CBT-I Effective for Insomnia in Patients with Chronic Diseases

In a recent meta-analysis, cognitive behavioral therapy for insomnia (CBT-I) demonstrated strong efficacy in patients with chronic diseases, such as chronic pain, cardiovascular disease, and cancer.1

“An average of 54% patients were found to meet remission criteria, a higher figure than was reported by Wu and colleagues,” study investigator Amelia J. Scott, PhD, from the school of psychological sciences at Macquarie University in Sydney, Australia, and colleagues wrote. 1 “Encouragingly, no significant differences in outcomes were observed between the disease groups examined.”

Many individuals with chronic disease suffer from insomnia, leading to poorer disease outcomes. For instance, 60% and 70% of people with cancer and chronic pain, respectively, report significant insomnia.

The American Academy of Sleep Medicine (AASM) recommends CBT-I as the first-line treatment for insomnia, but it is unknown whether this therapy helps patients experiencing insomnia alongside their chronic disease. Pain, fatigue, and cognitive impairment, all symptoms of chronic pain, interfere with implementing CBT-I components, such as stimulus control and sleep restriction. There is also concern that temporary sleep restriction could trigger adverse events in individuals with epilepsy, cardiovascular disease, and immunosuppression.

“These clinical realities raise questions about the feasibility, acceptability, and efficacy of CBT-I in these contexts,” investigators wrote.1

Investigators conducted a meta-analysis and systematic review to assess the efficacy and acceptability of CBT-I in adults with chronic disease and to identify moderators of treatment outcomes.1 Primary outcomes included insomnia severity, sleep efficiency, and sleep onset latency. Secondary outcomes included treatment acceptability and adverse events.

The team searched PsycINFO, Medline, Embase, and CENTRAL from database inception to June 5, 2025. Eligible studies included randomized clinical trials (RCTs) that examined CBT-I and measured sleep outcomes in adults aged ≥ 18 years with chronic disease and insomnia. The meta-analysis included 67 RCTs, with 5232 participants.

Most studies focused on cancer (n = 17) and chronic pain (n = 17), though cardiovascular disease, kidney disease, and traumatic brain injury each had 5 studies. The remaining studies focused on chronic obstructive pulmonary disease, epilepsy, irritable bowel syndrome, and tinnitus; 3 studies included participants with mixed chronic diseases. Treatment methods included face-to-face (n = 30), group face-to-face (n = 21), internet-delivered CBT-1 (n = 13), and blended delivery (n = 4).1

CBT-I was linked to significantly improved outcomes for insomnia severity (95% confidence interval [CI], 0.81 – 1.16), moderate effect sizes regarding sleep efficiency (95% CI, 0.63 – 0.91), and sleep onset latency (95% CI, 0.50 – 0.78). Investigators found substantial heterogeneity, with I2 values between 63% and 77%. The pooled prevalence of remission in treatment groups was 54% (95% CI, 40.3% - 67%) compared with 18% (95% CI, 11.9% - 26.5%) in controls.1

Subgroup analyses identified some moderators of treatment outcomes. For instance, longer CBT-I treatment led to better outcomes for sleep efficiency and sleep onset latency. This aligned with research findings that participants viewed a brief behavioral treatment of 4 weeks as insufficient.2

The satisfaction of CBT-I was high, with a mean dropout rate of 13.3%. There were low rates of treatment-related adverse events.1

“This meta-analysis provides strong evidence that CBT-I is an effective and acceptable intervention for insomnia in chronic disease populations,” investigators concluded.1 “Despite variability in study outcomes and some evidence of publication bias, the overall findings reinforce the efficacy of CBT-I in this population. Efforts should now shift toward broadening access and evaluating its potential benefits beyond insomnia to improve outcomes for those with chronic diseases.”

References

1. Scott AJ, Correa AB, Bisby MA, et al. Cognitive Behavioral Therapy for Insomnia in People With Chronic Disease: A Systematic Review and Meta-Analysis. JAMA Intern Med. Published online September 22, 2025. doi:10.1001/jamainternmed.2025.4610

2. Armstrong S, Pattinson J, Siriwardena AN, et al. Nurse-delivered sleep restriction therapy in primary care for adults with insomnia disorder: a mixed-methods process evaluation. Br J Gen Pract. 2023;74(738):e34-e40. Published 2023 Dec 28. doi:10.3399/BJGP.2023.0162