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BackgroundChronic insomnia disorder is highly prevalent, disabling and costly. Cognitive-behavioural therapy for insomnia (CBT-I) is recommended as the first-line treatment. CBT-I may contain various educational, cognitive and behavioural strategies delivered in a range of formats, but the effect of each component remains unclear.MethodsWe performed a systematic review and component network meta-analysis (cNMA) of CBT-I trials for chronic insomnia. We searched PubMed, CENTRAL, PsycINFO and ICTRP for randomised controlled trials published from database inception to 14thMay 2022, comparing any form of CBT-I against each other or a control condition for chronic insomnia disorder in adults (aged ≥18 years). We included insomnia both with and without comorbidities. Concomitant treatments were allowed if they were equally distributed among the arms. Two independent reviewers identified components, extracted data, and assessed trial quality. Primary outcome of interest in this study was treatment efficacy (remission defined as reaching a satisfactory state at endpoint measured by any validated self-reported scale) at post-treatment. (PROSPERO; CRD42022324233)FindingsWe identified 226 trials, including 29,982 participants. Mean age was 45·7 years and 71% were women. The results suggests that critical components of CBT-I are cognitive restructuring (incremental odds ratio[iOR] 1·63 [95% confidence interval 1·25 to 2·14]), sleep restriction (iOR 1·44 [1·00 to 2·06]) and stimulus control (iOR 1·44 [1·00 to 2·07]) Sleep hygiene education was not essential (iOR 1·05 [0·79 to 1·38]) and relaxation procedures may be counterproductive (iOR 0·81 [0·64 to 1·03]). Face-to-face, therapist-led program was found to be most beneficial (iOR 1·86 [1·21to 2·85]). The overall risk of bias was low in 8% of the trials, some concerns in 56%, and high in 36%.InterpretationThis cNMA suggests that effective and efficient CBT-I packages can include cognitive restructuring, sleep restriction and stimulus control, but not relaxation.FundingNone.

IntroductionInsomnia is highly prevalent and disabling. Clinical practice guidelines recommend cognitive-behavioral therapy for insomnia (CBTI) as the first-line treatment. However, CBTI includes various combinations of many different components and its clinical benefits have been shown as a package, whereas the effect of each component remains unclear. In this study, we will explore the effect of each component of CBTI with the use of component network meta-analysis.Methods and analysisWe will include all randomized controlled trials that compared any form of CBTI against another form of CBTI or a control condition in the treatment of adults with chronic insomnia. Concomitant treatments will be allowed as long as they are equally distributed among the arms. We will include both primary and secondary insomnia. The primary outcome of interest in this study is (1) treatment efficacy (remission defined as reaching a satisfactory state at endpoint measured by any validated self-reported scale) at four weeks post-treatment or at its closest time point. Secondary outcomes are (2) acceptability, (3) sleep diary measures and (4) efficacy at long-term follow-up. We will systematically search in PubMed, CENTRAL, PsycINFO and WHO International Clinical Trials Registry Platform. We will assess risk of bias using Cochrane Risk of Bias 2.0 tool. We will conduct component network meta-analysis with the netmeta package in R.Ethics and disseminationThis study will use published data and does not require ethical approval. Findings will be disseminated in a peer-reviewed journal.PROSPEROCRD42022324233.