#418 Enough Evidence to Put One to Sleep: Cognitive behavioural therapy for insomnia

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#418 Enough Evidence to Put One to Sleep: Cognitive behavioural therapy for insomnia

CLINICAL QUESTION

QUESTION CLINIQUE

How effective is Cognitive Behavioural Therapy for Insomnia (CBTi)?

BOTTOM LINE

RÉSULTAT FINAL

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

DONNÉES PROBANTES

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 control^1-7
  - 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
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

CONTEXT
CONTEXTE

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