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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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“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]
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“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
“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
“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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“All participants undertook the same protocol except insomnia patients were enrolled into a digital cognitive behavioural therapy for insomnia after baseline testing (SHUTi; Ritterband et al., 2009), whereas control participants received AUD200 for participation.”
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“Sleepio, SHUTi/Somryst, SleepWell), FastAsleep is short—only 4 weeks compared to, for example, a minimum of 6 and up to 9 weeks (Espie et al., 2012; Jernelöv et al., 2012; Ritterband et al., 2009).”
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“As Dr. Espie and colleagues note, there have been a number of publications demonstrating the potential of using the Internet to deliver CBT-I, 6-8 but their trial adds to that literature in a number of ways, including the exceptional use of a strong placebo control group and relatively large sample…”
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The Effect of Reducing Insomnia Severity on Work- and Activity-Related Impairment
Kjørstad, K., Sivertsen, B., Vedaa, Ø., Langsrud, K., Faaland, P. M., Vethe, D., Vestergaard, C. L., Scott, J. L., & Kallestad, H. (2020) · Behavioral Sleep Medicine · doi:10.1080/15402002.2020.1799792 · Cited by 13
“Face-to-face CBT-I was delivered by trained practitioners whilst digital CBT-I was made available via a fully automated web-based program called Sleep Healthy Using the Internet (SHUTi) (Ritterband et al., 2009).”
MethodSchlarb, A. A., Schulte, H., Selbmann, A., & Och, I. (2020) · Somnologie - Schlafforschung und Schlafmedizin · doi:10.1007/s11818-020-00280-7 · Cited by 13
Advances in the management of insomnia
Pigeon, W. R., Bishop, T. M., & Marcus, J. A. (2014) · F1000Prime Reports · doi:10.12703/p6-48 · Cited by 13
“One has been a large-scale dissemination effort by the US Veterans Administration to train clinicians to deliver CBT-I [73] with preliminary evidence of the effectiveness of these clinicians now available [74].”
BackgroundInfluentialHermes, E. D. A., & Rosenheck, R. A. (2016) · Psychiatric Services · doi:10.1176/appi.ps.201400532 · Cited by 12
Nazem, S., Sun, S., Barnes, S. M., Monteith, L. L., Hostetter, T. A., Forster, J. E., Brenner, L. A., Galfalvy, H., & Haghighi, F. G. (2024) · Translational Behavioral Medicine · doi:10.1093/tbm/ibae032 · Cited by 12
Knutzen, S. M., Christensen, D. S., Cairns, P., Damholdt, M. F., Amidi, A., & Zachariae, R. H. (2024) · JMIR Mental Health · doi:10.2196/58217 · Cited by 14
“This efficacy extends not only to individuals with insomnia as their primary concern [37,38] but also to those with comorbid insomnia, for example, survivors of cancer [39].”
BackgroundSato, D., Sutoh, C., Seki, Y., Nagai, E., & Shimizu, E. (2019) · JMIR Formative Research · doi:10.2196/12635 · Cited by 12
“Accumulating evidence in recent years suggests that internet-based, computerized CBT for insomnia can be an effective treatment [13-15], and attention has turned to internet-based CBT for insomnia as an alternative to face-to-face CBT [16].”
The Use of Digital Health Technologies to Manage Insomnia in Military Populations
Cavanagh, R., Mackey, R., Bridges, L., Gleason, A., Ciulla, R., Micheel, L., Bradshaw, D. H., Armstrong, C. M., & Hoyt, T. (2019) · Journal of Technology in Behavioral Science · doi:10.1007/s41347-019-00114-w · Cited by 16
Deak, M. C., & Winkelman, J. W. (2012) · Neurologic Clinics · doi:10.1016/j.ncl.2012.08.012 · Cited by 13
Asano, K., Ishimura, I., Abe, H., Nakazato, M., Nakagawa, A., & Shimizu, E. (2015) · Open Journal of Medical Psychology · doi:10.4236/ojmp.2015.41002 · Cited by 10
“It was shown improvements in self-reported sleep quality after internet-delivered CBTI, with gains maintained at 6-month follow-up [17].”
BackgroundLes troubles du sommeil dans l’addiction à Internet
Petit, A., Karila, L., Estellat, C., Moisan, D., Reynaud, M., d’Ortho, M., Lejoyeux, M., & Levy, F. (2016) · La Presse Médicale · doi:10.1016/j.lpm.2016.04.025 · Cited by 11
Evaluating the Effectiveness of Website Content Features Using Retrospective Pretest Methodology
Mueller, C. (2015) · Evaluation review · doi:10.1177/0193841x15582142 · Cited by 14
“…as treatments for specific target groups—such as people in certain medical conditions or other groups sharing specific characteristics (e.g., Ritterband et al., 2009; Salonen, Pridham, Brown, & Kaunonen, 2014; Ybarra & Bull, 2007)—and they are interested in the effects on these target…”
BackgroundLien, M., Bredeli, E., Sivertsen, B., Kallestad, H., Pallesen, S., Smith, O. R. F., Faaland, P. M., Ritterband, L. M., Thorndike, F. P., & Vedaa, Ø. (2019) · Chronobiology International · doi:10.1080/07420528.2019.1647435 · Cited by 11
“One current unguided ICBTi treatment program is Sleep Healthy Using the InternetTM (SHUTi), which has demonstrated lasting treatment effects comparable to that of in-person delivered CBTi (Hagatun et al. 2019; Ritterband et al. 2009, 2017; Vedaa et al. 2019).”
BackgroundMethodSelf-citationCognitive Behavioral Therapy for Insomnia in the Digital Age
Kang, S., & Kim, Y. (2019) · Advances in experimental medicine and biology · doi:10.1007/978-981-32-9721-0_30 · Cited by 11
Yu, H., Zhang, Y., Liu, Q., & Yan, R. (2021) · Annals of Palliative Medicine · doi:10.21037/apm-21-2387 · Cited by 10
“However, most patients with insomnia do not receive safe and effective treatment (8).”
BackgroundEfficacy of an Internet-Based Behavioral Intervention for Adults With Insomnia
Nolan, B. F. (2010) · Yearbook of Neurology and Neurosurgery · doi:10.1016/s0513-5117(10)79203-6 · Cited by 11
A Randomized Trial of a Self-Administered Parenting Intervention for Infant and Toddler Insomnia
Stevens, J. H., Splaingard, D., Webster-Cheng, S., Rausch, J. R., & Splaingard, M. (2019) · Clinical Pediatrics · doi:10.1177/0009922819832030 · Cited by 11
Meaklim, H., Abbott, J.-A., Kennedy, G. A., Murray, G., Klein, B., & Rehm, I. C. (2018) · Australian Psychologist · doi:10.1111/ap.12374 · Cited by 11
“…on subjective measures of sleep and insomnia symptoms, comparable to face-to-face CBT-I (Anderson, Goldsmith, & Gardiner, 2014; Espie et al., 2012; Ritterband et al., 2009; Strom, Pettersson, & Andersson, 2004; Suzuki et al., 2008). iCBT-I programs, therefore, offer a convenient and effective…”
BackgroundKey Enablers to Facilitate Healthy Behavior Change: Workshop Summary
Teyhen, D. S., Aldag, M., Centola, D. M., Edinborough, E., Ghannadian, J. D., Haught, A., Jackson, T. N., Kinn, J. T., Kunkler, K. J., Levine, B. A., et al. (2014) · Journal of Orthopaedic and Sports Physical Therapy · doi:10.2519/jospt.2014.0301 · Cited by 11
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“[25] criticised current online resources for being predominately information and support based, with a need for evidenced-based treatment interventions.”
BackgroundComputerised cognitive behavioural therapy: helping Ireland log on
Twomey, C., O'Reilly, G., & Byrne, M. (2013) · Irish Journal of Psychological Medicine · doi:10.1017/ipm.2012.5 · Cited by 11
Engagement in Digital Self-management Interventions for Chronic Pain
MacLean, R. R., Shor, R., Reilly, E. D., Reuman, L., Solar, C. A., Halat, A. M., & Higgins, D. M. (2025) · Clinical Journal of Pain · doi:10.1097/ajp.0000000000001289 · Cited by 12
Effectiveness of digital interventions for eight mental disorders: A meta-analytic synthesis
Harrer, M., Miguel, C., Tong, L., Kuper, P., Sprenger, A. A., Furukawa, Y., Wang, Y., van Ballegooijen, W., Čihařová, M., Panagiotopoulou, O. M., et al. (2025) · Internet Interventions · doi:10.1016/j.invent.2025.100860 · Cited by 10
“For insomnia, we identified six trials evaluating Somryst ( SHUTi ; Pear Therapeutics/Nox Health, USA; Hagatun et al., 2019; Lorenz et al., 2019; Ritterband et al., 2009, 2012; Christensen et al., 2016; Nazem et al., 2023).”
田村, 典., & Tanaka, H. (2017) · Journal of Behavioral Medicine · doi:10.1007/s10865-017-9836-0 · Cited by 9
Sleep hygiene in paramedics: What do they know, and what do they do?
Shriane, A. E., Russell, A. M. T., Ferguson, S. A., Rigney, G., & Vincent, G. E. (2023) · Sleep Health · doi:10.1016/j.sleh.2022.10.008 · Cited by 11
New models of care for psychology in Canada's health services.
Graff, L. A., Kaoukis, G., Vincent, N., Piotrowski, A. S., & Ediger, J. P. (2012) · Canadian Psychology/Psychologie canadienne · doi:10.1037/a0026635 · Cited by 10
Zhang, Y., Su, J., Wang, J., Tang, G., Hu, W., Mao, J., Ren, W.-W., Liu, Y., & Yu, Z. (2018) · Medicine · doi:10.1097/md.0000000000012383 · Cited by 9
Fragmented sleep - fragmented mind : the role of sleep in dissociative symptoms
der Kloet, D. V. H. (2013) · Research Publications (Maastricht University) · doi:10.26481/dis.20131115dk · Cited by 9
Meaklim, H., & Cunnington, D. (2018) · Evidence-Based Mental Health · doi:10.1136/eb-2017-102726 · Cited by 8
Benz, F., Grolig, L., Hannibal, S., Buntrock, C., Cuijpers, P. J., Domschke, K., Ebert, D. D., Ell, J., Janneck, M., Jenkner, C., et al. (2024) · Trials · doi:10.1186/s13063-024-08214-6 · Cited by 10
“Internet-delivered CBT-I (iCBT-I) has the potential to make guideline-recommended therapy more accessible to people suffering from insomnia [17].”
BackgroundSelf-citationScott, A. J., Hathway, T., Bisby, M. A., Titov, N., & Dear, B. F. (2024) · Internet Interventions · doi:10.1016/j.invent.2024.100778 · Cited by 8
Spiegelhalder, K., Baglioni, C., Morin, C. M., Nissen, C., Palagini, L., Perlis, M. L., Scott, H., & Riemann, D. W. (2026) · Nature Reviews Disease Primers · doi:10.1038/s41572-026-00693-y · Cited by 17
Self-citationCockayne, N. L., Christensen, H. M., Griffiths, K. M., Naismith, S. L., Hickie, I. B., Thorndike, F. P., Ritterband, L. M., & Glozier, N. (2015) · BMC Psychiatry · doi:10.1186/s12888-015-0397-x · Cited by 8
“With the development and initial evaluation of Sleep Healthy Using the Internet (SHUTi), members of our team have demonstrated the efficacy of an internet intervention for adults with insomnia [20].”
BackgroundResultSelf-citationFelder, J. N., Mirchandaney, R., Manber, R., Cuneo, J., Krystal, A. D., Solomon, N., Janette, S., Zhang, L., Moran, P. J., Mashash, M., et al. (2024) · Behavioral Sleep Medicine · doi:10.1080/15402002.2024.2359415 · Cited by 8
“This rate of insomnia non-remission following CBT-I during pregnancy is higher than in non-perinatal populations (Cheng et al., 2019; Ritterband et al., 2009), potentially because CBT-I does not target the pregnancy-specific factors of poor sleep quality, such as pain and discomfort.”
InfluentialHermes, E. D. A., Rosenheck, R. A., Burrone, L., Dante, G., Lukens, C. L., & Martino, S. (2021) · Implementation Research and Practice · doi:10.1177/26334895211053659 · Cited by 9
“In research trials, SHUTi participants have experienced reduced insomnia severity, improved sleep measures, and reduced depression symptoms (Christensen et al., 2016; Ritterband et al., 2009).”
Background
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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