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What's the evidence in support of this? I'm looking at this: https://www.ncbi.nlm.nih.gov/books/NBK343508/#results.s3
Saying most effective in medicine is probably overstating my case, although if asked to justify that I could easily point to adherence issues being the primary point of failure for CBT-I and say something like "if only the patients actually followed the treatment it would work!" which is absolutely true but is a bit dickish.
If you look at your link in the key points section it says things like "CBT-I across several delivery modes improves global and sleep outcomes compared with passive control in the general adult population (moderate strength evidence). Evidence was insufficient to assess adverse effects of CBT-I."
Keep in mind that that the quotes you pulled out are looking at individual sleep metrics as opposed to global sleep outcomes. It is not unreasonable for a treatment method to have more impact on say sleep onset than sleep maintenance.
The AAFP guidelines note:
"Psychological interventions included stimulus control, sleep restriction, relaxation techniques, sleep hygiene education, and CBT for insomnia. CBT for insomnia is a combination of cognitive therapy, behavioral interventions (i.e., sleep restriction and stimulus control), and education (i.e., sleep hygiene). There were insufficient data to draw conclusions on the effectiveness of specific interventions alone (e.g., stimulus control, sleep restriction, relaxation techniques), but based on a meta-analysis of 20 trials, CBT for insomnia improved global and sleep outcomes in the general adult population."
Which is fair and measured.
That said if you change my quoted statement to "CBT-I is the most effective treatment modality for sleep" it becomes significantly more relevant and strictly speaking more accurate. All of the guidelines recommend CBT-I over medication in most circumstances because of severe safety/benefit issues with medication management.
But why aren't the results positive in a clear majority of trials, and why are trials with sham controls less likely to have positive results? If an intervention is effective, shouldn't it be consistently effective, including when compared to sham controls? The evidence for global outcomes wasn't very good, either.
"CBT-I is the most effective treatment modality for sleep" comes across as something of a bailey to the motte of "All of the guidelines recommend CBT-I over medication in most circumstances because of severe safety/benefit issues with medication management," given that the former is a statement about effectiveness and the latter is a statement about safety - in a like-for-like "per-protocol" or "intention-to-treat" comparison, to account for "adherence issues" and safety/abuse potential, is there a clear difference in QALYs?
Thanks!
If you are expecting a wide body of clear and convincing evidence you just aren't going to find it often in medicine, especially when something drifts more into psychiatry, nutrition, and the other more complicated domains.
CBT-I seems to have a good number of sources saying it does something helpful. That's enormously more efficacious than most of the medications which research often suggests do nothing or are counter productive.
Mechanistically this makes sense in the same sense that exercise is better for weight loss than medication. Yes implementation is hard, but working out actually works and medications of various kinds are significantly more variable.
Additionally some of the other sources (like the AAFP) are more positive.
Ultimately medical research is hard and is hampered by ethics and expense. The evidence base for ANYTHING is pretty poor but if it seems to work and makes biological sense, we run with it.
Most medications do not or run into clear issues which just doesn't apply to CBT-I.
To benchmark this, I looked up gabapentin for neuropathic pain, as an example of a common treatment for a heterogenous condition defined by a subjective, placebo-responsive symptom, which commonly has psychiatric comorbidities/involvement. The first review I found with clear figures was this 2017 Cochrane review for "Gabapentin for chronic neuropathic pain in adults", which found all placebo controlled trials favored treatment, even for the greatest, best defined improvement. (You'll have to take my word for it that I didn't cherry-pick, but a <10 year old Cochrane review of gabapentin for neuropathic pain hopefully isn't suspicious.) Should CBTi be held to the standard of gabapentin for chronic neuropathic pain or should gabapentin for chronic neuropathic pain be considered a superlative treatment, above and beyond the superlative you gave CBTi?
If I told you Gabapentin wasn't actually indicated for neuropathic pain would that alter your thoughts at all?
What does "not indicated" mean? "Off-label" (but widely recommended) vs "FDA/equivalent-approved?"
But if the evidence for a "not indicated" treatment with similar challenges is better than that for CBTi, what does that say about CBTi? What standard should we be using?
It's not actually FDA approved for neuropathic pain (or most of what it actually ends up using for) because there isn't enough evidence that the benefits outweigh the risks. Except you just pointed to a study? Shit is messy. One study does not equal consensus.
CBT-I is cheap and found to be effective in a variety of studies and has an extremely small harm profile. Medications for insomnia have been found to be ineffective more often than not and have side effects that include up to things like dementia and death.
CBT-I first.
Aren't off-label prescriptions ~25% of all prescriptions? And doesn't applying for FDA approval de facto require a positive return to be expected before the patent expires? And NICE and other meta-analyses came to the same conclusion as Cochrane. And CBT-I isn't FDA approved, either.
But what proportion of studies finding positive result is sufficient and what control problems are acceptable? If only a borderline majority of studies are positive and better controlled studies are less likely to have positive results, shouldn't we assign a low probability to a treatment being effective, rather than a high probability?
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