School of Occupational Therapy

Touro University Nevada

OCCT 643 Systematic Reviews in Occupational Therapy

CRITICALLY APPRAISED TOPIC (CAT) WORKSHEET
Focused Question:
Does cognitive-behavioral therapy improve sleep in adults and older adults with insomnia?
Prepared By:
Melody Klatt ot16.melody.klatt@nv.touro.edu
Jennifer Tom ot16.jennifer.tom@nv.touro.edu
Department of Occupational Therapy
Touro University Nevada
874 American Pacific Dr.
Henderson, NV 89014
Date Review Completed:
8/2/2015
Clinical Scenario:
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). Epidemiologic studies worldwide report
the prevalence of a clinical insomnia disorder being at 10% and 12% (Espie et al., 2012).
Additionally, longitudinal investigation has shown that once an insomnia disorder is
established, the disorder tends to persist (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). One of the main
advantages of CBT is that it is a non-invasive and nonpharamocological approach to treating
insomnia symptoms. Increasing evidence has demonstrated the effectiveness of CBT in
Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

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
occupational therapists may utilize in practice to improve quality of sleep in clients who are
living with a diagnosis of insomnia.

Summary of Key Findings:

Summary of Levels I, II and III:

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 (Morin et al., 2009; Morin, Colecchi,
Stone, Sood, & Brink, 1999; Morin et al., 2004; Sivertsen et al., 2006).
However, across all studies, the most significant reports of improvement were
associated with interventions that used a combined approach, utilizing both
CBT and sleep medication (Morin et al., 2009; Morin et al., 1999; Morin et al.,
2004; Sivertsen et al., 2006).

One study compared the effectiveness of CBT versus Tai Chi Chih, 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 (Espie et al., 2014). CBT was associated with improvements in
self-reported sleep latency, wakefulness after sleep onset, and sleep efficiency
when compared with the TAU group (Espie et al., 2014).

One study compared the effectiveness of CBT versus sleep hygiene education.
The results indicated that CBT 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),

Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

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 web-based 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).

Summary of Level IV and V:

N/A
Contributions of Qualitative Studies:
N/A
Bottom Line for Occupational Therapy Practice:
The clinical and community-based practice of OT:
Research supports the use of CBT as an effective intervention in treating primary and
comorbid insomnia as it has shown to increase sleep quality, sleep duration and decrease
fatigue (Edinger et. al., 2009, Level 1).

Research indicates that CBT alone is more effective compared to other forms of treatment
such as medication alone, Tai Chi alone, or treatment as usual (Morin et al., 2009, Level
I; Morin, Colecchi, Stone, Sood, & Brink, 1999, Level I; Morin et al., 2004, Level I;
Sivertsen et al., 2006, Level I; Espie et al., 2014, Level I; Irwin et al., 2014, Level I).
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
(Morin et al., 2009, Level I; Morin et al., 1999, Level I; Morin et al., 2004, Level I;
Sivertsen et al., 2006, Level I).

This lends evidence to the fact that nonpharmacological interventions such as CBT may
be used to treat insomnia symptoms in adult clients, and this should be considered by OTs
who may treat clients with this diagnosis.
Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

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, as a form of treatment for individuals
who are suffering from symptoms of insomnia (Edinger & Sampson, 2003, Level I).

Societal needs:
CBT has been shown to be an effective nonpharmacological intervention to treat clients
who are suffering from primary and comorbid insomnia (Edinger et al., 2009, Level I).
For clients within society who may want to limit their medication intake, this treatment
option may be an important consideration. In addition, the nature of CBT when
provided to a client may reduce the amount of overall medical treatment that a client
may pursue in the interest of relieving their symptoms.

ACBT may be a viable treatment method to treat symptoms of insomnia. Utilizing this
treatment technique could potentially save time and resources, and could stand as a
nonpharmacological option for treating insomnia symptoms.

One study suggests web-based CBT as an effective means of treating insomnia symptoms
in adults (Espie et al., 2012, Level I). In a society that is continuously becoming more
and more dependent on computers and online interactions, web-based CBT may be a
more appealing and convenient option for clients particularly clients who would
otherwise have to travel significant distances to receive the treatment at a facility.

Healthcare delivery and policy:

Further research is required on the use of CBT in this population because results should
be considered preliminary in regard to directing funds for policy, as the sample size of the
studies are relatively small (Edinger et al., 2009, Level I; Irwin et al., 2014, Level I;
Edinger & Sampson, 2003, Level I; Espie et al., 2012, Level I; Morin et al., 1999, Level
I; Espie et al., 2014, Level I; Morin et al., 2004, Level I; Sivertsen et al., 2006, Level I).

On the other hand, CBT is more economical and effective in comparison to other
interventions such as using only medications in treating symptoms of insomnia.

Education and training of OT students:

OT students are well-educated on sleep hygiene and sleep as an important occupation.
Poor quality and duration of sleep can negatively impact ones mental and physical
Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

health as it can affect participation and engagement in ones daily occupations.

Students will require education and formal training in regards to implementing CBT in
practice to provide a form of intervention in treating symptoms of insomnia. Thus, CBT
would be a valuable component of education for entry-level therapists and should be
incorporated into the education and training of OT students so that they may consider
CBTT as a form of nonpharmacological intervention for treating symptoms of insomnia
in adults and older adults.

Refinement, revision, and advancement of factual knowledge or theory:

Further research is required due to the small sample sizes that were used in the studies
that were reviewed, as this that affects the generalizability of the results. Future research
should use larger sample sizes to improve the quality of the data (Edinger et al., 2009;
Irwin et al., 2014; Edinger & Sampson, 2003; Espie et al., 2012; Morin et al., 1999; Espie
et al., 2014; Morin et al., 2004; Sivertsen et al., 2006).

Additional research is required due to the need for more diversity in diagnoses for
participants with comorbid insomnia, as well as better randomization for the recruitment
process (Edinger et al., 2009).

Further research should also be conducted with more proportionate representations of

males and females to improve the generalizability of the results (Edinger et al., 2009;
Irwin et al., 2014; Edinger & Sampson, 2003; Espie et al., 2012; Morin et al., 1999I).

Future research methods should prevent the possibility of cointervention bias as this can
skew the psychometric properties of the results (Espie et al., 2012).

Review Process:

A focus question that identified a population, intervention, and outcome (PIO) was
comprised.
The focus question was articulated and submitted for the course instructor to review.
After the focus question was accepted and approved by the course instructor, a
comprehensive literature search was completed.
Selected articles that met the PIO were gathered and compiled into a comprehensive
literature search.
Comprehensive literature search was completed, and priority articles were appraised after
exclusions and inclusion criteria were applied.
Summarizations of the prioritized articles were submitted to the course instructor and
Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

returned with feedback.

The evidence table was comprised based on the priority articles and was submitted for
review and returned with feedback.
Finally, the evidence table was summarized into a critically appraised topic.

Procedures for the Selection and Appraisal of Articles:

Inclusion Criteria:
Studies that were included in this review were outcomes-based research Level I (RCT) studies
that focused on an adult and older adult age group, studies that included cognitive behavioral
therapy as a means of treating insomnia symptoms, and studies that were written in English.
Exclusion Criteria:
Studies that were excluded in this review included reviews older than 20 years (nothing included
before the year 1995), studies that focused on younger adults, and studies that were in any other
language other than English. Qualitative studies and dissertations were also excluded.
Search Strategies:
Categories
Patient/Client Population
Intervention
Outcomes

Key Search Terms

Older adults, adults, insomnia
CBT, cognitive behavioral therapy
Sleep duration, sleep quality, sleep improvement

Databases and Sites Searched

CINAHL, The Cochrane Library, Google Scholar, PubMed
Quality Control/Peer Review Process:

Focus question was developed by student with refinement by instructor of record.

Focus question, literature review, evidence table, articles, and critically appraised topic
(CAT) were reviewed by peer and course instructor and feedback was provided to ensure
accuracy and thoroughness of process.
CAT was completed by students after articles were reviewed and evidence tables were
comprised. All feedbacks and comments given by course instructor were considered.

Results of Search:
Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

Summary of Study Designs of Articles Selected for Appraisal:

Level of
Evidence
I
II
III
IV
V
Other

Study Design/Methodology of Selected Articles

9 RCT

Qualitative Studies
TOTAL:

Number of Articles
Selected
9
0
0
0
0
0
9

Limitations of the Studies Appraised:

Levels I, II, and III

Small sample size. Larger sample sizes would have increased the
generalizability of results and the representation of the population (Edinger et
al., 2009, Level I; Irwin et al., 2014, Level I; Edinger & Sampson, 2003, Level
I; Espie et al., 2012, Level I; Morin et al., 1999, Level I; Espie et al., 2014,
Level I; Morin et al., 2004, Level I; Sivertsen et al., 2006, Level I).

Participants were recruited from one single site, which also may have limited
the generalizability of the results and the representation of the population
(Edinger et al., 2009, Level I; Irwin et al., 2014, Level I; Edinger & Sampson,
2003, Level I).

The sample of participants included a disproportionate representation of men

versus women, which may have limited the generalizability of the results to
both sexes (Edinger et al., 2009, Level I; Irwin et al., 2014, Level I; Edinger &
Sampson, 2003, Level I; Espie et al., 2012, Level I; Morin et al., 1999, Level I).

There was a possibility of co-intervention bias in one study due to the fact that
participants were receiving other types of treatment for their insomnia during
the implementation of the studys interventions (Espie et al., 2012, Level I).

Participants were recruited through newspaper advertisements, which decreases

the generalizability of the results to the general population and people who may
not read the newspaper (Morin et al., 1999, Level I; Morin et al., 2004, Level I).

In one study, the data set was limited to self-report and actigraphic estimation,
Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

which may have influenced the objectivity and reliability of the results (Espie et
al., 2014, Level I).

In one study, participants were similar in characteristics and demographics,

which decreases generalizability of the results to the general population (Morin
et al., 2004, Level I).

Researchers were unable to blind the CBT condition, which can lead to result
biases (Sivertsen et al., 2006, Level I).

Levels IV and V
N/A
Other
N/A

Articles Selected for Appraisal:

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.
Espie, C. A., Kyle, S. D., Williams, C., Ong, J. C., Douglas, N. J., Harnes, P., & Brown, J. S. L.
(2012). A randomized, placebo-controlled trial of online cognitive behavioral therapy for
chronic insomnia disorder delivered via an automated media-rich web application.
Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

SLEEP, 35(6), 769-781.

Espie, C. A., MacMahon, K. M. A., Kelly, H., Broomfield, N. M., Douglas, N. J., Engleman, H.
M.Wilson, P. (2014). Randomized clinical effectiveness trial of nurse-administered
small-group cognitive behavior therapy for persistent insomnia in general practice.
SLEEP, 30(5), 574-584.
Irwin, M. R., Olmstead, R., Carrillo, C., Sadeghi, N., Breen, E. C., Witarama, T.Nicassio, P.
(2014). Cognitive behavioral therapy vs. Tai Chi for late life insomnia and inflammatory
risk: A randomized controlled comparative efficacy trial. SLEEP, 37(9). 1543-1552.
Morin, C. M., Bastien, C., Guay, B., Radouco-Thomas, M., Leblanc, J., & Vallieres, A. (2004).
Randomized clinical trial of supervised tapering and cognitive behavior therapy to
facilitate Benzodiazepine discontinuation in older adults with chronic insomnia.
Psychiatry, 161, 332-342.
Morin, C. M., Colecchi, C., Stone, J., Sood, R., & Brink, D. (1999). Behavioral and
pharmacological therapies for late-life insomnia: A randomized controlled trial. Journal
of American Medical Association, 281(11), 991-999.
Morin, C. M., Vallieres, A., Guay, B., Iyers, H., Savard, J., Chantal, M.Baillargeon, L. (2009).
Cognitive behavioral therapy, singly and combed with medication, for persistent
insomnia: A randomized controlled trial. The Journal of the American Medical
Association, 301(19), 2005-2015.
Sivertsen, B., Omvik, S., Pallesen, S., Bjorvatn, B., Havik, O. E., Kvale, G.Nordhus, I. H.
(2006). Cognitive behavioral therapy vs. Zopiclone for treatment of chronic primary
insomnia in older adults: A randomized controlled trial. JAMA, 295(24), 2851-2858.

Other References:
Dobson, D. & Dobson, K. (2009). Evidence-based practice of cognitive-behavioral therapy.
New York, NY: The Guilford Press.
Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05