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Meta-Analysis
. 2021 Feb 1;17(2):263-298.
doi: 10.5664/jcsm.8988.

Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment

Jack D Edinger  1   2 , J Todd Arnedt  3 , Suzanne M Bertisch  4 , Colleen E Carney  5 , John J Harrington  6 , Kenneth L Lichstein  7 , Michael J Sateia  8 , Wendy M Troxel  9 , Eric S Zhou  10 , Uzma Kazmi  11 , Jonathan L Heald  11 , Jennifer L Martin  12   13
Affiliations
Meta-Analysis

Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment

Jack D Edinger et al. J Clin Sleep Med. .

Abstract

Introduction: The purpose of this systematic review is to provide supporting evidence for a clinical practice guideline on the use of behavioral and psychological treatments for chronic insomnia disorder in adult populations.

Methods: The American Academy of Sleep Medicine commissioned a task force of 9 experts in sleep medicine and sleep psychology. A systematic review was conducted to identify randomized controlled trials that addressed behavioral and psychological interventions for the treatment of chronic insomnia disorder in adults. Statistical analyses were performed to determine if the treatments produced clinically significant improvements in a range of critical and important outcomes. Finally, the Grading of Recommendations Assessment, Development, and Evaluation process was used to evaluate the evidence for making specific treatment recommendations.

Results: The literature search identified 1,244 studies; 124 studies met the inclusion criteria, and 89 studies provided data suitable for statistical analyses. Evidence for the following interventions is presented in this review: cognitive-behavioral therapy for insomnia, brief therapies for insomnia, stimulus control, sleep restriction therapy, relaxation training, sleep hygiene, biofeedback, paradoxical intention, intensive sleep retraining, and mindfulness. This review provides a detailed summary of the evidence along with the quality of evidence, the balance of benefits vs harms, patient values and preferences, and resource use considerations.

Keywords: behavioral treatments; chronic insomnia disorder; clinical practice guideline; psychological treatments.

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Conflict of interest statement

All authors have seen and approved the manuscript. The development of this article was funded by the American Academy of Sleep Medicine. The following include all the conflicts managed throughout guideline development. Dr. Edinger received funding from Merck for an insomnia research study, and his research program was loaned portable polysomnography recorders from Philips/Respironics to support a National Institute of Mental Health–funded research grant. Dr. Arnedt was loaned U.S. Food & Drug Administration–cleared device treatment for insomnia by Ebb (2018–-present), served as a consultant to Magna Seating Systems Engineering until 2016 to develop a report on drowsy driving, served on a contract project with the National Highway Safety Transportation Board on drowsy driving (2018–present), and was a coinvestigator for a study funded by the National Basketball Association and contracted with the University of Michigan to evaluate the validity of commercially available devices to measure sleep (ended 2019). Dr. Bertisch was a coinvestigator on an insomnia research project funded by Merck (ended 2017), serves as an unpaid member of the board of directors of the Alliance of Sleep Apnea Partners, a non -profit patient centered group. Dr. Lichstein is a member of the insomnia advisory board for Merck, the topic of which is unrelated to the behavioral treatments of insomnia. Dr. Sateia served as a consultant for Physicians Seal for melatonin in 2018. Dr. Troxel was a coinvestigator on a study about the prevalence and risk factors for nocturia using data from the British Healthy Workers (ended March 2020), served as a consultant for Guidepoint as a subject matter expert on sleep to industry clients (January 2018–present), has received research funding from the National Institutes of Health, was principal investigator on a grant funded by Feelmore Labs to review a clinical trial design and protocol for an investigational neurostimulation device (ended June 2020), and serves on the scientific advisory board for Feelmore Labs. Mr. Heald was employed by the American Academy of Sleep Medicine during his work on this article, but his employment by the American Academy of Sleep Medicine ended in July 2020. Dr. Martin serves on the American Academy of Sleep Medicine board of directors. Ms. Kazmi is employed by the American Academy of Sleep Medicine. The remaining authors report no conflicts of interest.

Figures

Figure 1
Figure 1. Evidence base flow diagram.
See this image and copyright information in PMC

References

    1. Edinger JD, Arnedt JT, Bertisch SM, et al. . Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2021;17(2):255–262. 10.5664/jcsm.8986 - DOI - PMC - PubMed
    1. Schutte-Rodin S, Broch L, Buysse D, Dorsey C, Sateia M. Clinical guideline for the evaluation and management of chronic insomnia in adults. J Clin Sleep Med. 2008;4(5):487–504. 10.5664/jcsm.27286 - DOI - PMC - PubMed
    1. Sateia MJ, Buysse DJ, Krystal AD, Neubauer DN, Heald JL. Clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2017;13(2):307–349. 10.5664/jcsm.6470 - DOI - PMC - PubMed
    1. American Academy of Sleep Medicine. International Classification of Sleep Disorders. 3rd ed. Darien, IL: American Academy of Sleep Medicine; 2014.
    1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Association Publishing; 2013.

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