Plain language summary
Insomnia disorder is characterised by problems getting to sleep at bedtime, periods of being awake, or waking early and not being able to go back to sleep. This leads to problems with daytime functioning (e.g. low energy levels, mood disruptions). Diagnosis requires difficulties for 3 or more nights each week for longer than 3 months. Cognitive behavioural therapy (CBT) is considered a viable treatment for patients with insomnia and usually is made up of elements such as sleep hygiene and relaxation, addressing problematic sleep behaviours, and dealing with unhelpful beliefs. However, the effectiveness of various CBT elements is still in question. This systematic review aims to address this, and is based on 1455 subjects in 32 studies. The review concluded there was support for paradoxical intention: instructing the subject to try to remain awake as long as possible rather than aiming to sleep, and cognitive therapy: to reverse unhelpful beliefs about sleep, sleep-worry, misperceptions of sleep and using safety behaviours. It also found that some cognitive elements appear promising including behavioural experiments: planned activities that help the subject test unhelpful beliefs and cognitive refocusing: getting subjects to focus on non-arousing thoughts such as film plots or by focusing on external things like audiobooks to shift attention. However, more methodologically robust studies are needed.
Abstract
Since the beginning of the twenty-first century, there has been an increased focus on developing and testing cognitive components and therapies for insomnia disorder. The aim of the current review was thus to describe and review the efficacy of cognitive components and therapies for insomnia. A systematic review was conducted on 32 studies (N = 1455 subjects) identified through database searches. Criteria for inclusion required that each study constituted a report of outcome from a cognitive component or therapy, that the study had a group protocol, adult participants with diagnosed insomnia or undiagnosed insomnia symptoms or reported poor sleep, and that the study was published until and including 2016 in English. Each study was systematically reviewed with a standard coding sheet. Several cognitive components, a multi-component cognitive program, and cognitive therapy were identified. It is concluded that there is support for paradoxical intention and cognitive therapy. There are also other cognitive interventions that appears promising, such as cognitive refocusing and behavioral experiments. For most interventions, the study quality was rated as low to moderate. We conclude that several cognitive treatment components and therapies can be viewed as efficacious or promising interventions for patients with insomnia disorder. Methodologically stronger studies are, however, warranted.
Methodological quality
Allocation concealment
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Not applicable
