Online CBT for Insomnia Offers Long-Term Benefit

Research shows that 35 percent to 50 percent of adults experience symptoms of insomnia, and up to 20 percent of adults meet diagnostic criteria for insomnia disorder. A study published in JAMA Psychiatry now suggests that a web-based form of cognitive-behavioral therapy for insomnia (CBT-I) can effectively treat people with chronic insomnia.

University of Michigan Health System

“Cognitive-behavioral therapy for insomnia is the first-line recommendation for adults with chronic insomnia,” said the study’s lead author, Lee Ritterband, Ph.D., a professor of psychiatry and neurobehavioral sciences at the University of Virginia School of Medicine. “Access to CBT-I, however, is limited by numerous barriers, including a limited supply of providers who are trained in CBT-I.” Offering CBT-I online might help to expand the number of patients who could access and benefit from the program, Ritterband said.

Ritterband and colleagues randomly assigned 303 adults aged 21 to 65 with chronic insomnia to either SHUTi (Sleep Healthy Using the Internet) or an online patient education (PE) program. The SHUTi group was given access to six intervention “core” assignments, with a new assignment made available seven days after the completion of the previous one, to parallel traditional weekly CBT-I sessions; the program featured personalized goal setting, feedback, and more. Participants in the PE group were given access to non-tailored material on insomnia, including information about symptoms and behavioral strategies to improve sleep. Both intervention groups had access to the online materials for nine weeks.

Adults with regular internet access were eligible to participate in the study if they met the following criteria: they required more than 30 minutes to fall asleep at the beginning of the night or more than 30 minutes of awake time after falling asleep, their total sleep averaged 6.5 hours or less, and they manifested sleep disturbances causing significant distress or impairment in social, occupational, or other areas of function. Patients with comorbid psychiatric conditions were included unless they were considered to be at a moderate to high risk of suicide, they were experiencing severe major depressive disorder or bipolar disorder, or had a history of alcohol or drug use disorder.

Self-reported ratings of insomnia severity (as measured by the Insomnia Severity Index [ISI]) and sleep-onset latency and wake after sleep onset symptoms (as measured by online sleep diary-derived values) were assessed at the beginning of the study, and again at nine weeks, six months, and one year.

Although participants in both intervention groups experienced significant sleep improvements, sleep-onset latency, and wake after sleep onset, those in the SHUTi group saw the greatest gains.

Over the nine week period, 52.6 percent of the SHUTi group reported a drop in ISI scores by seven or more points (treatment responders) compared with 16.9 percent of PE group. At the six-month follow up, 59.7 percent of the SHUTi group and 35.7 percent of the PE group were considered responders, while 69.7 percent of the SHUTi group and 43.0 percent of the PE group were deemed responders at the one-year follow up.

Adherence to the SHUTi program was also good, with 60.3 percent of SHUTi participants completing all six core sections of the program.

In an editorial describing the findings, Andrew Krystal, M.D., M.S., of the University of California, San Francisco, and Aric Prather, Ph.D., of Duke University School of Medicine noted that although the current study excluded individuals with severe forms of comorbidities that were likely to worsen insomnia, the “results provide an indication that the benefits conferred by SHUTi are not diminished by the presence of either psychiatric or medical comorbidities. ... Still, a true characterization of how SHUTi performs in patients seen in clinical practice will require evaluation in a setting where less-stringent eligibility criteria are applied.”

CBT-I expert J. Todd Arnedt, Ph.D., an associate professor psychiatry and neurology and director of the Behavioral Sleep Medicine Program at the University of Michigan Health System, agreed.

“While the results from this study are encouraging, we still need to understand better for whom and under what conditions online therapy programs work best, so that we can best allocate this resource to the patients who are most likely to benefit,” Arnedt, who was not involved with the study, told Psychiatric News.

Arnedt continued, “As of now, online delivery of CBT for insomnia is by no means sufficient to address the demand for insomnia services. We need to continue to develop innovative strategies for delivering this evidence-based treatment to make it even more accessible to the substantial proportion of adults who need it.”

The study was funded by the National Institute of Mental Health. ■