Key Components Identified for Improving Efficacy of Cognitive Behavioral Therapy in Chronic Insomnia


A recent review revealed critical components, including cognitive restructuring and third-wave strategies, that enhance the effectiveness of cognitive behavioral therapy for insomnia.

Michael Perlis, PhD, an associate professor of psychology and the director of the Behavioral Sleep Medicine Program at the University of Pennsylvania

Michael Perlis, PhD

Credit: Pyschwire

A new systematic review published in JAMA Psychiatry identified beneficial components of cognitive behavioral therapy, including strategies and delivery, for patients living with chronic insomnia disorder.1 These findings suggest that a combination of these components may maximize the benefit and efficacy of cognitive behavioral therapy for insomnia (CBT-I) in patients with this condition.2

Among 241 trials with 31,452 participants (mean age, 45.4 years; 67% women), critical components of CBT-I detected were cognitive restructuring (remission 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). Notably, investigators observed that sleep hygiene education was not essential (iOR, 1.01; 95% CI, 0.77-1.32), and relaxation procedures were potentially inefficient (iOR, 0.81; 95% CI, 0.64-1.02). In addition, results showed that in-person therapist-led programs were most beneficial for patients (iOR, 1.83; 95% CI, 1.19-2.81).

Top Clinical Takeaways

  • Cognitive restructuring, third-wave components, and in-person delivery stand out as crucial components, highlighting the need for a personalized approach in CBT-I interventions.
  • Sleep hygiene education was deemed non-essential, and relaxation procedures potentially counterproductive, challenging established notions in the treatment of chronic insomnia.
  • While the findings offer valuable insights, the authors emphasized the need for large-scale trials to confirm the identified components and encourage practitioners to adopt streamlined CBT-I approaches for wider accessibility.

“We found that sleep restriction, stimulus control, cognitive restructuring and third wave components were beneficial. In terms of delivery formats, in-person delivery appeared to be best. Sleep hygiene education alone was not effective and relaxation could be even counterproductive,” lead author Yuki Furukawa, MD, department of neuropsychiatry at University of Tokyo Hospital, told NeurologyLive®.

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Senior author Michael Perlis, PhD, an associate professor of psychology and the director of the Behavioral Sleep Medicine Program at the University of Pennsylvania, and colleagues, searched for randomized clinical trials comparing any form of CBT-I against another or a control condition for chronic insomnia disorder. Researchers searched databases including PubMed, Cochrane Central Register of Controlled Trials, PsycInfo, and International Clinical Trials Registry Platform up until July 21, 2023. Only 2 independent reviewers recognized components, collected the data, and assessed the quality of the trials. Following this, researchers performed random-effects component network meta-analyses. The primary outcome was efficacy of the treatment, with remission defined as reaching a satisfactory state, posttreatment and secondary outcomes included all-cause dropout, self-reported sleep continuity, and long-term remission.

In the analysis, investigators observed that improved subjective sleep quality was associated with cognitive restructuring, third-wave components, and in-person delivery. In addition, authors observed that sleep restriction was associated with improved subjective sleep quality, sleep efficiency, and wake after sleep onset, and stimulus control with enhanced subjective sleep quality, sleep efficiency, and sleep latency. The most efficacious combination consisted of an in-person format of cognitive restructuring, third wave, sleep restriction, and stimulus control and in-person psychoeducation, which showed an increase in the remission rate by a risk difference of 0.33 (95% CI, 0.23-0.43) and a number needed to treat of 3.0 (95% CI, 2.3-4.3), given that the median observed control event rate of 0.14.

All told, the overall quality of evidence for the network estimates at the treatment level and component level varied from moderate to low overall. Also, authors noted that the high dropout rate may have influenced the results. The analysis only considered components as either present or absent, but these may have varied between programs in terms of contents and implementation. Authors noted that the additivity assumption may not hold in practice because the trials were not designed to test such interactions. Furthermore, the contents of some components may not be completely mutually exclusive, which is another limitation, according to the investigators.

“We hope that our study contributes to the development of streamlined CBT-I package, and in turn, more patients can be offered the treatment,” Furukawa added. “Ideally, our findings should be replicated in a larger trial. It is even more important to figure out how we can disseminate the treatment.”

1. Furukawa Y, Sakata M, Yamamoto R, et al. Components and Delivery Formats of Cognitive Behavioral Therapy for Chronic Insomnia in Adults: A Systematic Review and Component Network Meta-Analysis. JAMA Psychiatry. Published online January 17, 2024. doi:10.1001/jamapsychiatry.2023.5060
2. Streamlining cognitive behavioral therapy for chronic insomnia. News Release. University of Tokyo. Published January 17, 2024. Accessed January 30, 3034.
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