Comparative Effects of Various Modalities of Cognitive Behavioral Therapy for Insomnia in Adolescents: A Systematic Review and Network Meta-Analysis.

Substantial heterogeneity across trials, with very high network heterogeneity for total sleep time and sleep onset latency, may have affected internal validity. About 32% of included studies had some risk-of-bias concerns, mainly in randomization, deviations from intended interventions and selective reporting. Studies were unevenly distributed across CBTi formats, so some comparisons had limited precision. CBTi components varied across trials, including sleep hygiene, stimulus control, sleep restriction, cognitive restructuring, relaxation, mindfulness or parent involvement, so the effect of delivery format alone may not be separable. The outcomes were mostly subjective sleep diaries or questionnaires, not objective actigraphy, and wake after sleep onset showed no superiority for any format. There were no direct head-to-head trials comparing face-to-face CBTi with web-based CBTi, so their relative effect is inferred indirectly.

The study was funded by National Science and Technology Council of Taiwan grants to H.Y.C.; the authors declare no conflicts of interest, and the funders had no role in design, collection, analysis, interpretation or writing.

Do not conclude that web-based CBTi is proven better than face-to-face CBTi in direct treatment comparison. The ranking came from indirect comparisons, and no head-to-head trial tested these two formats. Do not conclude that any modality is best for wake after sleep onset, because no treatment was superior to any other.