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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]
The cited source says what the claim attributes to it.
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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“Although studies have sought to evaluate the effectiveness of specific components of CBT-I, the selectively efficacy of each has not yet been determined (Morin et al., 1994, 2006; Trauer et al., 2015).”
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“CBT-I, a multicomponent intervention, addresses dysfunctional cognitions and behaviors contributing to sleep problems [22,23], including stimulus control, sleep restriction, sleep hygiene, relaxation techniques, and cognitive restructuring [24-28].”
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Insomnia Medication Use by University Students: A Systematic Review
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“…behavioural therapy for insomnia (termed CBT-I) often consists of several different therapeutic activities, including education (educating sleep hygiene), stimulus control (reducing bad habits), sleep restriction/compression (limiting sleep time), and relaxation (meditation activities) [30,31].”
BackgroundInitial Sleep Time Predicts Success in Manual-Guided Cognitive Behavioral Therapy for Insomnia
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“Keywords Insomnia DBAS Unhelpful beliefs Cognitive therapy Behavior therapy CBTi Several meta-analyses have identified cognitive behavioral and behavioral therapies as efficacious in the treatment of insomnia (Jacobs et al. 2004; Morin et al. 2006; Murtagh and Greenwood 1995; Smith et al. 2002).”
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Self-citationBehaviorally Induced Insufficient Sleep
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Self-citationChapter 4. Dementia and Milder Cognitive Syndromes
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“Studies implementing this multi-component treatment approach indicate greater efficacy than single component treatments (Morin et al., 1994; 2006).”
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“…TBI in children, (ii) develop a manualized treatment programme, as manualized approach increases fidelity and consistency of treatment delivery (Morin et al., 2006), (iii) adapt a CBT-I programme originally validated for use with adolescents with insomnia and comorbid physical and psychiatric…”
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“Psychological and behavioral therapies are backed by evidence, but they are often underutilized due to the need for extensive training and long-term implementation [4, 5].”
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“14,17 Moreover, BT utilizes sleep restriction to target the sleep homeostat by limiting the time an individual spends in their bed (sleep opportunity) through assigned bedtimes and rise times.”
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“SET targets day-to-day behavioural and environmental factors that contribute to poor sleep and was performed for the control group during a single session (Morin et al., 2006).”
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“Relaxation techniques, which are adopted as a therapeutic component of cognitive behavioral therapy for insomnia (32, 37), are effective for the treatment of insomnia and can promote relaxation and sympathetic inhibition (38).”
MethodDreyer, R. P., Berkowitz, A., Yaggi, H. K., Schneeberg, L., Shah, N. D., Emanuel, L., Kolla, B. P., Jeffery, M. M., Deeg, M. A., Ervin, K. R., et al. (2022) · BMJ Open · doi:10.1136/bmjopen-2022-062041 · Cited by 5
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“…targets behavioral, cognitive and physiological perpetuating factors of insomnia through stimulus control, sleep restriction, relaxation, and cognitive therapy [34, 35], our UP-based approach addresses the underlying emotional processes that maintain both insomnia and emotional disorders.”
Prise en charge comportementale de l’insomnie chronique
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“At present, promising new research suggests that internet-based delivery of Cognitive-Behavioral Therapy for Insomnia (CBT-I) can be a valid, efficacious treatment (i.e. Espie et al., 2012; Ritterband et al., 2009).”
InfluentialKareri, D. G. R., Manafe, D. R. T., & Payon, M. K. E. (2020) · Indonesian Journal of Physical Medicine and Rehabilitation · doi:10.36803/ijpmr.v9i1.252 · Cited by 5
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“The multicomponent CBT-I typically includes the interventions of stimulus control, sleep restriction, sleep hygiene, relaxation techniques, and cognitive restructuring [4,5].”
MethodDing, X., Cao, F., Li, M., Yang, Z., & Tang, Y. (2023) · Brain Topography · doi:10.1007/s10548-023-00978-5 · Cited by 5
“Subjective complaint of difficulty in falling asleep or staying asleep is one of the diagnostic criteria of insomnia (Morin et al. 2006).”
Sleep Disorders and Aging in Women
Gadodia, R., Nandamuru, D., Akberzie, W., & Kataria, L. (2023) · Sleep Medicine Clinics · doi:10.1016/j.jsmc.2023.06.017 · Cited by 5
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“Subgroup analysis also found similar effects in studies with different disease groups, delivery methods, and the use of medications, which was in line with the findings from previous studies (Morin et al., 2006; Trauer et al., 2015).”
Yu, J., Du, J., Yang, Z., Chen, W., Sun, S., Gan, M., Cai, Y., Zhang, L., Sun, K., Xu, Q., et al. (2024) · BMC Psychiatry · doi:10.1186/s12888-024-06218-9 · Cited by 5
“Primary treatments for insomnia in clinical practice include cognitive behavioral therapy for insomnia (CBT-I) and pharmacotherapy, with CBT-I being the first-line treatment at present [7].”
BackgroundAlsaied, M. A., Elettreby, A. M., Serag, I., Rajput, J., Zabady, N. A., Li, H., & Elnaga, A. A. A. (2025) · Naunyn-Schmiedeberg s Archives of Pharmacology · doi:10.1007/s00210-025-04072-4 · Cited by 7
“Of all therapeutic modalities available for chronic insomnia, CBT-1 is preferable as it includes sleep–wake behavioral therapy, stimulus control, sleep restriction, relaxation, and cognitive therapy (Morin et al. 2006).”
Validation of the Insomnia Treatment Acceptability Scale (ITAS) in Primary Care
Guardia, A. C. L., Rutledge, C., & Bluestein, D. A. (2011) · Journal of Clinical Psychology in Medical Settings · doi:10.1007/s10880-011-9257-0 · Cited by 5
“Individual behavioral interventions include sleep hygiene-education, relaxation therapy, stimulus-control, sleep restriction, paradoxical intent, and cognitive therapy (Morin et al., 2006).”
Insomnia is associated to depressive symptoms in patients with chronic heart failure
Johansson, P., & Broström, A. (2013) · Open Journal of Nursing · doi:10.4236/ojn.2013.31005 · Cited by 5
The Effect of Insomnia on Functional Status of Community-Dwelling Older Adults
Deratnay, P. H., & Sidani, S. (2013) · Journal of Gerontological Nursing · doi:10.3928/00989134-20130827-01 · Cited by 5
Incidence of and Risk Ractors for Zolpidem-Induced Delirium
Kim, Y. M., Lee, S., Jung, J. Y., Shin, K. H., Kim, D. H., Kim, J. H., & Jee, Y. (2013) · Korean Journal of Medicine · doi:10.3904/kjm.2013.84.6.804 · Cited by 5
Knowledge and attitudes of primary care nurses about the management of patients with insomnia
Vidal-Thomàs, M. C., Yañez-Amoros, B., Torrens, I., Torres-Solera, E., & Esteva, M. (2017) · Enfermería Clínica (English Edition) · doi:10.1016/j.enfcle.2016.11.005 · Cited by 2
Chronobiology and Treatment in Depression
Geoffroy, P. A., & Yeim, S. (2017) · Springer eBooks · doi:10.1007/978-981-10-6577-4_9 · Cited by 5
Negotiation in Automated E-Coaching
Beun, R. J., Griffioen-Both, F., & Lancee, J. (2018) · Electronic workshops in computing · doi:10.14236/ewic/hci2018.24 · Cited by 5
Clarke, G. N., Sheppler, C. R., Firemark, A. J., Rawlings, A. M., Dickerson, J. F., & Leo, M. C. (2020) · Contemporary Clinical Trials · doi:10.1016/j.cct.2020.105967 · Cited by 5
Psychological and Behavioral Treatments for Insomnia II
Edinger, J. D., Means, M. K., Carney, C. E., & Manber, R. (2011) · Elsevier eBooks · doi:10.1016/b978-1-4160-6645-3.00080-3 · Cited by 5
Self-citationImpact of a brief behavioral treatment for insomnia (BBTi) on metacognition in older adults
McCrae, C. S., Curtis, A. F., Nair, N., Berry, J., Davenport, M., McGovney, K., Berry, R. B., McCoy, K. J. M., & Marsiske, M. (2021) · Sleep Medicine · doi:10.1016/j.sleep.2021.01.039 · Cited by 5
Sleep Interventions: A Developmental Perspective
McGlinchey, E., & Harvey, A. (2014) · Springer eBooks · doi:10.1007/978-1-4614-9608-3_21 · Cited by 6
Waldman, L., & Morrison, L. J. (2014) · The Cancer Journal · doi:10.1097/ppo.0000000000000072 · Cited by 5
Insomnia in College Students: Specificities Regarding Psychological Treatment
Marques, D. R., Gomes, A. A., & Gellis, L. A. (2018) · Sleep and Hypnosis · doi:10.5350/sleep.hypn.2019.21.0186 · Cited by 5
“…bed only when the patient feels sleepy; (2) getting out of bed if he/she doesn´t fall asleep within 10 minutes (Harvey & Tang, 2003) or 20 minutes (Morin et al., 2006), going to another room, occupying himself/herself with a monotonous activity and returning to bed only when he/she feels sleepy…”
BackgroundImproved sleep as an adjunctive treatment for smoking cessation
Patterson, F., & Ashare, R. L. (2019) · Elsevier eBooks · doi:10.1016/b978-0-12-815373-4.00022-8 · Cited by 5
Cognitive Behavioral Treatment as a Digital Therapeutic for Insomnia
Lee, E. M. (2020) · Chronobiology in Medicine · doi:10.33069/cim.2020.0007 · Cited by 5
Gebara, M. A., DiNapoli, E. A., Hamm, M., Rodriguez, K. L., Kasckow, J., Lederer, L. G., Bramoweth, A. D., & Karp, J. F. (2020) · Annals of Clinical Psychiatry · doi:10.1177/104012372003200207 · Cited by 5
“37 While CBTI is typically conducted in 4 to 6 sessions, depending on symptom severity and treat-ment response, and requires specific training, behavioral treatments such as CBTI are feasible to deliver and effective in older veterans.”
Espie, C. A. (2010) · Elsevier eBooks · doi:10.1016/b978-0-12-381522-4.00006-7 · Cited by 5
“Moreover, PI is often included as an element of multi-component CBT, which, like PI alone, is an effective treatment for insomnia disorder [22,23].”
BackgroundSelf-citationFuture outlook of nonpharmacological treatments for insomnia in adults: clinical trial progress
Bootzin, R. R., & Manber, R. (2013) · Clinical Investigation · doi:10.4155/cli.13.95 · Cited by 5
Self-citationPiper, B. F. (2011) · Elsevier eBooks · doi:10.1016/b978-1-4377-1015-1.00014-x · Cited by 5
Clinical inquiries. Which nondrug alternatives can help with insomnia?
Whitworth, J. D., Crownover, B. K., Nichols, W., & Hallgren, J. D. (2007) · PubMed · Cited by 5
Clinical Medicine Insights: Geriatrics
Sakuraba, A. (2018) · Clinical Medicine Insights Geriatrics · doi:10.4137/cmger · Cited by 5
Type 2 diabetes and insomnia: Impact on metabolic control
Tannas, C. L. (2012) · Human Biology · Cited by 5
Park, K., Kim, G., Lee, J., & Suh, S. (2023) · Behavioral Sleep Medicine · doi:10.1080/15402002.2022.2093880 · Cited by 7
“Numerous studies have been published to attest to its effectiveness (Morin et al., 2006; Trauer et al., 2015; Wu et al., 2015).”
BackgroundResultInfluentialTanskanen, T. E., Wegelius, A., Härkönen, T., Gummerus, E.-M., Stenberg, J., Selinheimo, S., Alakuijala, A., Tenhunen, M. L., Paajanen, T. I., Järnefelt, H., et al. (2024) · BMJ Open · doi:10.1136/bmjopen-2023-076129 · Cited by 4
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Ludwig, R. L., Rippee, M. A., D’Silva, L. J., Radel, J. D., Eakman, A. M., Morris, J. K., Drerup, M. L., & Siengsukon, C. F. (2022) · JMIR Research Protocols · doi:10.2196/38608 · Cited by 4
“Chronic insomnia is defined as difficulty in falling asleep or staying asleep 3 or more days a week for more than 3 months [15,16].”
Yeung, K. W. C. M., Lee, S. K. M., Bin, Y. S., & Cheung, J. M. Y. (2023) · International Journal of Clinical Pharmacy · doi:10.1007/s11096-023-01605-w · Cited by 4
“Despite the availability of evidence-based treatments, there is a strong propensity among individuals experiencing insomnia to defer medical care in favour of self-management/self-treatment [8–10].”
BackgroundExploring the role of sleep stages in memory consolidation and cognitive function
Wu, K. (2023) · Theoretical and Natural Science · doi:10.54254/2753-8818/23/20231019 · Cited by 4
Sforza, M., Morin, C. M., Dang‐Vu, T. T., Pomares, F. B., Perrault, A. A., Gouin, J., Bušková, J., Janků, K., Vgontzas, A. N., Fernández‐Mendoza, J., et al. (2024) · Journal of Sleep Research · doi:10.1111/jsr.14452 · Cited by 4
“CBT-I is effective (Harvey, 2002; McCurry et al., 2007; Montgomery & Dennis, 2004; Morin et al., 2006; Murtagh & Greenwood, 1995; Siebern & Manber, 2011; van Straten et al., 2018) in patients with ID alone (Trauer et al., 2015) or in comorbidity with other mental or somatic disorder (Geiger-Brown…”
Self-citationA review of symptom, pathogenesis and treatment characteristics of the elderly with chronic insomnia
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“CBT-I includes a multifaceted approach, targeting behavioral, cognitive, and physiological factors to modify maladaptive behaviors and erroneous beliefs concerning sleep and insomnia [6].”
Ramos, S. A. T., & Muñoz, M. D. C. L. (2011) · Revista Colombiana de Psiquiatría · doi:10.1016/s0034-7450(14)60126-8 · Cited by 4
Drug treatment of chronic insomnia — dawn at the end of a long night?
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Application of Cognitive Behavioral Therapy for Insomnia in the Pediatric Population
Lewin, D. S. (2014) · Sleep Medicine Clinics · doi:10.1016/j.jsmc.2014.03.003 · Cited by 5
Ogawa, A., Hinotsu, S., Urushihara, H., & Kawakami, K. (2011) · Sleep Medicine · doi:10.1016/j.sleep.2011.03.009 · Cited by 4
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[Cognitive behavioral therapy for chronic insomnia].
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Psychological Models of Insomnia
Talbot, L. S., & Harvey, A. G. (2016) · doi:10.3109/9781420080803-7 · Cited by 4
Evaluating Acceptance and Commitment Therapy for Insomnia: A Randomized Controlled Trial
Baik, K. D. (2015) · ScholarWorks@BGSU (Bowling Green State University) · Cited by 4
Asok, A., Sreekumar, S., K, R. T., C, A. C., Devi, P. U., & Pavithran, K. (2018) · Journal of Oncology Pharmacy Practice · doi:10.1177/1078155218801062 · Cited by 4
Havens, J., Hughes, J. H., McMaster, F., & Kingerlee, R. (2018) · Military Behavioral Health · doi:10.1080/21635781.2018.1526148 · Cited by 5
“The SH session was based on standard components listed below (Morin et al., 2006), and the training material was reviewed by an independent Occupational Therapist at Help for Heroes.”
Method
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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