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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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In the citing paper
“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]
The cited source says what the claim attributes to it.
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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Factors Influencing Sleep Quality in Nursing Students and non Nursing Students
Kim, G.-H., & Yoon, H. S. (2013) · Journal of Korean Academy of Psychiatric and Mental Health Nursing · doi:10.12934/jkpmhn.2013.22.4.320 · Cited by 20
“스트레스는 수면을 방해하는 요소로 취침에서 각성상태를 지속하거나 수 면을 간헐적 지속적으로 방해한다(Morin et al., 2006).”
InfluentialKyriazakos, S. A., Valentini, V., Cesario, A., & Zachariae, R. H. (2017) · Clinical and Translational Radiation Oncology · doi:10.1016/j.ctro.2017.11.006 · Cited by 22
“…therapy for insomnia (CBT-I) [53], which consists of various combinations of various evidence-based approaches for treating insomnia [54], including sleep hygiene education [55], sleep restriction [56], stimulus-control instructions [57], cognitive therapy challenging and modifying…”
BackgroundCho, C., Jee, H., Nam, Y.-J., An, H., Kim, L., & Lee, H. (2020) · Scientific Reports · doi:10.1038/s41598-020-61694-9 · Cited by 26
The Effect of Benson Relaxation on Quality of Sleep of Cancer Patients
Efendi, S., Agus, A. I., Syatriani, S., Amir, H., Alam, R. I., Nurdin, S., Batara, A. S., & Ikhtiar, M. (2022) · Open Access Macedonian Journal of Medical Sciences · doi:10.3889/oamjms.2022.8295 · Cited by 21
Mijnster, T., Boersma, G. J., Meijer, E., & Lancel, M. (2022) · Journal of Personalized Medicine · doi:10.3390/jpm12071070 · Cited by 24
Systematic Review of Hypnotherapy for Sleep and Sleep Disturbance
Wofford, N., Snyder, M., Corlett, C. E., & Elkins, G. R. (2023) · International Journal of Clinical and Experimental Hypnosis · doi:10.1080/00207144.2023.2226177 · Cited by 25
“…widely used approaches for treating sleep disturbance are pharmacotherapy, such as benzodiazepines, z-drugs, and serotonin receptor antagonists and reuptake inhibitors (SARIs), and cognitive behavioral therapy for insomnia (CBT-I; Buscemi et al., 2007; Matheson & Hainer, 2017; Morin et al., 2006).”
MethodMaruani, J., Stern, É., Boiret, C., Leseur, J., Romier, A., Lejoyeux, M., & Geoffroy, P. A. (2023) · Psychiatry Research · doi:10.1016/j.psychres.2023.115527 · Cited by 23
Gartenberg, D., Thornton, R., Masood, M., Pfannenstiel, D., Taylor, D. J., & Parasuraman, R. (2012) · Personal and Ubiquitous Computing · doi:10.1007/s00779-012-0508-3 · Cited by 21
“Behavioral treatments already play a role in alleviating many sleep and mood disorders [12–14].”
BackgroundSelf-reported Sleep Quality and Cognitive Style in Older Adults
Willis, T. A., Yearall, S. M., & Gregory, A. M. (2009) · Cognitive Therapy and Research · doi:10.1007/s10608-009-9270-x · Cited by 21
“Cognitive therapy constitutes a successful treatment for insomnia (Morin et al. 2006).”
Effects of blue light and caffeine on mood
Ekström, J., & Beaven, C. M. (2014) · Psychopharmacology · doi:10.1007/s00213-014-3503-8 · Cited by 22
“…associated with improved human health in hospital environments (Walch et al. 2005; Joarder and Price 2013), behavioural therapy (Golden et al. 2005; Morin et al. 2006), academic performance (Heschong et al. 2002; Mott et al. 2012) and workplace well-being (Viola et al. 2008; Iskra-Golec et al.…”
Advancing cognitive behaviour therapy for older adults with comorbid insomnia and depression
Sadler, P., McLaren, S., Klein, B., & Jenkins, M. (2017) · Cognitive Behaviour Therapy · doi:10.1080/16506073.2017.1359206 · Cited by 21
“In addition, sleep improvements following CBT-I can endure 12 to 36 months after treatment is completed (Blom, Jernelöv, Lindefors, & Kaldo, 2016; Dzierzewski et al., 2010; Morin et al., 2006; Smith et al., 2005).”
BackgroundMethodInfluentialTorrens, I., Argüelles, R., Lorente, P., Molero-Alfonso, C., & Esteva, M. (2019) · Atención Primaria · doi:10.1016/j.aprim.2018.02.014 · Cited by 21
Trained-feature–specific offline learning by sleep in an orientation detection task
Tamaki, M., Wang, Z., Watanabe, T., & Sasaki, Y. (2019) · Journal of Vision · doi:10.1167/19.12.12 · Cited by 21
Morin, C. M., & Benca, R. M. (2010) · Handbook of clinical neurology · doi:10.1016/b978-0-444-52007-4.00004-7 · Cited by 22
Self-citationMessineo, L., Taranto‐Montemurro, L., Sands, S. A., Marques, M., Azabarzin, A., & Wellman, A. (2017) · Frontiers in Neurology · doi:10.3389/fneur.2017.00718 · Cited by 21
Progressive muscle relaxation increases slow‐wave sleep during a daytime nap
Simon, K. C. N. S., McDevitt, E. A., Ragano, R., & Mednick, S. C. (2022) · Journal of Sleep Research · doi:10.1111/jsr.13574 · Cited by 24
“Accessibility to sleep interventions administered by experts can be limited, but relaxation methods, common components of psychological and behavioural sleep interventions, are easily available and can be equally efficacious at home (Morin et al., 2006).”
BackgroundKatofsky, I., Backhaus, J., Junghanns, K., Rumpf, H., Hüppe, M., von Eitzen, U., & Hohagen, F. (2012) · Sleep Medicine · doi:10.1016/j.sleep.2011.12.008 · Cited by 20
Clinical Manual of Geriatric Psychiatry
Thakur, M. E., Blazer, D. G., & Steffens, D. C. (2013) · American Psychiatric Association Publishing eBooks · doi:10.1176/appi.books.9781615370016 · Cited by 20
Phelps, A. J., Varker, T., Metcalf, O., & Dell, L. (2017) · Military Medicine · doi:10.7205/milmed-d-16-00010 · Cited by 21
Zhou, F., Yang, Y., Wang, Y.-Y., Rao, W., Zhang, S.-F., Zeng, L., Zheng, W., Ng, C. H., Ungvari, G. S., Zhang, L., et al. (2020) · Psychiatric Quarterly · doi:10.1007/s11126-020-09820-8 · Cited by 22
Neurofeedback for insomnia: Current state of research
Lambert-Beaudet, F., Journault, W.-G., Provençal, A. R., & Bastien, C. (2021) · World Journal of Psychiatry · doi:10.5498/wjp.v11.i10.897 · Cited by 26
Sullivan, S. S. (2010) · Medical Clinics of North America · doi:10.1016/j.mcna.2010.02.012 · Cited by 20
Black, D. S., O’Reilly, G. A., Olmstead, R., Breen, E. C., & Irwin, M. R. (2014) · Contemporary Clinical Trials · doi:10.1016/j.cct.2014.06.013 · Cited by 21
Jhaveri, M., Seal, B. S., Pollack, M. F., & Wertz, D. A. (2007) · Current Medical Research and Opinion · doi:10.1185/030079907x199619 · Cited by 20
de Bruin, E. J., Meijer, A. M., & Bögels, S. M. (2020) · Mindfulness · doi:10.1007/s12671-019-01290-9 · Cited by 20
“…therapy for insomnia (CBTI) has been shown to be effective in many modalities over the past two decades, including face-to-face individual CBTI, group CBTI, and internet-delivered CBTI (Espie et al. 2012; Lancee et al. 2012; Medalie and Cifu 2017; Morin et al. 2006; Van Straten et al. 2018).”
BackgroundFrøjd, L. A., Papageorgiou, C., Munkhaugen, J., Moum, T., Sverre, E., Nordhus, I. H., & Dammen, T. (2021) · Journal of Clinical Sleep Medicine · doi:10.5664/jcsm.9712 · Cited by 19
Marks, E. M., Hallsworth, C. A., Vogt, F., Klein, H., & McKenna, L. (2022) · Cognitive Behaviour Therapy · doi:10.1080/16506073.2022.2084155 · Cited by 19
“CBTi for primary insomnia shows medium (d = 0.44) to large (d = 1.09) effect sizes on subjective measures (Morin et al., 2006; Okajima et al., 2011).”
BackgroundInfluentialHughes, A. J., Gunn, H. E., Siengsukon, C. F., Stearns, M. A., James, E., Donley, T., Grandner, M. A., Thomas, S. J., Hansen, K., & Williams, N. J. (2022) · Behavioral Sleep Medicine · doi:10.1080/15402002.2022.2149523 · Cited by 19
“CBT-I is effective in double-blind placebo-controlled trials, and positive effects lasting for up to two years (Morin et al., 2006).”
BackgroundAnderson, K. N., Goldsmith, P., & Gardiner, A. (2014) · Nature and Science of Sleep · doi:10.2147/nss.s57852 · Cited by 20
“14,15 CBT-i tackles factors that maintain insomnia over time, including sleep-related dysfunctional cognitions, behaviors which perpetuate insomnia, and dysregulation of the homoeostatic sleep drive.”
Precision Medicine in Circadian Rhythm Sleep–Wake Disorders: Current State and Future Perspectives
Keijzer, H., Snitselaar, M. A., Smits, M. G., Spruyt, K., Zee, P. C., Ehrhart, F., & Curfs, L. (2017) · Personalized Medicine · doi:10.2217/pme-2016-0079 · Cited by 19
Current Validated Medical Treatments for Tinnitus
McKenna, L., Vogt, F., & Marks, E. M. (2020) · Otolaryngologic Clinics of North America · doi:10.1016/j.otc.2020.03.007 · Cited by 20
Psychosocial factors affecting sleep misperception in middle-aged community-dwelling adults
Park, S., Park, K., Shim, J., Youm, Y., Kim, J., Lee, E. M., & Kim, H. C. (2020) · PLoS ONE · doi:10.1371/journal.pone.0241237 · Cited by 21
Hsu, H.-M., Chou, K., Lin, K., Chen, K., Su, S., & Chung, M. (2015) · Behaviour Research and Therapy · doi:10.1016/j.brat.2015.07.016 · Cited by 19
Norell‐Clarke, A., Nyander, E., & Jansson‐Fröjmark, M. (2010) · Behavioural and Cognitive Psychotherapy · doi:10.1017/s1352465810000664 · Cited by 19
“Cognitive behavioural therapy is an evidence-based treatment for adult insomnia (Morin et al., 2006), but adolescent sleep is affected by specific developmental and lifestyle factors so Reprint requests to Annika Norell-Clarke, Örebro University, School of Law, Psychology and Social Work,…”
BackgroundWeber, M. (2013) · Journal of Sleep Disorders & Therapy · doi:10.4172/2167-0277.1000110 · Cited by 20
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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