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Psychological and behavioral treatment of insomnia: update of the recent evidence (1998-2004)
Open accessAbstract
BACKGROUND: Recognition that psychological and behavioral factors play an important role in insomnia has led to increased interest in therapies targeting these factors. A review paper published in 1999 summarized the evidence regarding the efficacy of psychological and behavioral treatments for persistent insomnia. The present review provides an update of the evidence published since the original paper. As with the original paper, this review was conducted by a task force commissioned by the American Academy of Sleep Medicine in order to update its practice parameters on psychological and behavioral therapies for insomnia. METHODS: A systematic review was conducted on 37 treatment studies (N = 2246 subjects/patients) published between 1998 and 2004 inclusively and identified through Psyclnfo and Medline searches. Each study was systematically reviewed with a standard coding sheet and the following information was extracted: Study design, sample (number of participants, age, gender), diagnosis, type of treatments and controls, primary and secondary outcome measures, and main findings. Criteria for inclusion of a study were as follows: (a) the main sleep diagnosis was insomnia (primary or comorbid), (b) at least 1 treatment condition was psychological or behavioral in content, (c) the study design was a randomized controlled trial, a nonrandomized group design, a clinical case series or a single subject experimental design with a minimum of 10 subjects, and (d) the study included at least 1 of the following as dependent variables: sleep onset latency, number and/or duration of awakenings, total sleep time, sleep efficiency, or sleep quality. RESULTS: Psychological and behavioral therapies produced reliable changes in several sleep parameters of individuals with either primary insomnia or insomnia associated with medical and psychiatric disorders. Nine studies documented the benefits of insomnia treatment in older adults or for facilitating discontinuation of medication among chronic hypnotic users. Sleep improvements achieved with treatment were well sustained over time; however, with the exception of reduced psychological symptoms/ distress, there was limited evidence that improved sleep led to clinically meaningful changes in other indices of morbidity (e.g., daytime fatigue). Five treatments met criteria for empirically-supported psychological treatments for insomnia: Stimulus control therapy, relaxation, paradoxical intention, sleep restriction, and cognitive-behavior therapy. DISCUSSION: These updated findings provide additional evidence in support of the original review's conclusions as to the efficacy and generalizability of psychological and behavioral therapies for persistent insomnia. Nonetheless, further research is needed to develop therapies that would optimize outcomes and reduce morbidity, as would studies of treatment mechanisms, mediators, and moderators of outcomes. Effectiveness studies are also needed to validate those therapies when implemented in clinical settings (primary care), by non-sleep specialists. There is also a need to disseminate more effectively the available evidence in support of psychological and behavioral interventions to health-care practitioners working on the front line.
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“there is a rationale for using CBT with both PI and IdI patients.”
From Comparative investigation of the psychophysiologic and idiopathic insomnia disorder phenotypes: Psychologic characteristics, patients' perspectives, and implications for clinical management (2012) · cites this paper as [44]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“CBT-I is recognised as being the treatment of choice for insomnia [93], both in isolated form or as a comorbidity [94], in psychiatric populations [95], among the elderly [96,97], and delivered remotely [98].”
From Cognitive behavioral therapy and acceptance and commitment therapy for the discontinuation of long-term benzodiazepine use in insomnia and anxiety disorders (2021) · cites this paper as [93]
Experimental — accuracy not yet measuredThe cited source says what the claim attributes to it.
In the citing paper
“There is a large body of evidence on the efficacy of cognitive behavioral therapy for insomnia (CBT-I).1-3”
From Acceptance and commitment therapy-based behavioral intervention for insomnia: a pilot randomized controlled trial (2021) · cites this paper as [1]
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“considering that the efficacy of behavioral therapy components is well established.1-3”
From Acceptance and commitment therapy-based behavioral intervention for insomnia: a pilot randomized controlled trial (2021) · cites this paper as [1]
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“It is important to mention that behavioral components, such as stimulus control and sleep restriction, were used in both groups, which may have contributed to similar results in both groups, considering that the efficacy of behavioral therapy components is well established.1-3”
From Acceptance and commitment therapy-based behavioral intervention for insomnia: a pilot randomized controlled trial (2021) · cites this paper as [1]
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“cognitive behavioral treatments produce significant improvement of chronic insomnia in the short-term”
From Clinical Guideline for the Evaluation and Management of Chronic Insomnia in Adults (2008) · cites this paper as [67]
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“and these improvements appear sustained at follow-up for up to two years. 67”
From Clinical Guideline for the Evaluation and Management of Chronic Insomnia in Adults (2008) · cites this paper as [67]
In the citing paper
“CBT-I has a robust efficacy profile in the treatment of insomnia (Irwin et al, 2006;Morin et al, 2006).”
From Sleep health: Reciprocal regulation of sleep and innate immunity (2017) · cites this paper as Morin et al, 2006
In the citing paper
“A range of non-pharmacological treatments can reduce sleep problems”
From The effect of non-pharmacological sleep interventions on depression symptoms: a meta-analysis of randomised controlled trials (2019) · cites this paper as [31]
In the citing paper
“Evidence suggests that CBT-I is effective when compared with placebos [19,20].”
From Comparative effectiveness of cognitive behavioral therapy for insomnia: a systematic review (2012) · cites this paper as [19]
In the citing paper
“In 2006, the task force completed another systematic review of 37 treatment studies subsequent to the previous review (1998)(1999)(2000)(2001)(2002)(2003)(2004) [32].”
From Non-Pharmacological Treatment of Insomnia (2012) · cites this paper as [32]
In the citing paper
“In addition to revealing sleep improvements sustained in time in primary insomnia and in the presence of medical/psychiatric comorbidities, 9 treatment studies in older adults also indicated facilitation of discontinuation of hypnotic medication after chronic use [32].”
From Non-Pharmacological Treatment of Insomnia (2012) · cites this paper as [32]
In the citing paper
“Cognitive behavioral therapy for insomnia (CBT-I), the first-line treatment for insomnia (Morin et al., 2006), requires frequent monitoring and has a high cost (Passos et al., 2012).”
From Exercise can improve sleep quality: A systematic review and meta-analysis (2018) · cites this paper as Morin et al., 2006
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“SEH is considered as a minimal treatment (M. R. Irwin, Cole, & Nicasso, 2006; Morin, Culbert, & Schwartz, 1994; Morin et al., 2006).”
Self-citationSleep Complaints in Community‐Living Older Persons: A Multifactorial Geriatric Syndrome
Fragoso, C. A. V., & Gill, T. M. (2007) · Journal of the American Geriatrics Society · doi:10.1111/j.1532-5415.2007.01399.x · Cited by 226
Sleep loss affects vigilance: effects of chronic insomnia and sleep therapy
Altena, E., van der Werf, Y. D., STRIJERS, R. L. M., & Someren, E. J. W. V. (2008) · Journal of Sleep Research · doi:10.1111/j.1365-2869.2008.00671.x · Cited by 227
“…Montgomery and Dennis, 2004; Morin et al., 2006), consisted of sleep restriction, cognitive restructuring and sleep hygiene (Bastien et al., 2004; Morin et al., 2004), bright-light exposure (Lack et al., 2005; Montgomery and Dennis, 2002), body temperature manipulations (Van Someren, 2003, 2006)…”
BackgroundIrwin, M. R., Olmstead, R., Breen, E. C., Witarama, T., Carrillo, C., Sadeghi, N., Arevalo, J. M. G., Ma, J., Nicassio, P., Bootzin, R., et al. (2015) · Biological Psychiatry · doi:10.1016/j.biopsych.2015.01.010 · Cited by 227
Self-citationAn open trial of cognitive therapy for chronic insomnia
Harvey, A. G., Sharpley, A. L., Ree, M. J., Stinson, K., & Clark, D. M. (2007) · Behaviour Research and Therapy · doi:10.1016/j.brat.2007.04.007 · Cited by 219
Sleep Disturbance in Bipolar Disorder: Therapeutic Implications
Plante, D. T., & Winkelman, J. W. (2008) · American Journal of Psychiatry · doi:10.1176/appi.ajp.2008.08010077 · Cited by 268
Eveningness and Insomnia: Independent Risk Factors of Nonremission in Major Depressive Disorder
Chan, J. W. Y., Lam, S. P., Li, S. X., Yu, M. W. M., Chan, N. Y., Zhang, J., & Wing, Y. K. (2014) · SLEEP · doi:10.5665/sleep.3658 · Cited by 217
Circadian rhythm in bipolar disorder: A review of the literature
Takaesu, Y. (2018) · Psychiatry and Clinical Neurosciences · doi:10.1111/pcn.12688 · Cited by 239
Harvey, A. G., Bélanger, L., Talbot, L., Eidelman, P., Beaulieu-Bonneau, S., Fortier-Brochu, É., Ivers, H., Lamy, M., Hein, K., Soehner, A. M., et al. (2014) · Journal of Consulting and Clinical Psychology · doi:10.1037/a0036606 · Cited by 215
“While cognitive therapy (CT) is typically incorporated within CBT programs, its unique contribution is not yet known (Morin et al., 2006).”
InfluentialSelf-citationSleep-wake disturbances after traumatic brain injury
Ouellet, M.-C., Beaulieu-Bonneau, S., & Morin, C. M. (2015) · The Lancet Neurology · doi:10.1016/s1474-4422(15)00068-x · Cited by 231
Self-citationde Bruin, E. J., Bögels, S. M., Oort, F. J., & Meijer, A. M. (2015) · SLEEP · doi:10.5665/sleep.5240 · Cited by 214
Effect of acute physical exercise on patients with chronic primary insomnia
Passos, G. S., Poyares, D., Santana, M. G., Garbuio, S. A., Tufik, S., & Mello, M. T. (2010) · Journal of Clinical Sleep Medicine · doi:10.5664/jcsm.27825 · Cited by 211
Gee, B., Orchard, F., Clarke, E., Joy, A., Clarke, T., & Reynolds, S. (2019) · Sleep Medicine Reviews · doi:10.1016/j.smrv.2018.09.004 · Cited by 212
“6 Non-pharmacological interventions are effective in improving sleep, both in individuals with primary insomnia [30,31], and in those with sleep p roblems in the context of medical and psychiatric disorders [32–34].”
Insomnia: prevalence, consequences and effective treatment
Cunnington, D., Junge, M. F., & Fernando, A. T. (2013) · The Medical Journal of Australia · doi:10.5694/mja13.10718 · Cited by 223
Meta-analytic review of the impact of cognitive-behavior therapy for insomnia on concomitant anxiety
Belleville, G., Cousineau, H., Levrier, K., & St-Pierre-Delorme, M.-È. (2011) · Clinical Psychology Review · doi:10.1016/j.cpr.2011.02.004 · Cited by 207
Ulmer, C. S., Edinger, J. D., & Calhoun, P. S. (2011) · Journal of Clinical Sleep Medicine · doi:10.5664/jcsm.28042 · Cited by 207
Self-citationKyle, S. D., Miller, C. B., Rogers, Z., Siriwardena, A. N., Macmahon, K., & Espie, C. A. (2014) · SLEEP · doi:10.5665/sleep.3386 · Cited by 205
Self-citationEfficacy and safety of acupuncture treatment on primary insomnia: a randomized controlled trial.
Yin, X., Gou, M., Xu, J., Dong, B., Yin, P., Masquelin, F., Wu, J.-Y., Lao, L., & Xu, S.-F. (2017) · Sleep Medicine · doi:10.1016/j.sleep.2017.02.012 · Cited by 205
Irwin, M. R., Olmstead, R. E., Carrillo, C., Sadeghi, N., Nicassio, P. M., Ganz, P. A., & Bower, J. E. (2017) · Journal of Clinical Oncology · doi:10.1200/jco.2016.71.0285 · Cited by 215
On the nature of burnout–insomnia relationships: A prospective study of employed adults
Armon, G., Shirom, A., Shapira, I., & Melamed, S. (2008) · Journal of Psychosomatic Research · doi:10.1016/j.jpsychores.2008.01.012 · Cited by 205
Music‐assisted relaxation to improve sleep quality: meta‐analysis
de Niet, G., Tiemens, B. G., Lendemeijer, B. H. G. M., & Hutschemaekers, G. J. M. (2009) · Journal of Advanced Nursing · doi:10.1111/j.1365-2648.2009.04982.x · Cited by 204
Irwin, M. R., Carrillo, C., Sadeghi, N., Bjurstrom, M. F., Breen, E. C., & Olmstead, R. (2022) · JAMA Psychiatry · doi:10.1001/jamapsychiatry.2021.3422 · Cited by 203
Owens, J. A., & Mindell, J. A. A. (2011) · Pediatric Clinics of North America · doi:10.1016/j.pcl.2011.03.011 · Cited by 201
Adherence to cognitive behavioral therapy for insomnia: a systematic review
Matthews, E. E., Arnedt, J. T., McCarthy, M. S., Cuddihy, L. J., & Aloia, M. S. (2013) · Sleep Medicine Reviews · doi:10.1016/j.smrv.2013.01.001 · Cited by 199
Gottlieb, J. F., Benedetti, F., Geoffroy, P. A., Henriksen, T. E. G., Lam, R. W., Murray, G., Phelps, J., Sit, D., Swartz, H. A., Crowe, M., et al. (2019) · Bipolar Disorders · doi:10.1111/bdi.12847 · Cited by 196
Blom, K., Jernelöv, S., Kraepelien, M., Bergdahl, M. O., Jungmarker, K., Ankartjärn, L., Lindefors, N., & Kaldo, V. (2015) · SLEEP · doi:10.5665/sleep.4412 · Cited by 197
The evidence base of sleep restriction therapy for treating insomnia disorder
Miller, C. B., Espie, C. A., Epstein, D. R., Friedman, L., Morin, C. M., Pigeon, W. R., Spielman, A. J., & Kyle, S. D. (2014) · Sleep Medicine Reviews · doi:10.1016/j.smrv.2014.01.006 · Cited by 192
“, The evidence base of sle Reviews (2014), http://dx.doi.org/10.1016/j.smrv.2014.01.006 However, no average ES data was examined for these outcomes as three studies with sufficient methodological strength [44e46] collected data prior to the development and validation of the ISI [62], GSES [63], and ISQ [64]. One study…”
BackgroundMethodInfluentialSelf-citationThe gluten-free/casein-free diet: a double-blind challenge trial in children with autism
Hyman, S. L., Stewart, P. A., Foley, J., Cain, U., Peck, R., Morris, D. D., Wang, H., & Smith, T. (2016) · Journal of Autism and Developmental Disorders · doi:10.1007/s10803-015-2564-9 · Cited by 192
Sleep Disorders in Adolescents
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Using cannabis to help you sleep: Heightened frequency of medical cannabis use among those with PTSD
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Integrated behavioral health in primary care: Step-by-step guidance for assessment and intervention.
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Ouellet, M., & Morin, C. M. (2007) · Archives of Physical Medicine and Rehabilitation · doi:10.1016/j.apmr.2007.09.006 · Cited by 189
Self-citationSleep disturbance in bipolar disorder across the lifespan.
Harvey, A. G., Talbot, L. S., & Gershon, A. (2009) · Clinical Psychology Science and Practice · doi:10.1111/j.1468-2850.2009.01164.x · Cited by 184
“However, there are not yet data on sleepspecific outcomes and these approaches have yet to fully draw from advances in knowledge on the effectiveness of psychological treatments for sleep difficulty among individuals with insomnia (Morin et al., 2006).”
BackgroundEfficacy of an insomnia intervention on fatigue, mood and quality of life in breast cancer survivors
Dirksen, S. R., & Epstein, D. R. (2008) · Journal of Advanced Nursing · doi:10.1111/j.1365-2648.2007.04560.x · Cited by 185
“It is imperative that we now broaden the narrowed outcomes of success in treating insomnia to include additional indicators such as positive changes in fatigue, mood and quality of life (Morin 2003, Morin et al. 2006).”
BackgroundHo, F. Y., Chan, C. S., & Tang, K. N. S. (2015) · Clinical Psychology Review · doi:10.1016/j.cpr.2015.09.005 · Cited by 196
Dissemination of CBTI to the Non-Sleep Specialist: Protocol Development and Training Issues
Manber, R., Carney, C., Edinger, J., Epstein, D., Friedman, L., Haynes, P. L., Karlin, B. E., Pigeon, W., Siebern, A. T., & Trockel, M. (2012) · Journal of Clinical Sleep Medicine · doi:10.5664/jcsm.1786 · Cited by 178
“45-48 Therefore, the consensus of the workgroup was to not exclude medication-dependent insomnia sufferers from treatment with CBTI.”
Self-citationWork stressors and impaired sleep: rumination as a mediator
Berset, M., Elfering, A., Lüthy, S., Lüthi, S., & Semmer, N. K. (2010) · Stress and Health · doi:10.1002/smi.1337 · Cited by 182
Clinical Management of Insomnia with Brief Behavioral Treatment (BBTI)
Troxel, W., Germain, A., & Buysse, D. J. (2012) · Behavioral Sleep Medicine · doi:10.1080/15402002.2011.607200 · Cited by 180
“Evidence suggests that these treatments are preferred by patients (as compared to pharmacotherapy) and have consistent, strong, short-and long-term efficacy (Irwin, Cole, & Nicassio, 2006; Morin et al., 2006).”
BackgroundSelf-citationA neurobiological model of insomnia
Buysse, D. J., Germain, A., Hall, M. H., Monk, T. H., & Nofzinger, E. A. (2011) · Drug Discovery Today Disease Models · doi:10.1016/j.ddmod.2011.07.002 · Cited by 188
Self-citationKrystal, A. D. (2009) · Sleep Medicine Reviews · doi:10.1016/j.smrv.2008.08.001 · Cited by 180
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Insomnia in Elderly Patients: Recommendations for Pharmacological Management
Abad, V. C., & Guilleminault, C. (2018) · Drugs & Aging · doi:10.1007/s40266-018-0569-8 · Cited by 185
Crönlein, T., Langguth, B., Geisler, P., & Hajak, G. (2007) · Progress in Brain Research · doi:10.1016/s0079-6123(07)66021-x · Cited by 247
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“However, relaxation exercises as stand-alone treatment were inferior to other CBT-I exercises, such as stimulus control and sleep restriction [12].”
Insomnia as a Transdiagnostic Process in Psychiatric Disorders
Dolsen, E. A., Asarnow, L. D., & Harvey, A. G. (2014) · Current Psychiatry Reports · doi:10.1007/s11920-014-0471-y · Cited by 163
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Metadata
- Authors
- Morin, C. M., Bootzin, R. R., Buysse, D. J., Edinger, J. D., Espie, C. A., & Lichstein, K. L.
- Affiliations
- Université Laval (CA)
- University of Arizona (US)
- University of Pittsburgh (US)
- Duke University (US)
- University of Glasgow (GB)
- University of Alabama (US)
- Corresponding author
- Morin, Charles M.
- Venue
- Sleep
- Publisher
- Oxford University Press (OUP)
- Published
- 2006-11
- Volume
- 29
- Issue
- 11
- Pages
- 1398-1414
- ISSN
- 0161-8105 (ISSN-L)
- 1550-9109
- OpenAlex
- W1684861691
- Cited by
- 1,345
- References
- 92
- Citations by year
- 2026: 33 · 2025: 39 · 2024: 37 · 2023: 52 · 2022: 67 · 2021: 72 · 2020: 78 · 2019: 72 · 2018: 65 · 2017: 79 · 2016: 72 · 2015: 113 · 2014: 100 · 2013: 96 · 2012: 86
- FWCI
- 5.83
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- SLEEP (publishedVersion)
- PubMed (publishedVersion)
- University of Regensburg Publication Server (University of Regensburg) (acceptedVersion)
- University of Regensburg Publication Server (University of Regensburg)
- Funders
- Eli Lilly and Company
- Pfizer
- GlaxoSmithKline
- Sanofi
- Servier
- Topics
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Sleep and related disorders
- Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Keywords
- insomnia, psychological intervention, behavior therapy, cognitive behavioral therapy, stimulus control therapy, relaxation training, paradoxical intention, sleep restriction, older adults, comorbid insomnia, sleep quality, daytime fatigue, treatment efficacy, treatment sustainability, empirically supported treatments, sleep efficiency, sleep latency, awakening, total sleep time, psychiatric comorbidity
- MeSH terms
- Adult, Aged, Behavior Therapy, Combined Modality Therapy, Cross-Sectional Studies, Female, Humans, Hypnotics and Sedatives, Sleep Initiation and Maintenance Disorders, Male, Middle Aged, Patient Education as Topic, Comorbidity, Cognitive Behavioral Therapy, Randomized Controlled Trials as Topic, Treatment Outcome, Evidence-Based Medicine
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