Efficacy and Acceptability of Cognitive Behavioral Therapy for Insomnia in Chronic Disease: A Comprehensive Meta-Analysis

Highlight

CBT-I significantly improves insomnia severity, sleep efficiency, and sleep onset latency in adults with chronic diseases such as cancer, chronic pain, and stroke. Treatment acceptability is high with low dropout rates and rare adverse effects. Effect sizes are comparable to those seen in general populations without chronic illness.

Study Background and Disease Burden

Insomnia is highly prevalent in populations with chronic diseases, including chronic pain, cardiovascular illness, cancer, irritable bowel syndrome, and stroke. This sleep disturbance exacerbates symptom burden, impairs quality of life, and is linked to unfavorable disease outcomes. Despite its recognized impact, insomnia in individuals with chronic conditions is undertreated, partly due to concerns about the applicability and efficacy of standard therapies in these complex populations. Cognitive behavioral therapy for insomnia (CBT-I) is endorsed as first-line treatment for chronic insomnia in the general population, but its clinical effectiveness, safety, and acceptability in chronic disease cohorts remained unclear prior to this comprehensive synthesis.

Study Design

This systematic review and meta-analysis synthesized data from 67 randomized clinical trials comprising 5,232 adult participants (≥18 years) diagnosed with chronic diseases and comorbid insomnia. Eligible studies incorporated CBT-I interventions—delivered via various formats—with measured objective and subjective sleep outcomes. The search strategy included major databases (PsycINFO, Medline, Embase, CENTRAL) from inception through June 5, 2025. Data extraction was performed independently by two assessors. The primary endpoints included validated measures of insomnia severity, sleep efficiency, and sleep onset latency. Secondary outcomes addressed treatment acceptability and adverse events. Effect sizes were calculated using Hedges g under random-effects models with subgroup analyses exploring moderators such as delivery method, disease subtype, and comparator group.

Key Findings

CBT-I demonstrated robust efficacy across primary sleep outcomes in chronic disease populations. The pooled effect size for insomnia severity was large (g = 0.98; 95% CI, 0.81–1.16), indicating notable symptom relief. Improvements in sleep efficiency (g = 0.77; 95% CI, 0.63–0.91) and sleep onset latency (g = 0.64; 95% CI, 0.50–0.78) were moderate but clinically meaningful.

Subgroup analyses revealed:
– Longer-duration CBT-I protocols yielded superior improvements in sleep efficiency and latency compared with shorter treatments.
– Efficacy was broadly consistent across disease categories such as cancer, chronic pain syndromes, irritable bowel syndrome, and stroke.
– Delivery formats (in-person, digital, group versus individual sessions) did not significantly alter treatment effectiveness.

Treatment acceptability was high, reflected by a modest mean dropout rate of 13.3%. Reported treatment-related adverse effects were rare, underscoring the safety profile of CBT-I in medically complex patients.

These findings align closely with effect sizes and tolerability documented in non-chronic disease insomnia populations, suggesting generalizability and therapeutic reliability.

Expert Commentary

CBT-I’s demonstrated efficacy and acceptability across a spectrum of chronic diseases addresses important clinical concerns about its adaptability in populations with multifactorial health challenges. As insomnia commonly amplifies physical and psychological distress in chronic illnesses, effective management via CBT-I could substantially improve patient-centered outcomes. However, individual variability in response and potential barriers such as limited accessibility to trained therapists and resource constraints must be acknowledged.

The identification of longer treatments improving sleep metrics supports optimizing session duration in clinical protocols. Future research should focus on personalized adaptations for specific subpopulations (e.g., cancer-related insomnia, stroke recovery) and implementation strategies for scaling CBT-I delivery within multidisciplinary chronic disease care models.

Conclusion

This systematic review and meta-analysis provide compelling evidence that CBT-I is an efficacious, well-accepted, and safe treatment for insomnia among adults with diverse chronic diseases. Moderate to large effects on critical sleep parameters and favorable tolerability highlight the potential for CBT-I integration in routine chronic disease management to enhance sleep health and overall quality of life. Addressing implementation challenges and tailoring interventions holds promise for broader clinical impact.

References

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