Digital insomnia therapeutic as a workplace performance solution for improving productivity.

Abstract Purpose of Review Insomnia disorder is a prevalent and impairing sleep-wake disorder characterized by persistent difficulty initiating or maintaining sleep, accompanied by daytime impairment. Cognitive behavioral therapy for insomnia (CBT-I) is the recommended first-line treatment and has a strong evidence base. Building on this foundation, recent work has increasingly focused on translating these advances into accessible and scalable interventions. This review (1) highlights key challenges in the delivery of insomnia interventions that constrain equitable access and (2) examines emerging approaches that may address these gaps. Recent Findings Recent research has identified four primary challenges limiting equitable access to insomnia interventions: high comorbidity with mental health and other sleep and circadian disorders, limited testing and adaptation outside of academic settings, a shortage of trained providers, and structural barriers related to funding and reimbursement. In response, growing evidence supports transdiagnostic treatment approaches, implementation strategies for real-world settings, delivery by non-specialist providers, brief and single-session interventions, and digital and stepped care models as promising pathways to improve access and scalability. Summary Our review underscores the importance of moving beyond testing efficacy to address the practical and structural barriers that limit access to evidence-based insomnia interventions. Advancing research that prioritizes real-world application remains essential for narrowing the longstanding gap between evidence and practice and to improve equitable access to effective insomnia interventions.

This pilot randomized controlled trial (RCT) evaluated feasibility, acceptability, and preliminary clinical benefits of ACTCOM-I, a novel intervention combining Acceptance and Commitment Therapy with behavioural strategies and self-compassion, compared with CBT-I. An analytic sample of 19 participants (63% women; M = 43.26 years, SD = 12.77) with chronic insomnia was randomized to ACTCOM-I (n = 10) or CBT-I (n = 9). Assessments occurred at baseline (T0), post-treatment (T1), 3-months (T2) and 6-months (T3) follow-ups. Measures included insomnia severity, beliefs, pre-sleep arousal, sleep effort, sleep diary, anxiety/depression, affect, quality of life, mindfulness, psychological flexibility, cognitive fusion, progress/obstructions to valued living, and self-compassion. Linear mixed models showed significant Time effects for insomnia severity (p < .001), with large within-group effect sizes maintained at follow-up. No significant between-group differences were found (p = .88), indicating similar improvement trajectories over time. Reliable change analysis (RCI) confirmed that 90% of ACTCOM-I and 89% of CBT-I participants achieved clinically significant improvements at post-treatment, with high response and remission rates. No participants deteriorated. Both interventions also led to comparable improvements in secondary sleep-related outcomes, anxiety/depression, and positive affect, while negative affect remained stable. Most process-related measures showed significant Time effects but no TimeXGroup interactions, further supporting similar patterns of change. Within-group analyses suggested greater improvements in psychological flexibility, cognitive fusion, obstructions to valued living and self-compassion in ACTCOM-I, particularly at follow-up. Despite high attrition, ACTCOM-I was feasible, well-accepted, and thematic analysis identified six overarching themes. Results suggest that ACTCOM-I is feasible, well-accepted, and preliminary findings support further studies on its potential as a complementary treatment to chronic insomnia.

ABSTRACT Introduction Suboptimal response to CBTi is common in non-Western populations (e.g. Arabs). Aligning CBTi with culturally shaped beliefs and practices may improve outcomes. Objectives A single-blind, three-arm randomized controlled trial was conducted to compare the efficacy of two-levels of cultural adaptations of CBTi against a wait-list condition for adults with insomnia disorder. Methods Fifty-four Arabs with insomnia were randomized to one of three conditions: (1) CBTi with surface-level adaptations (i.e. integration of socio-behavioral characteristics to foster treatment engagement and delivery); (2) CBTi with surface and deep-level adaptations (i.e. targeting sociocultural factors that may modulate perceptions of causes, prognosis and treatment); or (3) wait-list (WL). Cultural adaptations of CBTi were informed by findings from our previous qualitative study. Primary outcome was the Insomnia Severity Index (ISI), measured at four time points. Secondary outcomes included: sleep diaries, beliefs and attitudes about sleep (DBAS), anxiety, depression and fatigue scales (HADS and MFI). Results Both treatment conditions showed significant pre- to post-treatmentimprovements in insomnia severity compared to the wait-list (SD-CBTi ISI mean change: −9.5 [95% CI, −12.3 to −6.7]; S-CBTi: −10.7 [−13.3 to −8.1] and WL: −0.1 [−2.7 to 2.5]; p < .001). Compared to controls, both treatment conditions demonstrated improvements in sleep parameters, HADS and DBAS. No statistically significant differences were observed between active conditions. Improvements were maintained at three-month follow-up. Conclusion Findings support the potential efficacy of culturally adapted CBTi compared to controls for Arabs. Future research comparing culturally adapted and standard CBTi is needed to determine the incremental benefit of cultural adaptations.

This secondary analysis of a randomized clinical trial explored (1) changes in memory performance and slow-wave activity (SWA) in older adults with insomnia disorder following cognitive behavioral therapy for insomnia (CBT-I) and its component therapies, (2) associations between changes in SWA and changes in memory performance, and (3) whether individual CBT-I component therapies (behavioral therapy (BT) and cognitive therapy (CT)) differ in their associations with these outcomes. A secondary analysis was conducted using data from 104 older adults with insomnia disorder who underwent polysomnography and RBANS memory testing to assess immediate (list learning and story memory) and delayed memory (list recall, story recall, figure recall, and list recognition) at baseline and again at 6-months following randomization to six sessions of CBT-I, BT, or CT. Linear-mixed effects models examined changes in memory and SWA from baseline and at 6-month follow-up. Regression analyses examined relationships between changes in SWA and memory. At 6-month follow-up, participants showed improvements in immediate memory (list learning and story memory) and delayed memory (list recall, story recall, and figure recall) compared to baseline. SWA did not change significantly following treatment. However, within-person increases in SWA were positively associated with improvements in list learning performance. Outcomes did not differ among treatments (CBT-I, BT, CT). Although a definitive randomized controlled trial is necessary to test causality, these findings add to a growing body of literature on sleep and memory and suggest a potential role for SWA in memory processes in older adults with insomnia. This study was a secondary analysis conducted using data from a clinical trial registered on ClinicalTrials.gov: https://clinicaltrials.gov/study/NCT02117388 . Treatments for Insomnia: Mediators, Moderators and Quality of Life. gov, NCT02117388. This secondary analysis leverages previously collected data from a clinical trial to explore changes in memory performance and SWA, and their potential associations, in older adults with insomnia disorder who received cognitive behavioral therapy for insomnia (CBT-I) or its individual component therapies cognitive therapy (CT) and behavioral therapy (BT). Memory performance improved from baseline to 6-month follow-up and within-person increases in SWA were positively associated with memory performance. While this secondary analysis cannot establish causality, these findings add to a growing body of literature on sleep and memory and suggest a potential role for SWA in memory processes in older adults with insomnia. These associations provide support for further investigation in confirmatory trials designed to test causal mechanisms.

INTRODUCTIONInsomnia is associated with increased risk for Alzheimer's disease (AD). It is unknown how cognitive behavioral therapy for insomnia (CBT‐I) impacts two hallmarks of AD progression, cognitive performance and beta‐amyloid (Aβ) burden.METHODSCognitively normal older adults with symptoms of insomnia were randomized into CBT‐I treatment (n = 100) or control (n = 100) groups. Cognitive performance was assessed at baseline, 6‐weeks, and 1‐year (1 year). Aβ burden was assessed in a subsample (n = 50).RESULTSNo differences were observed between groups in change in cognitive performance, including speed of information processing (mean difference, 0.017; 95% confidence interval [CI], −0.1036 to 0.1376; p = 0.78), executive function (−0.0881; 95% CI, −0.2945 to 0.1182; p = 0.40), and memory (0.4068; 95% CI, −2.3965 to 3.2101; p = 0.77). No group differences were observed in Aβ deposition.DISCUSSIONCBT‐I did not improve cognitive performance or Aβ deposition by one year. Longer follow up is needed to understand the potential impact of CBT‐I on AD risk.CLINICAL TRIAL REGISTRATIONThe study was registered on clinicaltrials.gov (NCT03954210) on 5/17/2019.

BackgroundChronic insomnia is a highly prevalent sleep disorder that adversely affects quality of life and mental health. Cognitive behavioral therapy for insomnia (CBT-I) is internationally recommended as the first-line treatment, and digital CBT-I (dCBT-I) has been developed to improve accessibility and scalability. While existing dCBT-I systems effectively support structured behavioral training through standardized protocols, they provide relatively limited support for users’ cognitive exploration and meaning-making processes, particularly in helping users reflect on and internalize the rationale behind CBT-I practices in daily life. These limitations may contribute to challenges in sustained engagement and long-term adherence.ObjectiveThis study aimed to examine the usability and feasibility of SleepPathfinder, a conversational CBT-I support chatbot that integrates Socratic questioning and a self-decision mechanism to support users’ understanding of and engagement with CBT-I practices.MethodsSleepPathfinder was designed around a 4-stage conversational flow: education on CBT-I techniques, Socratic cognitive exploration, self-decision, and advice provision. We conducted (1) a single-session pilot usability study (n=45) to assess system stability and user experience and (2) a 5-day condition-based comparative experiment (n=30) consisting of daily sessions, comparing an exploratory dialogue condition with a directive, protocol-guided dialogue condition. Quantitative measures assessed usability, cognitive appraisals related to sleep problems, autonomy-related experiences, and behavioral readiness, while qualitative feedback and conversational log analyses were used to examine interaction patterns and engagement characteristics.ResultsIn the comparative experiment, the exploratory dialogue condition showed a tendency toward reduced perceived threat and severity appraisal of sleep problems compared with the directive condition, accompanied by moderate effect sizes in cognitive perception measures. Autonomy-related experiences, including perceived choice and engagement, demonstrated suggestive upward trends in the exploratory condition. Behavioral intention changes were comparable across conditions, while overall readiness for change increased across participants. Conversational log analyses indicated that greater depth and volume of user self-narrative were associated with larger shifts in cognitive appraisals, whereas the frequency of chatbot questions alone was not. The pilot usability study indicated generally positive evaluations of system usability and content credibility, while identifying areas for improvement in emotional responsiveness and conversational naturalness.ConclusionsThese findings suggest that a Socratic questioning–based and self-decision–based conversational structure is usable and feasible as a supportive interaction layer within dCBT-I systems. Rather than altering the directive behavioral structure of CBT-I, such an approach may complement existing protocols by facilitating cognitive exploration and supporting user-perceived autonomy. This study provides design-oriented evidence to inform the refinement of dialogue-supported digital CBT-I systems aimed at enhancing user engagement with CBT-I practices.

ABSTRACT Objectives Cognitive behavioral therapy for insomnia (CBT-I) is widely recommended, but access remains limited, particularly among rural adults. Medications to treat insomnia, including zolpidem and trazodone, are widely used but can have significant side effects. Empirical evidence remains sparse to support the choice of CBT-I, medication, or combined treatment in clinical practice. Method This paper describes the Comparative Effectiveness of Zolpidem/Trazodone and Cognitive Behavioral Therapy for Insomnia (COZI) study, which aimed to compare the effectiveness of medications and behavioral interventions for chronic insomnia. Results COZI was a multi-center randomized trial in rural adults (aged 18–80) with chronic insomnia. The effects of three insomnia treatments were compared: digital CBT-I (dCBT-I), medication (patient/provider choice of zolpidem or trazodone), and the combination of medication plus dCBT-I. Treatment outcomes were measured at 9 weeks, 6 months, and 12 months. The primary outcome was change in severity of insomnia symptoms (ISI) over 6 months. Secondary outcomes included change in insomnia symptom severity at 9 weeks and 12 months, adverse events, and other patient-centered outcomes. Conclusions Study results will provide support for clinical decision-making in insomnia treatment.

Insomnia and poor sleep quality are common sleep-related problems in adults and are associated with impaired quality of life, psychological distress, and increased physical health burden. Although cognitive behavioral therapy for insomnia (CBT-I) is recommended as the first-line non-pharmacological treatment for chronic insomnia, internet-based Acceptance and Commitment Therapy (iACT) has increasingly been explored as an alternative or complementary digital psychological intervention for improving sleep-related outcomes. To systematically evaluate the effects of iACT on sleep quality and insomnia-related outcomes in adults. PubMed, Web of Science, Cochrane Library, CINAHL, and Embase were systematically searched from inception to December 6, 2025. We included randomized controlled trials evaluating internet-based Acceptance and Commitment Therapy in adults that reported validated outcomes for sleep quality or insomnia. Standardized mean differences were pooled using a random-effects model, and risk of bias was assessed using the Cochrane Risk of Bias 2 tool. Eight randomized controlled trials met the inclusion criteria. Five studies were included in the meta-analysis of sleep quality outcomes and three in the meta-analysis of insomnia outcomes. Compared with passive control conditions, iACT was associated with better sleep quality outcomes (SMD = - 0.92, 95% CI - 1.45 to - 0.38; p < 0.001) and reduced insomnia symptoms (SMD = - 0.40, 95% CI - 0.64 to - 0.16; p < 0.001). Exploratory subgroup analyses suggested possible variation in sleep quality outcomes according to intervention duration, participant characteristics, and delivery format, although these findings should be interpreted cautiously. iACT may have potential to improve sleep quality and insomnia-related outcomes in adults. However, the available evidence remains limited by heterogeneous populations, intervention characteristics, delivery formats, and overall low certainty of evidence. Therefore, the findings should be considered preliminary rather than definitive.

The effectiveness of a cognitive behavioural therapy for insomnia based intervention to improve sleep quality in nursing home residents, a cluster randomised controlled trial.

Rationale:Dexmedetomidine is extensively recognized as a sedative featuring a relatively mild respiratory depressant effect. Nevertheless, for patients who are on long-term sedative use and potentially suffer from co-morbid insomnia and sleep apnea (COMISA), the safety of this drug remains ambiguous. This case report uncovers a rare yet severe adverse reaction associated with this drug.Patient concerns:A 62-year-old male with a 2-year history of insomnia has been on long-term use of multiple sedative agents. He reported persistent symptoms including poor sleep quality, daytime fatigue, and cognitive decline, along with a strong desire to reduce his medication burden.Diagnoses:During the patient’s hospitalization, polysomnography results confirmed that the patient suffered from severe obstructive sleep apnea-hypopnea syndrome (OSAHS). This condition was induced by the administration of dexmedetomidine during the infusion process.Interventions:Before conducting the sleep monitoring, CBTI (cognitive behavioral therapy for insomnia), stellate ganglion block, ozone enema, and traditional Chinese medicine treatment were performed. After the diagnosis of severe OSAHS was confirmed, dexmedetomidine was immediately discontinued. Subsequently, noninvasive ventilation was adopted as the main auxiliary treatment method.Outcomes:After the intervention measures were implemented, the patient’s sleep quality and oxygen supply condition significantly improved. During the follow-up, he successfully reduced his reliance on sedative-hypnotic drugs.Lessons:This case indicates that for patients with a long history of using sedatives, dexmedetomidine may cause or exacerbate severe OSAHS. Clinicians should be vigilant and consider conducting sleep apnea screening for high-risk patients before using sedatives and be prepared with noninvasive ventilation support equipment.

Cognitive behavioural therapy for insomnia (CBT-I) is recommended as first-line treatment for insomnia disorder. However, around 25% of the patients do not respond to the treatment, and only 40% achieve full remission. The current study investigates the therapeutic potential of light therapy as an add-on to CBT-I. Insomnia severity and questionnaire-related secondary outcomes were assessed at baseline, post-treatment and follow-up. Sleep diary-related variables and the cortisol awakening response were assessed at pre- and post-treatment. Linear mixed models were calculated for each outcome variable. The study included 42 patients with insomnia disorder. Reduction in insomnia severity did not significantly differ between groups from baseline to post-treatment (β = 0.35, SE = 1.31, p = 0.792). Regarding exploratory secondary outcomes, daytime sleepiness was significantly more reduced from baseline to follow-up in the CBT-I + light therapy group than in the CBT-I + placebo light group (β = -1.05, SE = 0.43, p = 0.020). There was no significant condition × time point interaction effect for any of the other secondary outcomes. The findings show no significant add-on effect of light therapy on insomnia severity. However, light therapy had a significant effect on daytime sleepiness that became evident only at the follow-up. Given that daytime functioning is of high clinical relevance for patients with insomnia disorder, daytime sleepiness should be further evaluated as treatment target and may be addressed with light therapy. TRIAL REGISTRATION: ClinicalTrials.gov identifier: DRKS00029640.

Fully automated digital cognitive behavioral therapy for insomnia (dCBT-I) is increasingly used as a scalable intervention for adults with insomnia. Although recent reviews have supported its overall efficacy, uncertainty remains regarding the interpretation of platform-related differences across trials. We aimed to evaluate the efficacy of fully automated dCBT-I in adults and to explore whether apparent differences by delivery platform may be related to study-level characteristics. We conducted a systematic review and random-effects meta-analysis of randomized controlled trials in general adult populations. Standardized mean differences (SMDs) were pooled using restricted maximum likelihood estimation with truncated Knapp-Hartung adjustment. Subgroup analyses and exploratory meta-regression examined delivery platform and publication year as potential moderators. Fifteen trials (N = 3,507) were included. Fully automated dCBT-I was associated with substantial reductions in insomnia severity (SMD = - 0.82) and consistent improvements in sleep initiation and sleep efficiency, with smaller but significant improvements in sleep quality. In exploratory multivariable meta-regression, the association between delivery platform and treatment effect was attenuated after adjustment for study-level characteristics, including publication year. More recent trials tended to yield smaller effect estimates. Given the limited number of app-based studies, these findings should be interpreted cautiously. Residual heterogeneity was low. Fully automated dCBT-I appears to be an effective intervention for adults with insomnia. Platform-related differences were not robust in exploratory analyses and may reflect broader temporal or design-related differences across studies rather than inherent advantages or limitations of a specific delivery format. Further trials, particularly app-based studies, are needed to clarify whether platform-specific effects exist.

Mental disorders are the leading cause of reduced quality of life due to illness worldwide. Most patients with mental disorders report difficulties initiating or maintaining sleep (insomnia). Current guidelines recommend cognitive behavioral therapy for insomnia (CBT-I) as the first-line treatment, including for patients with comorbid mental disorders. Particularly, data on the management of insomnia in inpatient psychiatric care remain scarce. This clinical practice evaluation examined the management of insomnia in inpatient psychiatric care through two complementary approaches. The project comprised a survey on insomnia management in 80 mental health professionals and data extraction of nighttime medication from 245 inpatients. Reports from the survey indicate that 95% of mental health professionals regularly care for patients with insomnia. 56% correctly identified CBT-I and 48% incorrectly identified benzodiazepines or benzodiazepine-receptor agonists as the first-line treatment for insomnia. 65% reported that CBT-I is not or rarely offered. The main reported challenges to implementing CBT-I were limited knowledge about CBT-I, patient expectations for pharmacological treatment, and time constraints in clinical practice. Data extracted from 245 patient records indicated that 40% of the patients took benzodiazepines, 9% melatonin, 7% benzodiazepine receptor agonists, 5% clomethiazole, 4% antihistamines, and 2% phytotherapy. The results indicate that insomnia is a prevalent health problem in inpatient psychiatric care. Implementation of CBT-I or adaptations remains insufficient, and treatment with hypnotics is common. Future work is needed to further adapt and test CBT-I in inpatient psychiatric care to improve sleep and health.

Predictors of cognitive-behavioral therapy for insomnia (CBT-I) outcomes in individuals with psychiatric disorders: A retrospective observational cohort study.

Insomnia is a heterogeneous disorder, for which cognitive behavioural therapy for insomnia (CBT-I) is the recommended first-line treatment. However, CBT-I is not effective for all patients. It is important to identify pre-treatment predictors and moderators of treatment-response to CBT-I and its variants to guide precision insomnia management approaches. This systematic review (PROSPERO: CRD42023476013) aimed to synthesise evidence on pre-treatment characteristics that predict or moderate insomnia outcomes following CBT-I. Peer-reviewed papers that reported such analyses from randomised and non-randomised studies of adults with insomnia were eligible. Four databases and citations of included reports were searched until April 2025. From 7325 unique records, 1494 full-text records were screened, of which 103 reports were included. Among 195 unique predictors/moderators identified from 1208 results, 92.3% were infrequently studied and/or rarely demonstrated statistical significance as predictors of insomnia improvement. The most consistent predictors of improvement included shorter insomnia duration, more severe insomnia, longer objective sleep duration, positive attitudes towards treatment, lower depression severity, and the absence of comorbid mental disorders, fatigue and pain. Further high-quality research using sufficiently powered samples and theoretically-justified moderators is needed to establish characteristics related to differential outcomes between cognitive behavioural interventions.

Nonpharmacologic Management of Insomnia Disorder in Primary Care.

Sleep disorders in addictions: State of the art and management.

Alterations in sleep and the biological clock in mood disorders: State of the art and therapeutic approaches.

Sleep disorders in the elderly and their management.