On-line Automated Psychotherapy for Chronic Insomnia

Cognitive behaviour therapy (CBT) aims to change thought patterns, for example reducing unrealistic expectations and changing overvalued ideas about sleep. Sleep-related cognitive distortions are replaced with positive attitudes and sleep-conducive behaviour. Consistent, good-quality patient-oriented evidence (Grade A) indicates that CBT is superior to medications in the treatment of chronic insomnia. CBT administered by primary care physicians to treat chronic insomnia has limited quality patient-oriented evidence (Grade B). CBT delivered face-to-face by a trained therapist can be unaffordable for many. CBT is not covered by the Canadian universal health care system, and is therefore unavailable to most. If you live in Canada and your family doctor does not offer CBT for insomnia, what are your options?

A group of researchers lead by Dr. Colin Espie at the University to Glasgow, Scotland, asked a daring question: Can CBT for chronic insomnia be delivered by an automated, media-rich web application? Such a web application would have the advantage of cost-effectively reaching millions of people. Savings in cost also come from rendering unnecessary millions of prescriptions for sleep aid pills.

The researchers designed a three-armed randomized controlled trial comparing three interventions:   CBT + treatment as usual (TAU), vs. Imagery Relief Therapy (IRT) + TAU, vs. TAU alone. Volunteers for the study were 164 adults from the UK, aged 18 and over, with chronic insomnia and significant daytime effects. The volunteers reported poor sleep (for example, trouble falling asleep, staying asleep, early morning awakening, non-restorative sleep), significant day time effects (for example, fatigue, daytime sleepiness, cognitive impairment, mood disturbance, impaired occupational or academic functioning, poor productivity, impaired interpersonal functioning). These symptoms affected the participants more than 3 nights per week for more than 3 months.

Participants assigned to the CBT treatment-group received 6 online CBT sessions with an animated personal therapist called “The Prof”. The web application is fully automated and media-rich. It recorded baseline, adherence, performance, and progress data. It delivered information, support, advice, in personally tailored manner. Most importantly, the web application used evidence-based information from a validated manual targeting behaviour (sleep restriction, stimulus control, cognitive, putting the day to rest, thought re-structuring, imagery, articulatory suppression, paradoxical intention, mindfulness, relaxation, progressive muscle relaxation, autogenic training, psychoeducation, lifestyle advice, sleep hygiene advice).

Additionally, the participants had automated web and email support, access to video library/catalogue of session contents, Wikipedia-style articles, and a moderated social network/community of users. IRT-arm assigned participants had a sham/mock web portal. The participants could search the World Wide Web for “IRT” and find evidence for its efficacy in therapy. Participants were assessed at baseline, post-treatment, and at eight weeks follow-up post-treatment for sleep efficiency (SE, time spent in bed sleeping as a percentage of total sleep time), sleep diary and daytime symptoms.

Results showed the group of participants who received online CBT had more than an average of 20% increase in post-treatment sleep efficiency sustained at 8 weeks post-treatment (25% was lost to follow-up). The other treatment groups, TAU and IRT, had an average of 6-9% increase in post-treatment sleep efficiency. These are averaged findings, some participants had more than 20% improvement in SE and some had less.

Further breakdown of results showed 76% online-CBT-treated participants had over 80% improved SE compared to 29% for the IRT-treated group and 18%TAU group. The proportion of online-CBT-treated group with more than 85% improved SE was 55% (compared to 17% IRT and 8% TAU). The proportion of online-CBT-treated group with more than 90% improved SE was 38% (compared to 6% IRT and 0% TAU). These numbers translate to number needed to treat (NNT) of 2, 3, and 4 to get over 80%, 85%, and 90% improved SE using online CBT, respectively. In other words, we have to treat 4 people with online-CBT to get 1 person 90% improved SE.  Significantly, the CBT treatment group had modest superiority over placebo on daytime outcomes but substantially improved sleep-wake functioning.

Some shortcomings of this study include a small difference in the baseline characteristic of the group receiving CBT: they are slightly more likely than the other two groups to self-report being mentally and physically “very good.” Selection bias is also possible. More motivated, energetic, self-directed participants would tend to agree to the email invitation to participate in the study and complete the study. These motivated participants are more likely to benefit from the online intervention. Others less motivated may still require face-to-face psychotherapy. Finally, No objective measure of sleep quality was used. The outcome was entirely self-rated and therefore subject to bias.

The authors concluded that CBT delivered using a media-rich web application with automated support and a community forum is effective in improving sleep and associated daytime functioning of adults with chronic insomnia. These findings in no way suggest that web-application replaces proper assessment, diagnosis, management, and treatment monitoring by a qualified health care professional. If you suspect chronic insomnia, it is best to consult a qualified health-care professional who can order further investigations, guide and monitor your treatment plan.

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You can find a psychotherapy provider in your area by using the Basic Search and selecting “Help with … Sleep problems”

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In the next blog entry, I will answer the question: Can online CBT be applied to other health problems?

References:

Espie CA, Kyle SD, Williams C, Ong JC, Douglas NJ, Hames P, Brown JS. A randomized, placebo-controlled trial of online cognitive behavioral therapy for chronic insomnia disorder delivered via an automated media-rich web application. Sleep. 2012 Jun 1;35(6):769-81.

Ramar K, Olson EJ. Management of common sleep disorders. Am Fam Physician. 2013 Aug 15;88(4):231-8. Review.

 

The views expressed in these blogs are the author’s own and not necessarily reflective of those of Psychotherapy Matters.  Copyright © 2015 PsychotherapyMatters.com

Vicky P.K.H. Nguyen
Vicky P.K.H. Nguyen

Vicky is a psychiatry resident at the Northern Ontario School of Medicine (NOSM). She completed her PhD and MD training at the University of Toronto. Her research interests are directed at promoting innovative practices and policies to address sub-optimal wait times, access, equity, and quality of health care services for disadvantaged populations in Ontario. She is certified to provide IPT and CBT. She is trained to provide other types of therapy including DBT, and Psychodynamic Psychotherapy.

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