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Efficacy of internet-delivered cognitive-behavioral therapy for insomnia— a systematic review and meta-analysis of randomized controlled trials

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Zachariae, Robert, Lyby, Marlene S., Ritterband, Lee M., O'Toole, Mia S.·2016·Sleep Medicine Reviews

DOI 10.1016/j.smrv.2015.10.004

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Abstract

Cognitive-behavioral therapy for insomnia (CBT-I) has been shown efficacious, but the challenge remains to make it available and accessible in order to meet population needs. Delivering CBT-I over the internet (eCBT-I) may be one method to overcome this challenge. The objective of this meta-analysis was to evaluate the efficacy of eCBT-I and the moderating influence of various study characteristics. Two researchers independently searched key electronic databases (1991 to June 2015), selected eligible publications, extracted data, and evaluated methodological quality. Eleven randomized controlled trials examining a total of 1460 participants were included. Results showed that eCBT-I improved insomnia severity, sleep efficiency, subjective sleep quality, wake after sleep onset, sleep onset latency, total sleep time, and number of nocturnal awakenings at post-treatment, with effect sizes (Hedges's g) ranging from 0.21 to 1.09. The effects were comparable to those found for face-to-face CBT-I, and were generally maintained at 4-48 wk follow-up. Moderator analyses showed that longer treatment duration and higher degree of personal clinical support were associated with larger effect sizes, and that larger study dropout in the intervention group was associated with smaller effect sizes. In conclusion, internet-delivered CBT-I appears efficacious and can be considered a viable option in the treatment of insomnia.

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Proof of Concept for an Adaptive Treatment Strategy to Prevent Failures in Internet-Delivered CBT: A Single-Blind Randomized Clinical Trial With Insomnia Patients
Forsell, E., Jernelöv, S., Blom, K., Kraepelien, M., Svanborg, C., Andersson, G., Lindefors, N., & Kaldo, V. (2019) · American Journal of Psychiatry · doi:10.1176/appi.ajp.2018.18060699 · Cited by 100
Improvements of adolescent psychopathology after insomnia treatment: results from a randomized controlled trial over 1 year
de Bruin, E. J., Bögels, S. M., Oort, F. J., & Meijer, A. M. (2018) · Journal of Child Psychology and Psychiatry · doi:10.1111/jcpp.12834 · Cited by 95
Pilot evaluation of the Sleep Ninja: A smartphone application for adolescent insomnia symptoms
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A single arm pilot trial of brief cognitive behavioral therapy for insomnia in adolescents with physical and psychiatric comorbidities
Palermo, T. M., Beals-Erickson, S., Bromberg, M., Law, E., & Chen, M. (2017) · Journal of Clinical Sleep Medicine · doi:10.5664/jcsm.6490 · Cited by 92
Insomnia in adult patients with cancer: ESMO Clinical Practice Guideline
Grassi, L., Zachariae, R., Caruso, R., Palagini, L., Campos-Ródenas, R., Riba, M. B., Lloyd-Williams, M., Kissane, D., Rodin, G., McFarland, D., et al. (2023) · ESMO Open · doi:10.1016/j.esmoop.2023.102047 · Cited by 96
Economic Evaluation of Cognitive Behavioural Therapy for Insomnia (CBT-I) for Improving Health Outcomes in Adult Populations: A Systematic Review
Natsky, A. N., Vakulin, A., Chai-Coetzer, C. L., Lack, L., McEvoy, R. D., Lovato, N., Sweetman, A., Gordon, C. J., Adams, R. J., & Kaambwa, B. (2020) · Sleep Medicine Reviews · doi:10.1016/j.smrv.2020.101351 · Cited by 91
Randomized Controlled Trial to Test the Efficacy of an Unguided Online Intervention with Automated Feedback for the Treatment of Insomnia
Lorenz, N., Heim, E., Rötger, A., Birrer, E., & Maercker, A. R. A. (2018) · Behavioural and Cognitive Psychotherapy · doi:10.1017/s1352465818000486 · Cited by 90
“One meta-analysis found eleven published randomized controlled trials (RCTs) which had tested the effect of internet-delivered CBT-I (Zachariae et al., 2016).”
BackgroundMethodInfluential
Comparative efficacy and acceptability of cognitive behavioral therapy delivery formats for insomnia in adults: A systematic review and network meta-analysis
Gao, Y., Ge, L., Liu, M., Niu, M., Chen, Y., Sun, Y., Chen, J., Yao, L., Wang, Q., Li, Z., et al. (2022) · Sleep Medicine Reviews · doi:10.1016/j.smrv.2022.101648 · Cited by 89
Systematic review and meta-analysis of cognitive-behavioural therapy for insomnia on subjective and actigraphy-measured sleep and comorbid symptoms in cancer survivors
Squires, L. R., Rash, J. A., Fawcett, J., & Garland, S. N. (2022) · Sleep Medicine Reviews · doi:10.1016/j.smrv.2022.101615 · Cited by 85
Internet and In-Person Cognitive Behavioral Therapy for Insomnia in Military Personnel: A Randomized Clinical Trial
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
“The primary hypotheses were that in-person and Internet CBTi would result in greater sleep efficiency improvement from pre-treatment to post-treatment than the control condition and that in-person CBTi would also be superior to Internet CBTi.”
MethodResultInfluential
Trajectories of change and long-term outcomes in a randomised controlled trial of internet-based insomnia treatment to prevent depression
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
Advances in PTSD Treatment Delivery: Review of Findings and Clinical Considerations for the Use of Telehealth Interventions for PTSD
Morland, L. A., Wells, S. Y., Glassman, L. H., Greene, C. J., Hoffman, J. E., & Rosen, C. S. (2020) · Current Treatment Options in Psychiatry · doi:10.1007/s40501-020-00215-x · Cited by 89
Acceptance and commitment therapy (ACT) improves sleep quality, experiential avoidance, and emotion regulation in individuals with insomnia-results from a randomized interventional study
Zakiei, A., Khazaie, H., Rostampour, M., Lemola, S., Esmaeili, M., Dürsteler, K., Brühl, A., Sadeghi-Bahmani, D., & Brand, S. (2021) · Life · doi:10.3390/life11020133 · Cited by 84
“CBT-i can be delivered as group-therapy interventions [19,20] or as internet-delivered interventions [21,22].”
Background
A systematic review of cognitive behavioral therapy for insomnia implemented in primary care and community settings
Cheung, J. M. Y., Jarrin, D. C., Ballot, O., Bharwani, A. A., & Morin, C. M. (2018) · Sleep Medicine Reviews · doi:10.1016/j.smrv.2018.11.001 · Cited by 88
Sleep disturbance in psoriasis: a case-controlled study
Jensen, P., Zachariae, C. O. C., Skov, L., & Zachariae, R. H. (2018) · British Journal of Dermatology · doi:10.1111/bjd.16702 · Cited by 87
Digital Interventions for Mental Disorders: Key Features, Efficacy, and Potential for Artificial Intelligence Applications
Ebert, D. D., Harrer, M., Apolinário-Hagen, J., & Baumeister, H. (2019) · Advances in Experimental Medicine and Biology · doi:10.1007/978-981-32-9721-0_29 · Cited by 76
Nurse-Guided Internet-Delivered Cognitive Behavioral Therapy for Insomnia in General Practice: Results from a Pragmatic Randomized Clinical Trial
van der Zweerde, T., Lancee, J., Slottje, P., Bosmans, J. E., Someren, E. J. W. V., & van Straten, A. (2020) · Psychotherapy and Psychosomatics · doi:10.1159/000505600 · Cited by 81
Step-by-Step, an E-Mental Health Intervention for Depression: A Mixed Methods Pilot Study From Lebanon
Harper Shehadeh, M. J., Abi Ramia, J., Cuijpers, P., El Chammay, R., Heim, E., Kheir, W., Saeed, K., van Ommeren, M., van’t Hof, E., Watts, S., et al. (2020) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2019.00986 · Cited by 75
Patient’s experience with blended video- and internet based cognitive behavioural therapy service in routine care
Etzelmueller, A., Radkovsky, A., Hannig, W., Berking, M., & Ebert, D. D. (2018) · Internet Interventions · doi:10.1016/j.invent.2018.01.003 · Cited by 75
How does cognitive behavioural therapy for insomnia work? A systematic review and meta-analysis of mediators of change
Parsons, C. E., Zachariae, R. H., Landberger, C., & Young, K. S. (2021) · Clinical Psychology Review · doi:10.1016/j.cpr.2021.102027 · Cited by 85
Efficacy of a Theory-Based Cognitive Behavioral Technique App-Based Intervention for Patients With Insomnia: Randomized Controlled Trial
Majd, N. R., Broström, A., Ulander, M., Lin, C., Griffiths, M. D., Imani, V., Ahorsu, D. K., Ohayon, M. M., & Pakpour, A. H. (2020) · Journal of Medical Internet Research · doi:10.2196/15841 · Cited by 78
“The insomnia intervention was delivered via a smartphone app to make it available and accessible to meet population needs; app-based interventions overcome some of the pragmatic problems of the face-to-face therapy, including time limitations and high costs [41,42].”
Method
Efficacy of a stepped care approach to deliver cognitive-behavioral therapy for insomnia in cancer patients: a noninferiority randomized controlled trial
Savard, J., Ivers, H., Savard, M., Morin, C. M., Caplette‐Gingras, A., Bouchard, S., & Lacroix, G. (2021) · SLEEP · doi:10.1093/sleep/zsab166 · Cited by 80
“For the current study, we developed a web-based version of our video-based program as the first treatment step in view of the accumulating evidence supporting the efficacy of web-based CBT-I [22, 23].”
Method
Profile of Somryst prescription digital therapeutic for chronic insomnia: overview of safety and efficacy
Morin, C. M. (2020) · Expert Review of Medical Devices · doi:10.1080/17434440.2020.1852929 · Cited by 66
Is the devil in the detail? A randomised controlled trial of guided internet-based CBT for perfectionism
Shafran, R., Wade, T. D., Egan, S. J., Kothari, R., Allcott-Watson, H., Carlbring, P., Rozental, A., & Andersson, G. (2017) · Behaviour Research and Therapy · doi:10.1016/j.brat.2017.05.014 · Cited by 79
Smartphone-Based Psychotherapeutic Micro-Interventions to Improve Mood in a Real-World Setting
Meinlschmidt, G., Lee, J.-H., Stalujanis, E., Belardi, A., Oh, M., Jung, E. K., Kim, H.-C., Alfano, J., Yoo, S.-S., & Tegethoff, M. (2016) · Frontiers in Psychology · doi:10.3389/fpsyg.2016.01112 · Cited by 68
“…Harvard Medical School, Boston, MA, USA, 6 Incheon St. Mary’s Hospital, The Catholic University of Korea, Incheon, South Korea Background: Using mobile communication technology as new personalized approach to treat mental disorders or to more generally improve quality of life is highly promising.”
Background
The Early Impact of COVID-19 on Chronic Pain: A Cross-Sectional Investigation of a Large Online Sample of Individuals with Chronic Pain in the United States, April to May, 2020
Mun, C. J., Campbell, C. M., McGill, L., & Aaron, R. V. (2020) · Pain Medicine · doi:10.1093/pm/pnaa446 · Cited by 73
“These online interventions are not only easily accessible and scalable, but also have demonstrated effect sizes comparable to those found in interventions delivered in person [31, 32].”
Background
Three-Year Follow-Up of Insomnia and Hypnotics after Controlled Internet Treatment for Insomnia
Blom, K., Jernelöv, S., Rück, C., Lindefors, N., & Kaldo, V. (2016) · SLEEP · doi:10.5665/sleep.5850 · Cited by 69
Habit Interventions
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The Importance of Sleep for People With Chronic Pain: Current Insights and Evidence
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Sleep interventions for osteoarthritis and spinal pain: a systematic review and meta-analysis of randomized controlled trials
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Cost-effectiveness of digital cognitive behavioral therapy ( Sleepio ) for insomnia: a Markov simulation model in the United States
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Efficacy of an m-Health Physical Activity and Sleep Health Intervention for Adults: A Randomized Waitlist-Controlled Trial
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“A unique contribution of this study is that it assessed sleep quality at 3 and 6 months, which is longer than the intervention periods and follow-up intervals of many sleep interventions.(56) The magnitude of the betweengroup difference in favor of the intervention group at 3 months is consistent with findings from tr…”
BackgroundResult
Prevention of internalizing disorders and suicide via adolescent sleep interventions
Blake, M. J., & Allen, N. B. (2019) · Current Opinion in Psychology · doi:10.1016/j.copsyc.2019.08.027 · Cited by 70
Sleep and Dreaming in Posttraumatic Stress Disorder
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Digital Delivery of Cognitive Behavioral Therapy for Insomnia
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“To our knowledge, no study has focused on insomnia complaints, despite the evidence that digital behavioral therapies are effective to treat insomnia [12-14].”
Internetbasierte Interventionen in der Behandlung psychischer Störungen
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Authors: Zachariae, R., Lyby, M. S., Ritterband, L. M., & O'Toole, M. S.
Affiliations: Aarhus University (DK)
University of Virginia (US)
Corresponding author: Zachariae, Robert
ORCID: Zachariae, Robert
Ritterband, Lee M.
Venue: Sleep Medicine Reviews
Publisher: Elsevier BV
Published: 2016-12
Volume: 30
Pages: 1-10
ISSN: 1087-0792 (ISSN-L)
DOI: 10.1016/j.smrv.2015.10.004
OpenAlex: W1863769327
Cited by: 704
References: 82
Citations by year: 2026: 27 · 2025: 81 · 2024: 69 · 2023: 76 · 2022: 78 · 2021: 70 · 2020: 136 · 2019: 47 · 2018: 45 · 2017: 50 · 2016: 22
FWCI: 5.07
Type: journal article
Language: en
Open access: green
pure.au.dk
Licence: cc-by-nc-nd
www.elsevier.com/tdm/userlicense/1.0/ (tdm)
Locations: Sleep Medicine Reviews (publishedVersion)
PubMed (publishedVersion)
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: internet-based cognitive behavioral therapy, insomnia, treatment efficacy, sleep efficiency, sleep quality, wake after sleep onset, sleep latency, nocturnal awakenings, treatment duration, follow-up maintenance, dropout
MeSH terms: Humans, Sleep Initiation and Maintenance Disorders, Cognitive Behavioral Therapy, Randomized Controlled Trials as Topic, Treatment Outcome, Internet

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Efficacy of internet-delivered cognitive-behavioral therapy for insomnia— a systematic review and meta-analysis of randomized controlled trials

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