Optimizing Insomnia Treatment: Combination Therapy vs. dCBT-I vs. Medication


Evidence shows digital cognitive behavioral therapy for insomnia is more effective than medication therapy, with comparable effectiveness to combination therapy.

Optimizing Insomnia Treatment: Combination Therapy, dCBT-I vs. Medication

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Combining cognitive behavioral therapy (CBT) with medication is the optimal treatment for patients with insomnia based on new evidence provided by a large clinical study. The data suggest that combination therapy was most effective, and digital CBT was more effective than medication therapy, with long-term benefits for insomnia.1

Cognitive behavioral therapy for insomnia (CBT-I) is a well-established and effective treatment, and digital cognitive behavioral therapy for insomnia (dCBT-I) has been gaining popularity due to its accessibility, convenience, and cost-effectiveness.

For this assessment, investigators aimed to evaluate the clinical effectiveness, engagement, durability, and adaptability of dCBT-I, compared with medication therapy or their combination, in a real-world clinical setting.

Combining Insomnia Treatment Approaches

The study was conducted using longitudinal data collected via a mobile app named Good Sleep 365 between November 2018-February 2022. The Pittsburgh Sleep Quality Index (PSQI) score and its essential subitems were used as the primary outcomes, and effectiveness on comorbid somnolence, anxiety, depression, and somatic symptoms were used as secondary outcomes.

Menglin Lu, MSC, Zhejiang University, Hangzhou, China, and a group of investigators, evaluated data on a total of 4052 patients with insomnia (74.7% were women) with a mean age of 44.29 years.

The patients were assigned to receive dCBT-I (n = 418), medication therapy (n = 862), or a combination of both (n = 2772), according to their prescriptions.

Significant reductions in the PSQI score at 6 months were observed in both dCBT-I and combination therapy approaches, compared with medication therapy alone. The study found that both dCBT-I and combination therapy were associated with

Specifically, dCBT-I had a comparable effect as combination therapy but showed unstable durability, investigators noted. They reported that outcomes of dCBT-I improved steadily and rapidly during the first 3 months and then fluctuated.

Additionally, response rates with dCBT-I and combination therapy were higher than with medication therapy. Changes in secondary outcomes indicated statistically significant benefits from dCBT-I and combination therapy.

Consistency Among Results

When investigators reviewed results from the subgroup analysis they found them to be consistent with the main findings, therefore demonstrating the superiority of dCBT-I vs medication therapy in various subpopulations.

The study acknowledged several strengths, including its real-world setting, large sample size, and comprehensive evaluation of the effectiveness, engagement, durability, and adaptability of dCBT-I.

However, it also had some limitations, such as its retrospective design, lack of a placebo control group, and reliance on self-reported outcomes.

The results emphasized the potential of dCBT-I as a first-line treatment option for insomnia, particularly in the context of limited access to traditional CBT-I. Investigators also expressed the need for future studies to analyze the clinical effectiveness and reliability of dCBT-I in distinct subpopulations, and to address the challenges of engagement and durability in dCBT-I interventions.

Overall, these data contributed to the expanded understanding related to the use of dCBT-I for managing insomnia and support the importance of personalized and evidence-based treatment approaches for this debilitating sleep disorder.


  1. Lu M, Zhang Y, Zhang J, et al. Comparative Effectiveness of Digital Cognitive Behavioral Therapy vs Medication Therapy Among Patients With Insomnia. JAMA Netw Open. 2023;6(4):e237597. doi:10.1001/jamanetworkopen.2023.7597
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