Efficacy of non-pharmacological interventions for alleviating insomnia in individuals with generalized anxiety disorder: systematic evaluation and net meta-analysis
Open accessAbstract
Introduction: Anxiety is closely related to sleep, and the two often interact with each other. Generalized anxiety disorder (GAD) is often accompanied by insomnia, but pharmacologic interventions are typically ineffective and cause safety concerns. Despite the potential of non-pharmacological interventions (NIPs), their relative efficacy has not been clarified. The network meta-analysis (NMA) aims to explore the impact of NIPs on alleviating insomnia symptoms in patients with GAD. Methods and analysis: 24 randomized controlled trials (1,953 patients) evaluating 14 NIPs for GAD-related insomnia were utilized in this NMA. This study systematically searched the databases including PubMed, Web of Science, EMBASE, Cochran, CNKI, SinoMed, VIP, and Wanfang. Meanwhile, Bayesian method was employed in conjunction with Markov Chain Monte Carlo (MCMC) simulation. In addition, this study conducted statistical analyses by using R (version 4.4.1) and STATA (version 15.1). Interventions were ranked by standardized mean difference (SMD) and surface under the cumulative ranking curve (SUCRA); study quality was evaluated using the Cochrane Risk of Bias tool (ROB2.0). Sleep quality was assessed with Pittsburgh Sleep Quality Index (PSQI) as well as Insomnia Severity Index (ISI), and anxiety symptoms were measured using Hamilton Anxiety Scale (HAMA) and Self-rating Anxiety Scale (SAS). Results: Acupuncture (AC) showed the best efficacy in improving sleep quality and alleviating anxiety symptoms. The combination of transcranial magnetic stimulation with psychotherapy (TMS+PT) significantly improved sleep quality and alleviating anxiety symptoms. Other interventions (e.g., relaxation therapy, exercise therapy, etc.) had limited efficacy. Conclusion: AC and TMS+PT are the best NIPs to improve insomnia and relieve anxiety in GAD patients. In the future, conducting multicenter trials and in-depth mechanistic studies is expected to validate the efficacy and optimize the individualized treatment regimen. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/ , identifier, CRD420251010334.
The claims and statistics of this paper haven’t been checked yet.
Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.
Integrity signals
Registry
Cites
Statistics
Claims the paper makes
The claims and statistics of this paper haven’t been checked yet.
Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
Mindfulness meditation cultivates nonjudgmental awareness of thoughts, diminishing the impact of intrusive and worry-based cognitions that interfere with sleep initiation.
“Mechanistically, mindfulness meditation cultivates nonjudgmental awareness of thoughts, diminishing the impact of intrusive and worry-based cognitions that interfere with sleep initiation [76].”
From Pre-Sleep Anxiety: Mechanisms and Therapeutic Approaches in Clinical Practice. (2026) · cites this paper as [76]
The Introduction reports that mindfulness therapy improved sleep quality in patients with anxiety disorders. The Discussion (Integrity and applicability of evidence) describes psychotherapy, which includes mindfulness therapy, as cultivating concentration and helping patients fall asleep. Neither section says mindfulness works through nonjudgmental awareness or by diminishing intrusive, worry-based thoughts. (LLM, conf=0.78)
Experimental — accuracy not yet measured
Self-check
Percentages, sums and reported differences re-computed from the paper’s own numbers.
The self-check needs the paper’s full text.
Cites
The PRISMA 2020 statement: An updated guideline for reporting systematic reviews
Page, M. J., McKenzie, J. E., Bossuyt, P. M., Boutron, I., Hoffmann, T. C., Mulrow, C. D., Shamseer, L., Tetzlaff, J. M., Akl, E. A., Brennan, S. E., et al. (2021) · BMJ · doi:10.1136/bmj.n71 · Cited by 108,283 · see citing works
The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research
Buysse, D. J., Reynolds, C. F., Monk, T. H., Berman, S. R., & Kupfer, D. J. (1989) · Psychiatry Research · doi:10.1016/0165-1781(89)90047-4 · Cited by 35,234 · see citing works
RoB 2: a revised tool for assessing risk of bias in randomised trials
Sterne, J. A. C., Savović, J., Page, M. J., Elbers, R. G., Blencowe, N. S., Boutron, I., Cates, C. J., Cheng, H.-Y., Corbett, M. S., Eldridge, S. M., et al. (2019) · BMJ · doi:10.1136/bmj.l4898 · Cited by 33,583 · see citing works
Validation of the Insomnia Severity Index as an outcome measure for insomnia research
Bastien, C. (2001) · Sleep Medicine · doi:10.1016/s1389-9457(00)00065-4 · Cited by 8,067 · cited 4× · see citing works
“…(Outcome): The primary outcome indicator was sleep quality assessed by overall scores from self-rating sleep scales, encompassing the Pittsburgh Sleep Quality Index (PSQI) (23), Insomnia Severity Index (ISI) (24), PROMIS Sleep Disturbance short form (25), and Self-rating Scale of Sleep (SRSS) (26).”
InfluentialThe Neurocircuitry of Fear, Stress, and Anxiety Disorders
Shin, L. M., & Liberzon, I. (2010) · Neuropsychopharmacology · doi:10.1038/npp.2009.83 · Cited by 2,083 · cited 1× · see citing works
“Due to the potential association of anxiety and related disorders with high reactivity to emotional stimuli (66), SWA-enriched sleep may function therapeutically by modulating such reactivity.”
Simultaneous comparison of multiple treatments: Combining direct and indirect evidence.
Caldwell, D. M., Ades, A. E., & Higgins, J. P. T. (2005) · BMJ · doi:10.1136/bmj.331.7521.897 · Cited by 1,600 · see citing works
Yu, L., Buysse, D. J., Germain, A., Moul, D. E., Stover, A., Dodds, N. E., Johnston, K. L., & Pilkonis, P. A. (2012) · Behavioral Sleep Medicine · doi:10.1080/15402002.2012.636266 · Cited by 1,241 · see citing works
Network meta‐analysis for indirect treatment comparisons
Lumley, T. (2002) · Statistics in Medicine · doi:10.1002/sim.1201 · Cited by 1,206 · see citing works
Automating network meta‐analysis
van Valkenhoef, G., Lu, G., de Brock, B., Hillege, H. L., Ades, A. E., & Welton, N. J. (2012) · Research Synthesis Methods · doi:10.1002/jrsm.1054 · Cited by 793 · see citing works
van Valkenhoef, G., Dias, S., Ades, A. E., & Welton, N. J. (2015) · Research Synthesis Methods · doi:10.1002/jrsm.1167 · Cited by 699 · see citing works
Stein, M. B., & Sareen, J. (2015) · New England Journal of Medicine · doi:10.1056/nejmcp1502514 · Cited by 523 · see citing works
Hamilton Rating Scale for Anxiety (HAM-A)
Thompson, E. (2015) · Occupational Medicine · doi:10.1093/occmed/kqv054 · Cited by 515 · see citing works
Sleep and anxiety: From mechanisms to interventions
Chellappa, S. L., & Aeschbach, D. (2022) · Sleep Medicine Reviews · doi:10.1016/j.smrv.2021.101583 · Cited by 509 · cited 1× · see citing works
“This differs from the earlier review study results (67).”
Triggering sleep slow waves by transcranial magnetic stimulation
Massimini, M., Ferrarelli, F., Esser, S. K., Riedner, B. A., Huber, R., Murphy, M., Peterson, M. J., & Tononi, G. (2007) · Proceedings of the National Academy of Sciences · doi:10.1073/pnas.0702495104 · Cited by 489 · see citing works
A systematic review of sleep disturbance in anxiety and related disorders
Cox, R. C., & Olatunji, B. O. (2016) · Journal of Anxiety Disorders · doi:10.1016/j.janxdis.2015.12.001 · Cited by 395 · see citing works
Nepon, J., Belik, S.-L., Bolton, J., & Sareen, J. (2010) · Depression and Anxiety · doi:10.1002/da.20674 · Cited by 374 · see citing works
Li, F., Fisher, K. J., Harmer, P., Irbe, D., Tearse, R. G., & Weimer, C. (2004) · Journal of the American Geriatrics Society · doi:10.1111/j.1532-5415.2004.52255.x · Cited by 370 · see citing works
Trends in the Use of Complementary and Alternative Medicine in the United States: 2002–2007
Su, D., & Li, L. (2011) · Journal of Health Care for the Poor and Underserved · doi:10.1353/hpu.2011.0002 · Cited by 355 · see citing works
Cognitive Behavioral Therapy in Persons with Comorbid Insomnia: A Meta-Analysis
Geiger-Brown, J. M., Rogers, V. E., Liu, W., Ludeman, E. M., Downton, K. D., & Diaz-Abad, M. (2015) · Sleep Medicine Reviews · doi:10.1016/j.smrv.2014.11.007 · Cited by 331 · see citing works
Williams, N. (2014) · Occupational Medicine · doi:10.1093/occmed/kqt161 · Cited by 331 · see citing works
Beck, A. T., Epstein, N., Brown, G. P., & Steer, R. A. (1988) · PsycTESTS Dataset · doi:10.1037/t02025-000 · Cited by 308 · see citing works
Internet-based mindfulness treatment for anxiety disorders: a randomized controlled trial
Boettcher, J., Åström, V., Påhlsson, D., Schenström, O., Andersson, G., & Carlbring, P. (2014) · Behavior Therapy · doi:10.1016/j.beth.2013.11.003 · Cited by 245 · see citing works
NPY and Stress 30 Years Later: The Peripheral View
Hirsch, D., & Żukowska, Z. (2012) · Cellular and Molecular Neurobiology · doi:10.1007/s10571-011-9793-z · Cited by 163 · see citing works
Acupuncture and immune modulation
Kim, S. K., & Bae, H. (2010) · Autonomic Neuroscience · doi:10.1016/j.autneu.2010.03.010 · Cited by 148 · see citing works
Huang, Z., Li, Y., Bianchi, M. T., Zhan, S., Fengying, J., Li, N., Ding, Y., Hou, Y., Wang, L., Ouyang, Q., et al. (2018) · Brain stimulation · doi:10.1016/j.brs.2018.05.016 · Cited by 107 · see citing works
Self-citationMarcks, B. A., Weisberg, R. B., Edelen, M. O., & Keller, M. B. (2010) · Psychiatry Research · doi:10.1016/j.psychres.2009.07.004 · Cited by 106 · see citing works
Nguyen, V. V., Zainal, N. H., & Newman, M. G. (2022) · Journal of Anxiety Disorders · doi:10.1016/j.janxdis.2022.102601 · Cited by 94 · see citing works
Acupuncture for Psychiatric Illness: A Literature Review
Samuels, N., Gropp, C., Singer, S. R., & Oberbaum, M. (2008) · Behavioral Medicine · doi:10.3200/bmed.34.2.55-64 · Cited by 82 · see citing works
(2010) · Journal of Anxiety Disorders · doi:10.1016/j.janxdis.2010.02.010 · Cited by 80 · see citing works
Autonomic Activation in Insomnia: The Case for Acupuncture
Huang, W., Kutner, N. G., & Bliwise, D. L. (2011) · Journal of Clinical Sleep Medicine · doi:10.5664/jcsm.28048 · Cited by 80 · see citing works
Pei, W., Peng, R., Gu, Y., Zhou, X., & Ruan, J. (2019) · BMC Complementary and Alternative Medicine · doi:10.1186/s12906-019-2606-5 · Cited by 71 · see citing works
Effect of Acupuncture on Hypothalamic–Pituitary–Adrenal System in Maternal Separation Rats
Park, H. J., Park, H., Chae, Y., Kim, J. W., Lee, H., & Chung, J. (2011) · Cellular and Molecular Neurobiology · doi:10.1007/s10571-011-9718-x · Cited by 63 · see citing works
Chiesi, F., Primi, C., & Carmona, J. (2011) · Journal of Psychoeducational Assessment · doi:10.1177/0734282911404985 · Cited by 62 · see citing works
de Niet, G., Tiemens, B. G., Kloos, M., & Hutschemaekers, G. J. M. (2009) · International Journal of Evidence-Based Healthcare · doi:10.1111/j.1744-1609.2009.00142.x · Cited by 58 · see citing works
Jun, J., Kapella, M. C., & Hershberger, P. E. (2021) · Intensive and Critical Care Nursing · doi:10.1016/j.iccn.2021.103124 · Cited by 58 · see citing works
Hazards of insomnia and the effects of acupuncture treatment on insomnia
Lin, Y.-F., Liu, Z., Ma, W., & Shen, W.-D. (2016) · Journal of Chinese Integrative Medicine · doi:10.1016/s2095-4964(16)60248-0 · Cited by 45 · see citing works
Jonsson, K., & Kjellgren, A. (2016) · BMC Complementary and Alternative Medicine · doi:10.1186/s12906-016-1089-x · Cited by 40 · see citing works
Fangfang, M. A., Hewei, Z., Bingxue, L. I., Peiyu, C., Mingwei, Y., & Xiao-min, W. (2023) · PubMed Central · doi:10.19852/j.cnki.jtcm.20230313.001 · Cited by 40 · see citing works
Chae, Y., Hong, M., Kim, G.-H., Hahm, D., Park, H., Ha, E., Kim, M., Park, H., Yang, J.-S., & Lee, H. (2007) · Neurological Research · doi:10.1179/016164107x172365 · Cited by 34 · see citing works
Gao, M., Roy, A., Deluty, A., Sharkey, K. M., Hoge, E. A., Liu, T., & Brewer, J. A. (2022) · Psychosomatic Medicine · doi:10.1097/psy.0000000000001083 · Cited by 24 · see citing works
Transcutaneous Auricular Vagus Nerve Stimulation in Insomnia: A Systematic Review and Meta-Analysis
de Oliveira, H. M., Ruelas, M. G., Diaz, C. A. V., de Paula, G. O., da Costa, P. R. F., & Pilitsis, J. G. (2025) · Neuromodulation Technology at the Neural Interface · doi:10.1016/j.neurom.2025.04.001 · Cited by 24 · see citing works
Non-pharmacological interventions
Lips, P. T. A. M., & Ooms, M. E. (2000) · Best Practice & Research Clinical Endocrinology & Metabolism · doi:10.1053/beem.2000.0073 · Cited by 23 · see citing works
Li, C., Bai, Y., Lee, Y.-C., Mao, W., Chen, M., Tu, P., Chen, Y.-S., Chen, T., Chang, W.-H., & Su, T. (2014) · SLEEP · doi:10.5665/sleep.3594 · Cited by 21 · see citing works
Self-citationKim, S. M., Park, J. M., Seo, H., Kim, J., Noh, J., & Kim, H. L. (2022) · BMJ Open · doi:10.1136/bmjopen-2021-058032 · Cited by 19 · see citing works
Danielsson, L., Scherman, M. H., & Rosberg, S. (2013) · Physiotherapy Theory and Practice · doi:10.3109/09593985.2013.778382 · Cited by 13 · see citing works
Jacoby, R. J., Brown, M. L., Wieman, S. T., Rosenfield, D., Hoeppner, S. S., Bui, É., Hoge, E. A., Khalsa, S. B. S., Hofmann, S. G., & Simon, N. M. (2023) · Journal of Sleep Research · doi:10.1111/jsr.13992 · Cited by 13 · see citing works
Scalp acupuncture for sleep disorder induced by pre-examination anxiety in undergraduates
Guo-juan, D. O. N. G., Cao, D., Yue, D. O. N. G., Zhang, J., & Wang, F. (2018) · 世界针灸杂志：英文版 · doi:10.1016/j.wjam.2018.09.003 · Cited by 9 · see citing works
Self-citationAcupuncture as an Adjunct Treatment to Cognitive-Behavioral Therapy for Insomnia
Kutana, S., Mao, J. J. J., & Garland, S. N. (2023) · Sleep Medicine Clinics · doi:10.1016/j.jsmc.2022.10.005 · Cited by 9 · see citing works
Vujnović, M., Manukhina, O., Reed, G. M., Theodorakis, P. N., & Fountoulakis, K. Ν. (2021) · Consortium Psychiatricum · doi:10.17816/cp74 · Cited by 8 · see citing works
Khodarahimi, S., Mirderikvand, F., & Amraei, K. (2020) · EXPLORE · doi:10.1016/j.explore.2020.11.011 · Cited by 5 · see citing works
Gao, L., Xie, J. M., Huang, T., Shang, Y., & Gao, Z. (2021) · PubMed Central · Cited by 4 · see citing works
Zhang, X., Wang, X., Chen, H., Li, X., Gao, Y., Zuo, G., Zhang, J., Liu, J., Fan, X., & She, Y.-F. (2024) · Journal of Acupuncture and Tuina Science · doi:10.1007/s11726-024-1463-z · Cited by 3 · see citing works
Self-citationThe effects of relaxation therapy on the sleep of patients with generalized anxiety disorder
Mu, J., Zhang, Z., Zhang, N., & Du, H. (2013) · Zhonghua wuli yixue zazhi · doi:10.3760/cma.j.issn.0254-1424.2013.05.016 · Cited by 1 · see citing works
Flagged first, then by citations
Research works printed but not linked: 14
- [15]Wang F Su WL Xie XH Liu MH Chen JY Wen LX. Application of Baduanjin combined with TCM emotional regulation in patients with generalized anxiety and insomnia. Guiding J Traditional Chin Med Pharmacol. (2022) 28: 75–9. doi: 10.13862/j.cn43-1446/r.2022.09.014 · DOI
- [20]Psychiatry CSo. Chinese classification and diagnostic criteria of mental disorders (3rd ed.). Chin J Psychiatry. (2001) 3: 59– 63. doi: 10.3760/j:issn:1006-7884.2001.03.028 · DOI
- [26]Li JM. Introduction to self-rating scale of sleep (SRSS). China J Health Psychol. (2012) 20: 1851–1. doi: 10.13342/j.cnki.cjhp.2012.12.040 · DOI
- [36]Sang N Chen C. Effect of moxibustion at Baihui (GV20) on emotion and sleep quality in patients with anxiety disorder. Hebei J Traditional Chin Med. (2023) 45: 2075–8. doi: 10.3969/j.issn.1002-2619.2023.12.031 · DOI
- [37]Wang Z Du XY Yang Y. Effect of ultrasound-guided stellate ganglion block combined with biofeedback on moderate anxiety patients. J Int Psychiatry. (2023) 50: 265– 267,271. doi: 10.13479/j.cnki.jip.2023.02.017 · DOI
- [38]Ding YM Zhao S Huang J. Application of low-frequency repetitive transcranial magnetic stimulation combined with cognitive behavioral therapy in patients with anxiety disorder and sleep disorders. Shanghai Nurs. (2024) 24: 30–3. doi: 10.3969/j.issn.1009-8399.2024.01.007 · DOI
- [39]Yang M Yang HM Sun LL Bi YF. Application of low-frequency repetitive transcranial magnetic stimulation combined with cognitive behavioral therapy in patients with anxiety disorder and sleep disorders. World J Sleep Med. (2024) 11: 873–5. doi: 10.3969/j.issn.2095-7130.2024.04.046 · DOI
- [40]Wang CF Duan N Guo ZY. Effects of relaxation training combined with willpower motivation on sleep and quality of life in patients with anxiety-induced sleep disorders. J Clin Psychosomatic Dis. (2021) 27: 81– 84,108. doi: 10.3969/j.issn.1672-187X.2021.03.018 · DOI
- [41]Wang D. Effect of cognitive behavioral intervention on sleep quality and anxiety symptoms in patients with generalized anxiety disorder. World J Sleep Med. (2021) 8: 1309–11. doi: 10.3969/j.issn.2095-7130.2021.08.003 · DOI
- [42]Huang W Zheng Z Zou K Li J. Randomized controlled study of low-frequency repetitive transcranial magnetic stimulation over the right parietal lobe for anxiety-related insomnia. J Psychiatry. (2024) 37: 1– 5. doi: 10.3969/j.issn.2095-9346.2024.01.001 · DOI
- [43]Gao JX. Effects of TCM characteristic nursing intervention combined with relaxation training on anxiety symptoms, sleep quality and quality of life in patients with anxiety disorder. Pract Clin J Integrated Traditional Chin Western Med. (2021) 21: 158–9. doi: 10.13638/j.issn.1671-4040.2021.20.075 · DOI
- [44]Huang Y. Clinical study on auricular point sticking combined with relaxation training for anxiety disorder. New Chin Med. (2022) 54: 147–50. doi: 10.13457/j.cnki.jncm.2022.04.038 · DOI
- [46]Liu K Li Q. Study on clinical effect of acupuncture in treatment of generalized anxiety disorder. China Pract Med. (2021) 16: 167–9. doi: 10.14163/j.cnki.11-5547/r.2021.09.071 · DOI
- [48]Liu QL Huang HL. Therapeutic effect of physical exercise on elderly patients with mild to moderate generalized anxiety disorder. Chin J Gerontology. (2020) 40: 3704–6. doi: 10.3969/j.issn.1005-9202.2020.17.038 · DOI
Cited by
Sorted by citations
The association of statin use with the risk of anxiety: a systematic review and meta-analysis
Yan, Y., Deng, S., Li, Y., Fu, J., Gong, H., Zhang, H., & Zhang, F. (2026) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2026.1769044 · Cited by 2 · see citing works
Self-citationPre-Sleep Anxiety: Mechanisms and Therapeutic Approaches in Clinical Practice.
Song, S., Irfan, M., Tahir, Z., Garrison, K. A., & Ziskind, S. (2026) · Current Sleep Medicine Reports · doi:10.1007/s40675-026-00370-2
Gao, X., Mu, S., Wang, W., Ru, Y., Zhang, C., Li, P., Zhang, J., Du, Y., Imane, E. J., Zhang, Q., et al. (2026) · Frontiers in Public Health · doi:10.3389/fpubh.2026.1917300
Self-citation
- Authors
- Zhang, B., Li, Y., Chu, W., Li, Y., Zhang, J., Lv, Z., Luo, Y., & Chen, Y.
- Affiliations
- Henan University of Chinese Medicine (CN)
- Corresponding author
- Chen, Yan
- Venue
- Frontiers in Psychiatry
- Publisher
- Frontiers Media SA
- Published
- 2025-10-31
- Volume
- 16
- Pages
- 1669888-1669888
- ISSN
- 1664-0640 (ISSN-L)
- PMC
- PMC12615457
- OpenAlex
- W4415723109
- Cited by
- 3
- References
- 52
- Citations by year
- 2026: 3
- FWCI
- 0.49
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- Frontiers in Psychiatry (publishedVersion, cc-by)
- Europe PMC (PubMed Central) (publishedVersion, cc-by)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Topics
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Sleep and related disorders
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
- Keywords
- generalized anxiety disorder, insomnia, non-pharmacological treatment, acupuncture, transcranial magnetic stimulation, psychotherapy, sleep quality, anxiety symptoms, relaxation training, exercise therapy
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
Are you an author, or do you see a problem with this page? Request a review
