cbt insomnia

Online CBT Improves Insomnia, Quality of Life.

Study showed small improvement functional health, well-being.

Action Points

  • * Cognitive behavioral therapy (CBT) via an online app was shown to greatly improve sleep-related quality of life and to somewhat improve functional health and psychological well-being in a randomized trial of patients with self-reported insomnia compared to sleep hygiene education.
  • * While this study examined effects on daytime functioning as well as nighttime improved sleep, it only focused on one available online program.

Online cognitive behavioral therapy delivered by a commercially available app was found to improve both daytime and nighttime symptoms of insomnia in a randomized clinical trial.

Patients with insomnia who participated in the digitally based program showed significantly greater improvements in functional health, psychological well-being, and sleep-related quality of life, compared with a control group of insomnia patients who participated in digital therapy that emphasized education about sleep hygiene.

At 24 weeks of follow-up, effect sizes among patients in the digital cognitive behavioral therapy (CBT) arm of the study were small, but significant, for functional health and psychological well-being and large for the sleep-related quality of life, the researchers reported in JAMA Psychiatry.

The study was designed to assess the commercial digital CBT program Sleepio, designed by lead researcher Colin Espie, Ph.D., of the University of Oxford in the United Kingdom. The study was funded by his company Big Health Ltd, which markets the program.

Sleepio is one of several online sleep therapy programs utilizing CBT, which is considered a first-line treatment for insomnia.

Previous research has shown similar online programs to be effective for improving sleep, but the new study is among the first to assess the impact of digitally delivered CBT on nighttime and daytime effects associated with insomnia, another of the co-authors, Jason C. Ong, Ph.D., of Northwestern University in Chicago, told MedPage Today.

He said CBT delivered via the internet is a natural fit for the treatment of insomnia because the therapy is somewhat standardized, compared with psychotherapy for other conditions.

“A lot of it is teaching people how the brain regulates sleep and wake, and how they can adjust behaviors to better synchronize and regulate sleep-and-wake cycles.”

Ong, who is a sleep specialist, said that despite a growing number of studies showing digital CBT to be efficacious for insomnia, it is not on the radar of most primary care physicians.

“Our hope is that studies like this will bring digital CBT to the attention of primary care docs and insurance companies so that it can be better integrated into the healthcare system. As many as 15% to 20% of adults have chronic insomnia and right now we aren’t reaching most of them with effective treatments.”

John Torous, MD, director of the digital psychiatry division of Beth Israel Deaconess Medical Center in Boston, who was not involved with the study or the company marketing it, told MedPage Today that while digital CBT may represent a novel strategy for the treatment of insomnia, the fact that there have been no head-to-head comparisons of the commercially available products makes it difficult to recommend one over the other.

And most online programs are not cheap: A year’s subscription to Sleepio costs around $400, and a 26-week subscription to another commercial program, SHUTi, costs between $149 and $174.

“The Veteran’s Administration offers a free internet-based insomnia program, CBT-i Coach, that may not be as fancy as the commercial ones, but it is evidence-based and may work just as well,” said Torous.

The newly published two-arm, parallel-group, randomized trial included 1,711 participants recruited via the internet with self-reported insomnia symptoms. The participants were randomized to receive the digital CBT over six 20-minute sessions delivered with an associated iOS app. The participants had access to the program for 12 weeks.

Control subjects received sleep hygiene education delivered through a website and downloadable booklet, plus usual treatment. The vast majority of the participants were female (77%) and white (91.1%) and had a mean age of 48 (SD 13.8).

       Among the main findings:

  • * Use of digital CBT was associated with a small improvement in functional health compared with sleep hygiene education (adjusted difference at week 4, 0.90, 95% CI 0.40-1.40; week 8, 1.76, 95% CI 1.24-2.28; week 24, 1.76, 95% CI 1.22-2.30)
  • * A small improvement with digital CBT was also seen in psychological well-being (adjusted difference at week 4, 1.04, 95% CI 0.28-1.80; week 8, 2.68, 95% CI 1.89-3.47; week 24, 2.95, 95% CI 2.13-3.76)
  • * A large improvement in sleep-related quality of life was seen with digital CBT (at week 4, −8.76, 95% CI −11.83 to −5.69; week 8, –17.60, 95% CI −20.81 to −14.39; week 24, −18.72, 95% CI −22.04 to −15.41) (all P<0.01)
  • * A large improvement in insomnia in the digital CBT group mediated these outcomes (range mediated, 45.5%-84.0%)

Torous said the homogeneous makeup of the study cohort raises questions about whether the findings can be extrapolated to other groups. And he also expressed concern about the online recruitment of study participants, the self-reporting of insomnia symptoms, and the high dropout rate among the digital CBT participants.

A total of 57.6% of patients randomized to digital CBT completed four sessions, and just under half (48.4%) completed all six.

“These researchers should be commended for doing a study that included a range of outcomes, but I would like to see more objective research done,” Torous concluded.

The study was funded by Sleepio marketer Big Health Ltd, in conjunction with the National Institute for Health Research, the Oxford Biomedical Research Centre, and others.

Lead researcher Colin Espie is co-founder, chief medical officer, and a shareholder of Big Health Ltd; co-author Jason Ong reported serving as an advisor to Big Health Ltd. and helping to develop the Sleepio program, but having no current financial stake in the company.

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