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VOLUME 35, ISSUE 06

EVALUATION OF ONLINE CBT FOR CHRONIC INSOMNIA DISORDER
A Randomized, Placebo-Controlled Trial of Online Cognitive Behavioral Therapy for Chronic Insomnia Disorder Delivered via an Automated Media-Rich Web Application

http://dx.doi.org/10.5665/sleep.1872

Colin A. Espie, PhD1,2,6; Simon D. Kyle, PhD1,2; Chris Williams, MD3; Jason C. Ong, PhD4; Neil J. Douglas, MD, DSc5; Peter Hames, MA Oxon6; June S.L. Brown, PhD7

1University of Glasgow Sleep Centre, Glasgow, Scotland, UK; 2Institute of Neuroscience & Psychology, University of Glasgow, Glasgow, Scotland, UK; 3Institute of Health & Wellbeing, University of Glasgow, Glasgow, Scotland, UK; 4Rush University Medical Center, Chicago, IL; 5Department of Sleep Medicine, Edinburgh Royal Infirmary, Edinburgh, UK; 6Sleepio Ltd., London, UK; 7Institute of Psychiatry, London, UK



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Study Objectives:

The internet provides a pervasive milieu for healthcare delivery. The purpose of this study was to determine the effectiveness of a novel web-based cognitive behavioral therapy (CBT) course delivered by an automated virtual therapist, when compared with a credible placebo; an approach required because web products may be intrinsically engaging, and vulnerable to placebo response.

Design:

Randomized, placebo-controlled trial comprising 3 arms: CBT, imagery relief therapy (IRT: placebo), treatment as usual (TAU).

Setting:

Online community of participants in the UK.

Participants:

One hundred sixty-four adults (120 F: [mean age 49y (18-78y)] meeting proposed DSM-5 criteria for Insomnia Disorder, randomly assigned to CBT (n = 55; 40 F), IRT placebo (n = 55; 42 F) or TAU (n = 54; 38 F).

Interventions:

CBT and IRT each comprised 6 online sessions delivered by an animated personal therapist, with automated web and email support. Participants also had access to a video library/back catalogue of session content and Wikipedia style articles. Online CBT users had access to a moderated social network/community of users. TAU comprised no restrictions on usual care and access to an online sleep diary.

Measurements and Results:

Major assessments at baseline, post-treatment, and at follow-up 8-weeks post-treatment; outcomes appraised by online sleep diaries and clinical status. On the primary endpoint of sleep efficiency (SE; total time asleep expressed as a percentage of the total time spent in bed), online CBT was associated with sustained improvement at post-treatment (+20%) relative to both TAU (+6%; d = 0.95) and IRT (+6%: d = 1.06), and at 8 weeks (+20%) relative to IRT (+7%: d = 1.00) and TAU (+9%: d = 0.69) These findings were mirrored across a range of sleep diary measures. Clinical benefits of CBT were evidenced by modest superiority over placebo on daytime outcomes (d = 0.23-0.37) and by substantial improved sleep-wake functioning on the Sleep Condition Indicator (range of d = 0.77-1.20). Three-quarters of CBT participants (76% [CBT] vs. 29% [IRT] and 18% [TAU]) completed treatment with SE > 80%, more than half (55% [CBT] vs. 17% [IRT] and 8% [TAU]) with SE > 85%, and over one-third (38% [CBT] vs. 6% [IRT] and 0% [TAU]) with SE > 90%; these improvements were largely maintained during follow-up.

Conclusion:

CBT delivered using a media-rich web application with automated support and a community forum is effective in improving the sleep and associated daytime functioning of adults with insomnia disorder.

Clinical Trial Registration:

ISRCTN – 44615689.

Citation:

Espie CA; Kyle SD; Williams C; Ong JC; Douglas NJ; Hames P; Brown JSL. A randomized, placebo-controlled trial of online cognitive behavioral therapy for chronic insomnia disorder delivered via an automated media-rich web application. SLEEP 2012;35(6):769-781.

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