Insomnia: A Narrative Review of Treatment Strategies For The Most Prevalent Sleep Disorder

This study examines the impact of cognitive behavioral therapy for insomnia (CBT-I) and positive airway pressure (PAP) therapy for comorbid insomnia and sleep apnea on nocturnal sleep and daytime functioning. A partial factorial design was used to examine treatment pathways with CBT-I and PAP and the relative benefits of each treatment. One hundred eighteen individuals with comorbid insomnia and sleep apnea were randomized to receive CBT-I followed by PAP, self-monitoring followed by CBT-I concurrent with PAP, or self-monitoring followed by PAP only. Participants were assessed at baseline, PAP titration, and 30 and 90 days after PAP initiation. Outcome measures included sleep diary- and actigraphy-measured sleep, Flinders Fatigue Scale, Epworth Sleepiness Scale, Functional Outcome of Sleep Questionnaire, and cognitive emotional measures. A main effect of time was found on diary-measured sleep parameters (decreased sleep onset latency and wake after sleep onset; increased total sleep time and sleep efficiency) and actigraphy-measured sleep parameters (decreased wake after sleep onset; increased sleep efficiency) and daytime functioning (reduced Epworth Sleepiness Scale, Flinders Fatigue Scale; increased Functional Outcome of Sleep Questionnaire) across all arms (all P < .05). Significant interactions and planned contrast comparisons revealed that CBT-I was superior to PAP and self-monitoring on reducing diary-measured sleep onset latency and wake after sleep onset and increasing sleep efficiency, as well as improving Functional Outcome of Sleep Questionnaire and Flinders Fatigue Scale compared to self-monitoring. Improvements in sleep and daytime functioning were found with PAP alone or concomitant with CBT-I. However, more rapid effects were observed on self-reported sleep and daytime performance when receiving CBT-I regardless of when it was initiated. Therefore, concomitant treatment appears to be a favorable approach to accelerate treatment outcomes. Registry: ClinicalTrials.gov; Name: Multidisciplinary Approach to the Treatment of Insomnia and Comorbid Sleep Apnea (MATRICS); URL: https://clinicaltrials.gov/ct2/show/NCT01785303; Identifier: NCT01785303. Tu AY, Crawford MR, Dawson SC, etal. A randomized controlled trial of cognitive behavioral therapy for insomnia and PAP for obstructive sleep apnea and comorbid insomnia: effects on nocturnal sleep and daytime performance. J Clin Sleep Med. 2022;18(3):789-800.

This study aimed to assess the effectiveness of cognitive behavioral therapy for insomnia (CBTI) during the postpartum period as part of a larger randomized controlled trial of CBTI on perinatal insomnia. A total of 179 women of 18-30 gestational weeks with insomnia disorder were randomly assigned to CBTI or an active control (CTRL) therapy. Participants were assessed between 18 and 32 weeks of pregnancy at baseline, after the intervention during pregnancy, and at 8, 18, and 30 weeks postpartum. The primary outcomes were Insomnia Severity Index (ISI) scores and total awake time, defined as minutes awake during the sleep opportunity period, assessed with actigraphy and sleep diaries. Included in the analyses were women who provided data for at least 1 of 3 postpartum assessments (68 in CBTI; 61 in CTRL). Piecewise mixed-effects models revealed a main effect reflecting reduction in ISI scores from 8-18 weeks postpartum (P = .036) and a nonsignificant increase from 18-30 weeks; significant effects for group allocation were present only in week 30 (P = .042). CTRL participants reported significantly longer time awake, excluding time spent caring for the infant, at each postpartum assessment; time awake at night caring for the infant did not differ between groups. There was no significant group difference in the postpartum trajectory of actigraphy-measured total awake time, the two diary measures of time awake (P values > .05). CBTI participants with at least 50% reduction in ISI during pregnancy had consistently stable ISI scores (mean < 6) during the postpartum period; those in the CTRL group had variable ISI scores over time with large individual differences. For women with insomnia disorder during pregnancy, CBTI initiated during pregnancy conferred postpartum benefits in terms of wakefulness after sleep onset (excluding time spent caring for the infant) and insomnia severity, though the latter emerged only later in the postpartum period. These findings underscore the importance of treating insomnia during pregnancy, a conclusion that is further supported by our finding that pregnant women who responded to insomnia treatment during pregnancy experienced better sleep in the postpartum period. Registry: Clinicaltrials.gov; Name: Treatment for Insomnia During Pregnancy; URL: https://www.clinicaltrials.gov/ct2/show/NCT01846585; Identifier: NCT01846585. Manber R, Bei B, Suh S, etal. Randomized controlled trial of cognitive behavioral therapy for perinatal insomnia: postpartum outcomes. J Clin Sleep Med. 2023;19(8):1411-1419.

Cognitive behavioral therapy for insomnia (CBT-I) has been shown to improve both sleep and depressive symptoms, but predictors of depression outcome following CBT-I have not been well examined. This study investigated how chronotype (i.e., morningness-eveningness trait) and changes in sleep efficiency (SE) were related to changes in depressive symptoms among recipients of CBT-I. Included were 419 adult insomnia outpatients from a sleep disorders clinic (43.20% males, age mean ± standard deviation = 48.14 ± 14.02). All participants completed the Composite Scale of Morningness and attended at least 4 sessions of a 6-session group CBT-I. SE was extracted from sleep diary; depressive symptoms were assessed using the Beck Depression Inventory (BDI) prior to (Baseline), and at the end (End) of intervention. Multilevel structural equation modeling revealed that from Baseline to End, SE increased and BDI decreased significantly. Controlling for age, sex, BDI, and SE at Baseline, stronger evening chronotype and less improvement in SE significantly and uniquely predicted less reduction in BDI from Baseline to End. Chronotype did not predict improvement in SE. In an insomnia outpatient sample, SE and depressive symptoms improved significantly after a CBT-I group intervention. All chronotypes benefited from sleep improvement, but those with greater eveningness and/or less sleep improvement experienced less reduction in depressive symptom severity. This suggests that evening preference and insomnia symptoms may have distinct relationships with mood, raising the possibility that the effect of CBT-I on depressive symptoms could be enhanced by assessing and addressing circadian factors.

Treat Chronic Insomnia With CBT-I, Says American College of Physicians

TMS and CBT-I for comorbid depression and insomnia. Exploring feasibility and tolerability of transcranial magnetic stimulation (TMS) and cognitive behavioral therapy for insomnia (CBT-I) for comorbid major depressive disorder and insomnia during the COVID-19 pandemic

Objectives Insomnia often involves physiological hyperarousal, particularly autonomic dysregulation. Although Cognitive Behavioral Therapy for Insomnia (CBT-I) is effective, some patients do not achieve complete remission. This preliminary study evaluated whether combining CBT-I with heart rate variability (HRV) biofeedback could enhance treatment effects by improving autonomic regulation. Methods Forty-four adults with insomnia were randomized to either a CBT-I group or a combined group that received HRV biofeedback (HRV-BF) and CBT-I (CBT-I+BF group). Both groups received seven weekly CBT-I sessions, with HRV-BF introduced in session four in the CBT-I+BF group. The primary outcome measure was the Insomnia Severity Index (ISI). Other outcome measures included the Pre-Sleep Arousal Scale (PSAS), sleep diaries, and HRV metrics. Assessments were conducted at baseline, post-treatment, and six-month follow-up. ISI and PSAS were also assessed at week 4 before the introduction of HRV-BF. Results Both groups significantly improved in insomnia severity, pre-sleep arousal, and some sleep diary variables.The CBT-I+BF group showed unique and significant improvement in subjective total sleep time. While overall autonomic balance only showed a trend-level improvement in the CBT-I+BF group, sensitivity analyses on participants with more severe objective sleep disturbance suggested greater autonomic balance improvement for the CBT-I+BF group. Conclusions Incorporating HRV-BF into CBT-I did not significantly enhance the benefits of CBT-I alone in this study. However, it offers additional advantages for individuals with more objective sleep disturbance, particularly in improving autonomic balance. Future research should identify optimal treatment intensity and explore the utility of HRV-BF in various insomnia sub-populations.

BackgroundInsomnia and eveningness are common and often comorbid conditions in youths. While cognitive behavioural therapy for insomnia (CBT-I) has been suggested as a promising intervention, it remains unclear whether it is sufficient to also address circadian issues in youths. In addition, despite that light has been shown to be effective in phase-shifting one’s circadian rhythm, there has been limited data on the effects of bright light therapy and its combination with CBT-I on sleep and circadian outcomes in youths. The current protocol outlines a randomised controlled trial that examines the efficacy of CBT-I and CBT-I plus bright light therapy (BLT) in reducing insomnia severity, improving mood symptoms and daytime functioning (e.g. sleepiness, fatigue, cognitive function), and improving subjective and objective sleep and circadian measures compared to a waitlist control group.MethodsWe will carry out a randomised controlled trial (RCT) with 150 youths aged 12–24 who meet the criteria of insomnia and eveningness. Participants will be randomised into one of three groups: CBT-I with bright light therapy, CBT-I with placebo light, and waitlist control. Six sessions of CBT-I will be delivered in a group format, while participants will be currently asked to use a portable light device for 30 min daily immediately after awakening throughout the intervention period for bright light therapy. The CBT-I with light therapy group will receive bright constant green light (506 lx) while the CBT-I with placebo light group will receive the modified light device with the LEDs emitting less than 10 lx. All participants will be assessed at baseline and post-treatment, while the two active treatment groups will be additionally followed up at 1 month and 6 months post-intervention. The primary outcome will be insomnia severity, as measured by the Insomnia Severity Index. Secondary outcomes include self-reported mood, circadian, daytime functioning, and quality of life measures, as well as sleep parameters derived from actigraphy and sleep diary and neurocognitive assessments. Objective measures of the circadian phase using dim-light melatonin onset assessment and sleep parameters using polysomnography will also be included as the secondary outcomes.DiscussionThis study will be the first RCT to directly compare the effects of CBT-I and BLT in youths with insomnia and eveningness. Findings from the study will provide evidence to inform the clinical management of insomnia problems and eveningness in youths.Trial registrationClinicalTrials.gov NCT04256915. Registered on 5 February 2020.

Investigating the antidepressant effects of CBT-I in those with major depressive and insomnia disorders

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.

To evaluate the effectiveness of cognitive behavioral therapy for insomnia during pregnancy. Randomized, unmasked, 3-site controlled trial. Participants were randomly allocated to cognitive behavioral therapy for insomnia (a first-line, empirically supported psychosocial intervention that addresses sleep-related behaviors and cognitions) or a control intervention consisting of imagery exercises that paired patient-identified distressing nighttime experiences with patient-identified neutral images. Participants were eligible if they met diagnostic criteria for insomnia disorder and were between 18 and 32 weeks of gestation. Patients were ineligible if they met diagnostic criteria for major psychiatric disorders, including depression, or were receiving nonstudy treatments that could affect sleep (or both). The primary outcome was the Insomnia Severity Index score, a validated brief questionnaire, with scores between 14 and 21 representing clinically meaningful insomnia of moderate severity, scores higher than 21 representing severe insomnia, and scores less than 8 representing no insomnia. Secondary outcomes included remission of insomnia (Insomnia Severity Index score less than 8), objectively measured and self-reported time awake (ie, total wake time), and the Edinburgh Postnatal Depression Scale score. All outcomes were measured weekly. Analysis included 48 participants who did not complete treatment. We estimated that 184 women would be required to have 80% power, with a two-tailed test, to detect a moderate Cohen's d effect size (.5) with α=.05. Between May 2013 and April 2017, 194 pregnant women were randomized and 149 completed treatment; 179 with available baseline data (92%) were ultimately analyzed, 89 in the cognitive therapy group and 90 in the control group. Women assigned to cognitive behavioral therapy for insomnia experienced significantly greater reductions in insomnia severity (scores decreased from 15.4±4.3 to 8.0±5.2 in the cognitive behavioral therapy group vs from 15.9±4.4 to 11.2±4.9 in the control therapy group [P<.001, d=0.5]). Remission of insomnia (to an Insomnia Severity Index score less than 8) disorder was attained by 64% of women in the cognitive behavioral therapy for insomnia group vs 52% in the control group. Women receiving cognitive behavioral therapy for insomnia experienced faster remission of insomnia disorder, with a median of 31 days vs 48 days in the control therapy (P<.001). Cognitive behavioral therapy for insomnia led to significantly greater reduction in self-reported but not objective total wake time and a small but significantly greater decline in Edinburgh Postnatal Depression Scale scores vs the control group. Cognitive behavioral therapy for insomnia is an effective nonpharmacologic treatment for insomnia during pregnancy. ClinicalTrials.gov, NCT01846585.

Do symptoms of depression, anxiety or stress impair the effectiveness of cognitive behavioural therapy for insomnia? A chart-review of 455 patients with chronic insomnia

Efficacy of cognitive behavioral therapy for insomnia in geriatric primary care patients.

SummaryAlthough there have been promising findings for smartphone application (app)‐delivered cognitive behavioural therapy for insomnia (CBT‐I), previous trials have not screened participants rigorously for insomnia disorder and used therapist support. Based on the above, we aimed to examine the effects of smartphone app‐delivered CBT‐I with telephone support against a waitlist (WL) in a sample with insomnia disorder. A total of 64 participants with insomnia disorder were randomised to smartphone app‐delivered CBT‐I (n = 32) or a WL (n = 32). Smartphone app‐delivered CBT‐I consisted of six weekly smartphone app modules with 15 min of telephone support per week. At pre‐ and post‐treatment, and the 3‐month follow‐up, we assessed insomnia symptoms and associated correlates and consequences. At post‐treatment, we also assessed measures related to adherence (therapist support, exercise/module completion), self‐rated perception of treatment content, activity, and adverse events. CBT‐I significantly outperformed the WL with large effects on the primary outcome (d = 2.26) and was significantly different on most of the secondary outcomes with medium to large effects. CBT‐I also resulted in a significantly larger proportion of treatment remitters (CBT‐I: 64.5–77.4%, WL: 6.5–6.9%) and responders (CBT‐I: 77.4–90.3%, WL: 19.4–24.1%) at post‐treatment and follow‐up, compared to the WL. Treatment was associated with high satisfaction, high adherence, low attrition, and few treatment‐impeding adverse events. Based on the medium to large effects of smartphone app‐delivered CBT‐I with telephone support, this trial highlights the potential of delivering CBT‐I exclusively through an app with therapist telephone support for high efficacy, satisfaction, and adherence.

Effectiveness of cognitive behavioral therapy for pharmacotherapy-resistant chronic insomnia: a multi-center randomized controlled trial in Japan

To determine the relative effectiveness and predictors of cognitive therapy (CT), behavioral therapy (BT), and cognitive behavioral therapy (CBT) for insomnia in older adults. In a registered clinical trial (NCT02117388), 128 older adults with insomnia disorder were randomly assigned to receive CBT, BT, or CT. Insomnia Severity Index (ISI) score was the primary outcome. Sleep diaries, fatigue, beliefs about sleep, cognitive arousal, and stress were secondary outcomes. Split-plot linear mixed models assessed within- and between-subject changes in outcomes among the treatments. As a secondary analysis, we used linear regression to test predictors of insomnia symptoms improvement, including sleep diary measures, cognitive arousal, stress, beliefs about sleep, baseline ISI score, and age. Benjamini-Hochberg correction was applied. All groups exhibited insomnia symptom reduction at posttreatment (CT: d = -2.53, P < .001; BT: d = -2.39, P < .001; CBT: d = -2.90, P < .001) and at the 6-month follow-up (CT: d = -2.68, P < .001; BT: d = -2.85, P < .001; CBT: d = -3.14, P < .001). There were no group differences in the magnitude of ISI improvement (Padj = .63), response (Padj > .63), or remission (ISI < 8; Padj > .27). All groups exhibited significant improvements in secondary outcomes at posttreatment (Padj < .05) and at the 6-month follow-up (Padj < .05). At posttreatment, the CT and CBT groups showed greater reductions in beliefs about sleep than the BT group (FInteraction(2,185) = 5.99, Padj = .03), and the CBT group showed a greater time in bed reduction than the CT group (FInteraction(2,185) = 7.05, Padj = .01). Baseline ISI was the only treatment predictor (b = 1.95, Padj < .001). CBT for insomnia and its components each independently result in significant improvements in self-reported insomnia symptoms, beliefs about sleep, worry, and fatigue in older adults. Registry: ClinicalTrials.gov; Name: Treatments for Insomnia: Mediators, Moderators and Quality of Life; URL: https://clinicaltrials.gov/study/NCT02117388; Identifier: NCT02117388. O'Hora KP, Morehouse AB, Freidman L, etal. Comparative effectiveness and predictors of cognitive behavioral therapy for insomnia and its components in older adults: main outcomes of a randomized dismantling trial. J Clin Sleep Med. 2025;21(10):1679-1695.