A meta-analysis on the treatment effectiveness of cognitive behavioral therapy for primary insomnia

Abstract

Previous meta-analyses have shown the effectiveness of cognitive behavioral therapy for insomnia (CBT-I). However, conclusive information about therapeutic effects (especially during follow-up), effect sizes of objective sleep parameters and self-rating scales, and the problem of publication bias has not been obtained. We conducted a meta-analysis focusing on these issues. We identified 14 randomized controlled studies published between 1990 and 2009 that fulfilled our selection criteria. Intra-group comparison of CBT-I and comparison between CBT-I and control groups were performed on these studies. The intra-group comparison revealed that the effect sizes of CBT-I for subjective sleep variables from sleep diaries were medium to large at the end point of treatment, and these effect sizes were favorably maintained on follow-up. A between-group comparison revealed that CBT-I was more effective than the control for subjective sleep variables at the end of treatment and that its effectiveness was also recognized on follow-up. With regard to self-rating scales, as compared to the control group, the effect sizes in the CBT-I group were medium to large both at the end of treatment and on follow-up. However, there were problems of publication bias in some of the subjective or objective sleep variables. The abovementioned results support the effectiveness of CBT-I for the treatment and prevention of relapse of primary insomnia despite the existence of a certain publication bias.

This is a preview of subscription content, access via your institution.

References

  1. 1

    Kim K, Uchiyama M, Okawa M et al. An Epidemiological study of insomnia among the Japanese general population. Sleep 2000; 23: 41–7.

    CAS  PubMed  Google Scholar 

  2. 2

    Mellinger GD, Balter MB, Uhlenhuth EH. Insomnia and its treatment: prevalence and correlates. Arch. Gen. Psychiatry 1985; 42: 225–32.

    CAS  Article  PubMed  Google Scholar 

  3. 3

    Ancoli-Israel S, Roth T. Characteristics of insomnia in the United States: results of the 1991 national sleep foundation survey. Sleep 1999; 22 (Suppl 2): S347–53.

    Google Scholar 

  4. 4

    Ford DE, Kamerow DB. Epidemiologic study of sleep disturbances and psychiatric disorders: an opportunity for prevention? JAMA 1989; 262: 1479–84.

    CAS  Article  PubMed  Google Scholar 

  5. 5

    Ohayon M. Epidemiology of insomnia: what we know and what we still need to learn. Sleep Med. Rev. 2002; 6: 97–111.

    Article  PubMed  Google Scholar 

  6. 6

    Nowell PD, Mazumder S, Buysse DJ et al. Benzodiaz-epines and zolpidem for chronic insomnia: a meta-analysis of treatment efficacy. JAMA 1997; 278: 2170–7.

    CAS  Article  PubMed  Google Scholar 

  7. 7

    Morin CM, Culbert JP, Schwartz SM. Nonpharmacological interventions for insomnia: a meta-analysis of treatment efficacy. Am. J. Psychiatry 1994; 151: 1172–80.

    CAS  Article  PubMed  Google Scholar 

  8. 8

    Murtagh DRR, Greenwood KM. Identifying effective psychological treatments for insomnia: a meta-analysis. J. Consult. Clin. Psychol. 1995; 63: 79–89.

    CAS  Article  PubMed  Google Scholar 

  9. 9

    Smith MT, Perlis ML, Park A et al. Comparative meta-analysis of pharmacotherapy and behavior therapy for persistent insomnia. Am. J. Psychiatry 2002; 159: 5–11.

    Article  PubMed  Google Scholar 

  10. 10

    Irwin MR, Cole JC, Nicassio PM. Comparative meta-analysis of behavioral interventions for insomnia and their efficacy in middle-aged adults and in older adults 55+ years of age. Health Psychol. 2006; 25: 3–14.

    Article  PubMed  Google Scholar 

  11. 11

    Buysse DJ, Reynolds III CF, Monk TH et al. The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Res. 1989; 28: 193–213.

    CAS  Article  PubMed  Google Scholar 

  12. 12

    Easterbrook PJ, Berlin JA, Gopalan R et al. Publication bias in clinical research. Lancet 1991; 337: 867–72.

    CAS  Article  PubMed  Google Scholar 

  13. 13

    Dickersin K, Min YI, Meinert CL. Factors influencing publication of research results. JAMA 1992; 267: 374–8.

    CAS  Article  PubMed  Google Scholar 

  14. 14

    Sutton AJ, Duval SJ, Tweedie RL et al. Empirical assessment of effect of publication bias on meta-analyses. BMJ 2000; 320: 1574–7.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  15. 15

    Cohen J. Statistical Power Analysis for the Behavioral Sciences, 2nd edn. Lawrence Erlbaum Associates Inc: Philadelphia, PA, 1988.

    Google Scholar 

  16. 16

    Edinger JD, Wohlgemuth WK, Radtke RA et al. Cognitive behavioral therapy for treatment of chronic primary insomnia: a randomized controlled trial. JAMA 2001; 285: 1856–64. References marked with an asterisk indicate studies included in the meta-analysis.

    CAS  Article  PubMed  Google Scholar 

  17. 17

    Jacobs GD, Pace-Schott EF, Stickgold R et al. Cognitive behavior therapy and pharmacotherapy for insomnia: a randomized controlled trial and direct comparison. Arch Intern. Med. 2004; 164: 1888–96. References marked with an asterisk indicate studies included in the meta-analysis.

    Article  PubMed  Google Scholar 

  18. 18

    Morin CM, Colecchi C, Stone J et al. Behavioral and pharmacological therapies for late-life insomnia: a ran-domized controlled trial. JAMA 1999; 281: 991–9. References marked with an asterisk indicate studies included in the meta-analysis.

    CAS  Article  PubMed  Google Scholar 

  19. 19

    Perlis ML, Smith MT, Orff H et al. The effects of modafinil and cognitive behavior therapy on sleep continuity in patients with primary insomnia. Sleep 2004; 27: 715–25. References marked with an asterisk indicate studies included in the meta-analysis.

    PubMed  Google Scholar 

  20. 20

    Sivertsen B, Omvik S, Pallesen S et al. Cognitive behavioral therapy vs zopiclone for treatment of chronic primary insomnia in older adults: a randomized controlled trial. JAMA 2006; 295: 2851–8. References marked with an asterisk indicate studies included in the meta-analysis.

    Article  PubMed  Google Scholar 

  21. 21

    Wu R, Bao J, Zhang C et al. Comparison of sleep condition and sleep-related psychological activity after cognitive-behavior and pharmacological therapy for chronic insomnia. Psychother. Psychosom. 2006; 75: 220–8.

    Article  PubMed  Google Scholar 

  22. 22

    Edinger JD, Wohlgemuth WK, Radtke RA et al. Dose-response effects of cognitive-behavioral insomnia therapy: a randomized clinical trial. Sleep 2007; 30: 203–12.

    PubMed  Google Scholar 

  23. 23

    Mimeault V, Morin CM. Self-help treatment for insomnia: bibliotherapy with and without professional guidance. J. Consult. Clin. Psychol. 1999; 67: 511–9.

    CAS  Article  PubMed  Google Scholar 

  24. 24

    Morin CM, Kowatch RA, Barry T et al. Cognitive-behavior therapy for late-life insomnia. J. Consult. Clin. Psychol. 1993; 61: 137–46.

    CAS  Article  PubMed  Google Scholar 

  25. 25

    Rybarczyk B, Lopez M, Benson R et al. Efficacy of two behavioral treatment programs for comorbid geriatric insomnia. Psychol. Aging. 2002; 17: 288–98.

    Article  PubMed  Google Scholar 

  26. 26

    Ström L, Pettersson R, Andersson G. Internet-based treatment for insomnia: a controlled evaluation. J. Consult. Clin. Psychol. 2004; 72: 113–20.

    Article  PubMed  Google Scholar 

  27. 27

    Espie CA, MacMahon KM, Kelly HL et al. Randomized clinical effectiveness trial of nurse-administered small-group cognitive behavior therapy for persistent insomnia in general practice. Sleep 2007; 30: 574–84.

    PubMed  Google Scholar 

  28. 28

    Edinger JD, Olsen MK, Stechuchak KM et al. Cognitive behavioral therapy for patients with primary insomnia or insomnia associated predominantly with mixed psychiatric disorders: a randomized clinical trial. Sleep 2009; 32: 499–510.

    PubMed  PubMed Central  Google Scholar 

  29. 29

    Jansson M, Linton SJ. Cognitive-behavioral group therapy as an early intervention for insomnia: a randomized controlled trial. J. Occup. Rehabil. 2005; 15: 177–90.

    Article  PubMed  Google Scholar 

  30. 30

    Spielman AJ, Saskin P, Thorpy MJ. Treatment of chronic insomnia by restriction of time in bed. Sleep 1987; 10: 45–56.

    CAS  PubMed  Google Scholar 

  31. 31

    Morin CM. Insomnia: Psychological Assessment and Management. Guilford Press: New York, 1993.

    Google Scholar 

  32. 32

    Morin CM, Stone J, Trinkle D et al. Dysfunctional beliefs and attitudes about sleep among older adults with and without insomnia complaints. Psychol. Aging. 1993; 8: 463–7.

    CAS  Article  PubMed  Google Scholar 

  33. 33

    Beck AT, Steer RA, Garbin MG. Psychometric properties of the beck depression inventory: twenty-five years of evaluation. Clin. Psychol. Rev. 1988; 8: 77–100.

    Article  Google Scholar 

  34. 34

    Spielberger CD, Gorsuch RL, Lushene RE. State-Trait Anxiety Inventory Manual. Consulting Psychologists Press: Palo Alto, CA, 1970.

    Google Scholar 

  35. 35

    Lacks P. Behavioral Treatment for Persistent Insomnia. Pergamon Press: New York, 1987.

    Google Scholar 

  36. 36

    McNair DM, Lorr M, Droppleman LF. Manual for the Profile of Mood States. EDITS: San Diego, CA, 1970.

    Google Scholar 

  37. 37

    Ishikawa S, Okajima I, Matsuoka H et al. Cognitive behavioral therapy for anxiety disorders in children and adolescents: a meta-analysis. Child Adolesc. Ment. Health 2007; 12: 164–72.

    Article  Google Scholar 

  38. 38

    Rosenthal R. Meta-Analystic Procedures for Social Research. Sage Publications: Beverly Hills, CA, 1984.

    Google Scholar 

  39. 39

    Breslau N, Roth T, Rosenthal L et al. Sleep disturbance and psychiatric disorders: a longitudinal epidemiological study of young adults. Biol. Psychiatry 1996; 39: 411–8.

    CAS  Article  PubMed  Google Scholar 

  40. 40

    Taylor DJ, Lichstein KL, Durrence HH et al. Epidemiology of insomnia, depression, and anxiety. Sleep 2005; 28: 1457–64.

    PubMed  Google Scholar 

  41. 41

    Taylor DJ, Lichstein KL, Weinstock J et al. A pilot study of cognitive-behavioral therapy of insomnia in people with mild depression. Behav. Ther. 2007; 38: 49–57.

    Article  PubMed  Google Scholar 

  42. 42

    Fava M, McCall WV, Krystal A et al. Eszopiclone co-administerd with fluoxetine in patients with insomnia coexisting with major depressive disorder. Biol. Psychiatry 2006; 59: 1052–60.

    CAS  Article  PubMed  Google Scholar 

  43. 43

    Jansson-Fröjmark M, Lundquist D, Jundquist N et al. How is persistent insomnia maintained? A prospective study on 50–60 years old adults in the general population. B r. J. Health Psychol. 2008; 13: 121–33.

    Article  Google Scholar 

  44. 44

    Jansson-Fröjmark M, Linton SJ. The role of sleep-related beliefs to improvement in early cognitive behavioral therapy for insomnia. Cogn. Behav. Ther. 2008; 37: 5–13.

    Article  PubMed  Google Scholar 

  45. 45

    Bastien CH, Morin CM, Ouellet MC et al. Cognitive-behavioral therapy for insomnia: comparison of individual therapy, group therapy, and telephone consultations. J. Consult. Clin. Psychol. 2004; 72: 653–9.

    Article  PubMed  Google Scholar 

Download references

Author information

Affiliations

Authors

Corresponding author

Correspondence to Dr Yuichi Inoue.

Additional information

This work was supported by KAKENHI (Grant-in-Aid for Young Scientists [Start-up]).

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Okajima, I., Komada, Y. & Inoue, Y. A meta-analysis on the treatment effectiveness of cognitive behavioral therapy for primary insomnia. Sleep Biol. Rhythms 9, 24–34 (2011). https://doi.org/10.1111/j.1479-8425.2010.00481.x

Download citation

  • cognitive behavioral therapy
  • insomnia
  • meta-analysis
  • publication bias
  • randomized controlled trial