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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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Background
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Assessing the Short-Term Efficacy of Digital Cognitive Behavioral Therapy for Insomnia With Different Types of Coaching: Randomized Controlled Comparative Trial
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“Meta-analyses have found mixed results regarding the effect sizes of dCBTi with different types of coaching support [24,25], but a direct comparative trial has not yet been conducted.”
Result
Patient Perceptions of Treatment Delivery Platforms for Cognitive Behavioral Therapy for Insomnia
Cheung, J. M. Y., Bartlett, D. J., Armour, C. L., Laba, T., & Saini, B. (2017) · Behavioral Sleep Medicine · doi:10.1080/15402002.2017.1293539 · Cited by 21
Positive impacts of e-aid cognitive behavioural therapy on the sleep quality and mood of nurses on site during the COVID-19 pandemic
Zhou, K., Kong, J., Wan, Y., Zhang, X., Liu, X., Qu, B., Wang, B., & Xue, R. (2022) · Sleep and Breathing · doi:10.1007/s11325-021-02547-1 · Cited by 20
A Pilot Randomized Controlled Trial to Assess Feasibility and Treatment Effect of a Web-Based Delivered Cognitive Behavioral Therapy for Insomnia Program in Individuals with Multiple Sclerosis
Siengsukon, C. F., Beck, E. S., & Drerup, M. L. (2020) · International Journal of MS Care · doi:10.7224/1537-2073.2019-122 · Cited by 20
Engagement of Stakeholders in the Design, Evaluation, and Implementation of Complex Interventions
Hudson, J. L., Moon, Z., Hughes, L. D., & Moss-Morris, R. E. (2020) · Cambridge University Press eBooks · doi:10.1017/9781108677318.024 · Cited by 20
The efficacy of digital cognitive behavioral therapy for insomnia and depression: a systematic review and meta-analysis of randomized controlled trials
Lin, W., Li, N., Yang, L., & Zhang, Y. (2023) · PeerJ · doi:10.7717/peerj.16137 · Cited by 24
“These results were consistent with previous meta-analysis studies ( Karyotaki et al., 2021 ; Zachariae et al., 2016 ; Frase et al., 2020 ).”
Low-Intensity Cognitive Behavioral Therapy for Insomnia as the Entry of the Stepped-Care Model in the Community: A Randomized Controlled Trial
Wong, K.-Y., Chung, K., & Au, C. W. (2020) · Behavioral Sleep Medicine · doi:10.1080/15402002.2020.1764000 · Cited by 20
“A recent meta-analysis supported our findings that the two CBTI formats did not differ in efficacy (Zachariae et al., 2016).”
Result
Incentive-Based Interventions
Uri Gneezy, B., Kajackaite, A., & Meier, S. (2020) · Cambridge University Press eBooks · doi:10.1017/9781108677318.036 · Cited by 20
Insomnia Interventions in the Workplace: A Systematic Review and Meta-Analysis
Vega‐Escaño, J., Pórcel‐Gálvez, A. M., de Diego‐Cordero, R., Romero‐Sánchez, J. M., Romero‐Saldaña, M., & Barrientos‐Trigo, S. (2020) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph17176401 · Cited by 20
“meta-analyses, which revealed positive and efficient effects in the general population for cognitive behavioral therapy on insomnia [52,53], which was the predominant treatment option in the studies included in our meta-analysis.”
Effect of an Internet–Delivered Cognitive Behavioral Therapy–Based Sleep Improvement App for Shift Workers at High Risk of Sleep Disorder: Single-Arm, Nonrandomized Trial
Ito-Masui, A., Sakamoto, R., Matsuo, E., Kawamoto, E., Motomura, E., Tanii, H., Yu, H., Sano, A., Imai, H., & Shimaoka, M. (2023) · Journal of Medical Internet Research · doi:10.2196/45834 · Cited by 20
Treatment of chronic primary sleep onset insomnia with Kundalini yoga: a randomized controlled trial with active sleep hygiene comparison
Khalsa, S. B. S., & Goldstein, M. R. (2021) · Journal of Clinical Sleep Medicine · doi:10.5664/jcsm.9320 · Cited by 23
Impact of an Online Sleep and Circadian Education Program on University Students’ Sleep Knowledge, Attitudes, and Behaviours
Semsarian, C. R., Rigney, G., Cistulli, P. A., & Bin, Y. S. (2021) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph181910180 · Cited by 23
Mindfulness-based Cognitive Therapy to Improve Sleep Quality in Older Adults with Insomnia
Camino, M., Satorres, E., Delhom, I., Real, E., Abella, M., & Meléndez, J. C. (2022) · Psychosocial Intervention · doi:10.5093/pi2022a12 · Cited by 26
“, CBT-I) in reducing scores on the sleep severity index (Arnedt et al., 2021; Cheung et al., 2019; Ho et al., 2015; McCurry et al., 2016; Zachariae et al., 2016) and improving sleep quality scores (Cheung et al.”
Sleep-HD trial: short and long-term effectiveness of existing insomnia therapies for patients undergoing hemodialysis
Unruh, M. L., Cukor, D., Rue, T. C., Abad, K., Roumelioti, M., McCurry, S. M., Heagerty, P. J., & Mehrotra, R. (2020) · BMC Nephrology · doi:10.1186/s12882-020-02107-x · Cited by 20
Investigating the efficacy of digital cognitive behavioural therapy in comparison to a sleep‐monitoring application via integrated diary and actigraphy: A randomised–controlled trial
Maurer, L., Bauermann, P., Karner, L., Müller, C., Lorenz, N., & Gieselmann, A. (2024) · Journal of Sleep Research · doi:10.1111/jsr.14255 · Cited by 17
Pharmacological interventions for the treatment of insomnia: quantitative comparison of drug efficacy
Zheng, X., He, Y., Yin, F., Liu, H., Li, Y., Zheng, Q., & Li, L. (2020) · Sleep Medicine · doi:10.1016/j.sleep.2020.03.022 · Cited by 18
Changing Behavior Using Theories at the Interpersonal, Organizational, Community, and Societal Levels
Ruiter, R. A. C., Crutzen, R., de Leeuw, E., & Kok, G. (2020) · Cambridge University Press eBooks · doi:10.1017/9781108677318.018 · Cited by 20
A randomized controlled trial of a digital cognitive behavioral therapy for insomnia for older adults
Ritterband, L. M., Shaffer, K. M., Thorndike, F. P., Chow, P. I., Gonder-Frederick, L., Ingersoll, K. S., Cohn, W. F., Frederick, C., MacDonnell, K., Glazer, J. V., et al. (2025) · npj Digital Medicine · doi:10.1038/s41746-025-01847-0 · Cited by 18
Association of sleep quality and internet addiction among the medical students
Nagori, N., Vasava, K., Vala, A., & Ratnani, I. J. (2019) · International Journal of Research in Medical Sciences · doi:10.18203/2320-6012.ijrms20192903 · Cited by 17
Music-based Intervention for Improving Sleep Quality of Adults without Sleep Disorder: A Systematic Review and Meta-analysis
Tang, Y. W., Teoh, S. L., Yeo, J. H. H., Ngim, C. F., Lai, N. M., Durrant, S. J., & Lee, S. W. H. (2021) · Behavioral Sleep Medicine · doi:10.1080/15402002.2021.1915787 · Cited by 20
“A high level of heterogeneity was observed. c. Performance bias and detection bias due to the lack of blinding of participants and personnel as well as the outcome assessment. versions (ICBT-I) with a virtual therapist (Luik et al., 2017) have also proven effective (Zachariae et al., 2016).”
Background
Sleep Health Assessment and Treatment in Children and Adolescents with Chronic Pain: State of the Art and Future Directions
Law, E., Kim, A., Ickmans, K., & Palermo, T. (2022) · Journal of Clinical Medicine · doi:10.3390/jcm11061491 · Cited by 18
“Results of meta-analyses demonstrated large positive benefits of CBT-I on global measures of sleep at post-treatment (SMD = 0.89) and follow-up (SMD = 0.56) [58].”
BackgroundInfluential
Digital cognitive behavior therapy for insomnia improving sleep quality: a real-world study
Liang, S., Mao, H., Yang, J., Deng, W., Cao, B., Yu, Z., Yang, L., Xu, Y., Hu, N., Liu, W., et al. (2022) · BMC Psychiatry · doi:10.1186/s12888-022-04411-2 · Cited by 18
Digital Therapeutics as a New Therapeutic Modality: A Review from the Perspective of Clinical Pharmacology
Ribba, B., Peck, R., Hutchinson, L. G., Bousnina, I., & Motti, D. (2023) · Clinical Pharmacology & Therapeutics · doi:10.1002/cpt.2989 · Cited by 18
Cost-Analysis of Telemedicine Interventions Compared with Traditional Care in the Management of Chronic Neurological Diseases: A Systematic Review
Maida, E., Morra, V. B., Triassi, M., Lanzillo, R., Bonavita, S., & Lavorgna, L. (2023) · Telemedicine Journal and e-Health · doi:10.1089/tmj.2023.0106 · Cited by 17
“24 An RCT conducted on subjects with severe insomnia, defined by an Insomnia Severity Index (ISI) > 14, sought to perform an economic evaluation of iCBT both from a societal perspective and a public health care perspective.”
Temporal network of experience sampling methodology identifies sleep disturbance as a central symptom in generalized anxiety disorder
Peng, J., Yuan, S., Wei, Z., Liu, C., Li, K., Wei, X., Yuan, S., Guo, Z., Wu, L., Feng, T., et al. (2024) · BMC Psychiatry · doi:10.1186/s12888-024-05698-z · Cited by 20
Digitale Behandlungsangebote für Insomnie – eine Übersichtsarbeit
Spiegelhalder, K., Acker, J. G., Baumeister, H., Büttner‐Teleagă, A., Danker‐Hopfe, H., Ebert, D. D., Fietze, I., Frase, L., Klein, S., Lehr, D., et al. (2020) · Somnologie - Schlafforschung und Schlafmedizin · doi:10.1007/s11818-020-00238-9 · Cited by 18
Digital cognitive behavioural therapy for insomnia: the answer to a major public health issue?
van Straten, A., & Lancee, J. (2020) · The Lancet Digital Health · doi:10.1016/s2589-7500(20)30167-9 · Cited by 17
A Self-Administered Multicomponent Web-Based Mental Health Intervention for the Mexican Population During the COVID-19 Pandemic: Protocol for a Randomized Controlled Trial
Rodríguez, A. D., la Rosa-Gómez, A. D., Jiménez, M. J. H., Arenas-Landgrave, P., Martínez-Luna, S. C., Silva, J. A., Hernández, J. E. G., Arzola-Sánchez, C. A., & Guzmán, V. A. (2020) · JMIR Research Protocols · doi:10.2196/23117 · Cited by 19
“Furthermore, studies have evaluated web-based treatment programs for sleep disorders in adults [48], reporting a significant improvement in participants who received the intervention based on positive psychology [49,50].”
Background
SERIES: eHealth in primary care. Part 5: A critical appraisal of five widely used eHealth applications for primary care – opportunities and challenges
Kasteleyn, M. J., Versluis, A., van Peet, P. G., Kirk, U. B., van Dalfsen, J. H., Meijer, E., Honkoop, P., Ho, K., Chavannes, N. H., & Talboom-Kamp, E. P. W. A. (2021) · European Journal of General Practice · doi:10.1080/13814788.2021.1962845 · Cited by 16
My Health Too: Investigating the Feasibility and the Acceptability of an Internet-Based Cognitive-Behavioral Therapy Program Developed for Healthcare Workers
Bureau, R., Bemmouna, D., Faria, C. G. F., Goethals, A.-A. C., Douhet, F., Mengin, A. C., Fritsch, A., Bertschy, A. Z., Frey, I., & Weiner, L. (2021) · Frontiers in Psychology · doi:10.3389/fpsyg.2021.760678 · Cited by 19
Making Space for the Quality Care
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“9% among different studies, with little explanation of the factors that contributed to participant motivations or continued engagement [68].”
Background
Feasibility of an online cognitive behavioral therapy program to improve insomnia, mood, and quality of life in bereaved adults ages 55 and older
Godzik, C. M., Crawford, S., & Ryan, E. (2020) · Geriatric Nursing · doi:10.1016/j.gerinurse.2020.12.006 · Cited by 17
A pilot study of sleep scholar: A single-session, internet-based insomnia intervention for college students with a history of suicide ideation
Crosby, E. S., & Witte, T. K. (2021) · Journal of American College Health · doi:10.1080/07448481.2021.1953028 · Cited by 19
“18 Importantly, degree of human support and number of CBT-I modules were not statistically significant moderators of the effectiveness of treatment.”
BackgroundMethod
Comparative effectiveness of three versions of a stepped care model for insomnia differing in the amount of therapist support in internet-delivered treatment: study protocol for a pragmatic cluster randomised controlled trial (GET Sleep)
Spiegelhalder, K., Baumeister, H., Al-Kamaly, A., Bader, M., Bauereiß, N., Benz, F., Braun, L., Buntrock, C., Burkhardt, M., Cuijpers, P. J., et al. (2022) · BMJ Open · doi:10.1136/bmjopen-2021-058212 · Cited by 16

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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