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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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Ford, M. E., Geurtsen, G. J., Groet, E., van Bennekom, C. A. M., & Someren, E. J. W. V. (2020) · Trials · doi:10.1186/s13063-020-04789-y · Cited by 6
Guided Internet-Based Cognitive Behavioral Therapy for Insomnia: Prognostic and Treatment-Predictive Factors
Pchelina, P. V., Duss, S. B., Bernasconi, C., Berger, T., Krieger, T., Bassetti, C. L., & Urech, A. (2023) · Diagnostics · doi:10.3390/diagnostics13040781 · Cited by 5
“A large number of meta-analyses and reviews have shown that chronic insomnia can be successfully managed with internet-based CBT-I (iCBT-I) programs with or without therapist guidance [10,11].”
Background
Efficacy and safety of digital therapeutic application of Sleep Index‐Based Treatment for Insomnia ( dSIBT‐I ): a pilot study
Chung, S., Cho, I., Kim, J., Lee, D., Cho, E., Choi, J. M., Ha, T. K., Lee, Y. J., Kim, J. H., & Choi, J. H. (2023) · Journal of Sleep Research · doi:10.1111/jsr.14039 · Cited by 5
“Even after the start of CBT, the chances of early dropout due to low patient perseverance should be considered (Zachariae et al., 2016).”
Background
Industry sponsorship bias in randomized controlled trials of digital cognitive behavioral therapy for insomnia: a meta-research study based on the 2023 Brazilian guidelines on the diagnosis and treatment of insomnia in adults
Kakazu, V. A., Assis, M., Bacelar, A., Bezerra, A. G., Ciutti, G. L. R., Conway, S. G., Galduróz, J. C. F., Drager, L. F., Khoury, M. P., Leite, I. P. A., et al. (2025) · Frontiers in Neurology · doi:10.3389/fneur.2025.1600767 · Cited by 5
Negotiation in Automated E-Coaching
Beun, R. J., Griffioen-Both, F., & Lancee, J. (2018) · Electronic workshops in computing · doi:10.14236/ewic/hci2018.24 · Cited by 5
“It is an effective form of treatment for insomnia in both classic face-to-face therapy (Van Straten et al., 2017) and in a computerized form (Zachariae et al., 2016).”
Background
Addressing Underserved Populations and Disparities in Behavior Change
Schüz, B., & Hooper, M. W. (2020) · Cambridge University Press eBooks · doi:10.1017/9781108677318.027 · Cited by 5
Development of a hybrid sleep and physical activity improvement intervention for adults with osteoarthritis-related pain and sleep disturbance: a focus group study with potential users
Whibley, D., Stelfox, K., Henry, A. L., Tang, N. K. Y., & Kratz, A. L. (2021) · British Journal of Pain · doi:10.1177/20494637211026049 · Cited by 5
“online websites or mobile phone apps, have also demonstrated efficacy.(26-28) Digital delivery of CBT-I content (including evidence-based cognitive and behavioural techniques, sleep hygiene education and relaxation exercises) may be particularly attractive given its flexibility of use, scalability, increased accessibi…”
Background
Effectiveness of Cognitive Behavioral Therapy for Sleep Disorder: An overview of Systematic Review
Lee, J. W., Yeo, J. J., Kim, K. S., & Hyun, M. K. (2022) · 대한한의학회지 · doi:10.13048/jkm.22021 · Cited by 4
The efficacy of intensive sleep retraining for insomnia: A systematic review and research agenda
Scott, H., Bensen-Boakes, D.-B., Lovato, N., Reynolds, A. C., Perlis, M. L., & Lack, L. C. (2023) · Journal of Sleep Research · doi:10.1111/jsr.13894 · Cited by 5
“This is largely due to the sheer volume of insomnia patients, a lack of trained CBT-I providers (particularly in rural and remote locations), the associated cost, and the real or perceived stigma for seeking psychological treatment (Haycock et al., 2022).”
BackgroundInfluential
Embedding digital sleep health into primary care practice: A triangulation of perspectives from general practitioners, nurses, and pharmacists
Cheung, J. M. Y., Schrire, Z. M., Aji, M., Rahimi, M. M., Salomon, H., Doggett, I., Glozier, N., Bartlett, D. J., WONG, K. K. H., Grunstein, R. R., et al. (2023) · Digital Health · doi:10.1177/20552076231180970 · Cited by 5
“3),(7) while potentially overcoming geographical,(8) resource and scheduling constraints of traditional care models.(6,9,10) A recent meta-analysis has further demonstrated comparable effects between face-to-face CBT-I and digital CBT-I involving a virtual or real therapist,(11) highlighting the potential for deliveri…”
Background
Caregiver Experiences With an Internet-Delivered Insomnia Intervention: SHUTi-CARE Trial Primary Qualitative Analysis
Shaffer, K. M., Perepezko, K. M., Glazer, J. V., Mattos, M. K., Klinger, J., Buysse, D. J., Ritterband, L. M., & Donovan, H. S. (2024) · Annals of Behavioral Medicine · doi:10.1093/abm/kaae041 · Cited by 5
Potential mediators of improvement in painful chemotherapy-induced peripheral neuropathy via a web-based cognitive behavioural intervention
Knoerl, R., Barton, D. L., Holden, J. E., Krauss, J. C., Lavasseur, B. I., & Smith, E. (2018) · Canadian Oncology Nursing Journal · doi:10.5737/23688076283178183 · Cited by 5
Cognitive Behavioral Treatment as a Digital Therapeutic for Insomnia
Lee, E. M. (2020) · Chronobiology in Medicine · doi:10.33069/cim.2020.0007 · Cited by 5
Modularized iCBT‑I self-learn training for university staff—prevention and early intervention in the SARS-CoV-2 crisis
Schlarb, A. A., Fründ, J. P., Kovačević, T., & Faber, J. (2021) · Somnologie - Schlafforschung und Schlafmedizin · doi:10.1007/s11818-021-00301-z · Cited by 5
Efficacy of Multicomponent CBT‐I and Its Single Components
Maurer, L., & Kyle, S. D. (2022) · Wiley eBooks · doi:10.1002/9781119891192.ch3 · Cited by 7
Real-world evidence for the use of digital cognitive behavioural therapy for insomnia within primary care
Maurer, L., Aust, F., & Lorenz, N. (2025) · Somnologie - Schlafforschung und Schlafmedizin · doi:10.1007/s11818-025-00502-w · Cited by 4
Impact of Adherence to Digital Cognitive Behavioral Therapy for Insomnia Effectiveness
Lee, S., Park, K., Lee, D. H., Choi, E. C., Lee, Y., & Lee, E. M. (2025) · Yonsei Medical Journal · doi:10.3349/ymj.2024.0398 · Cited by 4
Digital and telehealth behavioral sleep interventions for improving sleep outcomes in children and adolescents with autism spectrum disorder: a systematic review and meta-analysis
Duan, Z., Wang, X., Zhang, Z.-Y., Wang, X., Zhang, Y., & Du, X. (2025) · Sleep Medicine · doi:10.1016/j.sleep.2025.106870 · Cited by 4
Cannabinol for Acute Treatment of Insomnia Disorder in a Randomized Placebo‐Controlled Crossover Trial
Lavender, I., Marshall, N. S., McCartney, D., Cho, G., Irwin, C. G., Suraev, A. S., Gordon, R., Arnold, J. C., D'Rozario, A. L., Gordon, C. J., et al. (2026) · Journal of Sleep Research · doi:10.1111/jsr.70284 · Cited by 4
Efficacy of Remote Cognitive Behavioural Therapy for Insomnia in Improving Health Status of Patients with Insomnia Symptoms: A Meta-analysis
Xu, D., Li, Z., Leitner, U., & Sun, J. (2024) · Cognitive Therapy and Research · doi:10.1007/s10608-023-10458-6 · Cited by 5
“In addition, sleep outcomes were more significantly improved in studies that had a shorter length of intervention, which differed from the findings of prior studies (Zachariae et al., 2016), in which greater effects were observed in longer interventions.”
Cognitive behavioural therapy for insomnia (CBT-I) in schizophrenia and schizoaffective disorder: protocol for a randomised controlled trial
Tanskanen, T. E., Wegelius, A., Härkönen, T., Gummerus, E.-M., Stenberg, J., Selinheimo, S., Alakuijala, A., Tenhunen, M. L., Paajanen, T. I., Järnefelt, H., et al. (2024) · BMJ Open · doi:10.1136/bmjopen-2023-076129 · Cited by 4
“30 The efficacy of CBT-I is well established 31 ; it is effectively performed as an individual treatment, 32 on a group basis, 33 or via the internet, 34 and it is also an effective, durable treatment for patients with insomnia and comorbid physical and mental conditions.”
Background
One Single Session to Sleep Them All? The Potential of Single‐Session Interventions for Insomnia
Carpi, M., Szkody, E. M., & Marques, D. R. (2025) · Journal of Sleep Research · doi:10.1111/jsr.70134 · Cited by 6
“In fact, robust clinical research has repeatedly reinforced the merits of psychological interventions (Alimoradi et al. 2022; Trauer et al. 2015; Zachariae et al. 2016; Zhang et al. 2022) in a field where traditional medications (i.e., benzodiazepines and benzodiazepine receptor agonists known as…”
Digital App Based Cognitive Behaviour Therapy CBT ‐I Course Improving Insomnia and Sleep Hygiene: A Randomised Controlled Trial
Kater, M., Wegener, N., Morath, N., & Vorster, A. P. A. (2025) · Journal of Sleep Research · doi:10.1111/jsr.70195 · Cited by 4
“Based on Zachariae et al. (2016), an expected effect size of f = 0.5 for treatment effects was assumed.”
Influential
Changing Behavior in the Digital Age
Kavanagh, D. J. (2020) · Cambridge University Press eBooks · doi:10.1017/9781108677318.029 · Cited by 4
Testing an early online intervention for the treatment of disturbed sleep during the COVID-19 pandemic in self-reported good and poor sleepers (Sleep COVID-19): study protocol for a randomised controlled trial
Sawdon, O. L., Elder, G. J., Santhi, N., Alfonso‐Miller, P., & Ellis, J. G. (2021) · Trials · doi:10.1186/s13063-021-05888-0 · Cited by 4
Cognitive-behavioral therapy for insomnia for primary care: Review of components and application for residents in primary care
Traupman, E. K., & Dixon, M. A. (2022) · The International Journal of Psychiatry in Medicine · doi:10.1177/00912174221112466 · Cited by 4
“A metanalysis of eCBT-I use found comparable effects on insomnia to that of face-to-face care and pharmacotherapy.(22) Thus, internet delivered CBT-I options should be considered a viable option in the treatment of insomnia.”
Method
Wearable Device-Delivered Intensive Sleep Retraining as an Adjunctive Treatment to Kickstart Cognitive-Behavioral Therapy for Insomnia
Bensen-Boakes, D.-B., Murali, T., Lovato, N., Lack, L. C., & Scott, H. (2023) · Sleep Medicine Clinics · doi:10.1016/j.jsmc.2022.09.006 · Cited by 4
Digital cognitive behavioral therapy for insomnia for people with comorbid psychological distress: A large scale randomized controlled trial
Skoglund, H., Sivertsen, B., Kallestad, H., & Vedaa, Ø. (2024) · Sleep Medicine · doi:10.1016/j.sleep.2024.06.026 · Cited by 4
Effectiveness of digital cognitive behavioral therapy for insomnia on professional activity: A systematic review and meta-analysis of randomized controlled trials
Zettor, D., Endomba, F. T., Pierandrei, A., Pinoit, J., Chauvet‐Gélinier, J., Forestier, N., & Hussami, A. (2024) · Sleep Medicine Reviews · doi:10.1016/j.smrv.2024.102024 · Cited by 4
eCBT-I dialogue system: a comparative evaluation of large language models and adaptation strategies for insomnia treatment
Bao, X., Zhu, X., Yang, D., Lou, H., Wang, R., Wu, Y., Li, W., Xia, Y., Zeng, L., Pan, Y., et al. (2025) · Journal of Translational Medicine · doi:10.1186/s12967-025-06871-y · Cited by 4
“However, given the limited availability of individual face-to-face (F2F) CBT-I in health care systems, alternative Internet-delivered cognitive-behavioral therapy for insomnia (eCBT-I) settings (e.g., group or internet-based CBT-I) have been proposed, and evidence for their efficacy exists [8, 9].”
Effectiveness comparisons of Chinese patent medicine on insomnia
Chao, R., Wu, C., An, H., Li, B., & Wu, J. (2021) · Medicine · doi:10.1097/md.0000000000024446 · Cited by 4
A focus group study to inform design of a symptom management intervention for adults with atrial fibrillation
Hilow, H. J., Whibley, D., Kratz, A. L., & Ghanbari, H. (2021) · Cardiovascular Digital Health Journal · doi:10.1016/j.cvdhj.2021.09.001 · Cited by 4
Development and acceptability of a mobile health application integrated with the electronic heath record for treatment of chronic insomnia disorder
Morgenthaler, T. I., Kolla, B. P., Anderson, S. E., Wahl, A., Clark, P., Smith, J. M., Luedke, T. C., McColley, S., Phillips, S. A., Harper, S. B., et al. (2022) · Journal of Clinical Sleep Medicine · doi:10.5664/jcsm.10218 · Cited by 4
Factors influencing the efficiency of cellphone-based CBT for treating sleep disorders
Hu, N., Xu, Y., & Mao, H. (2022) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2022.974888 · Cited by 4
Digital Health Interventions for Insomnia: Turning Promise into Reality
Kutana, S., Garland, S. N., & Zhou, E. S. (2023) · Current Sleep Medicine Reports · doi:10.1007/s40675-023-00260-x · Cited by 4
“…provide support for the effectiveness of iCBT-I, with effect sizes similar to those achieved through traditional face-to-face approaches [3, 4]. iCBT-I has been shown to be appropriate for patients presenting with a wide range of physical and psychological comorbidities such as…”
BackgroundInfluential
Reduction of Sleep Medications via a Combined Digital Insomnia and Pharmacist-Led Deprescribing Intervention: Protocol for a Feasibility Trial
Bramoweth, A. D., Hough, C. E., McQuillan, A. D., Spitznogle, B. L., Thorpe, C. T., Lickel, J. J., Boudreaux-Kelly, M. Y., Hamm, M., & Germain, A. (2023) · JMIR Research Protocols · doi:10.2196/47636 · Cited by 5
“Digital CBT-I mobile apps are available, including several developed by the VA, that have similar sleep outcomes as in-person CBT-I [52].”
Method
British Sleep Society: the COVID-19 pandemic response
Steier, J. S., Durrant, S. J., & Hare, A. (2020) · Journal of Thoracic Disease · doi:10.21037/jtd-2020-059 · Cited by 4
“The European CBT-I Academy have released more detailed advice for sleep in the context of COVID-19 (13).”
Background
Evaluating a mobile application based intervention for insomnia in college students: a preliminary study
Floyd, V., & Vargas, I. (2024) · Journal of American College Health · doi:10.1080/07448481.2024.2423225 · Cited by 3
Applying a mobile intervention for chronic insomnia in routine care: Study protocol for a multicenter randomized controlled trial
Moon, D. U., Kim, J., Sun, J. H., & Lee, Y. (2025) · Internet Interventions · doi:10.1016/j.invent.2025.100848 · Cited by 3
“DCBT-I programs integrate interactive tools such as sleep diaries, psychoeducation, and structured cognitive-behavioral interventions (Soh et al., 2020; Zachariae et al., 2016; van der Zweerde et al., 2020).”
My Back Exercise app: an automated exercise intervention supported by educational notifications, a sleep programme and diet advice to improve function in people with chronic non-specific low back pain – protocol for a superiority, adaptive multi-arm multi-stage randomised controlled trial
Cabral, A. M., Comachio, J., Castrillón, C. I. M., Roberts, K. E., Beckenkamp, P. R., Ho, E. K., Ferreira, M. L., Gordon, C. J., Lo, S., Bennell, K. L., et al. (2025) · BMJ Open · doi:10.1136/bmjopen-2024-098324 · Cited by 4
Digitally delivered cognitive behavioral therapy for insomnia (CBT-I) for patients with chronic pain and insomnia (The Back2Sleep Trial): study protocol for a randomized controlled trial
Olsen, M. L. S., Thorlund, J. B., Zachariae, R. H., Vach, W., Bendix, L., Jespersen, J. R., Kidmose, P., Parsons, C. E., Kidholm, K., & Vægter, H. B. (2025) · Trials · doi:10.1186/s13063-025-09013-3 · Cited by 3
“While a meta-analysis of 11 trials has shown digital CBT-I to be effective in treating insomnia [23], the pain-relieving effect of digitally delivered CBT-I has only been explored in a small randomized controlled study in patients with chronic disabling pain and comorbid insomnia [24].”

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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