Effect of a Web-Based Cognitive Behavior Therapy for Insomnia Intervention With 1-Year Follow-up: A Randomized Clinical Trial
Abstract
IMPORTANCE: Although cognitive behavior therapy for insomnia (CBT-I) has been established as the first-line recommendation for the millions of adults with chronic insomnia, there is a paucity of trained clinicians to deliver this much needed treatment. Internet-delivered CBT-I has shown promise as a method to overcome this obstacle; however, the long-term effectiveness has not been proven in a representative sample with chronic insomnia. OBJECTIVE: To evaluate a web-based, automated CBT-I intervention to improve insomnia in the short term (9 weeks) and long term (1 year). DESIGN, SETTING, AND PARTICIPANTS: A randomized clinical trial comparing the internet CBT-I with internet patient education at baseline, 9 weeks, 6 months, and 1 year. Altogether, 303 adults with chronic insomnia self-referred to participate, of whom 151 (49.8%) reported at least 1 medical or psychiatric comorbidity. INTERVENTIONS: The internet CBT-I (Sleep Healthy Using the Internet [SHUTi]) was a 6-week fully automated, interactive, and tailored web-based program that incorporated the primary tenets of face-to-face CBT-I. The online patient education program provided nontailored and fixed online information about insomnia. MAIN OUTCOMES AND MEASURES: The primary sleep outcomes were self-reported online ratings of insomnia severity (Insomnia Severity Index) and online sleep diary-derived values for sleep-onset latency and wake after sleep onset, collected prospectively for 10 days at each assessment period. The secondary sleep outcomes included sleep efficiency, number of awakenings, sleep quality, and total sleep time. RESULTS: Among 303 participants, the mean (SD) age was 43.28 (11.59) years, and 71.9% (218 of 303) were female. Of these, 151 were randomized to the SHUTi group and 152 to the online patient education group. Results of the 3 primary sleep outcomes showed that the overall group × time interaction was significant for all variables, favoring the SHUTi group (Insomnia Severity Index [F3,1063 = 20.65, P < .001], sleep-onset latency [F3,1042 = 6.01, P < .001], and wake after sleep onset [F3,1042 = 12.68, P < .001]). Within-group effect sizes demonstrated improvements from baseline to postassessment for the SHUTi participants (range, Cohen d = 0.79 [95% CI, 0.55-1.04] to d = 1.90 [95% CI, 1.62-2.18]). Treatment effects were maintained at the 1-year follow-up (SHUTi Insomnia Severity Index d = 2.32 [95% CI, 2.01-2.63], sleep-onset latency d = 1.41 [95% CI, 1.15-1.68], and wake after sleep onset d = 0.95 [95% CI, 0.70-1.21]), with 56.6% (69 of 122) achieving remission status and 69.7% (85 of 122) deemed treatment responders at 1 year based on Insomnia Severity Index data. All secondary sleep outcomes, except total sleep time, also showed significant overall group × time interactions, favoring the SHUTi group. CONCLUSIONS AND RELEVANCE: Given its efficacy and availability, internet-delivered CBT-I may have a key role in the dissemination of effective behavioral treatments for insomnia. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01438697.
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Recent studies have shown that those who received Web-based CBTi had improved sleep outcomes.
“Recent studies have shown that those who received Web-based CBTi had improved sleep outcomes [22-26].”
From Tamper-Resistant Mobile Health Using Blockchain Technology. (2017) · cites this paper as [26]
In a study of Somryst, participants who completed all six modules of CBT significantly improved their insomnia compared to those who did not, and the efficacy was sustained at 12-month follow up.
“In the case of ‘Somryst,’ which is ‘Pear Therapeutics’ digital treatment for insomnia, a study has shown that participants who completed all six modules of CBT significantly improved their insomnia compared to those who did not, and the efficacy was sustained at 12-month follow up [10,11].”
From A Review of Current Digital Mental Health Care Applications for Anxiety Symptoms and Future Prospects (2024) · cites this paper as [10]
Fully automated CBT-I treatment showed large improvement effects.
“Ritterband et al. [7] showed large improvement effects as a result of fully automated CBT-I treatment.”
The large treatment reduction in insomnia for the students is very similar to that found in trials with general adult populations.
“The large treatment reduction in insomnia for the students is very similar to that found in trials with general adult populations,10, 11, 36”
From The effects of improving sleep on mental health (OASIS): a randomised controlled trial with mediation analysis (2017) · cites this paper as [10]
The use of remote treatment across the internet has been increasing and its effectiveness has been demonstrated for various intractable diseases.
“The use of remote treatment across the internet has been increasing and its effectiveness has been demonstrated for various intractable diseases [11-14].”
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- Authors
- Ritterband, L. M., Thorndike, F. P., Ingersoll, K. S., Lord, H. R., Gonder-Frederick, L., Frederick, C., Quigg, M. S., Cohn, W. F., & Morin, C. M.
- Affiliations
- University of Virginia (US)
- Université Laval (CA)
- Corresponding author
- Ritterband, Lee M.
- ORCID
- Venue
- JAMA Psychiatry
- Publisher
- American Medical Association (AMA)
- Published
- 2017-01-01
- Volume
- 74
- Issue
- 1
- Pages
- 68
- ISSN
- 2168-622X (ISSN-L)
- OpenAlex
- W2558123475
- Cited by
- 325
- References
- 37
- Citations by year
- 2026: 33 · 2025: 29 · 2024: 32 · 2023: 40 · 2022: 41 · 2021: 33 · 2020: 35 · 2019: 26 · 2018: 34 · 2017: 21 · 2016: 1
- FWCI
- 38.98
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- JAMA Psychiatry (publishedVersion)
- PubMed (publishedVersion)
- Funders
- National Institute of Mental Health (R01MH086758)
- 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 › Obstructive Sleep Apnea Research
- Keywords
- cognitive behavioral therapy for insomnia, online therapy, chronic insomnia, long-term follow-up, sleep latency, wake after sleep onset, insomnia severity, sleep efficiency, sleep quality, online patient education, medication adherence, psychiatric comorbidity, sleep diary, clinician shortage
- MeSH terms
- Adult, Behavior Therapy, Female, Follow-Up Studies, Humans, Sleep Initiation and Maintenance Disorders, Male, Middle Aged, Patient Education as Topic, Therapy, Computer-Assisted, Comorbidity, Treatment Outcome, Internet
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