Cognitive Behavioral Therapy for Insomnia Comorbid With Psychiatric and Medical Conditions

Abstract

IMPORTANCE Cognitive behavioral therapy for insomnia (CBT-I) is the most prominent nonpharmacologic treatment for insomnia disorders. Although meta-analyses have examined primary insomnia, less is known about the comparative efficacy of CBT-I on comorbid insomnia.OBJECTIVE To examine the efficacy of CBT-I for insomnia comorbid with psychiatric and/or medical conditions for ( 1) remission from insomnia; (2) self-reported sleep efficiency, sleep onset latency, wake after sleep onset, total sleep time, and subjective sleep quality; and (3) comorbid symptoms. DATA SOURCES A systematic search was conducted on June 2, 2014, through PubMed, PsycINFO, the Cochrane Library, and manual searches. Search terms included (1) CBT-I or CBT or cognitive behavioral [and its variations] or behavioral therapy [and its variations] or behavioral sleep medicine or stimulus control or sleep restriction or relaxation therapy or relaxation training or progressive muscle relaxation or paradoxical intention; and (2) insomnia or sleep disturbance.STUDY SELECTION Studies were included if they were randomized clinical trials with at least one CBT-I arm and had an adult population meeting diagnostic criteria for insomnia as well as a concomitant condition. Inclusion in final analyses (37 studies) was based on consensus between 3 authors' independent screenings. DATA EXTRACTION AND SYNTHESIS Data were independently extracted by 2 authors and pooled using a random-effects model. Study quality was independently evaluated by 2 authors using the Cochrane risk of bias assessment tool. MAIN OUTCOMES AND MEASURESA priori main outcomes (ie, clinical sleep and comorbid outcomes) were derived from sleep diary and other self-report measures.RESULTS At posttreatment evaluation, 36.0% of patients who received CBT-I were in remission from insomnia compared with 16.9% of those in control or comparison conditions (pooled odds ratio, 3.28; 95% CI, 2.30-4.68; P < .001). Pretreatment and posttreatment controlled effect sizes were medium to large for most sleep parameters (sleep efficiency: Hedges g = 0.91 [95% CI, 0.74 to 1.08]; sleep onset latency: Hedges g = 0.80 [95% CI, 0.60 to 1.00]; wake after sleep onset: Hedges g = 0.68; sleep quality: Hedges g = 0.84; all P < .001), except total sleep time. Comorbid outcomes yielded a small effect size (Hedges g = 0.39 [95% CI, 0.60-0.98]; P < .001); improvements were greater in psychiatric than in medical populations (Hedges g = 0.20 [95% CI, 0.09-0.30]; χ 2 test for interaction = 12.30; P < .001). CONCLUSIONS AND RELEVANCECognitive behavioral therapy for insomnia is efficacious for improving insomnia symptoms and sleep parameters for patients with comorbid insomnia. A small to medium positive effect was found across comorbid outcomes, with larger effects on psychiatric conditions compared with medical conditions. Large-scale studies with more rigorous designs to reduce detection and performance bias are needed to improve the quality of the evidence.

Cognitive Behavioral Insomnia Therapy for Those With Insomnia and Depression: A Randomized Controlled Clinical Trial

“…However, a meta-analysis including studies of differing treatment duration found similarly large effects, such as observed in this trial, in those with comorbid insomnias. 63 Similarly, it is possible that the therapy was not potent enough because it was delivered by novices (i.e., graduate students). Although fidelity to the protocol was measured formally, there was no formal competence evaluation beyond the observation of the students and weekly supervision of these sleep-therapy naive novice therapists.…”

A Single Arm Pilot Trial of Brief Cognitive Behavioral Therapy for Insomnia in Adolescents with Physical and Psychiatric Comorbidities

“…Within the CBT-I trial literature, it is not uncommon for TST to show minimal or no improvement posttreatment. 6,11 Given the brevity of the intervention period (4 to 6 w) and the focus on sleep restriction, it is not entirely surprising that changes in TST were not observed. Indeed, actigraphic sleep assessment showed shorter TST from the pretreatment to posttreatment period, which is consistent with the goals of sleep restriction (i.e., to minimize time awake in bed).…”

“…4,5 There is a large evidence base supporting the efficacy of cognitive behavioral therapy for insomnia (CBT-I) among adults with a diverse range of comorbid physical and psychiatric conditions. 6 In contrast, CBT-I is still in early stages of development within child and adolescent populations.…”

Comorbid insomnia and sleep apnea: a prevalent but overlooked disorder

“…Similarly, many patients with insomnia have an inadequate response to pharmacologic therapy, as was present in the article by Rezaeitalab et al, and cognitive behavioral therapy for insomnia (CBTi). In a metaanalysis of CBTi in comorbid medical and psychiatric disorders, only 36% of patients were in remission after treatment [15]. Supporting the role that Boccult^sleep disordered breathing is present in many patients with refractory insomnia is an article by Krakow et al that reported 90% of nocturnal awakenings in patients with chronic insomnia only (no suspicion of OSA) were due to respiratory events [16].…”