CBT for insomnia improves sleep outcomes in patients with chronic disease

Cognitive behavioural therapy (CBT) for insomnia (CBT-I) helps reduce its severity and improve other sleep outcomes in patients with chronic disease, such as chronic pain, cardiovascular disease, and cancer, according to the results of a meta-analysis.

Pooled data from 67 randomized controlled trials showed that CBT-I yielded significant improvements, with a large effect size observed for insomnia severity (g, 0.98, 95 percent confidence interval [CI], 0.81–1.16) and moderate effect sizes for sleep efficiency (g, 0.77, 95 percent CI, 0.63–0.91) and sleep onset latency (g, 0.64, 95 percent CI, 0.50–0.78). [JAMA Intern Med 2025;doi:10.1001/jamainternmed.2025.4610]

The overall pooled prevalence of remission was higher with CBT-I than with control, at 54 percent vs 18 percent (odds ratio, 5.35, 95 percent CI, 2.66–10.75).

“These effects are comparable to those observed in populations without comorbid conditions. Encouragingly, no significant differences in outcomes were observed between the disease groups examined. This provides evidence for the widespread efficacy of CBT-I among chronic disease populations,” the investigators noted. [Sleep Med Rev 2018;38:3-16]

Effect sizes appeared to vary depending on a variety of factors. For instance, longer treatment resulted in better outcomes for sleep efficiency and sleep onset latency. Additionally, effects were smaller when CBT-I was compared with active control (eg, education, therapist contact) and larger when CBT-I was compared with inactive controls (eg, waiting list control, treatment as usual).

Heterogeneity across studies was substantial, with I² values ranging between 63 percent and 77 percent.

The total study population consisted of 5,232 participants with insomnia who had cancer, chronic pain, irritable bowel syndrome, and stroke.

Implementation

“CBT-I is a nonpharmacological treatment that targets the psychological and behavioural factors that maintain insomnia, using strategies such as stimulus control, sleep restriction, and cognitive restructuring,” the investigators said.

Using CBT-I in chronic disease populations is believed to present unique challenges. This is because people with chronic disease experience symptoms such as pain, fatigue, and cognitive impairment that may interfere with implementing the core behavioural components of CBT-I such as stimulus control and sleep restriction, the investigators explained.

“For example, patients may struggle to get out of bed during nighttime awakenings because of mobility limitations. Clinicians may also be concerned that temporary sleep restriction could exacerbate symptoms or trigger adverse health events, particularly in certain populations (eg, those with epilepsy, cardiovascular disease, or immunosuppression),” they continued.

In some of the studies included in the meta-analysis, CBT-I was modified to safely and practically address the unique limitations of patients with chronic disease. These adaptations included fatigue management strategies (eg, activity pacing), modified advice around naps (eg, permitting naps during chemotherapy), modified stimulus control for those with mobility restrictions (eg, instruction to sit up in bed instead of getting out of it), and a minimum sleep window of 6 hrs to reduce the risk of seizures due to sleep deprivation, among others.

“CBT-I still showed a moderate effect size when compared with matched active controls, reinforcing the efficacy of core components, such as sleep restriction therapy and cognitive restructuring, beyond general therapeutic factors. This supports CBT-I as a targeted, mechanism-driven intervention for insomnia,” the investigators pointed out

“Indicators of acceptability and tolerability were also encouraging,” they added.

Participant satisfaction with CBT-I was high, with a mean dropout rate of 12.7 percent, lower than that typically seen in psychotherapy (eg, 19.9 percent for depression). Treatment-related adverse effects were rare. [Clin Psychol Rev 2015;40:57-65]