The researchers note that the effect sizes in their analysis are similar in magnitude to those seen in meta-analyses of hypnotics, although such studies are often limited by short duration of treatment and absence of long-term follow-up. They add that unlike hypnotics, effects persist after treatment cessation, and although hypnotics are an effective treatment, limitations include tolerance, adverse effects and rebound insomnia after discontinuation. They suggest that because chronic insomnia is a condition in which nearly half of patients remain symptomatic over 10 years and behavioural treatments are likely to be associated with fewer adverse effects, CBT has several advantages over pharmacotherapy.
According to an editorial, despite the robust statistical significance of most findings on such outcomes as sleep onset latency, wake after sleep onset, and sleep efficiency, one could question the clinical significance of the improvements in terms of patients' well-being. The commentator asks whether falling asleep 19 minutes faster or spending 26 fewer minutes awake during the night improve next-day functioning and long-term psychological and physical health outcomes? He notes that CBT for insomnia improves nocturnal sleep and some aspects of daytime functioning (such as fatigue and distress), but there is less evidence about its effect on long-term health outcomes. He also questions the transportability of CBT to clinical practice as there is a major gap between the current state of the science and actual clinical practice, as CBT is relatively unfamiliar to and underused by medical practitioners. In addition, barriers such as limited time and expertise complicate the management of insomnia with CBT in primary care.