Psychological Interventions With Cultural Adaptations More Effective for Treatment of Sleep Disorders

The study authors conducted a systematic review to examine sociodemographic characteristics of behavioral randomized controlled trials for prevalent sleep-wake disorders and sleep disturbances that targeted undeserved adults, identified types of cultural adaptations, and described intervention effectiveness on primary sleep outcomes.

Cultural adaptations likely improve the effectiveness of psychological interventions for sleep disorders. These findings, from a systematic review, were published in Sleep Medicine Reviews.

Researchers from Columbia University searched publication databases for randomized clinical trials of psychological interventions for sleep disorders conducted in the United States. A total of 56 studies were included in the final analysis.

These studies comprised an average sample size of 85.23 (range, 11-219) individuals in the intervention and 38.40 (range, 5-91) individuals in the control arms. The vast majority had 2-arm trial designs (91.07%) lasting an average of 7.69 weeks (range, 2 weeks to 2 years).

These studies were dominated by participants who were women (mean, 55.35%; standard deviation [SD], 43.22%) and White (mean, 64.86%; SD, 21.67%) and only 6.97% focused on underserved populations.

Participants had definitive diagnoses of a sleep disorder in 32 studies, 9 studies included individuals with probable sleep disturbance, and 15 with potential sleep disturbance. Among studies of patients with an established diagnosis, 75% studied insomnia, 9.38% nightmares with poor sleep quality, 6.25% poor sleep quality, 3.12% restless leg syndrome, 3.12% nocturia, and 3.12% nightmares with insomnia.

The primary outcome was sleep quality (n=40), insomnia (n=30), sleep efficiency (n=21), sleep duration (n=21), nightmares (n=8), and drowsiness (n=4).

The most studied interventions were cognitive behavioral therapy for insomnia (CBT-I; n=20), complementary and alternative medicine (n=8), and behavioral therapy (n=7), cognitive behavioral therapy (n=4), among others.

These interventions were tailored to their study populations by either surface- and/or deep-level cultural adaptations (64.29%). CBT-I was most commonly adapted (38.89%). Surface-level adaptations included changes to the delivery modality, setting, dosing, constituent-involving strategies, and linguistic changes. Deep-level adaptations were content-level, core component, sociocultural, and linguistic changes.

The studies with a cultural adaptation component generally found insomnia was significantly improved compared with pharmacotherapy, but few found changes in nightmares, sleep efficiency, or sleep duration.

Participants who received CBT-I with surface- or deep-level cultural adaptation (n=11 studies) had significantly improved symptoms of insomnia compared with various control groups, usual care, hygiene education, or healthy eating educations. A subset of these studies also reported improvements to sleep efficiency (n=6) and sleep quality (n=7).

Few studies of surface- or deep-level cultural adaptations for interventions of probable or possible sleep disturbances found significant improvements to sleep.

These findings were limited by the underlying study populations which lacked diversity.

The study authors concluded that interventions for established sleep disorders which have been culturally tailored for the population were more successful than control conditions or usual care.


Alcántara C, Cosenzo LG, McCullough E, Vogt T, Falzon AL, Ibarra IP. Cultural adaptations of psychological interventions for prevalent sleep disorders and sleep disturbances: A systematic review of randomized controlled trials in the United States. Sleep Med Rev. 2021;101455. doi:10.1016/j.smrv.2021.101455