Cognitive behavioral therapy for adult insomnia disorder in routine clinical care: a systematic review and meta-analysis

A systematic review and meta-analysis was conducted of different types of CBTs for ID in adults treated in routine clinical care. Ovid MEDLINE, Embase OVID, and PsycINFO were systematically searched for studies published until January 2025. The effectiveness of CBT, methodological quality, and moderators of treatment outcomes were examined and benchmarked by meta-analytically comparing them with efficacy studies for ID. Thirty-two studies were included, comprising 5231 participants. Very large within-group effect sizes (ES; Hedges' g) were obtained for ID-severity at post-treatment (1.87), and follow-up (1.68), on average 12 months post-treatment. Remission rates were 45% post-treatment and 51% at follow-up. Attrition rate was 13.9%. Risk of bias was considerable in the majority of studies. The benchmarking analysis showed that effectiveness studies (1.83) had almost exactly the same ES as efficacy studies (1.82) at post-treatment. Furthermore, there was no significant difference between effectiveness and efficacy studies on sleep diary measures, remission rates, and self-ratings of depression and anxiety. CBTs for ID are effective when delivered in routine clinical care, with ESs comparable to those found in efficacy studies. However, the evidence needs to be interpreted with caution because of the risk of bias in a high proportion of studies.Prospero registration id: CRD420251032141.