Effectiveness of Cognitive Behavioral Therapy for Sleep Disorder: An overview of Systematic Review

Jang Won Lee; Jin Ju Yeo; Kyung Sik Kim; Min Kyung Hyun; Lee, Jang Won; Yeo, Jin Ju; Kim, Kyung Sik; Hyun, Min Kyung

doi:10.13048/jkm.22021

JKM > Volume 43(2); 2022 > Article

Lee, Yeo, Kim, and Hyun: Effectiveness of Cognitive Behavioral Therapy for Sleep Disorder: An overview of Systematic Review

Review Article

The Journal of Korean Medicine 2022; 43(2): 75-91.

Published online: June 1, 2022

DOI: https://doi.org/10.13048/jkm.22021

Effectiveness of Cognitive Behavioral Therapy for Sleep Disorder: An overview of Systematic Review

Jang Won Lee¹^{, 2}^{, †}

, Jin Ju Yeo²^{, †}

, Kyung Sik Kim³

, Min Kyung Hyun¹^{, *}

¹Department of Preventive Medicine, College of Korean Medicine, Dongguk University, Gyeongju, Republic of Korea

²Department of Preventive Medicine, Dongguk University Graduate School of Korean Medicine, Seoul, Republic of Korea

³College of Korean Medicine, Dongguk University, Gyeongju, Republic of Korea

Correspondence to: Min Kyung Hyun, Department of Preventive Medicine, College of Korean Medicine, Dongguk University, 123, Dongdae-ro, Gyeongju-si, Gyeongsanbuk-do, 38066, Republic of Korea, Tel:+82-54-770-2655, Fax:+82-54-770-2281, E-mail:mk3three@dongguk.ac.kr

† These authors contributed equally to this work.

Received January 21, 2022 Revised April 1, 2022 Accepted May 19, 2022

Abstract

Objectives

The purpose of this overview was to summarize the evidence regarding the effectiveness of Cognitive Behavioral Therapy (CBT) for sleep disorders through systematic reviews (SRs) and meta-analyses (MAs).

Methods

An overview of systematic review was conducted according to the study protocol (reviewregistry1320). A comprehensive literature search was performed using three databases (Pubmed, Cochrane Central Register of Controlled Trials, and Web of Science) and three Korean databases (KoreaMed, KMbase, and ScienceON). Final studies were selected by three authors according to inclusion and exclusion criteria, and data needed for analysis were extracted by a pre-planned extraction framework. Methodological quality of systematic review was assessed using the ‘Assessment of multiple systematic reviews 2 (AMSTAR2)’.

Results

Fourteen SRs and MAs were included, of which eleven SRs were performed MAs. Twelve studies studied insomnia among sleep disorders, and the rest are nightmares and sleep disturbances with PTSD. Ten studies reported the effect of CBT on sleep disorders measured by insomnia severity index (ISI) and sleep onset latency (SOL), and all reported a significant improvement effect. Eight studies reported the effect of CBT on sleep disorders measured by wake time after sleep onset (WASO), and seven studies reported a significant improvement effect. The methodological quality of the studies evaluated with AMSTAR 2 was mainly low or very low because of omission of protocol registration and excluded study list.

Conclusions

Practical guidelines and studies show that CBT is effective for sleep disorders, but access to CBT needs to be improved.

Keywords: Cognitive behavioral therapy, sleep disorders, overview, systematic review

Fig. 1

Study selection process

Fig. 2

Methodological and reporting quality: Evaluation results of each AMSTAR2 question of included studies

Table 1

Characteristics of the included systematic review

First author (year)	Country	Number of included studies (Total sample size)	Comorbid disease	Age (mean or range)	Gender	Comparator	Outcome measure
First author (year)	Country	Number of included studies (Total sample size)	Comorbid disease	Age (mean or range)	Gender	Comparator	ISI	PSQI	SOL	TST	WASO	NOA	SE
Insomnia
SR+MA
Cheng (2012)	China	4 RCTs (443)		39.6–56.7	M : 201 (45.40%) F : 242 (54.60%)	Waiting list Alternative treatment	P		P	N	N	P	P
Trauer (2015)	Australia	20 RCTs (1,162)		55.6	M : 418 (36.00%) F : 744 (64.00%)	Waiting list Placebo Hygiene Usual treatment			P	N	P		P
Zachariae (2016)	Denmark	11 RCTs (1,460)		NR	NR	Waiting list Treatment as usual Active control	P		P	P	P	P	P
Seyffert (2016)	United States	13 RCTs (2,392)		20–56	M : 696 (29.10%) F : 1,696 (70.90%)	Waiting list	P		P	P	P		P
Johnson (2016)	Canada	8 RCTs (752)	Cancer	NR	NR	Waiting list Treatment as usual Sleep education Placebo Mindfulness based stress reduction	P		P		P		P
Cheung (2019)	Canada	12 RCTs (1625)		37.5–77.2	M : 553 (34.00%) F :1,073 (66.00%)	Treatment as usual Primary care mental health General practice Education control Self-monitoring control	P						P
Feng (2020)	China	17 RCTs (1,756)	Depression	32.21–57.8	M : 673 (38.30%) F : 1,083 (61.70%)	Waiting list No treatment Pharmacological treatment	P	P
Zhou (2020)	China	13 RCTs (853)		30.8–59.8	M : 189 (22.10%) F : 664 (77.90%)	Behavioral desensitization Hygiene	P	P	P	N	P	N	P
Curtis (2021)	UK	5 RCTs (470)	Tinnitus	22–83	NR	Waiting list Weekly monitoring control group Online discussion forum	P
Tsai (2022)	Taiwan	4 RCTs (3,970)		15.3–24.8	M : 1,969(49.60%) F : 2,001 (50.40%)	Waiting list Sleep-hygiene	P	P
SR
Wang (2005)	Taiwan	7 RCTs (396)		36.7–64.7	M : 150 (37.90%) F : 246 (62.10%)	Placebo Waiting list Stimulus control Relaxation training Educational programme Pharmacological treatment			P	U	P		U
Mitchell (2012)	United States	5 RCTs (223)		25–64	NR	Pharmacological treatment			P	U	P		P
NightMare
SR
Lancee (2008)	Netherlands	12 RCTs (437)		NR	NR	Waiting list		N
Sleep disturbances treating symptom in PTSD
SR+MA
Ho (2016)	China	11 RCTs (593)		45.3	M : 382 (64.40%) F : 211 (35.60%)	Waiting list Treatment as usual Hygiene Placebo	P	P	P	N	P		P

PSIQ, Pittsburgh Sleep Quality; ISI, Insomnia Severity Index; SOL, Sleep Onset Latency; TST, Total sleep time; WASO, Wake time after sleep onset; NOA, Number of awakenings; SE, Sleep efficiency; SR, Systematic review; MA, meta-analysis; RCTs, Randomized Controlled Trials; M, Male; F, Female; P, Positive; N, Negative; U, Uncertain; NR, Not reported;

Table 2

Overall result of meta-analysis

First author (year)	Comparisons (Patients)	Statistical Model	Pooled effect	95% CI	Heterogeneity I2
Insomnia

Sleep onset latency

Chneg (2012)	CBT-I versus Control group	Fixed	−0.55	−0.80, −0.30	0%
Trauer (2015)	CBT-I versus Control group	Random	−19.03	−23.93, −14.12	41.9%
Seyffert (2016)	CBT versus Waiting list group	Random	−10.68	−16.00, −5.37	4.3%
Zachariae (2016)	CBT versus Control group	Random	0.41	0.29, 0.53	0%
Zhou (2020)	CBT versus Control group	Random	−0.36	−0.62, −0.10	51%

Number of awakenings

Chneg (2012)	CBT-I versus Control group	Fixed	−0.45	−0.70, −0.20	51%
Zachariae (2016)	CBT versus Control group	Random	0.21	0.05, 0.37	2.5%
Zhou (2020)	CBT versus Control group	Random	0.20	−0.16, 0.57	0%

Wake time after sleep onset

Chneg (2012)	CBT-I versus Control group	Fixed	−0.18	−0.43, 0.06	55%
Trauer (2015)	CBT-I versus Control group	Random	−26.00	−36.52, −15.48	7.2%
Seyffert (2016)	CBT versus Waiting list group	Random	−20.44	−34.87, −6.01	69.3%
Zachariae (2016)	CBT versus Control group	Random	0.45	0.25, 0.66	48.5%
Zhou (2020)	CBT versus Control group	Random	−0.21	−0.38, −0.04	34%

Total sleep time

Chneg (2012)	CBT-I versus Control group	Fixed	0.22	−0.03, 0.46	0%
Trauer (2015)	CBT-I versus Control group	Random	7.61	−0.51, 15.74	3.1%
Seyffert (2016)	CBT versus Waiting list group	Random	19.57	8.56, 30.58	24.7%
Zachariae (2016)	CBT versus Control group	Random	0.29	0.17, 0.42	5.4%
Zhou (2020)	CBT versus Control group	Random	−0.13	−0.30, 0.04	45%

Sleep efficiency

Chneg (2012)	CBT-I versus Control group	Fixed	0.40	0.15, 0.64	63%
Trauer (2015)	CBT-I versus Control group	Random	9.91	8.09, 11.73	47.1%
Johnson (2016)	CBT versus Control group	Random	0.53	0.38, 0.68	0%
Seyffert (2016)	CBT versus Waiting list group	Random	7.22	5.13. 9.32	39.5%
Zachariae (2016)	CBT versus Control group	Random	0.58	0.36, 0.81	68.4%
Cheung (2019)	CBT versus Control group	Fixed	0.38	0.25, 0.51	60%
Zhou (2020)	CBT versus Control group	Random	0.18	0.00, 0.36	36%

Insomnia Severity Index

Chneg (2012)	CBT-I versus Control group	Fixed	−0.86	−1.18. −0.53	0%
Seyffert (2016)	CBT versus Waiting list group	Random	−4.29	−7.12, −1.46	86.7%
Zachariae (2016)	CBT versus Control group	Random	1.09	0.74, 1.45	82.8%
Cheung (2019)	CBT versus Control group	Fixed	0.40	0.24, 0.55	81%
Feng (2020)	CBT versus no treatment group	Random	−4.47	−7.46, −1.48	86%
Zhou (2020)	CBT versus Control group	Random	−0.74	−0.92, −0.56	39%
Curtis (2021)	CBT versus Control group	Random	−3.28	−4.51. −2.05	0%

Pittsburgh sleep quality index

Feng (2020)	CBT versus no treatment group	Random	−2.57	−3.50, −1.65	64%
Zhou (2020)	CBT versus Control group	Random	−0.76	−1.09, −0.42	61%

Insomnia Severity Index and Pittsburgh sleep quality index

Tsai (2022)	CBT versus Control group	Random	−0.58	−1.03, −0.13	84%

Sleep disturbances

Sleep onset latency

Ho (2016)	CBT versus Waiting list or psychoeducation group	Random	−0.83	−1.19, −0.47	0%

Wake time after sleep onset

Ho (2016)	CBT versus Waiting list or psychoeducation group	Random	−1.02	−1.39. −0.66	0%

Total sleep time

Ho (2016)	CBT versus waiting list or psychoeducation group	Random	0.39	−0.05, 0.84	38%

Sleep efficiency

Ho (2016)	CBT versus waiting list or psychoeducation group	Random	1.15	0.75, 1.56	37%

Insomnia Severity Index

Ho (2016)	CBT versus waiting list or psychoeducation group	Random	−1.15	−1.81, −0.49	77%

Pittsburgh sleep quality index
Ho (2016)	CBT versus waiting list or psychoeducation group	Random	−0.87	−1.18, −0.56	33%

Table 3

Summary of the systematic reviews of the conclusion of the effects of CBT

First author (year)	Authors’ main conclusions
Insomnia
Cheng (2012)	CCBT is effective as a short-term self-treatment therapy for insomnia. CCBT-I may be an acceptable low-intensity treatment model for insomnia.
Trauer (2015)	As recommended by the guidelines for use as the first-line treatment for insomnia, CBT-I is a highly effective treatment for non-comorbid chronic insomnia.
Zachariae (2016)	Internet-delivered CBT-I showed a statistically significant and strong effect on improving the ISI. A study is needed to directly compare internet-delivered CBT-I, face to face CBT-I, and pharmacotherapy.
Seyffert (2016)	Internet-delivered CBT-I is effective in improving sleep in adults with insomnia. Efforts should be made to increase the acceptability and applicability of Internet-delivered CBT-I.
Johnson (2016)	CBT-I is effective in improving sleep outcomes in cancer survivors. Future studies should investigate the cost-effective delivery method and improvement in quality of life of CBT-I.
Cheung (2019)	While it demonstrates the validity and usefulness of providing a lower-tiered CBT-I program as the first-line treatment in a community settings, more standardized research is needed to reach a firm conclusion.
Feng (2020)	Although CBT-I seems to be effective and safe for insomnia comorbid with depression, it is unclear whether CBT-I can improve the depression.
Zhou (2020)	CBT-I is effective for patients with insomnia comorbid with medical or psychiatric, but the effect size of the treatment decreases with time.
Wang (2005)	CBT showed statistically significant improvement in patients with persistent primary insomnia. So, most nurses should be able to deliver CBT to primary insomnia patients.
Mitchell (2012)	CBT-I is an effective insomnia treatment with durable results in short visits.
Curtis (2021)	CBT-based interventions can significantly improve sleep in adults with tinnitus
Tsai (2022)	These preliminary findings from the meta-analysis suggest that dCBT-i is a moderately effective treatment in managing insomnia in younger age groups.
Nightmare
Lancee (2008)	Nightmare-focused CBT consisting of exposure and imagery rehearsal therapy is effective for nightmares, but further research is needed to determine which of exposure and imagery rehearsal therapy is superior.
Sleep disturbances treating symptom in PTSD
Ho (2016)	CBT is effective in treating PTSD symptoms as well as sleep disturbances, but further studies are needed due to the lack of related studies.

CBT-I, Cognitive behavioral therapy for insomnia; CCBT-I, Computerized cognitive behavioral therapy for insomnia;

Table 4

Assessment of multiple systematic review 2(AMSTAR2) result of the 12 included systematic review

Author (year)	AMSTAR 2																Overall methodological quality

	Q1	Q2	Q3	Q4	Q5	Q6	Q7	Q8	Q9	Q10	Q11	Q12	Q13	Q14	Q15	Q16
Wang (2005)	Y	N	Y	PY	Y	Y	N	Y	PY	N	No-MA	No-MA	N	N	No-MA	N	Critically low
Lancee (2008)	Y	N	Y	Y	Y	Y	N	Y	N	N	No-MA	No-MA	N	N	No-MA	Y	Critically low
Mitchell (2012)	Y	N	Y	Y	N	N	N	Y	N	N	No-MA	No-MA	Y	N	No-MA	Y	Critically low
Cheng (2012)	Y	N	N	Y	N	N	N	Y	N	Y	Y	N	N	N	N	Y	Critically low
Trauer (2015)	Y	PY	Y	Y	Y	Y	N	PY	Y	Y	Y	Y	Y	Y	Y	Y	Low
Ho (2016)	Y	N	Y	Y	Y	Y	Y	Y	Y	N	Y	Y	Y	N	Y	Y	Low
Zachariae (2016)	Y	Y	Y	Y	Y	Y	N	Y	Y	N	Y	Y	Y	Y	Y	Y	Low
Seyffert (2016)	Y	Y	Y	Y	Y	Y	N	PY	Y	N	Y	Y	Y	Y	Y	Y	Low
Johnson (2016)	Y	N	Y	Y	Y	Y	N	Y	Y	N	Y	Y	Y	Y	Y	Y	Critically low
Cheung (2019)	Y	PY	Y	Y	Y	Y	N	Y	Y	N	Y	Y	Y	Y	Y	Y	Low
Feng (2020)	Y	PY	Y	Y	Y	Y	N	Y	Y	N	Y	Y	Y	Y	Y	Y	Low
Zhou (2020)	Y	Y	Y	Y	Y	Y	N	Y	Y	N	Y	Y	Y	Y	Y	Y	Low
Curtis (2021)	Y	Y	Y	Y	Y	Y	N	Y	Y	Y	Y	Y	Y	Y	Y	Y	Low
Tsai (2022)	Y	Y	Y	Y	Y	Y	N	Y	Y	Y	Y	Y	Y	Y	Y	Y	Low

Q1 : Did the research questions and inclusion criteria for the review include the components of PICO?

Q2 : Did the report of the review contain an explicit statement that the review methods were established prior to the conduct of the review and did the report justify any significant deviations from the protocol?

Q3 : Did the review authors explain their selection of the study designs for inclusion in the review?

Q4 : Did the review authors use a comprehensive literature search strategy?

Q5 : Did the review authors perform study selection in duplicate?

Q6 : Did the review authors perform data extraction in duplicate?

Q7 : Did the review authors provide a list of excluded studies and justify the exclusions?

Q8 : Did the review authors describe the included studies in adequate detail?

Q9 : Did the review authors use a satisfactory technique for assessing the risk of bias (RoB) in individual studies that were included in the review?

Q10 : Did the review authors report on the sources of funding for the studies included in the review?

Q11 : If meta-analysis was performed did the review authors use appropriate methods for statistical combination of results?

Q12 : If meta-analysis was performed, did the review authors assess the potential impact of RoB in individual studies on the results of the meta-analysis or other evidence synthesis?

Q13 : Did the review authors account for RoB in individual studies when interpreting/discussing the results of the review?

Q14 : Did the review authors provide a satisfactory explanation for, and discussion of, any heterogeneity observed in the results of the review?

Q15 : If they performed quantitative synthesis did the review authors carry out an adequate investigation of publication bias (small study bias) and discuss its likely impact on the results of the review?

Q16 : Did the review authors report any potential sources of conflict of interest, including any funding they received for conducting the review?

Y : Yes

PY : Partial Yes

No-MA : No meta-anlysis conducted

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