Components and Delivery Formats of Cognitive Behavioral Therapy for Chronic Insomnia in Adults: A Systematic Review and Component Network Meta-Analysis.
Level 1 - systematic review of randomized trials
Systematic review and component network meta-analysis of randomized controlled trials
PubMed 38231522 · doi:10.1001/jamapsychiatry.2023.5060
What was done
A systematic review and random-effects component network meta-analysis of randomized clinical trials evaluating cognitive behavioral therapy for insomnia (CBT-I) in adults aged 18 years and older with chronic insomnia disorder (with or without comorbidities). Searches spanned PubMed, Cochrane Central Register of Controlled Trials, PsycInfo, and ICTRP from inception to July 21, 2023. The primary outcome was posttreatment remission (defined as reaching a satisfactory state); secondary outcomes included all-cause dropout, self-reported sleep continuity, and long-term remission.
What was found
Across 241 randomized trials with 31,452 participants (mean age 45.4 years, 67% women), key components significantly associated with posttreatment remission were cognitive restructuring (incremental odds ratio [iOR], 1.68; 95% CI, 1.28-2.20), third-wave components (iOR, 1.49; 95% CI, 1.10-2.03), sleep restriction (iOR, 1.49; 95% CI, 1.04-2.13), and stimulus control (iOR, 1.43; 95% CI, 1.00-2.05). Sleep hygiene education showed no incremental benefit (iOR, 1.01; 95% CI, 0.77-1.32), and relaxation procedures trended toward being counterproductive (iOR, 0.81; 95% CI, 0.64-1.02). In-person therapist-led delivery was the most effective format (iOR, 1.83; 95% CI, 1.19-2.81). The optimal combination (in-person cognitive restructuring, third-wave, sleep restriction, and stimulus control) versus in-person psychoeducation yielded a remission risk difference of 0.33 (95% CI, 0.23-0.43) with a number needed to treat of 3.0 (95% CI, 2.3-4.3) against a control event rate of 0.14.
Why it matters
This component network meta-analysis identifies the specific active ingredients of CBT-I, demonstrating that cognitive restructuring, third-wave methods, sleep restriction, and stimulus control delivered in-person drive therapeutic success, while relaxation techniques and isolated sleep hygiene provide no incremental benefit.
Limits
Component network meta-analysis relies on the assumption of additive component effects, meaning undetected component interactions could undermine the conclusions. Sleep continuity outcomes were limited to self-report rather than objective polysomnography.
Cited by
- supports Dismantling studies of Cognitive Behavioral Therapy for Insomnia (CBT-I) show that sleep restriction and stimulus control are the most critical components for achieving positive outcomes.