Initial treatment choices for long‐term remission of chronic insomnia disorder in adults: a systematic review and network meta‐analysis
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Background: We aimed to evaluate the comparative efficacy and acceptability of cognitive behavioral therapy for insomnia (CBT‐I), pharmacotherapy, and their combination in the long and short terms among adults with chronic insomnia disorder. Methods: We searched multiple databases to December 27, 2023. We included trials in hypnotic‐free adults with chronic insomnia comparing at least two of CBT‐I, pharmacotherapy, or their combination. We assessed the confidence in evidence using CINeMA. The primary outcome was long‐term remission. Secondary outcomes included all‐cause dropout and self‐reported sleep continuity measures in the long term, and the same outcomes in the short term. We performed frequentist random‐effects network meta‐analyses (CRD42024505519). Findings: We identified 13 trials including 823 randomized participants (mean age, 47.8 years; 60% women). CBT‐I was more beneficial than pharmacotherapy in the long term (median duration, 24 weeks [range, 12 to 48 weeks]; remission odds ratio, 1.82 [95% confidence interval (CI), 1.15–2.87]; [certainty of evidence: high]), while there was weaker evidence of benefit of combination against pharmacotherapy (1.71 [95% CI, 0.88–3.30: moderate]) and no clear difference of CBT‐I against combination (1.07 [95% CI, 0.63–1.80: moderate]). CBT‐I was associated with fewer dropouts than pharmacotherapy. Short‐term outcomes favored CBT‐I over pharmacotherapy except total sleep time. Given the average long‐term remission rate in the pharmacotherapy‐initiating arms of 28%, CBT‐I resulted in a long‐term remission rate of 41% (95% CI, 31%–53%) and combination 40% (95% CI, 25%–56%). Interpretation: The current study found that starting with CBT‐I for chronic insomnia leads to better outcomes than pharmacotherapy. Combination may be better than pharmacotherapy alone, but unlikely to be worth the additional burden over CBT‐I alone.
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Reduced heart-rate variability relates to impaired stress regulation during bedtime; lower pre-sleep HRV is associated with greater cognitive and somatic arousal, longer sleep-onset latency, and poorer overall sleep quality in insomnia and high-stress populations.
“Autonomic indicators such as reduced heart-rate variability (HRV) have also been found to relate to impaired stress regulation during bedtime, where lower pre-sleep HRV is associated with greater cognitive and somatic arousal, longer sleep-onset latency, and poorer overall sleep quality in both insomnia and high-stress populations [31,32].”
From Pre-Sleep Anxiety: Mechanisms and Therapeutic Approaches in Clinical Practice. (2026) · cites this paper as [32]
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Self-citation
- Authors
- Furukawa, Y., Sakata, M., Furukawa, T. A., Efthimiou, O., & Perlis, M.
- Affiliations
- The University of Tokyo (JP)
- Nagoya City University (JP)
- Department of Health Promotion and Human Behavior and of Clinical Epidemiology Kyoto University Graduate School of Medicine / School of Public Health Kyoto Japan
- University of Bern (CH)
- University of Pennsylvania (US)
- Corresponding author
- Furukawa, Yuki
- Venue
- Psychiatry and Clinical Neurosciences
- Publisher
- Wiley
- Published
- 2024-08-26
- Volume
- 78
- Issue
- 11
- Pages
- 646-653
- ISSN
- 1323-1316 (ISSN-L)
- 1440-1819
- PMC
- PMC11804918
- OpenAlex
- W4401926918
- Semantic Scholar
- 91690d0506445e0510c77440e3470828d5963bf6
- Cited by
- 27
- References
- 47
- Citations by year
- 2026: 15 · 2025: 12
- FWCI
- 1.99
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- Locations
- Psychiatry and Clinical Neurosciences (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Institutional Repositories DataBase (IRDB) (submittedVersion, cc-by)
- Kyoto University Research Information Repository (Kyoto University) (submittedVersion, cc-by)
- Open Access CRIS of the University of Bern
- Funders
- Shionogi
- Daiichi Sankyo Europe
- Topics
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Sleep and related disorders
- Health Sciences › Medicine › Physiology › Obstructive Sleep Apnea Research
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Keywords
- chronic insomnia, cognitive behavioral therapy for insomnia, insomnia pharmacotherapy, combination therapy, long-term remission, treatment discontinuation, sleep continuity, total sleep time
- MeSH terms
- Adult, Combined Modality Therapy, Humans, Sleep Initiation and Maintenance Disorders, Remission Induction, Cognitive Behavioral Therapy
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