Comparative efficacy of onsite, digital, and other settings for cognitive behavioral therapy for insomnia: a systematic review and network meta-analysis

Abstract

Given the limited availability and accessibility of onsite cognitive behavioral therapy for insomnia (CBT-I), other CBT-I settings, such as internet-delivered CBT-I (iCBT-I), have been proposed. The primary aim of the study was to compare the efficacy of available CBT-I settings on insomnia severity. A systematic review and frequentist network meta-analysis of available CBT-I settings was performed. PsycINFO, PsycARTICLES, MEDLINE, PubMed, and CINAHL were searched for randomized controlled trials (RCTs) investigating any CBT-I settings in adults with insomnia disorder. The systematic literature search (3851 references) resulted in 52 RCTs. For the primary outcome insomnia severity, all examined CBT-I settings except smartphone-delivered CBT-I yielded significant effects when compared to WL. Large standardized mean differences were found for individual onsite CBT-I (− 1.27;95%CI − 1.70, − 0.84), group-delivered CBT-I (− 1.00;95%CI − 1.42. − 0.59), telehealth (− 1.28;95%CI − 2.06, − 0.50), and guided bibliotherapy (− 0.99;95%CI − 1.67, − 0.32). Both guided iCBT-I (− 0.71;95%CI − 1.18, − 0.24) and unguided iCBT-I (− 0.78;95%CI − 1.18, − 0.38) yielded medium effect sizes. The results underline that health care systems should intensify their efforts to provide synchronously-delivered CBT-I (individual onsite, group-delivered, and telehealth), and particularly individual onsite CBT-I, given its solid evidence base. Medium to large effect sizes for iCBT-I and guided bibliotherapy indicate that self-help settings may be a viable alternative when synchronously-delivered CBT-I is not available.

Internet-delivered cognitive behavior therapy versus treatment as usual for anxiety and depression among Latin American university students: A randomized clinical trial.

“…However, these results were robust given their consistency across per-protocol sensitivity analyses, preregistered disaggregated analyses, and post hoc exploratory subgroup analyses. The 37%–50% of students who experienced joint remission of both GAD-7 and PHQ-9 were comparable to the 38%–56% pooled response–remission rates for guided i-interventions and higher than the 21%–35% pooled response–remission rates for self-guided i-interventions found in a meta-analysis of prior controlled trials for depression (Karyotaki et al, 2018) and comparable to the 35%–70% pooled response–remission rates found in a separate meta-analysis of i-CBT for anxiety, depression, and other common behavioral health problems (Andersson et al, 2019; Davey et al, 2023; Simon et al, 2023).…”

Training of professionals in cognitive behavioural therapy for insomnia – A systematic review of peer‐reviewed studies

“…The initial evaluations of the remote training programmes are favourable, but preliminary, as the studies are few and of varying aim and quality. However, given the positive outcomes of digital or internet‐delivered CBT‐I (Gao et al, 2022; Simon et al, 2023) – which can be conceptualised as “patient training including behaviour change” – it would not be entirely surprising if digitally delivered CBT‐I training for therapists would also be successful. However, there may be differences that are not yet apparent, and it is an empirical question if training outcome is equivalent to in‐person training workshops, and whether teacher support is needed or can be added to improve outcome of training.…”

“…CBT‐I can be effectively delivered in many different modes. Treatment delivered individually face‐to‐face has the largest number of studies, but other evaluated modes such as group delivered and self‐help formats and digitally delivered treatment also have strong support to be effective (Gao et al, 2022; Simon et al, 2023). According to the stepped‐care model for insomnia (Baglioni et al, 2020; Baglioni et al, 2023; Espie, 2009), in the interest to conserve resources and expertise for patients with the highest needs, CBT‐I should be administered in steps, where the initial step may be to guide patients to high‐quality self‐help treatments that do not require much therapist support, and the highest step may be individual face‐to‐face CBT‐I delivered by behavioural sleep medicine (BSM) specialists (Espie, 2009).…”

The European Insomnia Guideline: An update on the diagnosis and treatment of insomnia 2023

“…Interestingly, the most contemporary network meta‐analysis on all forms of CBT‐I administrations (i.e. onsite versus digital and other settings; Simon, Steinmetz, et al, 2023) demonstrated that individual F2F CBT‐I, group F2F CBT‐I, telehealth (videoconference, phone call) and guided bibliotherapy conveyed the strongest effects on insomnia, whereas guided and unguided dCBT‐I yielded medium effect sizes, slightly favouring guided over unguided dCBT‐I. Smart phone applied CBT‐I did not attain significant effects compared with control.…”