Initial treatment choices for long‐term remission of chronic insomnia disorder in adults: a systematic review and network meta‐analysis
Background
We aimed to evaluate the comparative efficacy and acceptability of cognitive behavioral therapy for insomnia (CBT‐I), pharmacotherapy, and their combination in the long and short terms among adults with chronic insomnia disorder.
Methods
We searched multiple databases to December 27, 2023. We included trials in hypnotic‐free adults with chronic insomnia comparing at least two of CBT‐I, pharmacotherapy, or their combination. We assessed the confidence in evidence using CINeMA. The primary outcome was long‐term remission. Secondary outcomes included all‐cause dropout and self‐reported sleep continuity measures in the long term, and the same outcomes in the short term. We performed frequentist random‐effects network meta‐analyses (CRD42024505519).
Findings
We identified 13 trials including 823 randomized participants (mean age, 47.8 years; 60% women). CBT‐I was more beneficial than pharmacotherapy in the long term (median duration, 24 weeks [range, 12 to 48 weeks]; remission odds ratio, 1.82 [95% confidence interval (CI), 1.15–2.87]; [certainty of evidence: high]), while there was weaker evidence of benefit of combination against pharmacotherapy (1.71 [95% CI, 0.88–3.30: moderate]) and no clear difference of CBT‐I against combination (1.07 [95% CI, 0.63–1.80: moderate]). CBT‐I was associated with fewer dropouts than pharmacotherapy. Short‐term outcomes favored CBT‐I over pharmacotherapy except total sleep time. Given the average long‐term remission rate in the pharmacotherapy‐initiating arms of 28%, CBT‐I resulted in a long‐term remission rate of 41% (95% CI, 31%–53%) and combination 40% (95% CI, 25%–56%).
Interpretation
The current study found that starting with CBT‐I for chronic insomnia leads to better outcomes than pharmacotherapy. Combination may be better than pharmacotherapy alone, but unlikely to be worth the additional burden over CBT‐I alone.
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