Comparative efficacy and acceptability of cognitive-behavioural therapy for insomnia and its abbreviated versions: a systematic review and network meta-analysis

Objective

To assess the comparative efficacy and acceptability of cognitive behavioural therapy for insomnia (CBT-I), its abbreviated versions and control conditions.

Design

Systematic review and network meta-analysis.

Methods

Screening, data extraction, coding, and risk of bias assessment were performed independently and in duplicate. Frequentist, random-effects network meta-analyses estimated odds ratios (ORs) or mean differences with 95% confidence intervals (CIs). The primary outcome was insomnia remission post-treatment. Secondary outcomes included dropout and subjective sleep continuity measures. Quality of the evidence for each arm was graded using the confidence in network meta-analysis (CINeMA).

Data sources

We searched MEDLINE, Embase, PsycINFO and Cochrane CENTRAL from inception to December 15, 2025, with a medical information specialist.

Eligibility criteria for selecting studies

Randomized –controlled trials (RCTs) comparing CBT-I and its abbreviated versions with each other or with control conditions, in adults with insomnia, with or without comorbidities. To reduce clinical heterogeneity related to treatment intensity and adherence, we restricted inclusion to in-person delivery.

Results

We identified 11,379 records and included 77 RCTs (5,731 participants; mean age 52.2 years; 3,473 female). CBT-I (number of arms k = 53; number of participants n = 2,002), sleep restriction and stimulus control therapy (SRT&SCT; k = 16; n = 549), sleep restriction therapy (SRT; k = 5; n = 196) and stimulus control therapy (SCT; k = 7; n = 144) were associated with higher remission than sleep hygiene, relaxation therapy and other control conditions. These interventions were also effective in improving subjective sleep continuity measures. Cognitive therapy for insomnia (CT-I) was more beneficial than relaxation therapy. Dropout did not differ meaningfully between interventions and controls. Confidence in evidence was moderate for CBT-I, low for SRT&SCT and SRT, very low for SCT. Given the weighted mean proportion of insomnia remission among sleep hygiene arms of 20%, CBT-I probably leads to a remission rate of 41% (95% CI, 34%; 48%), SRT&SCT may lead to a remission rate of 40% (30%; 52%), SCT 43% (25%; 63%), and SRT 41% (26%; 57%).

Conclusions

CBT-I doubles the absolute insomnia remission compared with sleep hygiene, and its abbreviated behavioural therapies, namely, SRT&SCT, SCT and SRT may offer similar benefits with lower resource requirements, but evidence is less certain. CT-I needs further investigations. Relaxation therapy was inferior to these therapies. Implementation decisions should consider resource requirements and evidence certainty.

What is already known on this topic

- Insomnia is prevalent and disabling, and cognitive behavioural therapy for insomnia (CBT-I) is recommended as the first-line treatment.

- CBT-I and its abbreviated versions are recommended in guidelines, but their comparative efficacy and acceptability remain uncertain.

What this study adds

- CBT-I and its core behavioural components (sleep restriction and stimulus control) probably achieve similar remission rates, offering scalable options where full CBT-I is not available.

- Relaxation therapy was inferior to cognitive behavioural therapy for insomnia, its abbreviated, behavioural interventions, and cognitive therapy for insomnia.

- Dissemination and implementation attempts should balance the confidence in the evidence and simplicity of abbreviated versions.