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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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In the citing paper
“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]
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“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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“…treatment alternative that targets the maladaptive behaviours and dysfunctional thoughts believed to perpetuate sleep difficulties, and it has been identified as one of the most effective insomnia treatments (Edinger, Wohlgemuth, Radtke, Marsh, & Quillian, 2001; Morin et al., 2006).”
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“However, given that sleep hygiene alone is not a considered an empirically-supported psychological treatment for insomnia (Morin et al., 2006), this is unlikely to be a major confounding factor.”
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Self-citationBehavioral Treatment of Insomnia in Bipolar Disorder
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“As the goal of sleep restriction and stimulus control is to increase sleep efficiency and regularize the sleep-wake cycle (6), it may be particularly useful for this population.”
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Sleep quality across pregnancy and postpartum: effects of parity and race
Christian, L. M., Carroll, J., Porter, K. M., & Hall, M. H. (2019) · Sleep Health · doi:10.1016/j.sleh.2019.03.005 · Cited by 111
Trockel, M., Manber, R., Chang, V., Thurston, A., & Tailor, C. B. (2011) · Journal of Clinical Sleep Medicine · doi:10.5664/jcsm.1072 · Cited by 108
Crönlein, T., Langguth, B., Popp, R., Lukesch, H., Pieh, C., Hajak, G., & Geisler, P. (2013) · Health and Quality of Life Outcomes · doi:10.1186/1477-7525-11-65 · Cited by 109
Sleep Loss and Affective Functioning: More Than Just Mood
Watling, J., Pawlik, B., Scott, K., Booth, S. A., & Short, M. A. (2016) · Behavioral Sleep Medicine · doi:10.1080/15402002.2016.1141770 · Cited by 124
“…for why cognitive behavioral therapies targeting mood can also have positive effects on sleep and why sleep interventions may improve mood (Manber et al., 2011; Morin et al., 2006; Nutt, Wilson, & Paterson, 2008), namely, because of the bidirectional causal relationship between sleep and mood.”
BackgroundArnedt, J. T., Conroy, D. A., Mooney, A., Furgal, A. K. C., Sen, A., & Eisenberg, D. (2020) · SLEEP · doi:10.1093/sleep/zsaa136 · Cited by 117
Smitherman, T. A., Walters, A. B., Davis, R. E., Ambrose, C. E., Roland, M., Houle, T. T., & Rains, J. C. (2016) · Headache: The Journal of Head and Face Pain · doi:10.1111/head.12760 · Cited by 121
Non-pharmacological Approaches for Management of Insomnia
Chan, N. Y., Chan, J. W. Y., Li, S. X., & Wing, Y. K. (2021) · Neurotherapeutics · doi:10.1007/s13311-021-01029-2 · Cited by 125
A transdiagnostic approach to treating sleep disturbance in psychiatric disorders
Harvey, A. G. (2009) · Cognitive Behaviour Therapy · doi:10.1080/16506070903033825 · Cited by 105
“Optional Module 1: treating insomnia Given that CBT for insomnia (known as CBT-I) has been shown to be an effective treatment for adults with insomnia (Morin et al., 2006), it should form thebasis for treating insomnia, should it be present.”
BackgroundInsomnia and Sleep-Related Breathing Disorders
Wickwire, E. M., & Collop, N. A. (2010) · CHEST Journal · doi:10.1378/chest.09-1485 · Cited by 109
Anxiety and sleep disorders in cancer patients
Trill, M. D. (2013) · European Journal of Cancer Supplements · doi:10.1016/j.ejcsup.2013.07.009 · Cited by 107
Zuraikat, F. M., Makarem, N., Liao, M., St‐Onge, M., & Aggarwal, B. (2020) · Journal of the American Heart Association · doi:10.1161/jaha.119.014587 · Cited by 105
Guidelines for Rehabilitation in Patients With Cardiovascular Disease (JCS 2012):– Digest Version –
JCSJointWorkingGroup (2014) · Circulation · Cited by 105
Lancee, J., van den Bout, J., Sorbi, M. J., & van Straten, A. (2013) · Behaviour Research and Therapy · doi:10.1016/j.brat.2013.09.004 · Cited by 104
“The effects of CBT-I are demonstrated in several reviews and meta-analyses (Irwin, Cole, & Nicassio, 2006; Morin et al., 1999, 2006).”
MethodMatthews, E. E., Berger, A. M., Schmiege, S. J., Cook, P. F., McCarthy, M. S., Moore, C. M., & Aloia, M. S. (2014) · Oncology Nursing Forum · doi:10.1188/14.onf.41-03ap · Cited by 103
“Improvements are sustained longer than pharmacologic therapies because the root cause of insomnia is addressed, and strategies can be used for a lifetime (Morin et al., 2006).”
BackgroundKyle, S. D., Aquino, M. R. J., Miller, C. B., Henry, A. L., Crawford, M., Espie, C. A., & Spielman, A. J. (2015) · Sleep Medicine Reviews · doi:10.1016/j.smrv.2015.02.003 · Cited by 108
Self-citationSleep Disturbances and Fatigue in Critically Ill Patients
Matthews, E. E. (2011) · AACN Advanced Critical Care · doi:10.1097/nci.0b013e31822052cb · Cited by 104
Alessi, C., Martin, J. L., Fiorentino, L., Fung, C. H., Dzierzewski, J. M., Tapia, J. C. R., Song, Y., Josephson, K. R., Jouldjian, S., & Mitchell, M. N. (2016) · Journal of the American Geriatrics Society · doi:10.1111/jgs.14304 · Cited by 106
as the Sleep Disturbance Expert Panel on behalf of the Cancer Journey Advisory Group of the Canadian Partnership Against Cancer, Howell, D., Oliver, T. K., Keller-Olaman, S., Davidson, J. R., Garland, S. N., Samuels, C. H., Savard, J., Harris, C. A., Aubin, M., et al. (2013) · Supportive Care in Cancer · doi:10.1007/s00520-013-1823-6 · Cited by 100
“evidence; these included reviews, information summaries, consensus statements, or guidelines that offered best practice advice, but were not necessarily cancer-focused or evidencebased [13,16,34–59].”
BackgroundMeltzer, L. J. (2010) · Behavioral Sleep Medicine · doi:10.1080/15402002.2010.487464 · Cited by 110
“Finally, rather than standard sleep restriction and stimulus control utilized with adults (for a review, see Morin et al., 2006), treatment for BIC involves teaching parents about behavior management (e.g., limit-setting and extinction).”
BackgroundMethodBelleville, G. (2010) · The Canadian Journal of Psychiatry · doi:10.1177/070674371005500904 · Cited by 100
The role of cognitive–behavioral therapy in behavioral childhood insomnia
Tikotzky, L., & Sadeh, A. (2010) · Sleep Medicine · doi:10.1016/j.sleep.2009.11.017 · Cited by 106
Passos, G. S., Poyares, D., Santana, M. G., Teixeira, A. A. D. S., Lira, F. S., Youngstedt, S. D., Santos, R. V. T. D., Tufik, S., & de Mello, M. T. (2014) · BioMed Research International · doi:10.1155/2014/498961 · Cited by 99
A test of the bidirectional association between sleep and mood in bipolar disorder and insomnia.
Talbot, L. S., Stone, S. I., Gruber, J., Hairston, I. S., Eidelman, P., & Harvey, A. G. (2011) · Journal of Abnormal Psychology · doi:10.1037/a0024946 · Cited by 102
“…are significant. study suggest that two of the most empirically supported treatments for insomnia, stimulus control and sleep restriction, may be relevant for bipolar disorder given the emphasis within these treatment approaches on de-conditioning and consolidated sleep (e.g., Morin et al., 2006).”
Putting Integrative Oncology Into Practice: Concepts and Approaches
Latte-Naor, S., & Mao, J. J. J. (2019) · Journal of Oncology Practice · doi:10.1200/jop.18.00554 · Cited by 98
Randomized Controlled Trial of Telephone-Delivered Cognitive Behavioral Therapy for Chronic Insomnia
Arnedt, J. T., Cuddihy, L. J., Swanson, L. M., Pickett, S. M., Aikens, J. E., & Chervin, R. D. (2013) · SLEEP · doi:10.5665/sleep.2448 · Cited by 98
Sleep Disruption at Home As an Independent Risk Factor for Postoperative Delirium
Todd, O. M., Gelrich, L., MacLullich, A. M. J., Drießen, M., Thomas, C., & Kreisel, S. H. (2017) · Journal of the American Geriatrics Society · doi:10.1111/jgs.14685 · Cited by 101
Dyas, J., Apekey, T. A., Tilling, M., Ørner, R., Middleton, H. C., & Siriwardena, A. N. (2010) · British Journal of General Practice · doi:10.3399/bjgp10x484183 · Cited by 96
“There is a recognised need to improve the management of sleep problems through education of evidence-based treatment of insomnia for clinicians and patients, using psychosocial interventions, including cognitive behavioural therapy for insomnia.(11,12) To provide better management and improve the user experience of ca…”
BackgroundGreater incidence of depression with hypnotic use than with placebo
Kripke, D. F. (2007) · BMC Psychiatry · doi:10.1186/1471-244x-7-42 · Cited by 95
Fitness and Exercise as Correlates of Sleep Complaints
Gerber, M., Brand, S., Holsboer‐Trachsler, E., & Pühse, U. (2010) · Medicine & Science in Sports & Exercise · doi:10.1249/mss.0b013e3181c0ea8c · Cited by 97
Treatment of Circadian Rhythm Sleep–Wake Disorders
Sun, S., & Chen, G. (2021) · Current Neuropharmacology · doi:10.2174/1570159x19666210907122933 · Cited by 103
Hypnotics in Insomnia: The Experience of Zolpidem
MacFarlane, J., Morin, C. M., & Montplaisir, J. (2014) · Clinical Therapeutics · doi:10.1016/j.clinthera.2014.09.017 · Cited by 94
Self-citationThorndike, F. P., Ritterband, L. M., Gonder-Frederick, L. A., Lord, H. R., Ingersoll, K. S., & Morin, C. M. (2013) · Journal of Clinical Psychology · doi:10.1002/jclp.22032 · Cited by 95
“…2003) works by targeting the maladaptive behaviors and dysfunctional thoughts believed to perpetuate sleep problems, going beyond mere sleep hygiene interventions (Edinger, Wohlgemuth, Radtke, Marsh, & Quillian, 2001; Morin et al., 1999; Morin et al., 2006; National Institutes of Health, 2005).”
BackgroundSelf-citationLancee, J., Eisma, M. C., van Straten, A., & Kamphuis, J. H. (2015) · Cognitive Behaviour Therapy · doi:10.1080/16506073.2015.1026386 · Cited by 98
“Several meta-analyses showed that sleeping problems can be effectively treated with cognitive behavioral therapy for insomnia (CBT-I; Irwin, Cole, & Nicassio, 2006; Morin et al., 2006; Morin et al., 1999).”
BackgroundA Transdiagnostic Intervention for Youth Sleep and Circadian Problems
Harvey, A. G. (2015) · Cognitive and Behavioral Practice · doi:10.1016/j.cbpra.2015.06.001 · Cited by 98
Metrik, J., Jackson, K. M., Bassett, S. S., Zvolensky, M. J., Seal, K. H., & Borsari, B. E. (2016) · Psychology of Addictive Behaviors · doi:10.1037/adb0000210 · Cited by 100
“Engaging veterans who use cannabis in evidence-based treatments that address sleep, such as cognitive–behavioral therapy for insomnia (CBT-I; Morin et al., 2006; Perlis, Jungquist, Smith, & Posner, 2006), may have high impact on clinical outcomes for PTSD and CUD (Babson, Ramo, Baldini, Vandrey, &…”
BackgroundNew developments in cognitive behavioral therapy as the first-line treatment of insomnia
Siebern, A. T., & Manber (2011) · Psychology Research and Behavior Management · doi:10.2147/prbm.s10041 · Cited by 99
Biological rhythms and chronotherapeutics in depression
Geoffroy, P. A., & Palagini, L. (2021) · Progress in Neuro-Psychopharmacology and Biological Psychiatry · doi:10.1016/j.pnpbp.2020.110158 · Cited by 127
Lorenz, N., Heim, E., Rötger, A., Birrer, E., & Maercker, A. R. A. (2018) · Behavioural and Cognitive Psychotherapy · doi:10.1017/s1352465818000486 · Cited by 90
“Despite the fact that evidence-based treatments exist and despite the negative impacts of sleep disturbances, insomnia often remains unrecognized and untreated (Morin et al., 2006b).”
BackgroundThe Effect of Mind-Body Therapies on Insomnia: A Systematic Review and Meta-Analysis
Wang, X., Li, P., Pan, C., Dai, L., Wu, Y., & Yun-long, D. (2019) · Evidence-based Complementary and Alternative Medicine · doi:10.1155/2019/9359807 · Cited by 102
“However, CBT-I is intensive, requiring administration by highly trained therapists [16].”
BackgroundScheduled Bright Light for Treatment of Insomnia in Older Adults
Friedman, L., Zeitzer, J. M., Kushida, C. A., Zhdanova, I. V., Noda, A. M., Lee, T. T., Schneider, M. B., Guilleminault, C., Sheikh, J. I., & Yesavage, J. A. (2009) · Journal of the American Geriatrics Society · doi:10.1111/j.1532-5415.2008.02164.x · Cited by 88
Non-Pharmacological Treatment of Insomnia
Siebern, A. T., Suh, S., & Nowakowski, S. (2012) · Neurotherapeutics · doi:10.1007/s13311-012-0142-9 · Cited by 88
Aging, circadian rhythms and depressive disorders: a review.
Costa, I. C., Carvalho, H. N., & Fernandes, L. P. N. S. (2013) · Europe PMC (PubMed Central) · Cited by 90
Lichstein, K. L., Scogin, F. R., Thomas, S. J., DiNapoli, E. A., Dillon, H. R., & McFadden, A. C. (2013) · Journal of Clinical Psychology · doi:10.1002/jclp.22030 · Cited by 88
“Cognitive-behavior therapy (CBT) is the most thoroughly investigated psychological treatment for both insomnia and depressive symptoms experienced by older adults (Morin et al., 2006; Scogin, Welsh, Hanson, Stump, & Coates, 2005).”
Self-citationWagley, J. N., Rybarczyk, B., Nay, W. T., Danish, S., & Lund, H. G. (2013) · Journal of Clinical Psychology · doi:10.1002/jclp.21927 · Cited by 85
Cassidy‐Eagle, E. L., Siebern, A. T., Unti, L. M., Glassman, J. R., & O'Hara, R. M. (2017) · Clinical Gerontologist · doi:10.1080/07317115.2017.1384777 · Cited by 91
“CBT-I treatment outcomes are comparable across younger and middle aged adults (Morin et al., 2006; Morin, Culbert, & Schwartz, 1994).”
Background
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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