#418 Enough Evidence to Put One to Sleep: Cognitive behavioural therapy for insomnia
CLINICAL QUESTION
How effective is Cognitive Behavioural Therapy for Insomnia (CBTi)?
BOTTOM LINE
About 45% of patients receiving CBTi achieve remission versus ~10% on control at 6 weeks, with effects sustained for at least 6 months. Remote CBTi (self-guided or group-based, synchronous or asynchronous) works, but it is not clear if it is as good as in-person, individual sessions. CBTi may be better than sleep medications but studies too small to find statistical differences.
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EVIDENCE
- Statistically significant unless stated.
- Focus on most recent/comprehensive systematic reviews of randomized controlled trials (RCTs) with patient-oriented outcomes [up to 36 RCTs, 1696 participants, ~6 weekly in-person individual sessions], control=waitlist, usual care, sleep hygiene education, or placebo.1,2
- At end of treatment (~6 weeks):
- Response1 ( 8 point improvement on 28-point insomnia scale): 53% versus 10% (control), number needed to treat (NNT)=3.
- Remission (based on scale scores):1 45% versus 9%, NNT=3.
- Other systematic review similar.2
- Sleep indices:2
- Time to fall asleep: 15 minutes faster [example: ~23 versus 38 minutes (control)].
- Total sleep time: 10 minutes more [328 versus 318 minutes (control)].
- Time asleep while in bed: 8% more [88% versus 80% (control)].
- Number awakenings: 0.3/night fewer [0.8 versus 1.1 (control)].
- At 6 months:1 Remission 42% versus 13% (control), NNT=4.
- Remote delivery (self-guided or group-based, synchronous or asynchronous via telephone/book/internet):
- Remote better than control1-7
- Example:1 Remission (6 weeks): 28% versus 9% (control)].
- Remote versus in-person: Inconsistent.1,2
- Example: Remission (end of treatment): 45% (individual/in-person) versus 28% (internet) in one review;1 no difference in another.2
- Remote better than control1-7
- CBTi versus sleep medications: 4 RCTs, no meta-analysis:
- CBTi numerically better but statistical differences inconsistent (possibly underpowered).8-10 Examples:
- Proportion with >85% time asleep in bed (6 months): 78% CBTi versus 40% zolpidem.8
- Proportion who fell asleep within 30 minutes during treatment: 50% CBTi versus 36% zolpidem, not statistically different.9
- CBTi plus medications versus CBTi: Inconsistent, often underpowered.9-11
- CBTi numerically better but statistical differences inconsistent (possibly underpowered).8-10 Examples:
CONTEXT
- CBTi has 4 main components: Sleep restriction therapy, stimulus control, sleep hygiene education, and cognitive therapy.
- Sleep restriction therapy alone is effective; sleep hygiene education alone is not.2,12
- Patient and clinician resources available.13
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