ImportanceChronic insomnia disorder is highly prevalent, disabling, and costly. Cognitive behavioral therapy for insomnia (CBT-I), comprising various educational, cognitive, and behavioral strategies delivered in various formats, is the recommended first-line treatment, but the effect of each component and delivery method remains unclear.ObjectiveTo examine the association of each component and delivery format of CBT-I with outcomes.Data SourcesPubMed, Cochrane Central Register of Controlled Trials, PsycInfo, and International Clinical Trials Registry Platform from database inception to July 21, 2023.Study SelectionPublished randomized clinical trials comparing any form of CBT-I against another or a control condition for chronic insomnia disorder in adults aged 18 years and older. Insomnia both with and without comorbidities was included. Concomitant treatments were allowed if equally distributed among arms.Data Extraction and SynthesisTwo independent reviewers identified components, extracted data, and assessed trial quality. Random-effects component network meta-analyses were performed.Main Outcomes and MeasuresThe primary outcome was treatment efficacy (remission defined as reaching a satisfactory state) posttreatment. Secondary outcomes included all-cause dropout, self-reported sleep continuity, and long-term remission.ResultsA total of 241 trials were identified including 31 452 participants (mean [SD] age, 45.4 [16.6] years; 21 048 of 31 452 [67%] women). Results suggested that critical components of CBT-I are cognitive restructuring (remission incremental odds ratio [iOR], 1.68; 95% CI, 1.28-2.20) third-wave components (iOR, 1.49; 95% CI, 1.10-2.03), sleep restriction (iOR, 1.49; 95% CI, 1.04-2.13), and stimulus control (iOR, 1.43; 95% CI, 1.00-2.05). Sleep hygiene education was not essential (iOR, 1.01; 95% CI, 0.77-1.32), and relaxation procedures were found to be potentially counterproductive(iOR, 0.81; 95% CI, 0.64-1.02). In-person therapist-led programs were most beneficial (iOR, 1.83; 95% CI, 1.19-2.81). Cognitive restructuring, third-wave components, and in-person delivery were mainly associated with improved subjective sleep quality. Sleep restriction was associated with improved subjective sleep quality, sleep efficiency, and wake after sleep onset, and stimulus control with improved subjective sleep quality, sleep efficiency, and sleep latency. The most efficacious combination—consisting of cognitive restructuring, third wave, sleep restriction, and stimulus control in the in-person format—compared with in-person psychoeducation, was associated with an increase in the remission rate by a risk difference of 0.33 (95% CI, 0.23-0.43) and a number needed to treat of 3.0 (95% CI, 2.3-4.3), given the median observed control event rate of 0.14.Conclusions and RelevanceThe findings suggest that beneficial CBT-I packages may include cognitive restructuring, third-wave components, sleep restriction, stimulus control, and in-person delivery but not relaxation. However, potential undetected interactions could undermine the conclusions. Further large-scale, well-designed trials are warranted to confirm the contribution of different treatment components in CBT-I.

中文翻译：

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成人慢性失眠认知行为疗法的组成部分和实施方式

重要性慢性失眠症非常普遍、致残且费用高昂。失眠认知行为疗法（CBT-I）包括以各种形式提供的各种教育、认知和行为策略，是推荐的一线治疗方法，但每种成分和治疗方法的效果仍不清楚。 CBT-I 的每个组成部分和交付格式及其结果。数据来源：PubMed、Cochrane 对照试验中央注册库、PsycInfo 和国际临床试验注册平台（从数据库建立到 2023 年 7 月 21 日）。研究选择已发表的随机临床试验，比较任何形式的 CBT- I 针对 18 岁及以上成人慢性失眠症的另一种或对照病症。有或没有合并症的失眠都包括在内。如果在各组间平均分配，则允许进行伴随治疗。数据提取和综合两位独立评审员确定了成分、提取数据并评估了试验质量。进行了随机效应成分网络荟萃分析。主要结果和测量主要结果是治疗后的治疗效果（缓解定义为达到满意的状态）。次要结局包括全因退出、自我报告的睡眠连续性和长期缓解。结果共确定了 241 项试验，包括 31 452 名受试者（平均 [SD] 年龄，45.4 [16.6] 岁；31 452 名受试者中的 21 048 名受试者[ 67%]女性）。结果表明，CBT-I 的关键组成部分是认知重建（缓解增量比值比 [iOR]，1.68；95% CI，1.28-2.20）第三波组成部分（iOR，1.49；95% CI，1.10-2.03）、睡眠限制（iOR，1.49；95% CI，1.04-2.13）和刺激控制（iOR，1.43；95% CI，1.00-2.05）。睡眠卫生教育不是必需的（iOR，1.01；95% CI，0.77-1.32），放松程序被发现可能适得其反（iOR，0.81；95% CI，0.64-1.02）。治疗师亲自主导的项目最为有益（iOR，1.83；95% CI，1.19-2.81）。认知重组、第三波成分和面对面交付主要与主观睡眠质量的改善相关。睡眠限制与主观睡眠质量、睡眠效率和入睡后觉醒的改善相关，刺激控制与主观睡眠质量、睡眠效率和睡眠潜伏期的改善相关。与面对面的心理教育相比，最有效的组合——包括认知重建、第三波、睡眠限制和面对面形式的刺激控制——与缓解率增加相关，风险差异为 0.33 (95 % CI，0.23-0.43）和需要治疗的数字 3.0（95% CI，2.3-4.3），考虑到观察到的中位控制事件率为 0.14。结论和相关性研究结果表明，有益的 CBT-I 方案可能包括认知重建、第三波成分、睡眠限制、刺激控制、和亲自交付但不放松。然而，潜在的未被发现的相互作用可能会破坏结论。需要进一步大规模、精心设计的试验来确认 CBT-I 中不同治疗成分的贡献。