly three to six months after the end of treatment.”
§ Cognitive behavioral therapy for insomnia in patients with mental disorders and comorbid insomnia: A systematic review and meta-analysis > Discussion
plain- Asserted: passes — The authors put it forward as true.
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It may state two separate claims as one.
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In the paper
“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.”
§ Cognitive behavioral therapy for insomnia in patients with mental disorders and comorbid insomnia: A systematic review and meta-analysis > Discussion
plaindirect- Asserted: passes — The authors put it forward as true.
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It may state two separate claims as one.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“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.”
§ Cognitive behavioral therapy for insomnia in patients with mental disorders and comorbid insomnia: A systematic review and meta-analysis > Main results
plain- Asserted: passes — The authors put it forward as true.
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It may state two separate claims as one.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“With three primary studies each, our metaanalysis indicates that CBT-I is effective in those with PTSD and alcohol dependency.”
§ Cognitive behavioral therapy for insomnia in patients with mental disorders and comorbid insomnia: A systematic review and meta-analysis > Discussion
hedgeddirect- Asserted: passes — The authors put it forward as true.
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It may state two separate claims as one.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“For mental health at follow-up, the effect was not significant for any subgroup and effect sizes were small to moderate.”
§ Cognitive behavioral therapy for insomnia in patients with mental disorders and comorbid insomnia: A systematic review and meta-analysis > Main results
plain- Asserted: passes — The authors put it forward as true.
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It may state two separate claims as one.
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In the paper
“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.”
§ Cognitive behavioral therapy for insomnia in patients with mental disorders and comorbid insomnia: A systematic review and meta-analysis > Description of the study sample
plain- Asserted: passes — The authors put it forward as true.
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It may state two separate claims as one.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Heterogeneity was still significant within the depression subgroup and within the mixed subgroup (Figs.2e5).”
§ Cognitive behavioral therapy for insomnia in patients with mental disorders and comorbid insomnia: A systematic review and meta-analysis > Main results
plain- Asserted: passes — The authors put it forward as true.
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- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
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It may state two separate claims as one.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“The overall risk of bias was low for five studies, high for four studies and moderate for remaining 13 studies.”
§ Cognitive behavioral therapy for insomnia in patients with mental disorders and comorbid insomnia: A systematic review and meta-analysis > Risk of bias
plain- Asserted: passes — The authors put it forward as true.
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It may state two separate claims as one.
The paper states this without a source or data behind it here, so there is nothing to check it against. The quote shows it is in the paper.
In the paper
“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.”
§ Cognitive behavioral therapy for insomnia in patients with mental disorders and comorbid insomnia: A systematic review and meta-analysis > Risk of bias
plaindirect- Asserted: passes — The authors put it forward as true.
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- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
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It may state two separate claims as one.
None of the sources cited for this claim have been checked yet.
In the paper
“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.”
§ Cognitive behavioral therapy for insomnia in patients with mental disorders and comorbid insomnia: A systematic review and meta-analysis > Description of the study sample
What the sources say
- Not checked yetcites [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 yetcites [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
plain- Asserted: passes — The authors put it forward as true.
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It may state two separate claims as one.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Only one RCT each fulfilling our inclusion criteria has been conducted with patients suffering from bipolar disorder and psychosis.”
§ Cognitive behavioral therapy for insomnia in patients with mental disorders and comorbid insomnia: A systematic review and meta-analysis > Discussion
plain- Asserted: passes — The authors put it forward as true.
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It may state two separate claims as one.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“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.”
§ Cognitive behavioral therapy for insomnia in patients with mental disorders and comorbid insomnia: A systematic review and meta-analysis > Main results
plaindirect- Asserted: passes — The authors put it forward as true.
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It may state two separate claims as one.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“The Cochrane Risk of Bias Tool (RoB) was used to estimate the risk of bias in the included studies.”
§ Cognitive behavioral therapy for insomnia in patients with mental disorders and comorbid insomnia: A systematic review and meta-analysis > Assessment of risk of bias
plain- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it.
None of the sources cited for this claim have been checked yet.
In the paper
“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].”
§ Cognitive behavioral therapy for insomnia in patients with mental disorders and comorbid insomnia: A systematic review and meta-analysis > Methods
What the sources say
- Not checked yetcites [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 yetcites [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
plain- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“Studies were reviewed by two independent raters.Discrepancies were discussed and solved in consensus with the co-authors.”
§ Cognitive behavioral therapy for insomnia in patients with mental disorders and comorbid insomnia: A systematic review and meta-analysis > Search strategy
plain- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.
In the paper
“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].”
§ Cognitive behavioral therapy for insomnia in patients with mental disorders and comorbid insomnia: A systematic review and meta-analysis > Introduction
What the sources say
- Not checked yetcites [18] Gee, 2019, The effect of non-pharmacological sleep interventions on depression symptoms: a meta-analysis of randomised controlled trials, Sleep Med Rev source
plaindirect- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. It may state two separate claims as one.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“This meta-analysis has been registered with PROSPERO with the registration number CRD42021249929.”
§ Cognitive behavioral therapy for insomnia in patients with mental disorders and comorbid insomnia: A systematic review and meta-analysis > Methods
plain- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it.
In the paper
“In their meta-analysis, Wu and colleagues found that CBT-I was more effective for patients with mental comorbidity compared to medical comorbidity [17].”
§ Cognitive behavioral therapy for insomnia in patients with mental disorders and comorbid insomnia: A systematic review and meta-analysis > Introduction
What the sources say
- Not checked yetcites [17] Wu, 2015, Cognitive behavioral therapy for insomnia comorbid with psychiatric and medical conditions: a meta-analysis, JAMA Intern Med source
plaindirect- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it.
In the paper
“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]”
§ Cognitive behavioral therapy for insomnia in patients with mental disorders and comorbid insomnia: A systematic review and meta-analysis > Discussion
What the sources say
- Not checked yetcites 59e62
plain- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it.
In the paper
“A recent meta-analysis concluded that sleep improvement after different non-pharmacological treatments for insomnia is causally related to improvements in mental health [19].”
§ Cognitive behavioral therapy for insomnia in patients with mental disorders and comorbid insomnia: A systematic review and meta-analysis > Introduction
What the sources say
- Not checked yetcites [19] Scott, 2021, Improving sleep quality leads to better mental health: a meta-analysis of randomised controlled trials, Sleep Med Rev source
boosteddirect- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it.
In the paper
“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].”
§ Cognitive behavioral therapy for insomnia in patients with mental disorders and comorbid insomnia: A systematic review and meta-analysis > Introduction
What the sources say
- Not checked yetcites [1] Seow, 2018, Evaluating DSM-5 insomnia disorder and the treatment of sleep problems in a psychiatric population, J Clin Sleep Med source
plaincorrelational- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
In the paper
“Visual inspection of funnel plots and Egger's tests were used to estimate publication bias [34].”
§ Cognitive behavioral therapy for insomnia in patients with mental disorders and comorbid insomnia: A systematic review and meta-analysis > Publication bias
What the sources say
- Not checked yetcites [34] Egger, 1997, Meta-analysis: principles and procedures, BMJ source
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it.
In the paper
“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].”
§ Cognitive behavioral therapy for insomnia in patients with mental disorders and comorbid insomnia: A systematic review and meta-analysis > Data extraction
What the sources say
- Not checked yetcites [28] Bastien, 2001, Validation of the Insomnia Severity Index as an outcome measure for insomnia research, Sleep Med source
boosted- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. It may state two separate claims as one.
In the paper
“CBT-I is also feasible and effective when delivered via the internet [11].”
§ Cognitive behavioral therapy for insomnia in patients with mental disorders and comorbid insomnia: A systematic review and meta-analysis > Introduction
What the sources say
- Not checked yetcites [11] Seyffert, 2016, Internet-delivered cognitive behavioral therapy to treat insomnia: a systematic review and meta-analysis, PLoS One source
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.
In the paper
“Absence of insomnia after successful antidepressant treatment is a predictor for the restoration of a normal level of functioning [6].”
§ Cognitive behavioral therapy for insomnia in patients with mental disorders and comorbid insomnia: A systematic review and meta-analysis > Introduction
What the sources say
- Not checked yetcites [6] Carney, 2011, Residual sleep beliefs and sleep disturbance following cognitive behavioral therapy for major depression, Depress Anxiety source
plaincorrelational- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“Risk of bias ratings were performed by ET and TS supervised by EH.Inconsistencies were discussed and agreed upon among the authors.”
§ Cognitive behavioral therapy for insomnia in patients with mental disorders and comorbid insomnia: A systematic review and meta-analysis > Assessment of risk of bias
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.
In the paper
“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].”
§ Cognitive behavioral therapy for insomnia in patients with mental disorders and comorbid insomnia: A systematic review and meta-analysis > Introduction
What the sources say
- Not checked yetcites [6] Carney, 2011, Residual sleep beliefs and sleep disturbance following cognitive behavioral therapy for major depression, Depress Anxiety source
boosteddirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“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.”
§ Cognitive behavioral therapy for insomnia in patients with mental disorders and comorbid insomnia: A systematic review and meta-analysis > Discussion
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
In the paper
“Since chronic stress can lead to depression, stress induced by constant worry about sleep may play a role in the development of depression [70e73].”
§ Cognitive behavioral therapy for insomnia in patients with mental disorders and comorbid insomnia: A systematic review and meta-analysis > Discussion
What the sources say
- Not checked yetcites [70e73]
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“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.”
§ Cognitive behavioral therapy for insomnia in patients with mental disorders and comorbid insomnia: A systematic review and meta-analysis > Discussion
plainconditional- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“3) Depression, post-traumatic stress disorder and alcohol dependency are the comorbid disorders with the best evidence base for CBT-I.”
§ Cognitive behavioral therapy for insomnia in patients with mental disorders and comorbid insomnia: A systematic review and meta-analysis > Discussion
plaincorrelational- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: fails — The paper may give no reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it. The paper may give no reason why it holds.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“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.”
§ Cognitive behavioral therapy for insomnia in patients with mental disorders and comorbid insomnia: A systematic review and meta-analysis > Discussion
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
In the paper
“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.”
§ Cognitive behavioral therapy for insomnia in patients with mental disorders and comorbid insomnia: A systematic review and meta-analysis > Discussion
What the sources say
- Not checked yetcites [17] Wu, 2015, Cognitive behavioral therapy for insomnia comorbid with psychiatric and medical conditions: a meta-analysis, JAMA Intern Med source
boosteddirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“This indicates a heightened need for research into the efficacy of CBT-I for patients with insomnia and previously under-researched patient groups.”
§ Cognitive behavioral therapy for insomnia in patients with mental disorders and comorbid insomnia: A systematic review and meta-analysis > Discussion
hedged- Asserted: passes — The authors put it forward as true.
- Checkable: fails — It may be too vague to check against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. It may be too vague to check against evidence.
In the paper
“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].”
§ Cognitive behavioral therapy for insomnia in patients with mental disorders and comorbid insomnia: A systematic review and meta-analysis > Discussion
What the sources say
- Not checked yetcites [9] Trauer, 2015, Cognitive behavioral therapy for chronic insomnia: a systematic review and meta-analysis, Ann Intern Med source
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“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.”
§ Cognitive behavioral therapy for insomnia in patients with mental disorders and comorbid insomnia: A systematic review and meta-analysis > Discussion
boostedconditional- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
In the paper
“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]”
§ Cognitive behavioral therapy for insomnia in patients with mental disorders and comorbid insomnia: A systematic review and meta-analysis > Discussion
What the sources say
- Not checked yetcites [3] Hertenstein, 2019, Insomnia as a predictor of mental disorders: a systematic review and meta-analysis, Sleep Med Rev source
boosteddirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
- Also stated in: § Discussion · boosted
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.”
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 cited source says what the claim attributes to it.
In the citing paper
“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]
The check wasn’t confident either way, so it gives no verdict — never disputed.
In the citing paper
“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]
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.
Rated minor: it would not touch a result — a value no result rests on, a p-value that stays on the same side of the significance level, or a conflict that is clerical, resolved elsewhere in the paper, or outside its own findings.
In the paper
§ Cognitive behavioral therapy for insomnia in patients with mental disorders and comorbid insomnia: A systematic review and meta-analysis > Description of the study sample
“The comorbid mental disorders in the included primary studies were depression (8 studies), PTSD (4 studies), alcohol dependency (3 studies), bipolar disorder (1 study), psychosis (1 study) and mixed comorbidities within one study (5 studies).”
§ Cognitive behavioral therapy for insomnia in patients with mental disorders and comorbid insomnia: A systematic review and meta-analysis > Discussion
“With three primary studies each, our metaanalysis indicates that CBT-I is effective in those with PTSD and alcohol dependency.”
Rated minor: it would not touch a result — a value no result rests on, a p-value that stays on the same side of the significance level, or a conflict that is clerical, resolved elsewhere in the paper, or outside its own findings.
In the paper
§ Cognitive behavioral therapy for insomnia in patients with mental disorders and comorbid insomnia: A systematic review and meta-analysis > Main results
“For mental health at follow-up, the effect was not significant for any subgroup and effect sizes were small to moderate.”
§ Cognitive behavioral therapy for insomnia in patients with mental disorders and comorbid insomnia: A systematic review and meta-analysis > Discussion
“PTSD Pigeon et al. 2021 [35] 110 CAPS Overall random effects model Heterogeneity: not applicable Test for effect in subgroup: z = 2.418 (p = 0.016)”
Citations
Cites
Quantifying heterogeneity in a meta‐analysis
Higgins, J. P. T., & Thompson, S. G. (2002) · Statistics in Medicine · doi:10.1002/sim.1186 · Cited by 36,763
The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research
Buysse, D. J., Reynolds, C. F., Monk, T. H., Berman, S. R., & Kupfer, D. J. (1989) · Psychiatry Research · doi:10.1016/0165-1781(89)90047-4 · Cited by 35,234
Meta-analysis of Observational Studies in Epidemiology<SUBTITLE>A Proposal for Reporting</SUBTITLE>
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Conducting Meta-Analyses in R with the metafor Package
Viechtbauer, W. (2010) · Journal of Statistical Software · doi:10.18637/jss.v036.i03 · Cited by 20,464
Liberati, A., Altman, D. G., Tetzlaff, J., Mulrow, C., Gøtzsche, P. C., Ioannidis, J. P. A., Clarke, M., Devereaux, P. J., Kleijnen, J., & Moher, D. (2009) · Journal of Clinical Epidemiology · doi:10.1016/j.jclinepi.2009.06.006 · Cited by 10,578
Validation of the Insomnia Severity Index as an outcome measure for insomnia research
Bastien, C. (2001) · Sleep Medicine · doi:10.1016/s1389-9457(00)00065-4 · Cited by 8,067
A basic introduction to fixed-effect and random-effects models for meta-analysis
Borenstein, M., Hedges, L. V., Higgins, J. P. T., & Rothstein, H. R. (2010) · Research Synthesis Methods · doi:10.1002/jrsm.12 · Cited by 6,793
Baglioni, C., Battagliese, G., Feige, B., Spiegelhalder, K., Nissen, C., Voderholzer, U., Lombardo, C., & Riemann, D. (2011) · Journal of Affective Disorders · doi:10.1016/j.jad.2011.01.011 · Cited by 2,779
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European guideline for the diagnosis and treatment of insomnia
Riemann, D., Baglioni, C., Bassetti, C., Bjorvatn, B., Dolenc Groselj, L., Ellis, J. G., Espie, C. A., Garcia‐Borreguero, D., Gjerstad, M., Gonçalves, M., et al. (2017) · Journal of Sleep Research · doi:10.1111/jsr.12594 · Cited by 2,049
Self-citation
Cited by
Sorted by citations
The European Insomnia Guideline: An update on the diagnosis and treatment of insomnia 2023
Riemann, D., Espie, C. A., Altena, E., Arnardottir, E. S., Baglioni, C., Bassetti, C. L. A., Bastien, C., Berzina, N., Bjorvatn, B., Dikeos, D., et al. (2023) · Journal of Sleep Research · doi:10.1111/jsr.14035 · Cited by 834
“Interestingly, especially in the area of mental disorders, the evidence indicates that CBT-I not only has sleep-related effects, but also has a positive effect on the symptoms of the comorbid disorder/condition (Hertenstein et al., 2022).”
BackgroundSelf-citationSleep, insomnia and mental health
Palagini, L., Hertenstein, E., Riemann, D. W., & Nissen, C. (2022) · Journal of Sleep Research · doi:10.1111/jsr.13628 · Cited by 360
Self-citationInsomnia disorder: State of the science and challenges for the future
Riemann, D. W., Benz, F., Dressle, R. J., Espie, C. A., Johann, A. F., Blanken, T. F., Leerssen, J., Wassing, R., Henry, A. L., Kyle, S. D., et al. (2022) · Journal of Sleep Research · doi:10.1111/jsr.13604 · Cited by 398
Self-citationGut liver brain axis in diseases: the implications for therapeutic interventions
Yan, M., Man, S., Sun, B., Ma, L., Guo, L., Huang, L., & Gao, W. (2023) · Signal Transduction and Targeted Therapy · doi:10.1038/s41392-023-01673-4 · Cited by 314
The sleep–circadian interface: A window into mental disorders
Meyer, N., Lok, R., Schmidt, C., Kyle, S. D., McClung, C. A., Cajochen, C., Scheer, F. A. J. L., Jones, M. W., & Chellappa, S. L. (2024) · Proceedings of the National Academy of Sciences · doi:10.1073/pnas.2214756121 · Cited by 190
Metadata
- 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)
- 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
- hybrid
- doi.org
- 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.
A language model drew the claims from the paper on 2026-10-09, under version 3 of the claim definition (model deepseek-v4.1-flash, prompt extract-v3).
A second model labelled each claim on 2026-10-09 (model jev-1.13-20260917, definition revision gold-guideline-v0.2).
Statistics and arithmetic are recomputed, not judged.
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