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INFLUENTIAL PUBLICATIONS   |    
Comparative Effectiveness of Cognitive Behavioral Therapy for Insomnia: A Systematic Review
Matthew D. Mitchell; Philip Gehrman; Michael Perlis; Craig A. Umscheid
FOCUS 2014;12:80-89. doi:10.1176/appi.focus.12.1.80
Abstract

Background  Insomnia is common in primary care, can persist after co-morbid conditions are treated, and may require long-term medication treatment. A potential alternative to medications is cognitive behavioral therapy for insomnia (CBT-I).

Methods  In accordance with PRISMA guidelines, we systematically reviewed MEDLINE, EMBASE, the Cochrane Central Register, and PsycINFO for randomized controlled trials (RCTs) comparing CBT-I to any prescription or non-prescription medication in patients with primary or comorbid insomnia. Trials had to report quantitative sleep outcomes (e.g. sleep latency) in order to be included in the analysis. Extracted results included quantitative sleep outcomes, as well as psychological outcomes and adverse effects when available. Evidence base quality was assessed using GRADE.

Results  Five studies met criteria for analysis. Low to moderate grade evidence suggests CBT-I has superior effectiveness to benzodiazepine and non-benzodiazepine drugs in the long term, while very low grade evidence suggests benzodiazepines are more effective in the short term. Very low grade evidence supports use of CBT-I to improve psychological outcomes.

Conclusions  CBT-I is effective for treating insomnia when compared with medications, and its effects may be more durable than medications. Primary care providers should consider CBT-I as a first-line treatment option for insomnia.
(Reprinted with permission from BMC Family Practice 2012;13:40:1–11) 

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Figure 1. PRISMA Flow Diagram for Literature Search and Article Inclusion.
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Table 1.Studies Comparing CBT-I to Pharmacological Therapies: Methods
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Table 2.Studies Comparing CBT-I to Pharmacological Therapies: Post-Treatment Results
Table Footer Note

SWS Slow wave sleep, WASO Wake after sleep onset.

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Table 3.Studies Comparing CBT-I to Pharmacological Therapies: Follow-Up Results
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SWS Slow wave sleep, WASO Wake after sleep onset.

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Table 4.Evidence Summary and GRADE Analysis
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Evidence assessed using methods of the GRADE Working Group [26-28].

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Evidence strength ratings:

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High: Further research is very unlikely to change our confidence in the estimate of effect.

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Moderate: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.

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Low: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.

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Very low: Any estimate of effect is very uncertain.

Table Footer Note

Short term outcomes typically 4 to 8 weeks, long-term outcomes typically 6 to 12 months.

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