Does Cognitive Behavioral Therapy Improve Sleep in Adults and Older Adults with

Insomnia?
Melody Klatt, OTS and Jennifer Tom, OTS
Touro University Nevada, School of Occupational Therapy

Introduction
Insomnia is a disorder that affects the quantity and quality of sleep. As a
result, it increases fatigue, affects work productivity, reduces quality of life and
relationship satisfaction, and negatively affects overall health (Espie et al.,
2012).
Chronic insomnia may also serve as a risk factor for the development of other
mental and physical health issues, and its importance and relevance to public
health is demonstrated by high healthcare costs that are reported in nations
such as the USA (Espie et al., 2012).
Cognitive behavioral therapy (CBT) is a type of psychotherapy in which
negative patterns of thought about oneself and the world are challenged in
order to change or alter unwanted behavior patterns or treat certain mood
disorders (Dobson & Dobson, 2009).
Increasing evidence has demonstrated the effectiveness of CBT in combating
insomnia symptoms in adults and older adults, and supports CBTs use in
therapy for clients who may suffer from primary or comorbid insomnia
(Belanger, LeBlanc, & Morin, 2012).
This evidence implies that CBT may be an effective intervention strategy that
an occupational therapist (OT) may utilize in practice to improve quality of
sleep in clients who are living with a diagnosis of insomnia.

Methods
Inclusion Criteria:
Level I, RCT studies
Adults and older adults with
insomnia
Cognitive behavioral therapy
as intervention
Published in English

Exclusion Criteria:
Older than 20 years (<1995)
Younger adults
Qualitative studies and
dissertations
Published in languages other
than English

Databases Searched:
Databases searched included PubMed, CINAHL, the Cochrane Library,
and Google Scholar.
Search Terms:
Categories
Patient/Client
Population

Key Search Terms

Older adults, adults, insomnia

Intervention

CBT, cognitive behavioral therapy

Outcomes

Sleep duration, sleep quality, sleep

improvement

Implications for
Occupational Therapy

Summary of Key Findings

Four studies compared the effectiveness of CBT versus
sleep medication. In all comparisons, CBT alone was
associated with greater improvement in sleep quality and
sleep duration, as well as decreased reports of fatigue
when compared with sleep medication alone. However,
across all studies, the most significant reports of
improvement were associated with interventions that used
a combined approach of both CBT and sleep medication
(Morin et al., 2009; Morin, Colecchi, Stone, Sood, &
Brink, 1999; Morin et al., 2004; Sivertsen et al., 2006).
One study compared the effectiveness of CBT versus Tai
Chi, as well as CBT versus a sleep education seminar to
relieve insomnia symptoms in adults. The results showed
that CBT yielded the most positive results in the
remission of insomnia and improvement in sleep quality,
sleep parameters, fatigue, and depressive symptoms in
adults when compared to the other two forms of treatment
(Irwin et al., 2014).
One study compared
the effectiveness of CBT
to treatment as usual (TAU)
for clients in primary care.
Participants that were in the
TAU group were instructed
to continue with the usual
care they were receiving
from their general practitioners.
CBT was associated with
improvements in sleep latency,
wakefulness after sleep onset,
and sleep efficiency when
compared with the TAU group
(Espie et al., 2014).

Clinical and Community-Based Practice of OT

Practicing occupational therapists should be aware that
cognitive behavioral therapy has been shown through
research to be an effective nonpharmacological means to
treat insomnia in adults and older adults. CBT has been
shown to be effective singly, and has been shown to be
particularly effective when used in combination with
sleep medication. Research lends evidence to support the
use of nonpharmacological interventions such as CBT in
treating insomnia symptoms in adults and older adults.
Program Development
For therapists who harbor an interest in establishing
nonpharmacological means within their practice to treat
insomnia in clients, the value of utilizing CBT could be
considered. Research supports the effectiveness of using
CBT in practice, even in various forms such as
abbreviated CBT (ACBT) and web-based CBT, and these
could be important considerations for a practitioner to
make if they are developing a treatment program.
Societal Needs
For clients within society who may want to limit their
medication intake for treatment of insomnia, CBT may be
a viable intervention for them to consider. Research
supports the effectiveness of CBT in its traditional form
as well as in non-traditional forms such as web-based
forms or abbreviated forms, which may be more
convenient and cost-effective for certain individuals.

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One study compared the effectiveness of CBT versus

sleep hygiene education. The results indicated that CBT,
like sleep hygiene education, is a viable option in treating
patients with primary or comorbid insomnia (Edinger et
al., 2009).
One study examined the effectiveness of an abbreviated
form of CBT (ACBT), and found that the treatment - even
in a condensed format - was still an effective means to
treat insomnia symptoms in adults and older adults
(Edinger & Sampson, 2003).
Lastly, one study examined the effectiveness of a webbased form of CBT for treating insomnia symptoms in
adults when compared with TAU and a placebo group.
The results indicated that the web-based form of CBT was
associated with sustained improvement in insomnia
symptoms at post-treatment (Espie et al., 2012).

Healthcare Delivery and Policy

Although results from this study are preliminary, certain
elements of the research produced significant enough
results to possibly impact treatment options for
individuals with insomnia. However, further
accumulation of evidence with larger, more
representative samples is necessary before advising
healthcare policy makers.
Education and Training of OT Students
Occupational therapy students are well-educated on sleep
hygiene and sleep as an important occupation. However,
students will require education and formal training in
regards to implementing CBT in practice before they will
be able to provide CBT as a form of intervention for
treating clients with insomnia.
Refinement and Revisions
Further research should be conducted with larger and
more diverse sample sizes, as well as more equal
representations of males and females. Co-intervention
bias should also be more rigidly avoided.

Contact Information: Melody Klatt, OTS, ot16.melody.klatt@nv.touro.edu. Jennifer Tom, OTS, ot16.jennifer.tom@nv.touro.edu.

Evidence Levels
Studies Reviewed:
9 Level I, Randomized Controlled Trials
Level I:
Systematic reviews,
meta-analyses, &
randomized
controlled trials
Level II:
Two groups, nonrandomized studies
Level III:
One group, nonrandomized studies
Level IV:
Descriptive studies with an analysis of outcomes
Level V:
Case reports and expert opinions, narrative literature reviews,
and consensus statements
Hierarchy of levels of research evidence

Conclusions
Sleep is an essential occupation for every individual, as it plays a significant
role in an individuals health. Insomnia is a disorder that affects the quality
and quantity of sleep, and can greatly impact the wellbeing of adults and older
adults.
Research suggests that cognitive behavioral therapy has the potential to
relieve symptoms of insomnia among adults and older adults, and is an
effective nonpharmacological intervention for treating this population.
Further research would support CBTs efficacy in treating adults and older
adults with insomnia, and would support the implementation of this
intervention in medical settings.

References (A Partial List)

Dobson, D. & Dobson, K. (2009). Evidence-based practice of cognitive-behavioral therapy. New
York, NY: The Guilford Press.
Edinger, J. D., Olsen, M. K., Stechuchak, K. M., Means, M. K., Lineberger, M. D., Kirby, A., &
Carney, C. E. (2009). Cognitive behavioral therapy for patients with primary insomnia or insomnia
associated predominantly with mixed psychiatric disorders: A randomized clinical trial. SLEEP,
32(4), 499-510.
Edinger, J. D. & Sampson, W. S. (2003). A primary care friendly cognitive behavioral insomnia
therapy. SLEEP, 26(2), 177-182.

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