Compelling evidence in favor of a self-guided, internet-based cognitive behavioral therapy for insomnia (CBT-I) called Sleep Healthy Using the Internet (SHUTi) was provided in a recent study published in JAMA Psychiatry.1 It was the first such study to evaluate large-scale methods for treating insomnia, which affects 35 to50% of the general population2, with 12 to20% estimated to have a diagnosable insomnia disorder.3,4
A total of 303 adults with chronic insomnia (aged 21-65) were randomly assigned to 9 weeks of SHUTi treatment or a nontailored online patient education program (PE). The SHUTi program utilizes the main features of in-person CBT-I, including sleep restriction and hygiene, controlling for stimuli, cognitive restructuring techniques, and relapse prevention, delivered via a fully-automated, customizable web-based program to the patient at home. All participants in the SHUTi (n=151) and PE (n=152) groups were asked to complete sleep questionnaires and keep sleep diaries for 10 days at baseline, and were assessed at 6 months and 1 year post-enrollment.
The SHUTi intervention was significantly superior to PE across all measures of the 3 primary outcomes: insomnia severity, sleep latency and wake after sleep onset.Initial post-assessments of within-group time interactions were greater among the SHUTi group than the PE group, ranging from 0.79 to 1.90 vs 0.37 to 0.77, respectively. Participants using SHUTi showed significant clinical benefit over the PE group during the post-assessment period, with 52.6% (70/133) responding to SHUTi treatment, compared to 16.9% (24/142) in the PE group.
These benefits were largely maintained at 1-year follow up, with 69.7% of SHUTi users (85/122) meeting criteria for response to treatment (defined as >7% reduction on the Insomnia Severity Index5) compared to 43% (55/128) in the PE group, and 56.6% (69/122) still in full remission at 1 year vs 27.3% (35/128) in the PE group.
The presence of medical or psychiatric comorbid conditions did not show a significant impact on the primary outcomes. Secondary outcomes, including sleep efficiency, number of awakenings, and sleep quality were all significantly improved from baseline to 6 months and 1 year in the SHUTi group compared to the PE group, but no large changes were observed in total sleep time. It was worth noting that 218 of the 303 participants who enrolled in the study were women (71%).
In an accompanying editorial,6 Andrew D. Krystal, MD, MS, and Aric A. Prather, PhD remarked on the clinical impact of the study, stating that “it seems inevitable that CBT-I will increasingly be used as a first-line therapy for insomnia.” They point out that due to ease of access, affordability, and convenience to the large base of people who suffer occasional or chronic insomnia, methods such as SHUTi offer “an attractive solution to challenges of scalability.”
- Ritterband LM, Thorndike FP, Ingersoll KS, et al. Effect of a web-based cognitive behavior therapy for insomnia intervention with 1-year follow up. A randomzed clinical trial. JAMA Psychiatry. 2016; doi:10.1001/jamapsychiatry.2016.3249 [Epub ahead of print]
- Walsh JK, Coulouvrat C, Hajak G, et al. Nighttime insomnia symptoms and perceived health in the America Insomnia Survey (AIS). Sleep. 2011;34:997-1011.
- Morin CM, LeBlanc M, Belanger L, et al. Prevalence of insomnia and its treatment in Canada. Can J Psychiatry. 2011;56:540-548.
- Roth T, Coulouvrat C, Hajak G, et al. Prevalence and perceived health associated with insomnia based on DSM-IV-TR; International Statistical Classification of Diseases and Related Health Problems, Tenth Revision; and Research Diagnostic Criteria/International Classification of Sleep Disorders, criteria: results from the America Insomnia Survey. Biol Psychiatry. 2011;69:592-600.
- Morin CM, Belleville G, B.langer L, Ivers H. The Insomnia Severity Index: psychometric indicators to detect insomnia cases and evaluate treatment response. Sleep. 2011;34(5):601-608.
- Krystal AD, Prather AA. Should Internet Cognitive Behavioral Therapy for Insomnia Be the Primary Treatment Option for Insomnia? Toward Getting More SHUTi. JAMA Psychiatry. 2016; doi:10.1001/jamapsychiatry.2016.3249 [Epub ahead of print]