A cognitive-behavioral therapy intervention delivered via the Internet significantly reduced insomnia severity and contributed to overall sleep improvement in a study of 44 adults, according to a report in the Archives of General Psychiatry.
The 9-week intervention reduced the number of nighttime awakenings and improved sleep efficiency to a similar degree as has been reported for face-to-face CBT, self-help bibliotherapy, group therapy, telephone therapy, and pharmacotherapy, said Lee M. Ritterband, Ph.D., of the University of Virginia Health System, Charlottesville, and his associates.
“An effective and inexpensive Internet intervention would expand treatment options for large numbers of adults with insomnia, especially those whose geographical location prohibits access to relevant care, and could be a substantive first-line treatment choice,” they noted. Although traditional CBT is one of the most effective treatments for insomnia, its availability is “severely limited,” in part because of a lack of trained clinicians, the uneven geographical distribution of trained clinicians, and the cost of treatment.
Dr. Ritterband and his colleagues assessed the feasibility and efficacy of a fully automated Internet-based intervention called SHUTi (Sleep Healthy Using the Internet).
SHUTi provides instruction on going to bed only when sleepy, getting out of bed when unable to sleep, and returning only when sleep is imminent. The program advises patients to avoid sleep-incompatible activities in the bedroom such as watching television, to forgo daytime napping, and to arise at the same hour every day. Patients also are instructed to improve their sleep hygiene by avoiding nicotine, caffeine, and alcohol before bedtime. SHUTi also addresses “unhelpful” beliefs and thoughts, such as the notion that people absolutely need 8 hours of sleep every night or excessive concern about the consequences of insomnia.
Participants fill out the Insomnia Severity Index (ISI) online and complete weekly sleep diaries. That information is then used to individually tailor recommendations for the coming week, all of which is computed automatically using algorithms developed specifically for SHUTi.
The intervention uses graphics and animation as well as text, and it includes quizzes, brief games, and vignettes to deliver information, Dr. Ritterband and his colleagues said (Arch. Gen. Psychiatry 2009;66:692-8).
They compared insomnia outcomes between 22 insomnia patients randomly assigned to the SHUTi intervention and 22 control patients who were wait-listed to participate in the program.
The mean age of participants was 45 years; they had had sleep problems for an average of more than 10 years, and at the time of enrollment they reported disruptive sleep more than 5 nights per week.
The intervention group showed marked improvement in insomnia severity at the conclusion of the program as well as 6 months later, while the control group showed little change. Sixteen of the intervention subjects (73%) were judged to be in remission by ISI score, compared with none of the control subjects.
“It is important to highlight that the treatment effect sizes found using this Internet intervention, which was delivered with no human support and at a relatively low cost, are comparable to those found in face-to-face studies,” the investigators said.
They also pointed out that this intervention might expand treatment options for adults whose geographical location prohibits access to care.
However, Dr. Ritterband and his colleagues added that their study sample was “small, relatively homogeneous, well educated, and restricted to individuals with primary insomnia and no comorbidities. Future studies should enroll larger and more heterogeneous samples to improve the generalizability of the findings.”
No relevant conflicts of interest were reported. The study was supported by a grant from the National Institute of Mental Health, National Institutes of Health.
The Sleep Healthy Using the Internet (SHUTi) intervention advises patients to arise at the same hour every day.
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