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

BACKGROUND

Insomnia during adolescence impairs mood and cognitive functioning, yet access to effective behavioral sleep treatment is limited. Although CBTi is considered the first-line therapy, the relative value of different delivery formats has remained unclear.

OBJECTIVE

This study systematically evaluated and compared the efficacy of various cognitive behavioral therapy for insomnia (CBTi) delivery formats in improving sleep outcomes among adolescents using a network meta-analysis (NMA).

METHODS

A comprehensive search of five databases, namely PubMed, Embase, PsycINFO, CINAHL, and the Cochrane Library, was conducted through September 28, 2025. Eligible studies were randomized controlled trials (RCTs) involving adolescents with insomnia that examined at least one CBTi modality, including web-based, face-to-face, group-based, mobile-app-based, self-help, brief CBTi, and sleep hygiene. Both pairwise and network meta-analyses were conducted using a frequentist random-effects model. Risk of bias was evaluated using the Cochrane Risk of Bias 2.0 tool, and confidence in evidence was examined using the Confidence in NMA framework. Sleep outcomes included total sleep time (TST), sleep onset latency (SOL), wake after sleep onset (WASO), sleep efficiency (SE), and insomnia severity.

RESULTS

Twenty-two RCTs evaluating seven CBTi modalities were analyzed. Web-based CBTi consistently outperformed other delivery formats across most outcomes, significantly improving TST by 33 min, reducing SOL by 23 min, increasing SE by 7%, and reducing insomnia severity by 5 points compared with usual care. P score analysis identified web-based CBTi as the most effective modality for TST (86%), SOL (79%), SE (74%), and insomnia severity (99%). No significant differences were observed for WASO.

LINKING EVIDENCE TO ACTION: Web-based CBTi is the most effective delivery format for improving sleep outcomes among adolescents. These findings support integrating CBTi into adolescent-focused sleep care pathways. Implementation of web-based CBTi as a first-line option in school and primary-care pathways could expand access and improve outcomes.

TRIAL REGISTRATION: PROSPERO: CRD420251128688.