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Cited by 15Sleep and related disordersDigital Mental Health InterventionsMindfulness and Compassion Interventions

The mediating role of insomnia severity in internet-based cognitive behavioral therapy for chronic stress: Secondary analysis of a randomized controlled trial

Open access
Lindsäter, Elin, Axelsson, Erland, Salomonsson, Sigrid, Santoft, Fredrik, Ljótsson, Brjánn, Åkerstedt, Torbjörn, Lekander, Mats, Hedman-Lagerlöf, Erik·2021·Behaviour Research and Therapy
DOI 10.1016/j.brat.2020.103782
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Abstract

The aim of this study was to investigate insomnia symptom severity as a putative mediator of treatment response in therapist-guided internet-based cognitive behavioral therapy (ICBT) for chronic stress, using data from a randomized controlled trial. Participants (N = 100) were randomized to 12 weeks of ICBT or to a waitlist control condition (WLC). Insomnia severity was assessed weekly with the Insomnia Severity Index (ISI), as were the stress-related outcomes the Perceived Stress Scale (PSS) and the Shirom-Melamed Burnout Questionnaire (SMBQ). Latent growth models indicated that ICBT (vs. WLC) predicted a decrease in insomnia severity (α-path), and that growth in insomnia severity was predictive of growth in perceived stress and exhaustion (β-paths). Most importantly, there were also significant indirect effects (αβ products) such that the beneficial effects of ICBT on perceived stress and exhaustion were mediated by a reduction in insomnia symptom severity (PSS: αβ = -0.44, 95% CI [-0.92, -0.14]; SMBQ: αβ = -0.08, 95% CI [-0.15, -0.04]). Explorative analysis of moderated mediation showed that more severe insomnia symptoms at baseline were associated with larger mediated effects. We conclude that reducing insomnia severity could be of importance for achieving successful treatment outcomes in ICBT for chronic stress.

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  • Of all secondary findings, only one was replicated across two studies: the effect of Internet-CBT on symptoms of stress and exhaustion was mediated by insomnia severity.

    “Of all secondary findings, only one was replicated across two studies, showing that the effect of Internet-CBT on symptoms of stress and exhaustion was mediated by insomnia severity [68, 80].”

    From Psychological Treatment of Exhaustion Due to Persistent Non-Traumatic Stress: A Scoping Review. (2024) · cites this paper as [68]

    The Mediation analysis reports that reduced insomnia severity statistically mediated Internet-CBT’s effects on both perceived stress and exhaustion. The Discussion says this is in line with an earlier face-to-face CBT study, but that earlier study found mediation for exhaustion; the extension to perceived stress and Internet delivery belongs to the present study. Thus, the source does not establish that the full Internet-CBT finding was replicated across two studies. (LLM, conf=0.88)

    Experimental — accuracy not yet measured

  • The importance of insomnia as a mediator of change in symptoms of exhaustion has later been corroborated in another RCT of Internet-CBT for ED and adjustment disorder.

    “The importance of insomnia as a mediator of change in symptoms of exhaustion has later been corroborated in another RCT of Internet-CBT for ED and adjustment disorder (Lindsäter et al., 2021).”

    From Mediators during a Multimodal intervention for stress-induced exhaustion disorder (2024) · cites this paper as Lindsäter et al., 2021

  • These findings corroborate previous studies identifying insomnia as a potential mediator in ED treatment.

    “These findings corroborate previous studies identifying insomnia as a potential mediator in ED treatment (Lindsäter et al., 2021; Santoft et al., 2019).”

    From Mediators during a Multimodal intervention for stress-induced exhaustion disorder (2024) · cites this paper as Lindsäter et al., 2021

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Research works printed but not linked: 2

  1. Bollen, K. A., & Curran, P. J. (2006). Latent curve models: A structural equation perspective (Vol. 467). John Wiley & Sons.
  2. Hassard, J., Teoh, K., Cox, T., Dewe, P., Cosmar, M., Gründler, R., et al. (2014). Calculating the cost of work-related stress and psychosocial risks: European risk observatory literature review. European Agency for Safety and Health at Work.

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Authors
Lindsäter, E., Axelsson, E., Salomonsson, S., Santoft, F., Ljótsson, B., Åkerstedt, T., Lekander, M., & Hedman-Lagerlöf, E.
Affiliations
  • Karolinska Institutet (SE)
  • Stockholm University (SE)
Corresponding author
Lindsäter, Elin
ORCID
Venue
Behaviour Research and Therapy
Publisher
Elsevier BV
Published
2021-01
Volume
136
Pages
103782
ISSN
0005-7967 (ISSN-L)
DOI
10.1016/j.brat.2020.103782
OpenAlex
W3108716376
Cited by
15
References
70
Citations by year
2026: 2 · 2025: 2 · 2024: 2 · 2023: 5 · 2022: 2 · 2021: 2
FWCI
2.18
Type
journal article
Language
en
Open access
Licence
Locations
  • Behaviour Research and Therapy (publishedVersion, cc-by)
  • PubMed (publishedVersion)
Funders
  • Stockholms Läns Landsting
  • Stockholm Stress Center
  • Karolinska Institutet
Topics
  • Social Sciences › Psychology › Experimental and Cognitive Psychology › Sleep and related disorders
  • Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
  • Social Sciences › Psychology › Clinical Psychology › Mindfulness and Compassion Interventions
Keywords
insomnia severity, internet-based cognitive behavioral therapy, chronic stress, perceived stress, burnout, exhaustion, mediation, moderated mediation, therapist-guided intervention, Insomnia Severity Index, Perceived Stress Scale
MeSH terms
Humans, Sleep Initiation and Maintenance Disorders, Surveys and Questionnaires, Cognitive Behavioral Therapy, Treatment Outcome, Internet

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