Summary of the best evidence that cognitive behavioral therapy for insomnia improves sleep quality in patients with chronic insomnia

Summary of the best evidence that cognitive behavioral therapy for insomnia improves sleep quality in patients with chronic insomnia | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 6 February 2025 V1 Latest version Share on Summary of the best evidence that cognitive behavioral therapy for insomnia improves sleep quality in patients with chronic insomnia Authors : Panpan Yan 0009-0008-2541-3131 , Siyu Feng , Miaomiao Ma , and Bo Li [email protected] Authors Info & Affiliations https://doi.org/10.22541/au.173884516.65174468/v1 Published Frontiers in Psychiatry Version of record Peer review timeline 352 views 142 downloads Contents Abstract 3.1 Search results 5 LIMITATIONS 6 CONCLUSION References Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Aim To evaluate and summarize the evidence that cognitive behavioral therapy for insomnia improves sleep quality in patients with chronic insomnia and provide reference for clinical practice. Design The PIPOST model from the Center for Evidence-Based Nursing at Fudan University was used to retrieve evidence and integrate it through structured evidence-based questions. Methods Current literatures were systematically searched for the best evidence that cognitive behavioral therapy for insomnia improves sleep quality in patients with chronic insomniaLiterature types included clinical guidelines,best practice information sheets, expert consensuses, systematic reviews, evidence summaries and cohort studies. Data Sources UpToDate,BMJ Best Practice,Joanna Briggs Institute,Guidelines International Network,National Institute for Health and Care Excellence,Registered Nurses Association of Ontario,Scottish Intercollegiate Guidelines Network,the Cochrane Library, Embase,PubMed, Sinomed,Web of Science,DynaMed,MEDLINE, CNKI, WanFang database, Chinese Medical Journal Full-text Database,The search period was from build to December 10, 2024 Results A total of 28 papers were included,including 5 guidelines,3 expert consensus papers,12 systematic evaluations, and 8 Meta-analyses, and the overall quality of the included papers was high.Forty-one pieces of best evidence were summarized in terms of diagnostic criteria for sleep disorders,assessment conditions, timing of initiation of multicomponent cognitive behavioral therapy for sleep (CBT-I), treatment format,composition of components,assessment metrics,assessment tools, symptom improvement metrics, comparisons of implementers, and adverse effects. Conclusion The study summarizes the best evidence that CBT-I improves sleep quality in patients with chronic insomnia and recommends that clinical staff should fully assess the patient’s overall condition before implementing the therapy and develop a personalized CBT-I treatment plan for the patient based on their assessment. Summary of the best evidence that cognitive behavioral therapy for insomnia improves sleep quality in patients with chronic insomnia Aim To evaluate and summarize the evidence that cognitive behavioral therapy for insomnia improves sleep quality in patients with chronic insomnia and provide reference for clinical practice. Design jabbrv-ltwa-all.ldf jabbrv-ltwa-en.ldf The PIPOST model from the Center for Evidence-Based Nursing at Fudan University was used to retrieve evidence and integrate it through structured evidence-based questions. Methods Current literatures were systematically searched for the best evidence that cognitive behavioral therapy for insomnia improves sleep quality in patients with chronic insomniaLiterature types included clinical guidelines,best practice information sheets, expert consensuses, systematic reviews, evidence summaries and cohort studies. Data Sources UpToDate,BMJ Best Practice,Joanna Briggs Institute,Guidelines International Network,National Institute for Health and Care Excellence,Registered Nurses Association of Ontario,Scottish Intercollegiate Guidelines Network,the Cochrane Library, Embase,PubMed, Sinomed,Web of Science,DynaMed,MEDLINE, CNKI, WanFang database, Chinese Medical Journal Full-text Database,The search period was from build to December 10, 2024 Results A total of 28 papers were included,including 5 guidelines,3 expert consensus papers,12 systematic evaluations, and 8 Meta-analyses, and the overall quality of the included papers was high.Forty-one pieces of best evidence were summarized in terms of diagnostic criteria for sleep disorders,assessment conditions, timing of initiation of multicomponent cognitive behavioral therapy for sleep (CBT-I), treatment format,composition of components,assessment metrics,assessment tools, symptom improvement metrics, comparisons of implementers, and adverse effects. Conclusion The study summarizes the best evidence that CBT-I improves sleep quality in patients with chronic insomnia and recommends that clinical staff should fully assess the patient’s overall condition before implementing the therapy and develop a personalized CBT-I treatment plan for the patient based on their assessment. 1 INTRODUCTION Chronic insomnia,also known as ”chronic insomnia disorder” (Regier DAet al. ,2013).The most recent diagnostic criteria for chronic insomnia disorder is the inability to initiate or maintain sleep for at least 3 months (occurring at least 3 times per week) despite the opportunity to sleep,with impaired daytime functioning(Cartwright R et al.,2014).Insomnia is a type of sleep disorder that contributes to the progression of diseases such as coronary heart disease,type 2 diabetes mellitus,and obesity through a variety of mechanisms such as inflammation, endothelial dysfunction,autonomic dysfunction,and metabolic abnormalities,which can have a serious impact on the quality of people’s lives (Sarode R et al.,2023;Sánchez-de-la-Torre M et al.,2022).The goal of treatment for insomnia is to improve sleep and reduce the distress or dysfunction caused by the disorder,and insomnia can be controlled by psychotherapy,medication,or a combination of both.Medications,although initially effective for sleep,have been shown to be habitual(Colten HR et al.,2006), usually requiring higher doses to maintain sleep,and are associated with other adverse effects such as falls, delirium,somnolence,headache,and upright hypotension(Haines A et al.,2021).Therefore,there is an urgent need to seek non-pharmacologic interventions to improve sleep quality.The American Academy of Sleep Medicine(AASM)considered the benefits and harms of overuse of medications,compared the cost of using both,and ultimately recommended Cognitive Behavioral Therapy for Insomnia(CBT-I)as a first-line treatment measure(Qaseem A et al.,2016). Cognitive behavioral therapy for insomnia(CBT-I)is a multimodal cognitive behavioral therapy specifically for insomnia,which includes a combination of cognitive therapy,behavioral interventions(e.g.,sleep restriction and stimulus control),and educational interventions(e.g.,sleep hygiene)(Machado FS et al.,2017;Morin CM et al.,2012).Currently,domestic and international sleep medicine experts have published several treatment guidelines on cognitive behavioral therapy for insomnia(CBT-I)for the treatment of sleep disorders,but the evidence is scattered and divergent.At this stage,clinical medical personnel have insufficient knowledge about the treatment of chronic insomnia,and still rely on sleeping medication to treat insomnia,with few systematic evidence-based management programs for medical personnel to learn from and be guided by (Albanese B et al.,2021).In this study,we systematically searched the domestic and international literature on CBT-I to improve sleep quality,and used evidence-based nursing to evaluate and summarize the evidence to provide an evidence-based basis for clinical medical personnel when implementing this therapy. 2 METHODS 2.1Problem establishment The PIPOST model(Zhuzheng et al.,2017)from the Center for Evidence-Based Nursing at Fudan University was used to retrieve evidence and integrate it through structured evidence-based questions.(1)P-population,i.e.,the target population for the application of evidence is:chronic insomnia population;(2) I-intervention,i.e.,the intervention is:cognitive behavioral therapy for insomnia (CBT-I);(3)P-professional,i.e.,clinicaldoctors,nurses,psychotherapists,and clinical health care workers;(4)O-outcome,i.e.,sleep onset latency(SOL),wake after sleep onset(WASO),total sleep time(TST),sleep efficiency(SE),sleep quality, and insomnia severity index (ISI);(5) S-setting,i.e., the place where the evidence was applied was the medical and surgical ward;(6) S-setting,i.e., the place where the evidence was applied was the medical and surgical ward.i.e.,the place of evidence application was medical-surgical wards,psychotherapy rooms, community or family;(6)T-type of evidence i.e.,the type of evidence resources were guidelines,expert consensus,systematic evaluation and Meta-analysis. 2.2 Evidence retrieval strategy jabbrv-ltwa-all.ldf jabbrv-ltwa-en.ldf Based on the ”6S” evidence resource pyramid model, we searched the Chinese and English guideline websites and related association websites from top to bottom using the search terms ”Sleep/Sleep Wake Disorders/Sleep disturbances/Sleep Wake/Cognitive-behavioral therapy/Behavioral Therapies/Cognitive/Behavioral Therapy”.therapy/Behavioral Therapies/Cognitive/Behavioral Therapy” as the search terms, searched the websites of Chinese and English guideline websites and related associations, and searched the National Guideline Database (NGD) of the United States of America (U.S.A.) from top to bottom.Clearinghouse (NGC), National Institute for Health and Care Excellence (NICE), Up To Date computerized decision support system, BMJ Best Clinical Practice, International Guidelines Collaboration Network, Joanna Briggs Institute (Australia), and the National Institute for Health and Care Excellence (UK).Joanna Briggs Institute (JBI) Evidence-Based Health Care Centers database, Australian Clinical Practice Guidelines(ACPG)Clinicalkey for Nursing, Canadian Clinical Practice Guidelines Database(CCPG)Canadian Medical Association Clinical Practice Guidelines Infobase,New Zealand Guidelines Group (NZGG),Scottish Intercollegiate Guidelines (SIG),and the New Zealand Guidelines Collaborative Group(NZGG).Scottish Intercollegiate Guidelines Network(SIGN),the Cochrane Library,the American College of Physicians (ACP),the European Sleep Research Society (ESRS),the Canadian Medical Association Clinical Practice Guidelines Infobase,the New Zealand Guidelines Group (NZGG),the European Society for Sleep Research (ESRS),and the European Society for the Study of Sleep.Cochrane Library, American College of Physicians (ACP), European Sleep Research Society(ESRS),American Academy of Sleep Medicine(AASM), Brazilian Sleep Society, Brazilian Society of Sleep Medicine (BSSM), Journal of the Chinese Medical Association (JCMA), and Medical Pulse website. Behavioral Therapies/Cognitive Behavioral Therapy/Cognitive Psychotherapy/Cognitive Psychotherapies/Cognitive Therapy/Cognitive TherapiesBehavioral Therapies/Cognitive Behavioral Therapy/Cognitive Psychotherapy/Cognitive Psychotherapies/Cognitive Therapy/Cognitive Therapies/Cognitive/Sleep hygiene education/Sleep restrictions/Stimulus control/Relaxation training” ”guideline/summary ofevidence/Meta analysis/systemaic review/consensus/” as the English search terms to ”sleep/Sleep disorders/Insomnia/Sleep disorders/Sleep interventions/Non-pharmacological interventions/Psychotherapies/Cognitive therapy/Cognitive behavioral therapy/Sleep hygieneEducation/stimulus control/sleep restriction/evidence summary/guidelines/expert consensus/systematic evaluation/meta-analysis” as the Chinese search terms, and ”sleep/sleep disorder/insomnia/sleep disorders/sleep intervention/non-pharmacological intervention/psychotherapy/cognitive therapy/cognitive behavioral therapy/sleep hygiene” as the English search terms.database, China Biomedical Literature Service (CBLS).The time limit for the search was from the establishment of the database to April 10, 2024, and the Chinese search was conducted on China Knowledge Network.The Chinese search formula is based on the China Knowledge Network (CNN), for example: (Topic = patients with sleep disorders + patients with insomnia) AND (Topic = sleep + sleep time + sleep duration + sleep disruption + sleep deprivation + sleep disorders + sleep efficiency) AND (Topic = sleep hygiene education + stimulus control + relaxation therapy + psychotherapy + sleep restriction + cognitive therapy +) AND (Topic = psychosocial interventions + non-pharmacological interventions) AND (Topic = psychological interventions + non-pharmacological interventions) AND (Topic = guideline + expert consensus + non-pharmacological interventions)(Topic=Guidelines+Expert Consensus+Systematic Evaluation+Summary of Evidence+Meta-Analysis) English databases were used as an example in Pub Med, and the search strategy is shown in Figure 1. #1 “Sleep Wake Disorder”[MeSH] #2“SleepWake”[Title/Abstract]OR“SubwakefullnessSyndrome”[Title/Abstract]OR “SleepDisorders”[Title/Abstract]OR“Sleep-RelatedNeurogenicTachypnea”[Title/Abstract]OR “LongSleeperSyndrome”[Title/Abstract]OR“ShortSleeperSyndrome”[Title/Abstract]OR “Short Sleep Phenotype”[Title/Abstract] #3 #1 OR #2 #4“Behavioral Therapies Cognitive”[MeSH] #5“Cognitive Behavioral Therapies”[Title/Abstract]OR“Behavioral Therapies ”[Title/Abstract]OR“Cognitive Psychotherapy”[Title/Abstract]OR“Cognition Therapy ”[Title/Abstract] #6 #4 OR #5 #7 “guideline”[Title/Abstract]OR“summary of evidence”[Title/Abstract]OR “Meta analysis”[Title/Abstract]OR“systemaic review”[Title/Abstract]OR“consensus”[Title/Abstract] #8 #3 AND #6 AND #7 Figure1 Pub Med retrieval strategy 2.3 Inclusion and exclusion criteria of evidences jabbrv-ltwa-all.ldf jabbrv-ltwa-en.ldf Inclusion criteria for this study were(1)The study population was all adults with sleep disorders;(2)The study was about the components of multicomponent cognitive-behavioral therapy (CBT-I),the differences between different forms of administration,indicators for assessing sleep outcomes,and tools for assessing sleep outcomes;(3)The types of literature were guidelines,expert consensus, systematic evaluations,evidence summaries,and Meta-analyses;and(4)The language of publication was limited to Chinese and English. Exclusion criteria were(1)Translated versions of guidelines,old guideline versions that have been updated,and interpreted versions of guidelines;(2)Duplicate published literature.(3)Incomplete information or inaccessible full text of the literature. 2.4Literature screening and data extraction jabbrv-ltwa-all.ldf jabbrv-ltwa-en.ldf The included literature was read article by article by two master’s degree nursing students trained in evidence-based nursing systems and evidence was extracted article by article,and in case of disagreement,a third researcher checked and verified.The JBI Evidence-Based Center evidence pre-grading system was used to grade the included evidence(Wang chunqing et al.,2015).,and the inclusion of evidence was based on the principles of high-quality evidence first,latest published literature first,and prestigious journals first. 2.5Evidence quality evaluation criteria The latest literature quality evaluation tools were selected according to different types of literature:(1)for guideline evaluation,the appraisal of guidelines for research and evaluation II(AGREE II)was used,which includes 23 entries,6 quality assessment domains,and 2 overall assessment entries.overall evaluation entries.Each entry of AGREE II and the two overall evaluation entries were graded on a 7-point scale(1 for strongly disagree and 7 for strongly agree) (Barraud D et al.,2013);(2)expert consensus was evaluated for quality using the JBI Centre for Evidence-Based Health Care Expert Consensus Evaluation Tool in Australia,which contained a total of 6 items and was graded by“yes”,“no”, “unclear”and“not applicable”.The 2014 edition of the JBI Evidence-Based Practice Center Standards was used for systematic evaluation(Aromataris E et al.,2015);(3)systematic evaluation and Meta-analysis were performed using the JBI Centre for Evidence-BasedCenter for Evidence-Based Health Care systematic evaluation tool for quality evaluation,The assessment tool contains 11 items,each of which is judged according to“yes,” “no,” “unclear,”and“not applicable”judgment (Aromataris E et al.,2015). 3 RESULTS 3.1 Search results The initial literature search yielded 344 articles,and after reading the full text content and screening,28 articles were finally included,and the process of literature screening is shown in Fig 2. 5 of them were guidelines (Qaseem A et al.,2016;Riemann D et al.,2023;Schutte-Rodin S et al.,2008;Drager, L. F et al.,2023;China Sleep Research Society，CSRS,2019), 3 expert consensus(Takaesu, Y et al.,2023;Douglas JA et al.,2017;Palagini, L et al.,2020),12 systematic evaluations(Chung KF et al.,2018;Jun J,et al.,2021;Tamrat R et al.,2014;Seyffert M et al.,2016;Yu H, Zhanget al.,2021;Zachariae Ret al.,2016;Zheng X,et al.,2023;González-Martín AM et al.,2023;Simon L, Steinmetz Let al.,2023;Gao Yet al.,2022;Wang MY et al.,2005;Trauer JM et al.,2015), and 8 Meta-analyses(Ho FY et al.,2015;Forma F et al.,2022;Ye YY et al.,2016;Soh HL et al.,2020;Geiger-Brown JM et al.,2015;van der Zweerde T et al.,2019;van Straten A.,2018;Koffel EA et al.,2015).The basic information of literature inclusion is shown in Table 1. 3.2 Quality evaluation results of the included literature 3.2.1Literature quality assessment and results of the guidelines A total of five guidelines were included (Qaseem A et al.,2016;Riemann D et al.,2023;Schutte-Rodin S et al.,2008;Drager, L. F et al.,2023;China Sleep Research Society，CSRS,2019), and the results of the scores for each domain of the guidelines are shown in Table 2 Scope and purpose Stakeholder involvement Rigour of development Clarity of presentation Applicability Editorial independence Qaseem A et al(2016) 89.86% 77.78% 78.67% 98.96% 75.68% 69.76% 6 6 A Riemann Det al(2023) 69.73% 72.67% 85.65% 95.68% 68.62% 73.63% 6 6 A Schutte-Rodin, S et al(2008) 87.62% 56.73% 75.65% 86.65% 78.86% 75.68% 5 6 A Drager, L et al(2023) 76.32% 76.63% 75.65% 87.72% 65.42% 78.63% 6 6 A Chinese Medical Association (2019) 56.52% 62.43% 53.26% 63.52% 43.25% 43.25% 2 6 B Table 2 Quality evaluation of the guidelines（n=5） Takaesu, Y et al.(2023) Yes Yes Yes Yes Yes Yes Douglas JAet al.(2017) Yes Yes Yes Yes Unclear Yes Palagini Let al.(2020) Yes Yes Yes Yes Yes Yes Table 3 Quality evaluation of included expert consensuses（n=3） Chung KF et al.(2018) Yes Yes Yes Yes Unclear Yes Yes Yes Yes Yes Yes Jun J et al.(2021) Yes Yes Yes Yes Yes Yes Yes Yes Unclear Yes Yes Tamrat R et al.(2014) Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Seyffert M et al.(2016) Yes Yes Yes Yes Unclear Yes Yes Yes Yes Yes Yes Yu H et al.(2021) Yes Yes Yes Yes Unclear Yes Yes Yes Yes Yes Yes Zachariae R et al.(2016) Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Zheng X et al.(2023) Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes González-Martín AM et al.(2023) Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Simon L et al.(2023) Yes Yes Yes Yes Unclear Yes Yes Yes Yes Yes Yes Gao Y et al.(2022) Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Wang MY et al.(2005) Yes Yes Yes Yes Unclear Yes Yes Yes Yes Yes Yes Trauer JM et al.(2015) Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Ho FY et al.(2015) Yes Yes Yes Yes Yes Yes Yes Unclear Yes Yes Yes Forma F et al.(2022) Yes Unclear Yes Yes Yes Yes Unclear Yes Yes Yes Yes Ye YY et al.(2016) Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Soh HL et al.(2020) Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Geiger-Brown JM et al.(2015) Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes van der Zweerde T et al.(2019) Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes van Straten A et al.(2018) Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Koffel EA et al.(2015) Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Table4 Quality evaluation of included systematic reviews（n=20） Diagnostic criteria 1. Sleep latency of more than 30 minutes, remaining awake for more than 30 minutes after falling asleep, sleep efficiency of less than 85%, or total sleep time of less than 6-6.5 hours, with complaints of at least 3 nights per week for at least 3 months(Wang MY et al.,2005;Forma F et al.,2022;Ye YY et al.,2016) a 1 Conditions of assessment 2. The assessment of insomnia involves evaluating the type, frequency and duration of nighttime sleep, as well as the sleep environment.In addition, the patient’s daytime lifestyle, such as type of work, social activities, diet and exercise, needs to be assessed in order to rule out its interfering factors contributing to insomnia(Wang MY et al.,2005;Steinmetz L et al.,2023;Gao Y et al.,2022) c 1 3. Treat patients with CBT-I based not only on recommended suggestions, but also on clinical experience, previous patient responses, and patient preferences and potential adverse effects(Chung KF, et al.,2018;Yu H et al.,2021;Forma F et al.,2022) a 1 4. It is recommended that the health risks of insomnia and the availability of psycho-behavioral treatments be made available to general practitioners(Chung KF, et al.,2018) a 1 5. Residents should develop standardized inpatient sleep protocols for hospitalized patients to minimize sleep disruption, such as not performing vital sign monitoring, medications, and other therapeutic measures during sleep time if not necessary(Tamrat R et al.,2014) c 1 Therapeutic target 6. The goal of treatment for insomnia is to improve sleep and reduce the pain or dysfunction caused by the disorder.(Ree M,et al.,2017; Cartwright R et al.,2014 ) a 1 Timing of activation 7. After a thorough evaluation of the patient, patients diagnosed with insomnia can start CBT-I treatment while treating their underlying disease.(Chung KF, et al.,2018;Tamrat R et al.,2014) c 1 Forms of treatment 8. Including face-to-face individual therapy, face-to-face group therapy, telephone-based follow-up therapy, web-based modular therapy, and self-help book therapy. 9. of which face-to-face individual therapy is the most recommended, and Internet-assisted CBT-I should be considered as the first choice when face-to-face CBT-I is limited by factors such as time, location, and cost of treatment(Ho FY et al.,2015). 10. Compared with Internet-delivered CBT-I, face-to-face CBT-I was more effective in decreasing SOL and WASO severity, but there was no significant difference in post-treatment efficacy between these two modalities when compared with face-to-face CBT-IThere is no significant difference in efficacy after treatment between these two modalities, and Internet-assisted CBT-I is less costly(Seyffert M et al.,2016;Yu H et al.,2021;Zachariae R et al.,2016;Zheng X et al.,2023;Simon L et al.,2023;Gao Y et al.,2022;Forma F et al.,2022;Ye YY et al.,2016;Soh H et al.,2020;Koffel EA et al.,2015)。 11. Individual CBT-I may be most effective in improving insomnia severity, and the CBT-I group may be most effective in improving WASO.Digitally assisted CBT-I may be most effective in improving sleep efficiency, SOL, and TST (Ho FY et al.,2015;Forma F et al.,2022) 12. guided self-help and non-guided self-help CBT-I are less acceptable than individual and group CBT-I. c 1 13. Self-help treatment is effective but not for everyone(González-Martín AM et al.,2023;Ho FY et al.,2015) a 5 14. If cognitive-behavioral therapy for insomnia (CBT-I) alone is unsuccessful, additional pharmacotherapy is recommended for patients with chronic insomnia disorders, with only short-acting benzodiazepines recommended, and extended-release melatonin is more recommended for older adults.Patients with insomnia that does not resolve within 7-10 days of combination therapy should be further evaluated( Takaesu, Y et al.,2023 ) a 5 15. There is no evidence that CBT-I combined with medication is superior to CBT-I alone in the treatment of( Schutte-Rodin S et al.,2008; Chung KF et al.,2018;Yu H et al.,2021) a 5 Components of CBT-I Sleep hygiene education（SH） 16. Sleep hygiene education is recommended as first-line treatment when benzodiazepine hypnotics are discontinued.(Regier DA et al.,2013)However, the single use of sleep hygiene education to improve insomnia symptoms is not recommended.( Schutte-Rodin S et al.,2008; Chung KF et al.,2018;Yu H et al.,2021) 17. It is recommended that those who use benzodiazepines for long-term treatment of insomnia disorders should taper off the medication when it is discontinued and try to use sleep hygiene education early on to alleviate adverse symptoms. a 5 18. Poor sleep hygiene is a prerequisite for the use of sleep hygiene education, which can be considered the first step in the treatment of insomnia when CBT-I is not available for various reasons.(Chung KF et al.,2018) a 1 stimulus control（SC） 19. Low-quality evidence suggests that stimulus control improves sleep latency and total sleep time in the general population.and has been shown to be superior to other treatment modalities such as progressive relaxation, imagery training and paradoxical intentions, but it is not recommended for use in older people.( Drager, L. F et al.,2023 ) a 5 cognitive therapy（CT） 20. CT is superior to any single-component component treatment and helps to break the vicious cycle of sleep disorders and reduce the risk of self-medication.Limited evidence suggests that positive thinking can be introduced to correct poor short- and long-term sleep quality.(Chung KF et al.,2018;González-Martín AM et al.,2023;van der Zweerde T et al.,2019;van Straten A et al.,2018) a 1 sleep restriction（SRT） 21. Some potential adverse effects, such as fatigue, excessive daytime sleepiness, and difficulty concentrating, may occur early in treatment.Therefore, it is not recommended for the following groups: people in high-risk occupations (drivers, heavy machinery operators), people with excessive daytime sleepiness, and studies have shown that restricting the duration of sleep can increase the risk of falls in elderly patients.( Drager, L. F et al.,2023; Chung KF et al.,2018;Seyffert M et al.,2016;Yu H, Zhang et al.,2021 ) a 1 relaxation training（RE） 22. Relaxation training has been used to reduce anxiety, pain, blood pressure, and heart rate, among other things, and its application is recommended to improve the quality of sleep in patients, but as a stand-alone treatment relaxation training is not as good as the other components of the practice.(Tamrat R et al.,2014) c 1 23. Relaxation training requires more training sessions and longer intervals than sleep restriction.(Tamrat R et al.,2014) c 1 24. Phototherapy and exercise interventions can be used as adjunctive therapies to CBT-I.(González-Martín AM et al.,2023) a 1 treatment cycle 25. An average of 8 weeks with 4 to 8 sessions per week, i.e., 4 to 8 individual or group sessions per week or every two weeks, lasting an average of 60 to 90 minutes.The lower the frequency and duration of the intervention, the fewer techniques it contains.(González-Martín AM et al.,2023;Geiger-Brown JM et al.,2015;van Straten A et al.,2018) c 1 26. It is recommended that when CBT-I is performed face-to-face, a minimum of 4 sessions is the optimal therapeutic dose, and 5 or more sessions are more effective.(Geiger-Brown JM et al.,2015;van Straten A et al.,2018) a 1 27. The therapeutic effect of CBT-I is stable, but intensified sessions are required over time to restore the initial therapeutic effect.(González-Martín AM et al.,2023;van Straten A et al.,2018) c 1 28. Due to the high recurrence rate of insomnia, sleep indicators should be reassessed every 6 months after the end of treatment to adjust the treatment program in a timely manner.(van der Zweerde T et al.,2019) c 1 29. Increasing the number of follow-up telephone counseling visits improves treatment adherence for CBT-I.(Wang MY et al.,2015) a 1 adverse reaction 30. Due to the non-invasive nature of CBT-I, no or very mild adverse effects have been reported.Therefore CBT-I provides better overall value than drug therapy.( Takaesu, Y et al.,2023; Douglas JA et al.,2017;Palagini, L et al.,2020;Chung KF et al.,2018;Jun J et al.,2021;Tamrat R et al.,2014) a 5 Indicators for assessing sleep outcomes 31. Primary outcome indicators: sleep onset latency (SOL), wake after sleep onset (WASO). Secondary outcome indicators: total sleep time (TST), sleep efficiency (SE), sleep quality, insomnia severity index (ISI).(Palagini, L et al.,2020;Chung KF et al.,2018;Jun J et al.,2021) a 5 Sleep Outcome Assessment Tool 32. Questionnaires (Epworth Sleepiness Scale), Pittsburgh Sleepiness Quotient Inventory (PSQI), Insomnia Severity Inventory (ISI), Epworth Sleepiness Scale (ESS), and Activity Recorder are recommended for assessing outcomes and guiding insomnia.( Drager, L. F et al.,2023; Douglas JA et al.,2017;Trauer JM et al.,2015) a 5 33. It is recommended to begin treatment by using a sleep diary to record insomnia symptoms for at least one to two weeks to monitor the dynamics of insomnia, and to complete the sleep diary for an additional one to two weeks post-treatment and at follow-up visits.(Trauer JM et al.,2015)) a 1 34. Polysomnography (PSG) is not recommended for routine use in the evaluation of insomnia, but may be used to rule out other subtypes of sleep disorders (lifelong insomnia, sleep state delusions, insomnia due to poor sleep habits) or when there is no response to medication.(Jun J et al.,2021) c 2 35. activity loggers are not recommended as a diagnostic tool for insomnia, they must be used in conjunction with other clinical information and patient history, and they are less sensitive to changes in insomnia following CBT-I than subjective measures such as sleep diaries.( Drager, L. F et al.,2023) a 5 36. If circadian rhythm disruption is suspected, wearing an activity recorder is recommended to assess sleep duration.(Gao Y et al.,2022) c 1 37. The Insomnia Severity Inventory (ISI) scores range from 0-28, with 8-4 indicating subclinical insomnia, 15-21 indicating moderate insomnia, and 22-28 indicating severe insomnia.When assessing insomnia disorders in community settings, a change score of 8.4 is recommended as a marker of moderate improvement(Douglas JA et al.,2017;Trauer JM et al.,2015) c 1 38. Sleep efficiency (SE) <80% is the cutoff value that distinguishes insomniacs from good sleepers( Drager, L. F et al.,2023;Schutte-Rodin S et al.,2008;Chinese Medical Association et al.,2017) a 1 Symptom improvement indicators 39. (1) Reduction of the main target symptom (sleep latency or time awake after sleep onset) by more than 50% . (2) Proportion of patients whose sleep efficiency changes from dysfunctional to normal levels ( >80%-85%). (3) Decrease in hypnotic drug use(Yu H et al.,2021;Zachariae R et al.,2016;Zheng X et al.,2023;González-Martín AM et al.,2023) a 1 Selection of CBT-I Implementers 40. There is still a shortage of trained therapists, and evidence suggests that treatment delivered by professionals (e.g., psychologists) has better outcome indicators than trainees.However, the therapeutic effects of treatment delivered by trainees are very similar and equally effective as those achieved by trained mental health professionals.(Wang MY et al.,2005;Geiger-Brown JM et al.,2015;Seyffert M et al.,2016) c 1 41. General psychotherapy is usually unable to alleviate insomnia, so clinicians should receive specialized training in CBT-I theory and implementation, which may include attending specialized CBT-I seminars, online CBT-I courses.(Palagini, L et al.,2020) a 1 Table5 Summary of the best evidence for cognitive behavioural therapy for insomnia to improve sleep quality in people with chronic insomnia 3.2.2Expert consensus quality assessment and results A total of three expert consensus papers were included(Takaesu, Y et al.,2023;Douglas JA et al.,2017;Palagini, L et al.,2020),of which Douglas JA et al.’s (Douglas JA et al,2017)study, with the exception of entry 5, ”Whether other existing literature was referenced”,which was ”unclear”,the rest of the entries were.”Yes”.The overall quality of the three literatures was high, and all of them were included.The results of their quality evaluation are shown in Table 3. 3.2.3Systematic evaluation, Meta-analysis quality evaluation and results A total of 12 systematic evaluations were included (Chung KF et al.,2018;Jun J,et al.,2021;Tamrat R et al.,2014;Seyffert M et al.,2016;Yu H, Zhanget al.,2021;Zachariae Ret al.,2016;Zheng X,et al.,2023;González-Martín AM et al.,2023;Simon L, Steinmetz Let al.,2023;Gao Yet al.,2022;Wang MY et al.,2005;Trauer JM et al.,2015), of which (Chung KF et al.,2018;Seyffert M et al.,2016;Yu H et al.2021, Simon L et al.,2023)all entries were ”yes”, except for ”Whether the quality criteria used were appropriate”.”In the study by Jun J(Jun J,et al.,2021),all entries were ”yes”,except”unclear”for”whether possible publication bias was assessed”.A total of eight Meta-analyses were included(Ho FY et al.,2015;Forma F et al.,2022;Ye YY et al.,2016;Soh HL et al.,2020;Geiger-Brown JM et al.,2015;van der Zweerde T et al.,2019;van Straten A.,2018;Koffel EA et al.,2015). of which the entries in the study by Ho FY(Ho FY et al.,2015)were all ”yes”except for”Whether the methodology of the integrated/combined studies was accurate”which was ”unclear”.In the study by Forma F(Forma F et al.,2022),all the entries were”Yes”except”Whether the inclusion criteria of the literature were appropriate”and”Whether certain measures were used to minimize errors when extracting the data”,which were”Unclear”.”unclear”, the rest of the entries were ”yes”.Therefore, the overall quality of the literature included in this study is good.The results of the quality evaluation are shown in Table 4 Qaseem A et al.(2016) United States of America 2016 ACP Guideline Management of chronic insomnia disorder in adults Riemann D et al.(2023) European 2023 ESRS Guideline Diagnosis and treatment of insomnia Schutte-Rodin, S et al.(2008) United States of America 2008 JCSM Guideline Assessment and management of chronic insomnia in adults Drager, L et al.(2023) Brazilian 2023 ABS Guideline Diagnosis and treatment of insomnia in adults China Sleep Research Society，CSRS(2019) CHINA 2019 Chinese Medical Association Guideline Diagnosis and treatment of insomnia in China Takaesu, Y. et al.(2023) Japan 2023 PubMed Expert consensus Treatment Strategies for Insomnia Douglas JA et al.(2017) Australia 2017 ELSEVIER Expert consensus Indications and performance of adult sleep studies Palagini L et al.(2020) Italy 2020 PubMed Expert consensus Assessment and management of insomnia Chung KF et al.(2018) United States of America 2018 PubMed Systematic review Sleep hygiene education for the treatment of insomnia Jun J et al.(2021) United States of America 2021 ELSEVIER Systematic review Nonpharmacologic interventions for insomnia in adult patients in the intensive care unit Tamrat R et al.(2014) United States of America 2013 PubMed Systematic review Nonpharmacological Interventions to Improve Sleep in Hospitalized Patients Seyffert M et al.(2016) United States of America 2016 PubMed Systematic review Cognitive Behavioral Therapy for Insomnia Available on the Internet Yu H et al.(2021) CHINA 2021 PubMed Systematic review Efficacy of cognitive behavioral therapy for insomnia Zachariae R et al.(2016) United States of America 2016 ELSEVIER Systematic review Efficacy of Cognitive Behavioral Therapy for Insomnia Available on the Internet Zheng X et al.(2023) CHINA 2023 PubMed Systematic review Effectiveness of cognitive behavioral therapy on sleep disorders in pregnant women González-Martín AM et al.(2023) Spanish 2023 PubMed Systematic review Effects of Positive Thought-Based Cognitive Therapy on Older Adults with Sleep Disorders Simon L et al.(2023) German 2023 PubMed Systematic review The efficacy of cognitive behavioral therapy for insomnia Gao Y et al.(2022) CHINA 2022 ELSEVIER Systematic review Acceptability of Cognitive Behavioral Therapy for Insomnia in Adults Wang MY et al.(2005) Taiwan, China 2005 PubMed Systematic review Cognitive Behavioral Therapy for Primary Insomnia Trauer JM et al.(2015) Melbourne 2015 PubMed Systematic review Cognitive Behavioral Therapy for Chronic Insomnia Ho FY et al.(2015) Hong Kong, China 2019 ELSEVIER Meta-analysis Self-help cognitive behavioral therapy for insomnia Forma F et al.(2022) United States of America 2022 PubMed Meta-analysis Digital versus behavioral therapy for chronic insomnia Ye YY et al.(2016) CHINA 2015 PubMed Meta-analysis Internet-based Cognitive Behavioral Therapy Soh HL et al.(2020) Singaporean 2020 ELSEVIER Meta-analysis Efficacy of Digital Cognitive Behavioral Therapy for Insomnia Geiger-Brown JM et al.(2015) United States of America 2015 ELSEVIER Meta-analysis Cognitive behavioral therapy for patients with comorbid insomnia van der Zweerde T et al.(2019) Netherlands 2019 ELSEVIER Meta-analysis Cognitive behavioral therapy for insomnia van Straten A et al.(2018) Netherlands 2018 ELSEVIER Meta-analysis Cognitive behavioral therapy for insomnia Koffel EA et al.(2015) United States of America 2014 ELSEVIER Meta-analysis Cognitive Behavioral Therapy for Insomnia Groups Table 1 Characteristics of included studies（n=28） Figure 2 Flow chart of literature screening 4 DISCUSSION 4.1 Clinical staff should adequately assess and select appropriate treatment components to improve patients’ insomnia symptoms Multiple guidelines(Qaseem A et al.,2016;Riemann D et al.,2023;Schutte-Rodin S et al.,2008;Drager, L. F et al.,2023;China Sleep Research Society，CSRS,2019)have identified multicomponent CBT-I as a first-line treatment for chronic insomnia in adults, recommending that all patients with insomnia, with or without other medical or mental health problems, should be offered CBT-I as initial treatment.Evidence #1 summarizes the diagnostic criteria for sleep disorders from the most recent guideline recommendations, and the quality of the evidence is high.Cognitive Behavioral Therapy for Insomnia is a multimodal cognitive behavioral therapy specifically for insomnia and should have different components tailored to each individual’s insomnia symptoms. Evidence 2-7 summarizes the conditions and components when assessing patients and the goals of treatment; the evidence is derived from guidelines and systematic evaluations; the quality of the evidence is low.The assessment and management of early insomnia should be prioritized to better identify strategies to improve the prevention and treatment of insomnia and its comorbidities.Prior to treatment clinicians should perform a thorough evaluation of the patient to rule out any other medical conditions that may be contributing to insomnia, such as depression, cardiovascular disease, and neurodegenerative diseases, as well as the use of other lifestyle products, alcohol and caffeine.All of these factors have the potential to be causative or contributing factors to insomnia.The results of the study by Sweetman A (Sweetman A et al.,2017)point out that it is important to screen patients with other physical and mental health conditions for insomnia to optimize the outcome of the treatment, and that coexisting disorders with insomnia do not diminish the efficacy of insomnia treatment. jabbrv-ltwa-all.ldf jabbrv-ltwa-en.ldf 4.2Clinical staff should closely observe and promptly adjust the treatment program according to the patient’s post-treatment effects and possible adverse reactions Evidence 8-15 summarizes the different treatment forms of CBT-I. The evidence is derived from guidelines, systematic evaluations, and the quality of the evidence is high.There are multiple treatment forms of CBT-I, and the majority of studies have focused on face-to-face CBT-I. However, there is evidence that other treatment modalities are equally effective.Individual, group, and digital forms of CBT-I are effective when face-to-face CBT-I is unavailable(Riemann D et al.,2021).Hasan F(Hasan F et al.,2022)’s findings point to personal support as the preferred option when CBT-I is administered digitally.In addition, Arnedt JT( Arnedt JT et al.,2021) found that the CBT-I model through online care was equivocal in terms of satisfaction, trustworthiness, and level of treatment compared to face-to-face CBT-I. Evidence 16-24 summarizes the different components of CBT-I, and the evidence is derived from guidelines, systematic evaluations, and the quality of its evidence is high.Although all patients with chronic insomnia should follow good sleep hygiene rules, there is insufficient evidence to suggest that sleep hygiene alone is effective in treating insomnia and that it should be used in combination with other therapies. Sleep restriction and stimulus control are two of the more commonly used forms of CBT-I in combination in the clinic, however, studies have shown that its use as a single strategy for both interventions should be fully considered prior to intervention in terms of patient motivation and safety, as sleep restriction and stimulus control are very challenging for patients and these therapies may increase daytime drowsiness and fatigue in the early stages of use. Evidence 25-30 summarizes the CBT-I treatment cycle and adverse effects.The evidence is derived from expert consensus, systematic evaluations, and its quality of evidence is low.Most clinical studies have focused on 4 courses of treatment as a start, usually requiring 4 to 8 treatments, suggesting that the more courses of treatment the better its therapeutic effect, and that clinical staff should follow up with regular telephone calls to increase patient compliance and enhance its therapeutic effect.After 4 sessions, if CBT-I therapy is not sufficiently effective, the patient and his or her primary care physician should reassess the patient’s overall condition and reach a consensus on whether to start the drug.There is no evidence directly comparing the effectiveness of CBT-I treatment with that of medications; however, there is evidence that the harms of CBT-I may be mild due to its noninvasive nature, and there are currently no clinically reported adverse effects similar to those associated with drug abuse, dose dependence, tolerance, and rebound, whereas medications may be associated with serious adverse events.The low likelihood of adverse events with CBT-I compared to medications is considered a strong advantage.Whether CBT-I should be initiated to treat patients when they are experiencing side effects from medications, a randomized controlled trial conducted by Gould RL(Gould RL et al.,2014),whose results showed that withdrawal was more efficient when psychotherapy was given at the same time as patients discontinued benzodiazepines, did not follow up on the later patients to see if there were any withdrawal symptoms or rebound effects of the medication.There is evidence(Regier DA et al.,2013;Haines A et al.,2021;Qaseem A et al.,2016),that CBT-I is more effective when it is used after discontinuing sleep medications, but how many doses of sleep medications should be discontinued to initiate CBT-I treatment is not yet clinically conclusive.Thus, CBT-I provides a better overall value than medication, and patients are more satisfied with a combination of its therapeutic effects. 4.3Clinical providers should use established sleep assessment tools to diagnose insomnia Evidence 31-39 summarizes the selection of sleep assessment tools, with evidence from guidelines, expert consensus, and systematic evaluations with high quality evidence.International guidelines recommend first assessing insomnia symptoms using a sleep diary for at least 1 to 2 weeks to assess insomnia variability, and both sleep diaries and self-reported questionnaires should be collected prior to and during sleep therapy.Activity loggers are more commonly used clinically to monitor changes in sleep dynamics, but their use in routine clinical assessment and diagnosis of insomnia has limited support.Activity loggers are unable to differentiate between patients with insomnia and those who sleep well, it may be useful primarily in the differential diagnosis of insomnia to recognize irregular bedtime patterns, and it does not provide as valid an estimate of sleep stages as PSG(Park G et al.,2024).There are also a number of lifestyle products that are offered in the form of watches or similar wearable devices that contain measurements of certain body metrics such as heart rate and blood pressure.However, there is no evidence of research on the validity and feasibility of such devices for diagnosing insomnia, and there are even studies suggesting that the use of such devices may negatively affect sleep.PSG is not a necessary tool for diagnosing insomnia, but it can be used in patients with insomnia who have failed to respond to various therapeutic interventions (CBT-I or hypnotic medications) for the detection of other types of sleep disorders, such as OSA. 4.4Clinical staff should be trained in multicomponent CBT-I to achieve more satisfactory treatment outcomes Evidence 40-41 summarizes the selection of CBT-I implementers, and the evidence is derived from guidelines, expert consensus, and systematic evaluations with high quality evidence.The adverse consequences of insomnia should be popularized clinically, and treatment guidelines indicate that clinicians should manage patients with insomnia disorders in order to develop effective treatment strategies for insomnia disorders.Because structured and multicomponent CBT-I require trained therapists, there is a paucity of clinically implementable CBT-I resources.A study conducted in THE LANCET(Morin CM et al.,2012)to test the clinical feasibility of nurse-delivered sleep restriction therapy demonstrated that nurse-delivered sleep restriction therapy in primary care settings reduced insomnia symptoms and was equally cost-effective, and that nurse-delivered therapy could be used as part of an insomnia stepped care management approach.There may be varying degrees of effectiveness between CBT-I provided by a professional therapist and CBT-I provided by a trainee trained in CBT-I. Ideally, this treatment is provided by a clinician with specialized training in the field.The American Academy of Sleep Medicine (AASM) has established a standardized process for certification in behavioral sleep medicine; however, the type of CBT-I administration and treatment regimen may vary from provider to provider, and given the current shortage of trained sleep therapists, CBT-I provided by a trainee and Internet-based administration may provide alternative options. 5 LIMITATIONS The best evidence of this study only applies to adult patients with sleep disorders, incorporating literature from different national regions around the world, then clinical healthcare professionals should consider the patients’ living environments, cultural differences, economic levels, and the state of healthcare in China when implementing this therapy.Before translating and applying the evidence, clinical staff should conduct a comprehensive and holistic assessment of the patient in order to develop a sound CBT-I treatment plan.Meanwhile, it is recommended that more clinical comparisons of the effects of different CBT-I component therapies be conducted in the future to provide more references for the clinical implementation of this therapy. 6 CONCLUSION Based on the method of evidence-based nursing, this study searched high-quality domestic and international literature and summarized the diagnostic criteria and assessment conditions of sleep disorders, the timing of the initiation of multicomponent cognitive behavioral therapy for sleep (CBT-I), the form of treatment, and the composition of the components, which can provide an evidence-based basis for the implementation of this therapy by clinical medical personnel. 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Google Scholar Information & Authors Information Version history V1 Version 1 06 February 2025 Peer review timeline Published Frontiers in Psychiatry Version of Record 29 Jan 2026 Published Copyright This work is licensed under a Non Exclusive No Reuse License. Keywords clinical phychology psychotheraphy quality of health care stress and coing Authors Affiliations Panpan Yan 0009-0008-2541-3131 Henan University View all articles by this author Siyu Feng Henan University View all articles by this author Miaomiao Ma Henan University View all articles by this author Bo Li [email protected] Henan University View all articles by this author Metrics & Citations Metrics Article Usage 352 views 142 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Panpan Yan, Siyu Feng, Miaomiao Ma, et al. Summary of the best evidence that cognitive behavioral therapy for insomnia improves sleep quality in patients with chronic insomnia. Authorea . 06 February 2025. 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