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Efficacy of an Internet-Based Behavioral Intervention for Adults With Insomnia
Open accessAbstract
CONTEXT: Insomnia is a major health problem with significant psychological, health, and economic consequences. However, availability of one of the most effective insomnia treatments, cognitive behavioral therapy, is significantly limited. The Internet may be a key conduit for delivering this intervention. OBJECTIVE: To evaluate the efficacy of a structured behavioral Internet intervention for adults with insomnia. DESIGN, SETTING, AND PARTICIPANTS: Forty-five adults were randomly assigned to an Internet intervention (n = 22) or wait-list control group (n = 23). Forty-four eligible participants (mean [SD] age, 44.86 [11.03] years; 34 women) who had a history of sleep difficulties longer than 10 years on average (mean [SD], 10.59 [8.89] years) were included in the analyses. INTERVENTION: The Internet intervention is based on well-established face-to-face cognitive behavioral therapy incorporating the primary components of sleep restriction, stimulus control, sleep hygiene, cognitive restructuring, and relapse prevention. MAIN OUTCOME MEASURES: The Insomnia Severity Index and daily sleep diary data were used to determine changes in insomnia severity and the main sleep variables, including wake after sleep onset and sleep efficiency. RESULTS: Intention-to-treat analyses showed that scores on the Insomnia Severity Index significantly improved from 15.73 (95% confidence interval [CI], 14.07 to 17.39) to 6.59 (95% CI, 4.73 to 8.45) for the Internet group but did not change for the control group (16.27 [95% CI, 14.61 to 17.94] to 15.50 [95% CI, 13.64 to 17.36]) (F(1,42) = 29.64; P < .001). The Internet group maintained their gains at the 6-month follow-up. Internet participants also achieved significant decreases in wake after sleep onset (55% [95% CI, 34% to 76%]) and increases in sleep efficiency (16% [95% CI, 9% to 22%]) compared with the nonsignificant control group changes of wake after sleep onset (8% [95% CI, -17% to 33%) and sleep efficiency (3%; 95% CI, -4% to 9%). CONCLUSIONS: Participants who received the Internet intervention for insomnia significantly improved their sleep, whereas the control group did not have a significant change. The Internet appears to have considerable potential in delivering a structured behavioral program for insomnia. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00328250.
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“However, within this growing number of studies, the range of outcomes can vary from virtually no effect to effect sizes that are similar to face-to-face interventions.”
From Behavioral Intervention Technologies: Evidence review and recommendations for future research in mental health (2013) · cites this paper as [18]
In the citing paper
“Attrition and non-adherence can also range widely, from extremely high (>95% for standalone depression sites), modest (many anxiety sites), to minimal (insomnia), depending on the disorder and how participants were sampled or screened.”
From Behavioral Intervention Technologies: Evidence review and recommendations for future research in mental health (2013) · cites this paper as [18]
In the citing paper
“Standalone interventions have produced a wide range of outcomes, from small or nonsignificant (e.g. many depression sites, substance abuse) to moderate (some anxiety disorders) to fairly large (insomnia) (14, 15, 18, 25).”
From Behavioral Intervention Technologies: Evidence review and recommendations for future research in mental health (2013) · cites this paper as [18]
In the citing paper
“The efficacy of web-based intervention has been demonstrated by a large number of trials for a number of mental health problems, including depression, anxiety disorders, alcohol and substance abuse, and insomnia (14–18).”
From Behavioral Intervention Technologies: Evidence review and recommendations for future research in mental health (2013) · cites this paper as [18]
In the citing paper
“Although initial results are promising, further work is needed because many of the trials have been relatively small [44-47].”
From Web-Based Interventions for Behavior Change and Self-Management: Potential, Pitfalls, and Progress (2012) · cites this paper as [45]
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Self-citationA Behavior Change Model for Internet Interventions
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BackgroundThe neurobiology, investigation, and treatment of chronic insomnia
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ResultEfficacy of Brief Behavioral Treatment for Chronic Insomnia in Older Adults
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“Other novel forms of behavioral treatment delivery such as Internet programs may also be efficacious.(60) Thus, a range of options is now available to administer behavioral treatments for insomnia across a range of clinical settings.”
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BackgroundS3-Leitlinie Nicht erholsamer Schlaf/Schlafstörungen
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BackgroundInfluentialPredictors of Continuous Positive Airway Pressure Adherence in Patients with Obstructive Sleep Apnea
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“Most of the previous group- or Internet-delivered therapy studies did not use ISI as primary outcome measure, but when comparing sleep diary data at post-assessment, guided ICBT in this study did well compared to other guided and un-guided Internettreatments (Lancee, van den Bout, van Straten, & Spoormaker, 2012; Ritt…”
ResultHermes, E. D., Lyon, A. R., Schueller, S. M., & Glass, J. E. (2019) · Journal of Medical Internet Research · doi:10.2196/11752 · Cited by 149
Realizing the Potential of Behavioral Intervention Technologies
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“, 2010), insomnia (Ritterband et al., 2009), diet (Resnicow et al.”
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Efficacy of an internet-based intervention for infant and toddler sleep disturbances
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Digital Cognitive Behavioral Therapy (dCBT) for Insomnia: a State-of-the-Science Review
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“However, for studies whereby the dCBT intervention did not address sleepmedication use or tapering specifically, there tended to be an absence of treatment effects on sleep medication use [12, 17, 19].”
BackgroundUnderstanding and Treating Insomnia
Bootzin, R. R., & Epstein, D. R. (2011) · Annual Review of Clinical Psychology · doi:10.1146/annurev.clinpsy.3.022806.091516 · Cited by 150
“One Internet program that had strong results in improving sleep provides interesting data for how to handle this issue of match between the program and the patient (Ritterband et al. 2009).”
BackgroundBrasure, M., Fuchs, E. L., MacDonald, R. H., Nelson, V. A., Koffel, E., Olson, C. M., Khawaja, I. S., Diem, S. J., Carlyle, M. H., Wilt, T. J., et al. (2016) · Annals of Internal Medicine · doi:10.7326/m15-1782 · Cited by 148
“Ritterband et al, 2009 (80) Vincent et al, 2009 (93) Subtotal”
BackgroundGeraghty, A. W. A., Torres, L. D., Leykin, Y., Pérez‐Stable, E. J., & Muñoz, R. F. (2012) · Health Promotion International · doi:10.1093/heapro/das029 · Cited by 136
“, 2001), and improve insomnia (Ritterband et al., 2009).”
Hasan, F., Tu, Y.-K., Yang, C.-M., James Gordon, C., Wu, D., Lee, H.-C., Yuliana, L. T., Herawati, L., Chen, T.-J., & Chiu, H.-Y. (2022) · Sleep Medicine Reviews · doi:10.1016/j.smrv.2021.101567 · Cited by 137
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“Several studies with no therapist support, or with automated feedback only, have presented positive results (Lancee, van den Bout, van Straten, & Spoormaker, 2012; Ritterband et al., 2009; Ritterband et al., 2012), in one case also when compared to a non-guided internet-based placebo condition (Espie et al.”
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Guided Internet-delivered cognitive behavioural treatment for insomnia: a randomized trial
van Straten, A., Emmelkamp, J., de Wit, J., Lancee, J., Andersson, G., Someren, E. J. W. V., & Cuijpers, P. J. (2013) · Psychological Medicine · doi:10.1017/s0033291713002249 · Cited by 131
“Other studies on Internet-delivered CBT (Suzuki et al. 2008; Ritterband et al. 2009; Vincent & Lewycky, 2009; Espie et al. 2012; Lancee et al. 2012) have concluded that this treatment has positive effects, although the interventions in these studies were provided without personal guidance or…”
BackgroundInfluentialIs Chronic Insomnia a Precursor to Major Depression? Epidemiological and Biological Findings
Baglioni, C., & Riemann, D. W. (2012) · Current Psychiatry Reports · doi:10.1007/s11920-012-0308-5 · Cited by 131
Simon, L., Steinmetz, L., Feige, B., Benz, F., Spiegelhalder, K., & Baumeister, H. (2023) · Scientific Reports · doi:10.1038/s41598-023-28853-0 · Cited by 145
Fragmented Sleep, Fragmented Mind
der Kloet, D. V. H., Merckelbach, H. L. G. J., Giesbrecht, T., & Lynn, S. J. (2012) · Perspectives on Psychological Science · doi:10.1177/1745691612437597 · Cited by 133
“Although sleep diaries represent a core assessment component in studies on sleep problems, polysomnography would be preferred to confirm objective changes in sleep (Ritterband et al., 2009).”
BackgroundGothe, N. P., Ehlers, D. K., Salerno, E. A., Fanning, J., Kramer, A. F., & McAuley, E. (2020) · Behavioral Sleep Medicine · doi:10.1080/15402002.2019.1690493 · Cited by 125
“For instance, Ritterband and colleagues have demonstrated the efficacy of automated, internet-delivered cognitive behavioral therapy for insomnia across several randomized controlled trials (Ritterband et al., 2009, 2017).”
BackgroundKlein, B., Mitchell, J., Abbott, J.-A., Shandley, K. A., Austin, D., Gilson, K., Kiropoulos, L. A., Cannard, G., & Redman, T. (2010) · Journal of Anxiety Disorders · doi:10.1016/j.janxdis.2010.04.005 · Cited by 136
Klein, B., Meyer, D., Austin, D. W., & Kyrios, M. (2011) · Journal of Medical Internet Research · doi:10.2196/jmir.1918 · Cited by 118
“e-Therapy programs can be broadly categorized as being self-help or therapist-assisted, and hundreds have been evaluated across a range of mental health disorders and symptoms, including panic disorder (eg, [13,14], SAD (eg, [15]), PTSD and symptoms (eg, [8,16,17]), anxiety prevention (eg, [18,19]), depression and dep…”
BackgroundVedaa, Ø., Kallestad, H., Scott, J. L., Smith, O. R. F., Pallesen, S., Morken, G., Langsrud, K., Gehrman, P., Thorndike, F. P., Ritterband, L. M., et al. (2020) · The Lancet Digital Health · doi:10.1016/s2589-7500(20)30135-7 · Cited by 118
Self-citationYe, Y.-Y., Chen, N.-K., Chen, J., Liu, J., Lin, L., Liu, Y.-Z., Lang, Y., Li, X.-J., Yang, X.-J., & Jiang, X.-J. (2016) · BMJ Open · doi:10.1136/bmjopen-2015-010707 · Cited by 115
Zhou, E. S., Ritterband, L. M., Bethea, T. N., Robles, Y., Heeren, T., & Rosenberg, L. A. (2022) · JAMA Psychiatry · doi:10.1001/jamapsychiatry.2022.0653 · Cited by 112
Self-citationTrockel, M., Manber, R., Chang, V., Thurston, A., & Tailor, C. B. (2011) · Journal of Clinical Sleep Medicine · doi:10.5664/jcsm.1072 · Cited by 108
Fanning, J. T., Porter, G. C., Awick, E. A., Ehlers, D. K., Roberts, S. A., Cooke, G. E., Burzynska, A. Z., Voss, M. W., Kramer, A. F., & McAuley, E. (2016) · Journal of Behavioral Medicine · doi:10.1007/s10865-016-9788-9 · Cited by 120
“For instance, Ritterband et al. (2009) adapted core concepts from cognitive behavioral therapy for insomnia for delivery via the internet.”
Insomnia and Sleep-Related Breathing Disorders
Wickwire, E. M., & Collop, N. A. (2010) · CHEST Journal · doi:10.1378/chest.09-1485 · Cited by 109
Lancee, J., van den Bout, J., Sorbi, M. J., & van Straten, A. (2013) · Behaviour Research and Therapy · doi:10.1016/j.brat.2013.09.004 · Cited by 104
“…internet-delivered CBT-I (Lancee, van den Bout, van Straten, & Spoormaker, 2012), and other authors have found even more pronounced effects for internet-delivered treatment with either automated (Espie et al., 2012; Ritterband et al., 2009) or human-delivered support (Van Straten et al., 2013).”
BackgroundHolmqvist, M., Vincent, N., & Walsh, K. (2014) · Sleep Medicine · doi:10.1016/j.sleep.2013.10.013 · Cited by 110
“Research shows that web-based programs improve sleep quality (SQ), daytime fatigue, and overall severity of insomnia relative to nontreatment control groups [7,9]; however, many of such interventions have yet to be compared to active treatments.”
BackgroundPregnancy-specific anxiety: which women are highest and what are the alcohol-related risks?
Arch, J. J. (2012) · Comprehensive Psychiatry · doi:10.1016/j.comppsych.2012.07.010 · Cited by 115
“[50]), results should be replicated in clinic samples.”
BackgroundBarney, L. J., Griffiths, K. M., & Banfield, M. (2011) · BMC Psychiatry · doi:10.1186/1471-244x-11-88 · Cited by 102
“It is known that self-help strategies such as limiting stimulants, undertaking physical exercise during the day or early evening, keeping to a regular sleep routine and other cognitive and behavioural strategies (refer to [26]) can be effective in reducing sleep problems and depressive symptoms among people with insom…”
BackgroundRandomized Controlled Trial of Telephone-Delivered Cognitive Behavioral Therapy for Chronic Insomnia
Arnedt, J. T., Cuddihy, L. J., Swanson, L. M., Pickett, S. M., Aikens, J. E., & Chervin, R. D. (2013) · SLEEP · doi:10.5665/sleep.2448 · Cited by 98
Glozier, N., Moullaali, T. J., Sivertsen, B., Kim, D., Mead, G. E., Jan, S., Li, Q., & Hackett, M. L. (2017) · Cerebrovascular Diseases Extra · doi:10.1159/000455751 · Cited by 96
de Bruin, E. J., Oort, F. J., Bögels, S. M., & Meijer, A. M. (2014) · Behavioral Sleep Medicine · doi:10.1080/15402002.2013.784703 · Cited by 95
“Third, Lancee, Van den Bout, Van Straten, and Spoormaker (2012) showed improvement on most sleep measures, insomnia symptoms, depression, and anxiety in 216 adults with chronic insomnia after online self-help CBT–i. Fourth, Ritterband et al. (2009) revealed improvement in the Insomnia Severity Index and primary sleep…”
BackgroundResultThorndike, F. P., Ritterband, L. M., Gonder-Frederick, L. A., Lord, H. R., Ingersoll, K. S., & Morin, C. M. (2013) · Journal of Clinical Psychology · doi:10.1002/jclp.22032 · Cited by 95
“To briefly summarize the findings from the primary trial, SHUTi was found to be efficacious in improving sleep, including insomnia severity, wake after sleep onset (WASO), and sleep efficiency (SE; Ritterband et al., 2009).”
BackgroundMethodInfluentialSelf-citationLancee, J., Eisma, M. C., van Straten, A., & Kamphuis, J. H. (2015) · Cognitive Behaviour Therapy · doi:10.1080/16506073.2015.1026386 · Cited by 98
“However, the effects appeared somewhat smaller than effects in a couple of recent studies (Espie, Kyle, Williams, et al., 2012; Lancee et al., 2012; Ritterband et al., 2009; van Straten et al., 2014), as well as in a recent study using the same treatment program (e.g., posttest within-group Cohen’s…”
New developments in cognitive behavioral therapy as the first-line treatment of insomnia
Siebern, A. T., & Manber (2011) · Psychology Research and Behavior Management · doi:10.2147/prbm.s10041 · Cited by 99
Lorenz, N., Heim, E., Rötger, A., Birrer, E., & Maercker, A. R. A. (2018) · Behavioural and Cognitive Psychotherapy · doi:10.1017/s1352465818000486 · Cited by 90
We know CBT-I works, now what?
Muench, A., Vargas, I., Grandner, M. A., Ellis, J. G., Posner, D. A., Bastien, C., Drummond, S. P. A., & Perlis, M. L. (2022) · Faculty Reviews · doi:10.12703/r/11-4 · Cited by 105
Sleep to Lower Elevated Blood Pressure: A Randomized Controlled Trial (SLEPT)
McGrath, E. R., Espie, C. A., Power, A., Murphy, A. W., Newell, J., Kelly, C., Duffy, N., Gunning, P., Gibson, I., Bostock, S., et al. (2016) · American Journal of Hypertension · doi:10.1093/ajh/hpw132 · Cited by 88
Wagley, J. N., Rybarczyk, B., Nay, W. T., Danish, S., & Lund, H. G. (2013) · Journal of Clinical Psychology · doi:10.1002/jclp.21927 · Cited by 85
Taylor, D. J., Peterson, A. L., Pruiksma, K. E., Young‐McCaughan, S., Nicholson, K. L., & Mintz, J. (2017) · SLEEP · doi:10.1093/sleep/zsx075 · Cited by 88
Batterham, P. J., Christensen, H. M., Mackinnon, A. J., Gosling, J. A., Thorndike, F. P., Ritterband, L. M., Glozier, N., & Griffiths, K. M. (2017) · BJPsych Open · doi:10.1192/bjpo.bp.117.005231 · Cited by 85
Self-citationHo, F. Y., Chung, K., Yeung, W., Ng, T. H., & Cheng, S. K.-W. (2014) · Behaviour Research and Therapy · doi:10.1016/j.brat.2014.10.002 · Cited by 86
“Participants were recruited from the community to imitate “realworld” setting, while in previous studies (Jernel€ ov et al., 2012; Ritterband et al., 2009), individuals with medical and psychiatric comorbidities were excluded.”
MethodDigital therapeutics in the clinic
Phan, P., Mitragotri, S., & Zhao, Z. (2023) · Bioengineering & Translational Medicine · doi:10.1002/btm2.10536 · Cited by 95
“Under its clinical trial name SHUTi (Sleep Healthy Using the Internet), the application was found to improve the insomnia severity index and sleep efficiency.(50,51) However, Somryst”
MethodMindell, J. A., Du Mond, C. E., Sadeh, A., Telofski, L. S., Kulkarni, N., & Gunn, E. (2011) · Journal of Clinical Sleep Medicine · doi:10.5664/jcsm.1320 · Cited by 85
Sleep and Productivity Benefits of Digital Cognitive Behavioral Therapy for Insomnia
Bostock, S., Luik, A. I., & Espie, C. A. (2016) · Journal of Occupational and Environmental Medicine · doi:10.1097/jom.0000000000000778 · Cited by 87
Liar! Liar! Identifying eligibility fraud by applicants in digital health research
Glazer, J. V., MacDonnell, K., Frederick, C., Ingersoll, K. S., & Ritterband, L. M. (2021) · Internet Interventions · doi:10.1016/j.invent.2021.100401 · Cited by 82
Self-citationSleep America: Managing the crisis of adult chronic insomnia and associated conditions
Kraus, S. S., & Rabin, L. A. (2011) · Journal of Affective Disorders · doi:10.1016/j.jad.2011.05.014 · Cited by 79
“For example, Ritterband et al. (2009) demonstrated that the core components of CBT-I delivered via the internet were effective in producing improved sleep parameters relative to non-treatment controls.”
BackgroundThe Delivery of Behavioral Sleep Medicine to College Students
Kloss, J. D., Nash, C. O., Horsey, S. E., & Taylor, D. J. (2010) · Journal of Adolescent Health · doi:10.1016/j.jadohealth.2010.09.023 · Cited by 78
Adherence to Technology-Mediated Insomnia Treatment: A Meta-Analysis, Interviews, and Focus Groups
Horsch, C. H. G., Lancee, J., Beun, R. J., Neerincx, M. A., & Brinkman, W. (2015) · Journal of Medical Internet Research · doi:10.2196/jmir.4115 · Cited by 81
“ISI, ≥8 N/A 34/10 22 Intervention Ritterband [39]”
Lintvedt, O., Griffiths, K. M., Eisemann, M. R., & Waterloo, K. K. (2013) · Journal of Medical Internet Research · doi:10.2196/jmir.2422 · Cited by 74
“There is now sufficient evidence to suggest that Internet interventions can be effective in the prevention and treatment of depression [39,18,40,41].”
BackgroundBaglioni, C., Spiegelhalder, K., Nissen, C., & Riemann, D. W. (2011) · The EPMA Journal · doi:10.1007/s13167-011-0079-9 · Cited by 73
“All the three studies available up to date [51, 53, 54] found that online CBT-I is efficacious.”
BackgroundCognitive‐Behavioral Therapy for Insomnia to Reduce Chronic Migraine: A Sequential Bayesian Analysis
Smitherman, T. A., Kuka, A. J., Calhoun, A. H., Walters, A. B. P., Davis-Martin, R. E., Ambrose, C. E., Rains, J. C., & Houle, T. T. (2018) · Headache The Journal of Head and Face Pain · doi:10.1111/head.13313 · Cited by 75
“In conjunction with evidence of efficacy across various comorbid conditions, advances have been made in condensing the traditional CBTi protocol into cost-efficient delivery formats using as few as 2 treatment sessions,(15,16) group administration,(17) and delivery via the internet.(18,19) These developments offer pro…”
BackgroundInsomnia Patients' Help-Seeking Experiences
Cheung, J. M. Y., Bartlett, D. J., Armour, C. L., Glozier, N., & Saini, B. (2014) · Behavioral Sleep Medicine · doi:10.1080/15402002.2013.764529 · Cited by 68
“Most found out about specialist help for insomnia serendipitously through the Internet, hospitals, or health department services (e.g., Medicare).”
BackgroundInfluentialEthical and legal considerations for internet-based psychotherapy
Dever Fitzgerald, T., Hunter, P. V., Hadjistavropoulos, T., & Koocher, G. P. (2010) · Cognitive Behaviour Therapy · doi:10.1080/16506071003636046 · Cited by 69
“Internetbased programs for smoking cessation, tinnitus, problem drinking, and insomnia also exist (e.g. Bewick et al., 2008; Cobb et al., 2005; Kaldo et al., 2008; Ritterband et al., 2009; Strom, Pettersson, & Andersson, 2004).”
BackgroundMethodInfluential
Metadata
- Authors
- Ritterband, L. M., Thorndike, F. P., Gonder-Frederick, L. A., Magee, J. C., Bailey, E. T., Saylor, D. K., & Morin, C. M.
- Affiliations
- University of Virginia Health System (US)
- ORCID
- Venue
- Archives of General Psychiatry
- Publisher
- American Medical Association (AMA)
- Published
- 2009-07-01
- Volume
- 66
- Issue
- 7
- Pages
- 692
- ISSN
- 0003-990X (ISSN-L)
- PMC
- PMC3723339
- OpenAlex
- W2126133436
- Cited by
- 482
- References
- 52
- Citations by year
- 2026: 19 · 2025: 18 · 2024: 25 · 2023: 28 · 2022: 28 · 2021: 26 · 2020: 23 · 2019: 24 · 2018: 31 · 2017: 31 · 2016: 30 · 2015: 44 · 2014: 28 · 2013: 33 · 2012: 33
- FWCI
- 39.71
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Archives of General Psychiatry (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Institute of Mental Health (R34 MH70805, R34MH070805)
- Topics
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Sleep and related disorders
- Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
- Health Sciences › Medicine › Physiology (medical) › Obstructive Sleep Apnea Research
- Keywords
- insomnia, online intervention, cognitive behavioral therapy, sleep restriction, stimulus control, sleep hygiene, cognitive restructuring, relapse prevention, insomnia severity, wake after sleep onset, sleep efficiency, treatment efficacy, maintenance of treatment gains, waitlist control, follow-up outcomes, Insomnia Severity Index, sleep diary, cost-effectiveness, acceptability
- MeSH terms
- Adult, Feasibility Studies, Female, Follow-Up Studies, Humans, Sleep Initiation and Maintenance Disorders, Male, Middle Aged, Patient Education as Topic, Therapy, Computer-Assisted, Cognitive Behavioral Therapy, Treatment Outcome, Self Efficacy, Internet
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