Key

CBT= cognitive behavioral therapy

SRT= sleep restriction therapy

SHE= sleep hygiene education

Brief description of patient problem/setting

A 55 year old female came into the family medicine practice for her annual physical and mentioned that she has a lot of trouble falling and staying asleep at night. She said that she scrolls on her phone for hours to help her fall asleep. The doctor took time to explain to her the harms of looking at her phone when going to sleep and told her all about sleep hygiene. I began to wonder if one conversation regarding sleep hygiene could actually provide much help and decided to research how the efficacy of sleep hygiene compares to CBT and SRT.

Search Question

In postmenopausal women, does the implementation of cognitive behavioral therapy (CBT) or sleep restriction therapy (SRT) compared to sleep hygiene education (SHE) alone yield reduced insomnia symptoms and less day time sleepiness?

Question Type

☐Prevalence                        ☐Screening              ☐Diagnosis

☐Prognosis                          ☒Treatment              ☐Harms

P	I	C	O
Post-menopausal women	CBT	Sleep hygiene	Improved symptoms of insomnia
Post-menopause	Cognitive behavioral therapy	Sleep wellness	Less insomnia symptoms
Peri-menopause	SRT	Nocturnal habits	Decreased daytime sleepiness
Menopausal women	Behavioral therapy	Sleep protocol	Improved daytime functioning
	Behavioral intervention	Bedtime rituals	Better sleep efficiency
	Sleep restriction therapy	Sleep strategies	Improved sleep patterns

Search tools and strategy used

PubMed:

• (sleep hygiene) AND (insomnia) AND (menopause)-> 31 results
  • Since 2019 -> 23 results
• (CBT) AND (insomnia) AND (menopause) -> 21 results
  • Since 2019 -> 16 results
• (CBT vs sleep hygiene) AND (insomnia) AND (menopause) -> 1 result

Science Direct:

• (CBT vs sleep hygiene) AND (insomnia) AND (menopause) -> 102 results
  • Since 2019 -> 41 results
    • Review articles -> 17 results
• (sleep hygiene) AND (insomnia) AND (post menopause) -> 442 results
  • Since 2019 -> 123 results
    • Review articles -> 45 results
• (peri menopause insomnia) AND (treatment) -> 857 results
  • Since 2019 -> 195 results
    • Review articles -> 70 results

Cochrane:

• (post menopause) AND (insomnia) AND (CBT) -> 16 results
  • Since 2019 -> 1 result
• (CBT vs sleep hygiene) AND (insomnia) AND (menopause) -> 2 results
• (post menopause) AND (insomnia) AND (treatments) -> 74 results
  • Since 2019 -> 25 results

I used three databases to find results for my PICO question. When too many results came up I used filters such as filtering by years and by filtering based on the type of study I wanted. When I narrowed it down enough I read through the titles and abstracts to find the articles that pertained to my PICO question in the best way. I placed emphasis on more recent articles and those that were an RCT or meta-analysis.

Results Found

Article 1:

Citation	Drake CL, Kalmbach DA, Arnedt JT, et al. Treating chronic insomnia in postmenopausal women: a randomized clinical trial comparing cognitive-behavioral therapy for insomnia, sleep restriction therapy, and sleep hygiene education. Sleep. 2019; https://academic.oup.com/sleep/article/42/2/zsy217/5179856
Abstract	Study ObjectivesInsomnia is a leading cause of disability in postmenopausal women. Multicomponent cognitive-behavioral therapy for insomnia (CBTI) is a first-line treatment for chronic insomnia, but support for its efficacy in treating menopause-related insomnia is scarce. The present study evaluated whether CBTI is an efficacious treatment for menopause-related chronic insomnia, and whether sleep restriction therapy (SRT)—a single component of CBTI—is equally efficacious compared with CBTI.MethodsIn a single-site, randomized controlled trial, 150 postmenopausal women (56.44 ± 5.64 years) with chronic DSM-5 insomnia disorder related to menopause were randomized to three treatment conditions: sleep hygiene education (SHE), SRT, or CBTI. Blinded assessments were performed at baseline, posttreatment, and 6 months after treatment. The Insomnia Severity Index (ISI) and sleep diaries served as primary outcomes.ResultsFrom baseline to posttreatment, ISI decreased 7.70 points in the CBTI group (p < .001), 6.56 points in the SRT group (p < .001), and 1.12 in the SHE group (p = .01). Although average sleep duration increased in all groups by 6 month follow-up, CBTI patients obtained 40–43 more minutes of nightly sleep than those who received SHE or SRT. Remission rates in the CBTI (54%–84%) and SRT (38%–57%) groups were higher than SHE patients (4%–33%) at posttreatment and 6 month follow-up. CBTI patients were generally more likely to remit than SRT patients.ConclusionsCBTI and SRT effectively treat menopause-related insomnia disorder and are superior to SHE. Response to CBTI and SRT is similar, but CBTI outperforms SRT in improving sleep maintenance, which may increase likelihood of remission.
Level of Evidence	RCT
Why I chose this	I chose to include this article because of a few reasons. First of all, it was published in a peer reviewed journal that conducts studies on sleep, entitled Sleep. It was also published in 2019, within the past 5 years. It is also an RCT which is one of the highest levels of evidence. It was conducted within the US. Finally, it also directly looks at my exact question and compares sleep hygiene and CBT for postmenopausal women.

Article 2:

Citation	Kalmbach DA, Cheng P, Arnedt JT, et al. Improving Daytime Functioning, Work Performance, and Quality of Life in Postmenopausal Women With Insomnia: Comparing Cognitive Behavioral Therapy for Insomnia, Sleep Restriction Therapy, and Sleep Hygiene Education. J Clin Sleep Med. 2019;15(7):999-1010. Published 2019 Jul 15. https://jcsm.aasm.org/doi/full/10.5664/jcsm.7882
Abstract	Study ObjectivesInsomnia is a chief complaint among postmenopausal women, and insomnia impairs daytime functioning and reduces quality of life. Recent evidence supports the efficacy of cognitive behavioral therapy for insomnia (CBTI) for menopausal insomnia, but it remains unclear whether treating insomnia improves daytime function in this population. This study evaluated whether CBTI improves daytime fatigue, energy, self-reported sleepiness, work productivity, and quality of life in postmenopausal women with insomnia, and whether sleep restriction therapy (SRT)—a single component of CBTI—is equally efficacious.MethodsSingle-site, randomized control trial. One hundred fifty postmenopausal women (56.44 ± 5.64 years) with perimenopausal or postmenopausal onset or exacerbation of chronic insomnia were randomized to 3 treatment conditions: sleep hygiene education control (SHE), SRT, and CBTI. Blinded assessments were performed at pretreatment, posttreatment, and 6-month follow-up.ResultsCBTI and SRT produced moderate-to-large improvements in fatigue, energy, sleepiness, and work function at posttreatment and 6 months later. The CBTI group reported better quality of life as indicated by substantial improvements in emotional wellbeing and resiliency to physical and emotional problems, whereas the SRT and SHE groups only showed improvements in resiliency to physical problems. Pain complaints decreased as sleep improved but were not associated with specific treatment conditions. Similarly, insomnia remitters reported fewer daytime and nighttime hot flashes, although reductions were not associated with any specific treatment.ConclusionCBTI and SRT are efficacious options for postmenopausal women with chronic insomnia. Both interventions improve daytime function, quality of life, and work performance, although CBTI produces superior results including the added benefit of improved emotional health.
Level of Evidence	RCT
Why I chose this	The first reason I chose to include this article is because it was published in a monthly peer reviewed journal. It was also recently published in 2019 and is very relevant. It also focuses directly on my question and compares CBT to sleep hygiene. I thought this gave a unique approach and specifically focused on how they affected the day time functioning of the participants. Finally, it is an RCT which is one of the highest levels of evidence and it was conducted in the US.

Article 3:

Citation	Chung KF, Lee CT, Yeung WF, Chan MS, Chung EW, Lin WL. Sleep hygiene education as a treatment of insomnia: a systematic review and meta-analysis. Fam Pract. 2018; https://academic.oup.com/fampra/article/35/4/365/4671078?login=false
Abstract	BackgroundSleep hygiene education (SHE) is commonly used as a treatment of insomnia in general practice. Whether SHE or cognitive-behavioural therapy for insomnia (CBT-I), a treatment with stronger evidence base, should be provided first remains unclear.ObjectiveTo review the efficacy of SHE for poor sleep or insomnia.MethodsWe systematically searched six key electronic databases up until May 2017. Two researchers independently selected relevant publications, extracted data and evaluated methodological quality according to the Cochrane criteria.ResultsTwelve of 15 studies compared SHE with CBT-I, three with mindfulness-based therapy, but none with sham or no treatment. General knowledge about sleep, substance use, regular exercise and bedroom arrangement were commonly covered; sleep-wake regularity and avoidance of daytime naps in seven programs, but stress management in only five programs. Major findings include (i) there were significant pre- to post-treatment improvements following SHE, with small to medium effect size; (ii) SHE was significantly less efficacious than CBT-I, with difference in effect size ranging from medium to large; (iii) pre- to post-treatment improvement and SHE-CBT-I difference averaged at 5% and 8% in sleep-diary-derived sleep efficiency, respectively, and two points in Pittsburgh Sleep Quality Index; (iv) only subjective measures were significant and (v) no data on acceptability, adherence, understanding and cost-effectiveness.ConclusionsAlthough SHE is less effective than CBT-I, unanswered methodological and implementation issues prevent a firm conclusion to be made on whether SHE has a role in a stepped-care model for insomnia in primary care.
Level of Evidence	Systematic review and meta-analysis
Why I chose this	The first reason I chose to include this article is because it is a meta-analysis which is considered to be the highest level of evidence. It was also published in a journal article called Family Practice which is peer reviewed. I also thought this would be interesting to include because it specifically focuses on the efficacy of sleep hygiene which is the intervention that the doctor in the scenario used. Although the title does not compare sleep hygiene to CBT, the comparison is included in the discussion. It does not specifically focus on post-menopausal women but I still thought it would be beneficial to include. It was also published in 2018, within the past 10 years.

Article 4:

Citation	Kalmbach DA, Cheng P, Arnedt JT, et al. Treating insomnia improves depression, maladaptive thinking, and hyperarousal in postmenopausal women: comparing cognitive-behavioral therapy for insomnia (CBTI), sleep restriction therapy, and sleep hygiene education. Sleep Med. 2019; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6503531/
Abstract	IntroductionDepression increases during menopause, and subclinical depressive symptoms increase risk for major depression. Insomnia is common among postmenopausal women and increases depression-risk in this already-vulnerable population. Recent evidence supports the efficacy of cognitive-behavioral therapy for insomnia (CBTI) to treat menopausal insomnia, but it remains unclear whether treating insomnia also alleviates co-occurring depressive symptoms and depressogenic features. This trial tested whether CBTI improves depressive symptoms, maladaptive thinking, and somatic hyperarousal in postmenopausal women with insomnia, and whether sleep restriction therapy (SRT)—a single component of CBTI—is equally efficacious. Materials and methods. Single-site, randomized controlled trial. 117 postmenopausal women (56.34±5.41 years) with peri-or-postmenopausal onset of chronic insomnia were randomized to 3 treatment conditions: sleep hygiene education control (SHE), SRT; and CBTI. Blinded assessments were performed at baseline, posttreatment, and 6-month follow-up.ResultsCBTI produced moderate-to-large reductions in depressive symptoms, whereas SRT produced moderate reductions but not until 6 months posttreatment. Treatment effects on maladaptive thinking were mixed. CBTI and SRT both produced large improvements in dysfunctional beliefs about sleep, but weaker influences on presleep cognitive arousal, rumination, and worry. Presleep somatic arousal greatly improved in the CBTI group and moderately improved in the SRT group. Improvements in depression, maladaptive thinking, and hyperarousal were linked to improved sleep. SHE produced no durable treatment effects.ConclusionsCBTI and SRT reduce depressive symptoms, dysfunctional beliefs about sleep, and presleep somatic hyperarousal in postmenopausal women, with CBTI producing superior results. Despite its cognitive emphasis, cognitive arousal did not respond strongly or durably to CBTI.
Level of Evidence	RCT
Why I chose this	First of all, this article was published in a peer reviewed journal so I chose to include this. Additionally, it is an RCT that was conducted within the US. RCTs are considered to be one of the highest levels of evidence. Also, I thought this provided a very unique approach. It brings another dimension to the treatments in question (CBT and sleep hygiene) for insomnia. It brings in the fact that insomnia can lead to depression and studies how these treatment methods help with the insomnia and concurrent depression. Lastly, it was published in 2019, very recently.

Author (Date)	Level of Evidence	Sample/Setting(# of subjects/ studies, cohort definition etc. )	Outcome studied	Key Findings	Limitations and Biases
Drake CL, Kalmbach DA, Arnedt JT, et al. (2019)	Randomized control trial	Inclusion criteria:Postmenopausal (12 months of amenorhhea)Wake after sleep onset of overa n hour for 3 days or moreInsomnia onset or worsening per DSM during menopausal periodExclusion criteria:Prior or current depressionSleep disorders other than insomniaMedications influencing sleepParticipants:317 women screened107 women were ineligible56 declined to participate154 participants were includedParticipants were randomly allocated to one of three groups (CBT, sleep hygiene [SHE] or sleep restriction therapy [SRT]) via concealed envelopes.	The outcomes studied were analyzed a few times:Prior to treatmentWithin 2 weeks of completing treatment6 months after treatmentDifferent outcomes measured:Insomnia symptoms via insomnia severity index (ISI)- a self reported index of insomnia severity.Sleep parameters collected via diary. This included sleep onset latency, frequency of nighttime awakenings, wake after sleep onset, sleep quality, time in bed, total sleep time and sleep efficiency.Remission rates	CBT and SRT both provided better insomnia symptom relief in menopausal women than SHE.In both groups, the treatments and relief of symptoms lasted even at the 6 month check in.CBT seems to be a better option than SRT because it provided larger improvements in sleep parameters (such as better long term sleep maintenance).CBT provided better sleep maintenance over SHE. SRT did not significantly differ from SHE in that regard.CBT provides more durable and lasting effects.	Lack of long term follow upAll the participants were from the Detroit area and some racial groups were not represented.The different groups had different modalities and dosing which may have interfered with the results.There were multiple comparisons which may lend itself to errors.
Kalmbach DA, Cheng P, Arnedt JT, et al. (2019)	Randomized control trial	Inclusion criteria:Postmenopausal (12 months of amenorhhea)Wake after sleep onset of overa n hour for 3 days or moreInsomnia onset or worsening per DSM during menopausal periodParticipants:317 women screened107 women were ineligible56 declined to participate154 participants were includedParticipants were randomly allocated to one of three groups (CBT, sleep hygiene [SHE] or sleep restriction therapy [SRT]) via concealed envelopes	The outcomes studied were analyzed a few times:Prior to treatmentWithin 2 weeks of completing treatment6 months after treatmentDifferent outcomes measured:Daytime function- via fatigue severity scale (FSS) (higher score meant more fatigue) and Epworth Sleepiness Scale (ESS)Work function and impairment measured via the Work Productivity and Activity Impairment (WPAI), with higher numbers indicating worse impairment.Quality of life via 36-item Medical Outcomes Study Short Form Health Survey (SF-36). It measured 8 domains and higher numbers indicate better quality of life.Insomnia symptoms via the ISI. Scores over 15 indicates insomnia. Scores under 7 after treatment indicated remission.Sleep-diary based ratings of sleepiness over the past 24 hours from 0 to 10.	CBT and SRT were both more effective in improving daytime function, work performance, and some aspects of quality of life than SHE.Both were effective in increasing energy and improving work productivity but CBT was slightly more efficacious than SRT.Regarding quality of life, the CBT group had greater emotional well being and resilience to physical and emotional problems. The SRT group only had significant improved resilience to physical problems.	Lack of long term follow upAll the participants were from the Detroit area and some racial groups were not represented.The different groups had different modalities and dosing which may have interfered with the results.Differences in treatment engagement, adherence and preference was not accounted for.
Chung KF, Lee CT, Yeung WF, Chan MS, Chung EW, Lin WL. (2018)	Meta-analysis and systematic review	A literature search was conducted on MEDLINE, EMBASE, CINAHL plus, PsycINFO, and Dissertation & Thesis A&I, as well as the Cochrane Library.The quality of studies was assessed using Cochrane’s risks of bias assessment.Inclusion criteria:RCTs including participants with insomnia or complaining of poor sleep.Participants got SHE compared to any other form of treatment.SHE is defined as advice provided to the participant to help improve their sleep but did not include any element of CBT.Texts included:2,361 articles were set for title and abstract screening.133 studies were included for full text screenings.15 studies were eligible for inclusion.	Primary outcome was the improvement in sleep questionnaire scores.If other outcomes were discussed, they also studied those. This included sleep diary data, actigraphy, and polysomnography-derived variables.	SHE seemed to be effective when comparing pre to post treatment outcomes.However, it was less effective than CBT and mindfulness based therapy.The difference between SHE and CBT was moderate to large and was measured in the differences in sleep efficiency and Pittsburgh Sleep Quality Index (PSQI) scores.	Small number of included trials leading to lack of generalizability.Variation in participant characteristics and baseline severity.Methodological limitations, such as the lack of ability to blind participants and personnel.Potential publication bias. This was unlikely because the findings were consistent across all studies.
Kalmbach DA, Cheng P, Arnedt JT, et al. (2019)	Randomized control trial	Inclusion criteria:Postmenopausal (12 months of amenorhhea)Wake after sleep onset of over an hour for 3 days or moreInsomnia onset or worsening per DSM during menopausal periodExclusion criteria:Prior or current depressionSleep disorders other than insomniaMedications influencing sleepParticipants:317 women screened107 women were ineligible56 declined to participate154 participants were includedParticipants were randomly allocated to one of three groups (CBT, sleep hygiene [SHE] or sleep restriction therapy [SRT]) via concealed envelopes.	The outcomes studied were analyzed a few times:Prior to treatmentWithin 2 weeks of completing treatment6 months after treatmentOutcomes measured:Depressive symptoms using the Beck Depression Inventory, 2nd editionMaladaptive thinking which was assessed across 4 surveys. The 4 surveys looked at dysfunctional beliefs about sleep, cognitive arousal during the presleep period, intrusive and deliberate rumination in response to life stress, and trait tendency to engage in worry.Hyperarousal which was measured via the Presleep Arousal Scale Somatic factor (PSAS Somatic).Insomnia symptoms assessed via the ISI.	CBT and SRT were more effective in reducing subclinical depressive symptoms, maladaptive thinking, and somatic hyperarousal than SHE in postmenopausal women with insomnia.Both of the above groups resulted in decreased depressive symptoms even at the 6 month follow up.Both groups were very effective at treating maladaptive thinking, particularly regarding dysfunctional beliefs about sleep.CBT was best at treating presleep hyperarousal with SRT providing only minimal reduction.Both groups showed limited effectiveness in reducing cognitive arousal and stress-related rumination and worry.	Excluded women with major depression and only focused on subclinical levels of depression.Lack of long term follow up.Variations in treatment modalities and delivery may have influenced the outcomes.

Conclusion

Article 1:

• This article concluded that both CBT and SRT provided significant remission rates. CBT showed slightly better remission rates at 54%-84% with SRT showing remission rates of 38%-57%. CBT showed significant improvement in remission and sleep maintenance. It proved to be slightly more efficacious than SRT. SRT required less sessions and could be considered a first line treatment for women who cannot attend many sessions each week. They say that although SHE is a commonly used approach, it provides little benefit and is rejected as a stand-alone treatment for menopausal insomnia.

Article 2:

• This article concludes that both CBT and SRT yields less fatigue and sleepiness, more energy, greater resilience to physical problems and better work productivity in menopausal women. CBT proved to be the better of the two options being that there were larger improvements in fatigue, energy, and daytime sleep propensity. Additionally, the CBT group experienced better resilience to emotional stressors which is something that the SRT group did not achieve. This was good because insomnia does lead to emotional stress. Regardless of the treatment modality, post-menopausal women who had remission from insomnia reported better general health and social functioning, less pain, and fewer hot flashes during the day and night. SHE did not yield any notable improvements.

Article 3:

• This study concluded that SHE did yield improvement in insomnia symptoms, though not as much as seen with CBT. They did mention that the difference in efficacy wasn’t much with the difference in sleep diary symptoms being just 8% and the difference in PSQI just being 2 points. They say that further research should be done comparing SHE to CBT in regards to acceptability, adherence, understanding, cost-effectiveness and ease of implementation. Additionally, they mention that in order to fully understand the efficacy of SHE, more research should be done comparing it to placebo.

Article 4:

• When post-menopausal women with insomnia go into remission, their depressive symptoms, maladaptive thinks and presleep hyperarousal symptoms improve. Women who were treated with CBT and SRT both experienced relief in these areas. However, the CBT group had slightly better results with immediate, durable, and larger reductions in depression, dysfunctional beliefs about sleep, and presleep somatic hyperarousal. Although these benefits were achieved, overall cognitive arousal  (including worry, rumination, and presleep perseverative cognitions) did not have such great response to treatment. Further research should be done to focus CBT and SRT for women with high levels of stress. SHE was less beneficial in all regards.

Overarching Conclusion:

• Research supports that CBT is the most efficacious when inducing remission of insomnia in post-menopausal women and is proved in many ways (less fatigue, more emotional and physical resilience and larger reductions in depression). SRT is also extremely effective in helping with symptoms of insomnia. SHE is not very helpful when it comes to treating post-menopausal insomnia.

Weight of Evidence

Article 1:

• I ranked this article as #2. It is very relevant as it was published within the past 5 years. It is also an RCT which is not the highest level of evidence, but it is second best when it comes to levels of evidence. The subject size was 150 which was divided into 3 groups. This left 50 participants per group, and is a nice, not too small sample size. The participants were assigned to groups via concealed envelopes. It was not able to remain a double blind study, but the participants were not told which group was the control and what they hypothesis was. I also ranked this second because it focused directly on improvement in symptoms of insomnia- waking up after sleep, trouoble falling asleep etc. The limitation of this that the participants were only from one small region and lacks the ability to be generalized.

Article 2:

• I ranked this article as #3. It is another RCT which is second highest in ranking of levels of evidence. It also included a 150 participant sample size which is a nice size. It was published within the past 5 years and is very relevant. The reason I ranked this third and not second as I did the article above is because the outcomes studies were not my most sought after question. It does give insight to how each group affects insomnia by looking at their day time functioning, but it does not answer direct insomnia symptoms. The limitation of this that the participants were only from one small region and lacks the ability to be generalized. There was also no long term follow up.

Article 3:

• I ranked this article as #1. This is a meta-analysis and is considered to be the best and highest level of evidence. It also directly compared SHE and CBT. It does not specifically focus on post-menopausal insomnia but looks at insomnia as a whole. It also has a sample size of 15 RCTs which is a good size and holds statistical value. Although it is an ok size, it is not a very large sample size and more studies would definitely be beneficial, this is one of the limitations of the study. Finally, it was published within the past 10 years.

Article 4

• I ranked this article as #4. Like the above RCTs, this article is an RCT which included 150 participants and was published within the past 5 years. The limitations for this article was very similar to the other RCTs, including the participants being from the same region and lack of long term follow up. Essentially, the evidence is on the same level as the above two RCTs. The reason I ranked this last is because the outcomes it looked at, although interesting and providing a new dimension to my question, it was not a part of my initial PICO question.

Magnitude of Effects

• All of the articles included conclude in a similar fashion stating that the CBT group yields the most improvement in the outcome that they were studying. SRT does provide benefit, though not as robust as CBT and SHE yields very little to no benefits. Because all articles essentially say the same conclusion, the research proves to hold a high magnitude of effect and validity and can be relied on.

Clinical Bottom Line

• My research has proven that between CBT, SRT and SHE, CBT has the most benefits when it comes to treating post-menopausal insomnia. SRT is a close second whereas although SHE may show some benefits it is not considered to be effective at inducing remission of insomnia. Each article proves this by studying the specific outcome that they set out to analyze. Article one found that insomnia symptoms, as studied via the ISI score was largely improved with the CBT group (mean -8.03) and SRT group (mean -7.02) at 6 months follow up. On the other hand, the SHE group had a mean of only -2.22 at the 6 month follow up. Article 2 showed similar results by looking at different outcomes. When they looked at fatigue scores they noted that at 6 months follow up, the CBT group had large decreases in fatigue (.81), the SRT group had moderate decreases in fatigue (.48) and the SHE group had no reported changes in their fatigue score. Next, when I was looking through the results of the fourth article, I found similar things. When they analyzed the decrease of depressive symptoms in each of the three groups after 6 months they found that the CBT group had a large decrease in symptoms (.79), the SRT group had moderate decrease (.50) and the SHE group had no significant changes. The SRT group had higher incidences of depressive symptoms over the other 2 groups. Lastly, article 3 showed how much more effective CBT is over SHE. CBT-I was more effective than SHE for improving sleep onset latency by 11 min, wake after sleep onset by 14 min, Pittsburgh sleep quality index by two points and insomnia severity index by four points.

• In clinical practice I would thus be inclined to provide a short informative talk regarding sleep hygiene, but I would make sure to discuss and send the patient for either SRT or CBT. The choice between CBT and SRT would be a joint decision with informed decision making in place. I would make sure to inform the patient about the slight larger benefits of CBT while making sure to mention that SRT requires less sessions to yield its benefits. I would make sure to mention the importance of one of the two interventions to ensure maintained remission and relief from symptoms of insomnia.