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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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In the citing paper
“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]
The cited source says what the claim attributes to it.
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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In the citing paper
“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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In the citing paper
“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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BackgroundSelf-citationClinical management of behavioral insomnia of childhood
Corkum, P. V., & Vriend (2011) · Psychology Research and Behavior Management · doi:10.2147/prbm.s14057 · Cited by 67
“51 Interventions for the adolescent population typically include sleep hygiene education, relaxation strategies, and sleep restriction (ie, limiting time in bed based on how long one actually sleeps) to create more positive associations with sleeping and a greater physiological pressure for sleep.”
Cognitive behavioral therapy for shift workers with chronic insomnia
Järnefelt, H., Lagerstedt, R., Kajaste, S., Sallinen, M., Savolainen, A., & Hublin, C. (2012) · Sleep Medicine · doi:10.1016/j.sleep.2012.10.003 · Cited by 67
Lund, H. G., Rybarczyk, B. D., Perrin, P. B., Leszczyszyn, D. J., & Stepanski, E. J. (2012) · Journal of Clinical Psychology · doi:10.1002/jclp.21938 · Cited by 67
“59 for improvements in sleep after treatment but these changes are frequently of a much lower magnitude than self-reported changes occurring over a larger window of time than one or two nights of PSG (Morin et al., 2006).”
BackgroundWhen Thinking Impairs Sleep: Trait, Daytime and Nighttime Repetitive Thinking in Insomnia
Lancee, J., Eisma, M. C., van Zanten, K. B., & Topper, M. (2015) · Behavioral Sleep Medicine · doi:10.1080/15402002.2015.1083022 · Cited by 73
“Cognitive behavioral therapy for insomnia (CBT-I) is currently the most effective treatment for insomnia (Irwin, Cole, & Nicassio, 2006; Morin et al., 2006; Morin et al., 1999; Rieman & Perlis, 2009; Smith et al., 2002).”
MethodFeasibility and Efficacy of a Self-Management Intervention for Insomnia in Stable Heart Failure
Redeker, N. S., Jeon, S., Andrews, L. K., Cline, J., Jacoby, D. L., & Mohsenin, V. (2015) · Journal of Clinical Sleep Medicine · doi:10.5664/jcsm.5082 · Cited by 67
“CBT-I has more durable effects on insomnia than hypnotic medications 17,18 and lacks the adverse effects of these drugs.”
A warm footbath before bedtime and sleep in older Taiwanese with sleep disturbance
Liao, W., Chiu, M., & Landis, C. A. (2008) · Research in Nursing & Health · doi:10.1002/nur.20283 · Cited by 66
“Recently published recommendations for the assessment of participants’ perceptions of sleep include completion of several screening questionnaires in addition to the PSQI, and completion of a sleep diary for 2 weeks to verify the extent of insomnia (Buysse, Ancoli-Israel, Edinger, Lichstein, & Morin, 2006; Monk et al.…”
BackgroundMethodCognitive-behavioral Therapy of Insomnia
Morin, C. M. (2006) · Sleep Medicine Clinics · doi:10.1016/j.jsmc.2006.06.008 · Cited by 66
Self-citationCasault, L., Savard, J., Ivers, H., & Savard, M. (2015) · Behaviour Research and Therapy · doi:10.1016/j.brat.2015.02.003 · Cited by 65
Bei, B., Ong, J. C., Rajaratnam, S. M. W., & Manber, R. (2015) · Journal of Clinical Sleep Medicine · doi:10.5664/jcsm.5018 · Cited by 66
de Bruin, E. J., van Steensel, F. J. A., & Meijer, A. M. (2016) · SLEEP · doi:10.5665/sleep.6024 · Cited by 66
High prevalence of insomnia and hypnotic use in patients visiting their general practitioner
Bjorvatn, B., Meland, E., Flo, E., & Mildestvedt, T. (2016) · Family Practice · doi:10.1093/fampra/cmw107 · Cited by 72
Sweetman, A., McEvoy, R. D., Smith, S., Catcheside, P. G., Antic, N. A., Chai-Coetzer, C. L., Douglas, J., O’Grady, A., Dunn, N., Robinson, J., et al. (2020) · Sleep · doi:10.1093/sleep/zsaa002 · Cited by 62
Hertenstein, E., Thiel, N., Lüking, M., Külz, A. K., Schramm, E., Baglioni, C., Spiegelhalder, K., Riemann, D., & Nissen, C. (2014) · Psychotherapy and Psychosomatics · doi:10.1159/000365173 · Cited by 63
Bright Light Therapy in Parkinson's Disease: An Overview of the Background and Evidence
Rutten, S., Vriend, C., van den Heuvel, O. A., Smit, J. H., Berendse, H. W., & van der Werf, Y. D. (2012) · Parkinson s Disease · doi:10.1155/2012/767105 · Cited by 63
“Behavioral and psychological interventions are also effective in treating insomnia [75, 76].”
BackgroundHagatun, S., Vedaa, Ø., Nordgreen, T., Smith, O. R. F., Pallesen, S., Havik, O. E., Bjorvatn, B., Thorndike, F. P., Ritterband, L. M., & Sivertsen, B. (2017) · Behavioral Sleep Medicine · doi:10.1080/15402002.2017.1301941 · Cited by 61
“According to clinical guidelines and recommendations, cognitive-behavioral therapy for insomnia (CBTi) is the first-line treatment option (Morin et al., 2006; National Institutes of Health, 2009; Wilson et al., 2010).”
MethodMcCrae, C. S., Curtis, A. F., Williams, J. M., Dautovich, N. D., McNamara, J. P. H., Stripling, A. M., Dzierzewski, J. M., Chan, W. S., Berry, R. B., McCoy, K. J. M., et al. (2018) · Sleep Medicine · doi:10.1016/j.sleep.2018.05.018 · Cited by 69
Mood-related Sleep Problems in Children and Adolescents
Lofthouse, N., Gilchrist, R., & Splaingard, M. (2009) · Child and Adolescent Psychiatric Clinics of North America · doi:10.1016/j.chc.2009.04.007 · Cited by 67
Ho, F. Y.-Y., Chan, C. S., Lo, W.-Y., & Leung, J. C.-Y. (2020) · Journal of Affective Disorders · doi:10.1016/j.jad.2020.01.062 · Cited by 58
Nobis, S., Lehr, D., Ebert, D. D., Berking, M., Heber, E., Baumeister, H., Becker, A., Snoek, F. J., & Riper, H. M. (2013) · BMC Psychiatry · doi:10.1186/1471-244x-13-306 · Cited by 64
Veqar, Z., & Hussain, M. E. (2017) · International Journal of Adolescent Medicine and Health · doi:10.1515/ijamh-2016-0090 · Cited by 63
Xie, C., Gu, Y., Wang, W., Lü, L., Fu, D.-L., Liu, A., Li, H., Li, J.-H., Lin, Y., Tang, W., et al. (2013) · BMC Complementary and Alternative Medicine · doi:10.1186/1472-6882-13-18 · Cited by 62
Memory for therapy in bipolar disorder and comorbid insomnia.
Lee, J. Y., & Harvey, A. G. (2014) · Journal of Consulting and Clinical Psychology · doi:10.1037/a0037911 · Cited by 62
Measures of cardiovascular autonomic activity in insomnia disorder: A systematic review
Nano, M.-M., Fonseca, P. M., Vullings, R., & Aarts, R. M. (2017) · PLoS ONE · doi:10.1371/journal.pone.0186716 · Cited by 64
Boafo, A., Greenham, S. L., Alenezi, S., Robillard, R., PAJER, K. A., Tavakoli, P., & Koninck, J. D. (2019) · Nature and Science of Sleep · doi:10.2147/nss.s181365 · Cited by 63
McCurry, S. M., Shortreed, S. M., Von Korff, M., Balderson, B. H., Baker, L. D., Rybarczyk, B. D., & Vitiello, M. V. (2014) · Sleep · doi:10.5665/sleep.3402 · Cited by 60
Chapoutot, M., Peter-Derex, L., Bastuji, H., Leslie, W., Schoendorff, B., Heinzer, R., Siclari, F., Nicolas, A., Lemoine, P., Higgins, S., et al. (2021) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph181910222 · Cited by 59
BJORVATN, B., FISKE, E., & PALLESEN, S. (2011) · Scandinavian Journal of Psychology · doi:10.1111/j.1467-9450.2011.00902.x · Cited by 60
“Cognitive behavioral therapy is recommended as the treatment of choice for chronic insomnia, and provides greater and more prolonged effect compared with sleep medications (Morin et al., 2006; Sivertsen, Omvik, Pallesen et al., 2006).”
Effect of Tai Chi Chuan in Breast Cancer Patients: A Systematic Review and Meta-Analysis
Luo, X., Liu, J., Fu, J., Yin, H., Shen, L., Liu, M., Lan, L., Ying, J., Qiao, X.-L., Tang, C., et al. (2020) · Frontiers in Oncology · doi:10.3389/fonc.2020.00607 · Cited by 63
“The cognitive behavioral therapy involves re-establishing a consistent sleep-wake schedule, sleep restriction, relaxation, sleep hygiene education and cognitive procedures (69).”
MethodInternet-delivered cognitive behavior therapy for anxiety and insomnia in a higher education context
Morris, J., Firkins, A., Millings, A., Möhr, C., Redford, P., & Rowe, A. (2015) · Anxiety Stress & Coping · doi:10.1080/10615806.2015.1058924 · Cited by 60
“Meta-analyses have found CBT to be effective at treating anxiety (Morin et al., 2006; Norton & Price, 2007) and insomnia (Harvey & Tang, 2003; Okajima, Komada, & Inoue, 2011) in a range of populations.”
BackgroundCognitive-behavioral therapy for sleep abnormalities of chronic pain patients
Tang, N. K. Y. (2009) · Current Rheumatology Reports · doi:10.1007/s11926-009-0066-5 · Cited by 56
Robbins, R., Grandner, M. A., Buxton, O. M., Hale, L. E., Buysse, D. J., Knutson, K. L., Patel, S. R., Troxel, W., Youngstedt, S. D., Czeisler, C. A., et al. (2019) · Sleep Health · doi:10.1016/j.sleh.2019.02.002 · Cited by 66
Self-citationTakaesu, Y., Utsumi, T., Okajima, I., Shimura, A., Kotorii, N., Kuriyama, K., Yamashita, H., Suzuki, M., Watanabe, N., & Mishima, K. (2019) · Sleep Medicine Reviews · doi:10.1016/j.smrv.2019.101214 · Cited by 57
Sleep Duration, Sleep Hygiene, and Insomnia in Adolescents with Asthma
Meltzer, L. J., Ullrich, M., & Szefler, S. J. (2014) · The Journal of Allergy and Clinical Immunology In Practice · doi:10.1016/j.jaip.2014.02.005 · Cited by 60
McCurry, S. M., Korff, M. V., Vitiello, M. V., Saunders, K. W., Balderson, B. H. K., Moore, A. L., & Rybarczyk, B. D. (2011) · Journal of Psychosomatic Research · doi:10.1016/j.jpsychores.2011.05.012 · Cited by 59
“A recent task force commissioned by the American Academy of Sleep Medicine called for additional prospective and randomized controlled trials targeting insomnia treatments in comorbid populations (4).”
BackgroundCognitive-Behavioral Therapy for the Management of Insomnia Comorbid with Mental Disorders
Sánchez-Ortuño, M. M., & Edinger, J. D. (2012) · Current Psychiatry Reports · doi:10.1007/s11920-012-0312-9 · Cited by 61
Self-citationCharacterizing Self-Reported Sleep Disturbance after Mild Traumatic Brain Injury
Sullivan, K. A., Edmed, S. L., Allan, A. C., Karlsson, L. J. E., & Smith, S. S. (2014) · Journal of Neurotrauma · doi:10.1089/neu.2013.3284 · Cited by 59
Predictors of dropout from internet-based self-help cognitive behavioral therapy for insomnia
Yeung, W., Chung, K., Ho, F. Y., & Ho, L. (2015) · Behaviour Research and Therapy · doi:10.1016/j.brat.2015.07.008 · Cited by 59
“Cognitive behavioral therapy for insomnia (CBT-I) is a multicomponent intervention including sleep hygiene education, sleep restriction, stimulus control, cognitive restructuring and relaxation training (Morin et al., 2006).”
BackgroundDalrymple, K. L., Fiorentino, L., Politi, M. C., & Posner, D. (2010) · Journal of Contemporary Psychotherapy · doi:10.1007/s10879-010-9145-1 · Cited by 58
The Future of Cognitive Behavioral Therapy for Insomnia: What Important Research Remains to Be Done?
Vitiello, M. V., McCurry, S. M., & Rybarczyk, B. D. (2013) · Journal of Clinical Psychology · doi:10.1002/jclp.21948 · Cited by 59
Rybarczyk, B. D., Lund, H. G., Shamaskin‐Garroway, A., & Mack, L. (2012) · Clinical Gerontologist · doi:10.1080/07317115.2012.731478 · Cited by 60
Fuller, J. M., WONG, K. K. H., Krass, I., Grunstein, R. R., & Saini, B. (2011) · Patient Education and Counseling · doi:10.1016/j.pec.2011.05.004 · Cited by 58
Dong, L., Dolsen, E. A., Martinez, A. J., Notsu, H., & Harvey, A. G. (2019) · Journal of Child Psychology and Psychiatry · doi:10.1111/jcpp.13154 · Cited by 58
“Owens J (2014). Insufficient Sleep in Adolescents and Young Adults: An Update on Causes and Consequences.”
BackgroundMethodInfluential
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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