Elsevier

Sleep Medicine Reviews

Volume 54, December 2020, 101351
Sleep Medicine Reviews

CLINICAL REVIEW
Economic evaluation of cognitive behavioural therapy for insomnia (CBT-I) for improving health outcomes in adult populations: A systematic review

https://doi.org/10.1016/j.smrv.2020.101351Get rights and content

Summary

Cognitive behavioural therapy for insomnia (CBT-I) is a promising intervention with established efficacy, yet evidence of its cost-effectiveness remains unclear. Systematic searches were conducted in Medline, Psychinfo, ProQuest, Cochrane, Scopus, CINAHL, Web of Science and Emcare. Titles and abstracts were screened against eligibility criteria, and studies reporting full economic evaluations of CBT-I in adult populations were included and examined in detail. Study characteristics were extracted using a standardised template. Quantitative measures and relevant findings were summarised using a qualitative approach following recommended reporting standards. 1,168 non-duplicate articles were identified, of which 44 were selected for full-text review. Seven full economic evaluations of CBT-I in adult populations met the inclusion criteria and were incorporated in the final synthesis. Using the dominance ranking framework to compare cost and outcomes, CBT-I was cost-effective compared to pharmacotherapy or no treatment. The limited number of studies included in this review implies that caution should be exercised when interpreting these results. Future studies are encouraged to employ longer time-horizons and larger sample sizes to enable better determination of sustained cost and outcomes changes.

Prospero registration number: CRD42019133554.

Section snippets

Background

Insomnia is a common sleep disorder among the general adult population. It is characterised by difficulties initiating sleep, maintaining sleep or early morning awakenings, despite sufficient opportunity for sleep, resulting in poor sleep quality and daytime impairment [[1], [2], [3], [4], [5]]. This condition is associated with a range of adverse health consequences for individuals, including increased risk of psychiatric disorders and reduced health-related quality of life (HRQoL) [[6], [7],

Methods and design

The methodology utilised for this review has been described in a previously published protocol [39]. Empirical and model-based economic evaluation studies comparing CBT-I with comparators (i.e., pharmacotherapy and no treatment) in individuals with insomnia aged 18 years or older and published in English were eligible for this systematic review. Exclusion criteria were studies reporting non-human subjects, children or adolescents (<18 years), as well as theoretical papers, commentaries,

Study selection

The schematic presentation of the study selection using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines is presented in Fig. 1:

  • i.

    Identification: A total of 1,475 citations were generated from the database searches, and an additional 17 were retrieved from backward and forward-searching of reference lists of the final studies. 324 duplicate articles were removed.

  • ii.

    Screening: 1,168 titles and abstracts were screened for eligibility; 1,224 did not meet basic

Discussion

This systematic review used strict reporting standards [50] to review economic evaluation studies investigating the cost and health benefits of CBT-I in adult populations with insomnia. Previous reviews have examined the use of economic evaluation approaches to sleep health, including insomnia interventions [35,37]. However, these reviews did not incorporate a systematic search strategy, standard reporting of economic studies, or the newer delivery mechanisms of CBT-I through online platforms [

Conclusion

This systematic review has provided evidence relating to the application of economic evaluation of CBT-I across a range of settings and different CBT-I modalities. Using comprehensive and standardised tools to appraise such evidence [[50], [51], [52]], we found that CBT-I is a cost-effective intervention for insomnia compared to control, highlighting the importance of promoting awareness and access to this therapy for insomnia. However, due to the heterogeneity within the limited number of

Conflicts of Interest

The authors do not have any conflicts of interest to disclose.

Acknowledgements

We thank Flinders University for enabling us to access not-freely available articles. Special thanks to Ms Leila Mohammadi, who helped with the database search strategy. We also acknowledge the authors of primary studies. Funding support is received from the Australian Government Research Training Program and NHMRC CRE - National Centre of Sleep Health Services Research.

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