Digitally delivered cognitive-behavioral therapy not only improved insomnia, but also provided “around-the-clock” health, psychological, and quality-of-life improvements, according to investigators.
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Compared with control subjects, patients who used a cognitive-behavioral therapy (CBT) program and associated iPhone app had small improvements in functional health and psychological well-being and large improvements in sleep-related quality of life, the investigators reported.
Those changes were mediated by a large improvement in insomnia, according to Colin A. Espie, PhD, professor of sleep medicine at the University of Oxford (England), and his colleagues.
“These findings indicate that digital CBT improves both daytime and nighttime aspects of insomnia, lending further weight to the clinical guideline recommendation of CBT as the treatment of choice for insomnia,” Dr. Espie and his colleagues reported in JAMA Psychiatry.
Their study included 1,711 adults with symptoms of insomnia that were self-reported and a score of 16 or less on the Sleep Condition Indicator (SCI), which has a range of 0-32. A total of 853 were randomized to receive digital CBT, of whom 413 completed six scheduled 20-minute sessions; an additional 276 adults completed at least one session. The control arm included 858 individuals randomized to sleep hygiene education, of whom 759 went on to receive that intervention.
Small but significant improvements were seen in self-reported measures of functional health, Dr. Espie and his colleagues reported. The adjusted differences in mean scores on the Patient-Reported Outcomes Measurement Information System: Global Health Scale were 0.90 in a midtreatment evaluation at 4 weeks after baseline, 1.76 in a posttreatment evaluation at 8 weeks, and 1.76 at a 24-week follow-up assessment (P less than 0.001 for all comparisons).
Likewise, adjusted differences in the Warwick-Edinburgh Mental Wellbeing Scale were 1.04, 2.68, and 2.95 at 4, 8, and 24 weeks, respectively.
Adjusted differences in the Glasgow Sleep Impact Index, which measures sleep-related quality of life, were –8.76, –17.60, and –18.72 at 4, 8, and 24 weeks, respectively, indicating a benefit of the digital CBT intervention over the control intervention, the investigators said.
About 45%-84% of these effects were attributable to changes in insomnia symptoms, results of a mediation analysis showed.
Insomnia scores as measured by the eight-item SCI scale were 6.5 and 6.6 at baseline for the digital CBT and control groups, respectively. By week 4, SCI scores were 9.96 and 13.00 for the two groups (P less than 0.001), with significant differences also reported at the 8- and 24-week evaluations.
The investigators noted that their findings might not be generalizable because participants were not drawn from patient populations. In addition, although 58% of the participants completed 4 weeks or more of the digital CBT sessions, the dropout rate was “substantial.”
Nevertheless, they wrote, these findings, together with results of a recently reported parallel study looking at the effects of sleep on mental health, affirm CBT as the treatment of choice for insomnia. “The mediation analyses in these two studies, with a total of 5,466 participants, provide novel and convincing evidence that insomnia may be a legitimate and important target for mental health and well-being.”
Dr. Espie reported that he is cofounder and chief medical officer of Big Health. He is a shareholder and receives a salary from the company, which was involved in the design and conduct of the study, interpretation of data, and development of the manuscript appearing in JAMA Psychiatry. The study was funded by Big Health and other sources, including the National Institute for Health Research Oxford Biomedical Research Centre.
SOURCE: Espie CA et al. JAMA Psychiatry. 2018 Sep 25. doi: 10.1001/jamapsychiatry.2018.2745.