Mode of delivery of Cognitive Behavioral Therapy for Insomnia: a randomized controlled non-inferiority trial of digital and face-to-face therapy

Non-guided, mobile, CBT-I-based sleep intervention in War-torn Ukraine: A feasibility study

BACKGROUND

War conditions can severely impact sleep and mental health at the population level, especially in the conflicts of such tremendous scale as in Ukraine. The aim of this research was to study whether a mobile, unguided Cognitive Behavioral Therapy-based Intervention for sleep problems, Sleep2, is feasible, acceptable, and potentially able to reduce mental health/sleep problems symptoms.

METHODS

A single-arm, open-label, uncontrolled pre-post evaluation study was conducted with 487 registered participants: 283 started, 160 (56.55%) finished, out of which 95 completed without an ambulatory heart rate (HR) sensor and 65 with. Assessments were conducted through online questionnaires and objective measurements via HR sensors. Besides feasibility and acceptability, outcome measures included symptoms in several mental health domains alongside self-reported and objectively reported sleep parameter.

RESULTS

Engagement with the Sleep2 app was high, achieving an 80.72% compliance rate, alongside high levels of feasibility and acceptance. Participants reported significant pre-post reductions in the severity of symptoms, with sleep problems decreasing by 22.60% (Cohen's d = 0.53), insomnia by 35.08% (d = 0.69), fear of sleep by 32.43% (d = 0.25), anxiety by 27.72% (d = 0.48), depression by 28.67% (d = 0.52), PTSD by 32.41% (d = 0.51), somatic symptoms by 24.52% (d = 0.51), and perceived stress by 17.90% (d = 0.39). Objective sleep measurements showed a significant reduction in sleep onset latency only.

CONCLUSION

The 'Sleep2Ukraine' program demonstrated high feasibility and acceptance, with significant improvements in subjective sleep and mental health measures among participants. However, given the study's uncontrolled design and reliance on self-selected participants, these findings should be considered preliminary. Randomized controlled trials are needed to establish efficacy. Nonetheless, the results highlight the potential of culturally adapted, scalable, mobile-based CBT-I interventions to address sleep and mental health needs in war-affected populations.

Prevention of Pain Interference in Insomnia Patients via Digital Cognitive-Behavioral Therapy for Insomnia

OBJECTIVES

Insomnia disorder is co-morbid with and predictive of developing pain conditions and a key factor in pain interference (PI) - the extent to which pain impedes daily living. Emerging literature suggests treating insomnia with cognitive-behavioral therapy for insomnia reduces co-occurring PI. This secondary data analysis tested the extent to which digital CBT-I (dCBT-I) vs. sleep education reduces and prevents significant PI by treating insomnia.

METHODS

Insomnia disorder participants were randomized into dCBT-I (n = 697) and sleep education (n = 623) and reported pre- and post-treatment insomnia and PI. Logistic regressions evaluated intervention effects: 1) reduction of insomnia severity changes in PI and 2) prevention of treatment condition on PI.

RESULTS

The reduction model showed that dCBT-I participants with moderate-to-severe pre-treatment PI experienced 17% odds increase in reduced PI for each one-point reduction in insomnia severity compared to control, OR = 1.17, 95% CI [1.01, 1.35]. In the prevention model, dCBT-I participants with little-to-no pre-treatment PI exhibited a 32% odds reduction of post-treatment progression to moderate-to-severe PI compared to control, OR = 0.68, 95% CI [0.51, 0.90].

CONCLUSION

dCBT-I demonstrated significant and clinically meaningful reduction and prevention effects against PI in a large sample. dCBT-I may help providers address sleep issues to restore pain-related impairments to daytime function, quality of life, and overall sleep.

Digital and AI-Enhanced Cognitive Behavioral Therapy for Insomnia: Neurocognitive Mechanisms and Clinical Outcomes

Background/Objectives: This systematic review explores the integration of digital and AI-enhanced cognitive behavioral therapy (CBT) for insomnia, focusing on underlying neurocognitive mechanisms and associated clinical outcomes. Insomnia significantly impairs cognitive functioning, overall health, and quality of life. Although traditional CBT has demonstrated efficacy, its scalability and ability to deliver individualized care remain limited. Emerging AI-driven interventions-including chatbots, mobile applications, and web-based platforms-present innovative avenues for delivering more accessible and personalized insomnia treatments. Methods: Following PRISMA guidelines, this review synthesized findings from 78 studies published between 2004 and 2024. A systematic search was conducted across PubMed, Scopus, Web of Science, and PsycINFO. Studies were included based on predefined criteria prioritizing randomized controlled trials (RCTs) and high-quality empirical research that evaluated AI-augmented CBT interventions targeting sleep disorders, particularly insomnia. Results: The findings suggest that digital and AI-enhanced CBT significantly improves sleep parameters, patient adherence, satisfaction, and the personalization of therapy in alignment with individual neurocognitive profiles. Moreover, these technologies address critical limitations of conventional CBT, notably those related to access and scalability. AI-based tools appear especially promising in optimizing treatment delivery and adapting interventions to cognitive-behavioral patterns. Conclusions: While AI-enhanced CBT demonstrates strong potential for advancing insomnia treatment through neurocognitive personalization and broader clinical accessibility, several challenges persist. These include uncertainties surrounding long-term efficacy, practical implementation barriers, and ethical considerations. Future large-scale longitudinal research is necessary to confirm the sustained neurocognitive and behavioral benefits of digital and AI-powered CBT for insomnia.

Systematic review and meta-analysis on fully automated digital cognitive behavioral therapy for insomnia

Insomnia impairs daily functioning and increases health risks. Cognitive behavioral therapy for insomnia (CBT-I) is effective but limited by cost and therapist availability. Fully automated digital CBT-I (FA dCBT-I) provides an accessible alternative without therapist involvement. This systematic review and meta-analysis evaluated the effectiveness of FA dCBT-I across 29 randomized controlled trials (RCTs) involving 9475 participants. Compared to control groups, FA dCBT-I demonstrated moderate to large effects on insomnia severity. Subgroup analyses indicated that FA dCBT-I had a significant impact when contrasted with most control groups but was less effective than therapist-assisted CBT-I. Meta-regression revealed that control group type moderated outcomes, whereas completion rate did not. This implies that treatment adherence, rather than merely completing the intervention, is crucial for its effectiveness. This study supports the potential of FA dCBT-I as a promising option for managing insomnia but underscores that a hybrid model combining therapist support is more beneficial.

Pharmacological and psychological approaches to insomnia treatment in cardiac patients: a narrative literature review

Sleep disorders are highly prevalent in the general population and are considered a major public health issue. Insomnia constitutes the most frequent sleep disorder in healthy individuals and has been shown to be even more frequent in patients with physical illnesses including cardiovascular diseases. Inadequate sleep quality and short sleep duration, independent of underlying causes, have been linked to the development and progression of cardiometabolic disorders. Additionally, insomnia has been found to be associated with adverse outcome measures, including daytime sleepiness, fatigue, decreased self-reported physical functioning, lower exercise capacity, poor health related quality of life, depressive symptoms, higher rates of hospitalization and increased mortality in patients with cardiovascular diseases. Against this background, comparatively little information is available in the literature regarding the treatment of chronic insomnia in cardiac patient populations. While guidelines for the general population suggest cognitive behavioral therapy for insomnia as a first-line treatment option and preliminary evidence suggests this treatment to be beneficial in cardiac patients with insomnia symptoms, it is often limited by availability and possibly the clinician's poor understanding of sleep issues in cardiac patients. Therefore, pharmacologic treatment remains an important option indicated by the high number of hypnotic drug prescriptions in the general population and in patients with cardiovascular disorders. In this narrative review of the literature, we summarize treatment options for chronic insomnia based on clinical guidelines for the general population and highlight necessary considerations for the treatment of patients with cardiovascular diseases.

Effects of a Triage Checklist to optimize insomnia treatment outcomes and reduce hypnotic use: the RCT of the effectiveness of stepped-care sleep therapy in general practice study

STUDY OBJECTIVES

Evaluate a triaged stepped-care strategy among adults 50 and older with insomnia disorder.

METHODS

Participants (N = 245) were classified at baseline by a Triage Checklist. Those projected to do better if they start treatment with therapist versus digitally delivered CBT-I (tCBT-I vs dCBT-I) constituted the YES stratum (n = 137); the rest constituted the NO stratum (n = 108). Participants were randomized within stratum to a strategy that utilized only dCBT-I (ONLN) or to a strategy that prospectively allocated the first step of care to dCBT-I or tCBT-I based on the Triage Checklist and switched dCBT-I nonresponders at 2-months to tCBT-I (STEP). Co-primary outcomes were the insomnia severity index (ISI) and the average nightly amount of prescription hypnotic medications used (MEDS), assessed at 2, 4, 6, 9, and 12 months postrandomization.

RESULTS

Mixed effects models revealed that, compared to ONLN, participants in STEP had greater reductions in ISI (p = .001; η2 = 0.01) and MEDS (p = .019, η2 = 0.01). Within the YES stratum, compared to ONLN, those in STEP had greater reductions in ISI (p = .0001, η2 = 0.023) and MEDS (p = .018, η2 = 0.01). Within the ONLN arm, compared to the YES stratum, those in the NO stratum had greater reductions in ISI (p = .015, η2 = 0.01) but not in MEDS. Results did not change with treatment-dose covariate adjustment.

CONCLUSIONS

Triaged-stepped care can help guide the allocation of limited CBT-I treatment resources to promote effective and safe treatment of chronic insomnia among middle-aged and older adults. Further refinement of the Triage Checklist and optimization of the timing and switching criteria may improve the balance between effectiveness and use of resources.

CLINICAL TRIAL INFORMATION

Name: The RESTING Insomnia Study: Randomized Controlled Study on Effectiveness of Stepped-Care Sleep Therapy.

TRIAL REGISTRATION ID

NCT03532282. URL: https://clinicaltrials.gov/study/NCT03532282.

Effect of cognitive behavioral therapy for insomnia on sleep quality among college students: the role of hyperarousal and dysfunctional beliefs

BACKGROUND

Although cognitive-behavioral therapy for insomnia (CBT-I) is an effective treatment for sleep disorders, little is known about the role of hyperarousal (especially trait arousal) in CBT-I interventions. Therefore, this study investigated the role of trait arousal in the maintenance of sleep problems using cross-sectional and longitudinal methods.

METHODS

Study 1, 1209 Chinese university students (63.9% female) completed the Dysfunctional Beliefs and Attitudes about Sleep (DBAS-16), Pre-sleep Arousal Scale (PSAS), Arousal Predisposition Scale (APS), and Pittsburgh Sleep Quality Index (PSQI). The study calculated the moderating role of trait arousal in the relationship between dysfunctional beliefs about sleep and sleep quality. In study two, 89 participants completed the questionnaire used in Study 1 during pre-and post-treatment. A within-subjects mediation analysis examined the indirect effects of dysfunctional beliefs about sleep pre-sleep arousal (cognitive and somatic) on sleep quality. A within-subjects moderation analysis was used to investigate whether baseline trait arousal moderated sleep quality.

RESULTS

Cross-sectional findings indicated that pre-sleep cognitive arousal mediated the effects of dysfunctional beliefs about sleep on sleep quality and that trait arousal moderated the first half of the mediating pathway described above; longitudinal analyses indicated that changes in dysfunctional beliefs about sleep and pre-sleep cognitive arousal mediated changes in sleep quality, and that, in addition, trait arousal moderated changes in sleep quality.

CONCLUSION

Trait arousal correlates with the maintenance of sleep problems, and participants with higher trait arousal benefited less from CBT-I. Enhancement programs that incorporate mindfulness may be a direction for future research.

Prevalence of insomnia and feasibility of a nurse-administered digital cognitive behavioural therapy two years after corona virus disease hospitalisation

BACKGROUND

Disturbed sleep is prevalent after corona virus disease (COVID-19). However, little is known of post infectious prevalence, course, predictors and treatment of chronic insomnia.

AIM

To estimate the prevalence of chronic insomnia three and twelve months after hospitalisation for COVID-19, to identify predictors of chronic insomnia, and to evaluate the feasibility of a nurse-administered digital cognitive behavioural therapy for insomnia (dCBTi) protocol.

METHOD

Patients hospitalised at Akershus University Hospital (Norway) for COVID-19 between February-June 2020 were eligible. The 94 patients that consented to participate were contacted by phone and interviewed with a modified DUKE structured interview three- and twelve months after discharge. Participants with chronic insomnia after twelve months were offered a nurse-administered dCBTi treatment protocol. Outcome measurements were sleep efficiency (SE) calculated by standard formulas (0-100 %) and the Bergen Insomnia Scale (BIS) (0-42).

RESULTS

At three-month follow-up, 22 persons (23 %) fulfilled the diagnostic criteria for chronic insomnia. At twelve-month follow-up, 23 fulfilled the diagnostic criteria. The odds ratios for chronic insomnia after twelve months were 0.857 (0.742-0.989) for body mass index (BMI), and 0.239 (0.069-0.821) for male sex. Ten participated in the dCBTi feasibility study. Five completed the treatment protocol. SE improved, but not significantly. The BIS score improved significantly from 24 to 12 (p-value = 0.036).

CONCLUSION

Chronic insomnia remained stable three- and twelve months post COVID-19 hospitalisation. Female sex and low BMI were independent predictors of chronic insomnia twelve months post infection, but only 50 % of participants completed the protocol. Completers significantly reduced insomnia symptoms.

Effects of Internet Cognitive Behavioral Therapy for Insomnia and Internet Sleep Hygiene Education on Sleep Quality and Executive Function Among Medical Students in Malaysia: Protocol for a Randomized Controlled Trial

BACKGROUND

Medical students are frequently affected by poor sleep quality. Since poor sleep quality has negative physiological and psychological consequences such as on executive function, there is an opportunity to improve sleep quality and executive functions using non-pharmacological intervention such as cognitive behavioural therapy.

OBJECTIVE

The aim of this study therefore is to determine if improving sleep quality could improve executive functions in medical students with poor sleep quality by comparing cognitive behavioural therapy for insomnia (CBT-I) with sleep hygiene education (SHE) in a randomized controlled trial (RCT).

METHODS

A parallel group, RCT with a target sample of 120 medical students recruited from government-based medical universities in Malaysia. Eligible participants will be randomized to internet group CBT-I or internet group SHE in a 1:1 ratio. Assessments will be performed at baseline, post-intervention, 1 month, 3-months, and 6-months. The primary outcome is between-group differences in sleep quality and executive function post-baseline. The secondary outcomes include pre-sleep worry, attitude about sleep, sleep hygiene and sleep parameters.

RESULTS

This study received approval from the Research Ethics Committee in Universiti Putra Malaysia (JKEUPM-2023-1446) and Universiti Kebangsaan Malaysia (JEP-2024-669). The clinical trial was also registered in Australian New Zealand Clinical Trial Registry (ACTRN1264000243516). As of June 2024, the recruitment process is ongoing and a total of 48 and 49 students have been enrolled from the universities into the CBT-I and ISHE groups, respectively. All the participants provided signed and informed consent to participate in the study. Data collection has been completed for the baseline (pre-treatment assessment), and follow-up assessments for T1 and T2 for all the participants in both groups, while T3 and T4 assessments will be completed by July 2025. Data analysis will be performed by August 2025 and the research will be completed by December 2025.

CONCLUSIONS

This study is the first attempt to design a CBT intervention to ameliorate poor sleep quality and its related negative effects among medical students. This research is also the first large-scale exploring the relationship between health status and CBT-mediated sleep improvement among medical students.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12624000243516; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=387030.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/59288.

Does format matter? A naturalistic study of digital and provider-led cognitive behavioral therapy for insomnia implemented in a healthcare system

OBJECTIVES

Cognitive Behavioral Therapy for Insomnia (CBTi) is a first-line treatment for a prevalent and impairing disorder. Digital CBTi programs increase access to internet-based self-directed care. However, the clinical effect of offering different forms of CBTi in a healthcare setting is not clearly understood. This study examines treatment engagement and clinical outcomes for individuals referred to either digital or provider-led CBTi.

METHODS

Over two years, providers at a Veterans Health Administration (VHA) facility referred patients to digital CBTi with telephone coaching support or traditional provider-led CBTi. Characteristics of those referred, proportions engaging in and completing treatment, as well as insomnia severity were compared among those referred to each format.

RESULTS

Providers referred 139 individuals to digital CBTi, 340 to provider-led CBTi, and 14 to both formats. Individuals referred to digital CBTi were older with less severe insomnia. Despite lower levels of program engagement and completion in the digital CBTi cohort, measures of insomnia symptom change were similar between the groups.

CONCLUSIONS

This is the first study to evaluate both digital and provider-led evidence-based treatments for insomnia disorder simultaneously deployed in a healthcare setting. While engagement in digital CBTi lagged that for provider-led CBTi, offering both formats may expand access to different groups, while fostering similar outcomes.

Digital cognitive behavioral therapy for insomnia for people with comorbid psychological distress: A large scale randomized controlled trial

STUDY OBJECTIVES

To examine if comorbid anxiety and depression symptoms (psychological distress) moderate intervention effect in participants receiving digital Cognitive Behavioral Therapy for Insomnia (dCBT-I) in a large-scale randomized controlled trial (RCT), compared to a patient education (PE) control condition. Further, we investigate if dCBT-I reduced levels of psychological distress for those with insomnia and comorbid psychological distress.

METHODS

1721 participants with insomnia completed online assessments of sleep, fatigue and psychological distress, at baseline and at nine-week follow-up. Primary outcome was Insomnia Severity Index (ISI), and secondary outcomes included self-reported sleep (diary), cognition, fatigue, and psychological distress. Participants with psychological distress (HADS>16) were separated from participants without psychological distress. Linear mixed models in SPSS were conducted to test the effects of the intervention.

RESULTS

At nine-week follow-up we found no difference in effect of the intervention between those who had comorbid psychological distress vs. those without psychological distress in terms of insomnia severity (p = 0.552) and fatigue (p = 0.744). Both groups had large effect size improvements on insomnia severity (p < 0.001=), small to medium (Cohen d < 0.08) improvements on fatigue (p < 0.01=) and sleep efficiency (p < 0.001), and small improvement on other sleep diary measures, compared to their respective control group. The psychological distress group showed a small, but statistically significant decrease in psychological distress (d = 0.2, p < 0.05) with dCBT-I compared to PE.

CONCLUSION

dCBT-I is a viable treatment for Insomnia also for those who have comorbid psychological distress.

One-week inpatient cognitive behavioral therapy for insomnia: a retrospective study

Objective

To examine the effectiveness of one-week inpatient cognitive behavioral therapy for insomnia (CBT-I) in patients without severe mental disorders in the real-world setting to answer the research question "Can inpatient CBT-I be abbreviated?".

Methods

In this retrospective, single-group, pretest-posttest study, the clinical outcome data of 94 patients who underwent one-week inpatient CBT-I were collected. Self-report scale scores and hypnotic medication use were obtained at baseline and at the 3-month follow-up after therapy.

Results

CBT-I significantly improved insomnia severity (Z = -7.65, P < 0.001, Cohen's d = 1.34), anxiety (Z = -6.23, P < 0.001, Cohen's d = 1.02), depression (Z = -6.42, P < 0.001, Cohen's d = 1.06), daytime sleepiness (Z = -2.40, P = 0.016, Cohen's d = 0.35), and fatigue severity (Z = -5.54, P < 0.001, Cohen's d = 0.88) and reduced hypnotic medication use (χ2 = 33.62, P < 0.001). At the follow-up assessment, 58 patients (67.4%) had clinically meaningful changes in insomnia, and 51 patients (59.3%) met the criteria for insomnia remission.

Conclusion

The results of this preliminary study imply that one-week inpatient CBT-I may be an effective intervention for the treatment of insomnia in patients without severe mental disorders.

Efficacy of eHealth Versus In-Person Cognitive Behavioral Therapy for Insomnia: Systematic Review and Meta-Analysis of Equivalence

BACKGROUND

Insomnia is a prevalent condition with significant health, societal, and economic impacts. Cognitive behavioral therapy for insomnia (CBTI) is recommended as the first-line treatment. With limited accessibility to in-person-delivered CBTI (ipCBTI), electronically delivered eHealth CBTI (eCBTI), ranging from telephone- and videoconference-delivered interventions to fully automated web-based programs and mobile apps, has emerged as an alternative. However, the relative efficacy of eCBTI compared to ipCBTI has not been conclusively determined.

OBJECTIVE

This study aims to test the comparability of eCBTI and ipCBTI through a systematic review and meta-analysis of equivalence based on randomized controlled trials directly comparing the 2 delivery formats.

METHODS

A comprehensive search across multiple databases was conducted, leading to the identification and analysis of 15 unique randomized head-to-head comparisons of ipCBTI and eCBTI. Data on sleep and nonsleep outcomes were extracted and subjected to both conventional meta-analytical methods and equivalence testing based on predetermined equivalence margins derived from previously suggested minimal important differences. Supplementary Bayesian analyses were conducted to determine the strength of the available evidence.

RESULTS

The meta-analysis included 15 studies with a total of 1083 participants. Conventional comparisons generally favored ipCBTI. However, the effect sizes were small, and the 2 delivery formats were statistically significantly equivalent (P<.05) for most sleep and nonsleep outcomes. Additional within-group analyses showed that both formats led to statistically significant improvements (P<.05) in insomnia severity; sleep quality; and secondary outcomes such as fatigue, anxiety, and depression. Heterogeneity analyses highlighted the role of treatment duration and dropout rates as potential moderators of the differences in treatment efficacy.

CONCLUSIONS

eCBTI and ipCBTI were found to be statistically significantly equivalent for treating insomnia for most examined outcomes, indicating eCBTI as a clinically relevant alternative to ipCBTI. This supports the expansion of eCBTI as a viable option to increase accessibility to effective insomnia treatment. Nonetheless, further research is needed to address the limitations noted, including the high risk of bias in some studies and the potential impact of treatment duration and dropout rates on efficacy.

TRIAL REGISTRATION

PROSPERO CRD42023390811; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=390811.

The gap between statistical and clinical significance: time to pay attention to clinical relevance in patient-reported outcome measures of insomnia

BACKGROUND

Appropriately defining and using the minimal important change (MIC) and the minimal clinically important difference (MCID) are crucial for determining whether the results are clinically significant. The aim of this study is to survey the status of randomized controlled trials (RCTs) for insomnia interventions to assess the inclusion and interpretation of MIC/MCID values.

METHODS

We conducted a cross-sectional study to survey the status of RCTs for insomnia interventions to assess the inclusion and appropriate interpretation of MIC/MCID values. A literature search was conducted by searching the main sleep medicine journals indexed in PubMed, the Excerpta Medica Database (EMBASE), and the Cochrane Central Register of Controlled Trials (CENTRAL) to identify a broad range of search terms. We included RCTs with no restriction on the intervention. The included studies used the Insomnia Severity Index (ISI) or the Pittsburgh Sleep Quality Index (PSQI) questionnaire as the outcome measures.

RESULTS

81 eligible studies were identified, and more than one-third of the included studies used MIC/MCID (n = 31, 38.3%). Among them, 21 studies with ISI as the outcome used MIC defined as a relative decrease ranging from 3 to 8 points. The most frequently used MIC value was a 6-point decrease (n = 7), followed by 8-point (n = 6) and 7-point decrease (n = 4), a 4 to 5-points decrease (n = 3), and a 30% reduction from baseline; 6 studies used MCID values, ranging from 2.8 to 4 points. The most frequently used MCID value was a 4-point decrease in the ISI (n = 4). 4 studies with PSQI as the outcome used a 3-point change as the MIC (n = 2) and a 2.5 to 2.7-point difference as MCID (n = 2). 4 non-inferiority design studies considered interval estimation when drawing clinically significant conclusions in their MCID usage.

CONCLUSIONS

The lack of consistent MIC/MCID interpretation and usage in outcome measures for insomnia highlights the urgent need for further efforts to address this issue and improve reporting practices.

Factors influencing the effectiveness of digital cognitive behavioural therapy for chronic insomnia in clinical practice

Digital cognitive behavioural therapy for chronic insomnia (D-CBT-I) has been shown to be as efficacious as traditional CBT-I. However, not all patients achieve insomnia remission after treatment. We explored the factors influencing the effectiveness of D-CBT-I in a clinical practice. A total of 414 Asian chronic insomniacs were studied during a 6 week D-CBT-I intervention. All patients were assessed at baseline and posttreatment and were determined to be remitters or non-remitters, responders or non-responders by posttreatment criteria; Insomnia Severity Index (ISI <8) or ISI reduction ≥8, to examine whether remission and response status were associated with patient baseline characteristics. The average baseline ISI score in all subjects was 16.29 points. At posttreatment, 192 (46.4%) patients achieved ISI remission and 218 (52.7%) patients demonstrated an ISI response. An increased baseline early morning awakening time and ISI score were independently associated with a lower odds for remission (OR, 0.995 and 0.991, respectively). Increased baseline Patients Health Questionnaire-9 score was independently associated with higher odds for response (OR, 1.114). Our results suggest that D-CBT-I can be recommended as the first-line treatment for chronic insomnia, particularly in insomniacs with milder insomnia symptoms and more severe depressive symptoms. Meanwhile, the effectiveness of D-CBT-I was adversely affected by longer early morning awakening time and higher insomnia severity at pretreatment, which may be improved by more intense intervention and greater therapeutic support or by traditional CBT-I.

Investigating non-inferiority of internet-delivered versus face-to-face cognitive behavioural therapy for insomnia (CBT-I): a randomised controlled trial (iSleep well)

BACKGROUND

Insomnia is a highly prevalent disorder associated with numerous adverse health outcomes. Cognitive behavioural therapy for insomnia (CBT-I) is recommended as first-line treatment by clinical guidelines but is accessible to only a minority of patients suffering from insomnia. Internet-delivered CBT-I (iCBT-I) could contribute to the widespread dissemination of this first-line treatment. As there is insufficient evidence regarding non-inferiority, this study directly aims to compare therapist-guided internet-delivered versus face-to-face CBT-I in terms of insomnia severity post-treatment. Furthermore, a health-economic evaluation will be conducted, and potential benefits and disadvantages of therapist-guided iCBT-I will be examined.

METHODS

This study protocol describes a randomised controlled two-arm parallel-group non-inferiority trial comparing therapist-guided iCBT-I with face-to-face CBT-I in routine clinical care. A total of 422 patients with insomnia disorder will be randomised and treated at 16 study centres throughout Germany. Outcomes will be assessed at baseline, 10 weeks after randomisation (post), and 6 months after randomisation (follow-up). The primary outcome is insomnia severity measured using the Insomnia Severity Index. Secondary outcomes include depression-related symptoms, quality of life, fatigue, physical activity, daylight exposure, adverse events related to treatment, and a health-economic evaluation. Finally, potential moderator variables and several descriptive and exploratory outcomes will be assessed (e.g. benefits and disadvantages of internet-delivered treatment).

DISCUSSION

The widespread implementation of CBT-I is a significant healthcare challenge. The non-inferiority of therapist-guided iCBT-I versus face-to-face CBT-I will be investigated in an adequately powered sample in routine clinical care, with the same therapeutic content and same level of therapist qualifications provided with both interventions. If this trial demonstrates the non-inferiority of therapist-guided iCBT-I, healthcare providers may be more confident recommending this treatment to their patients, contributing to the wider dissemination of CBT-I.

TRIAL REGISTRATION

Trial registration number in the German Clinical Trials Register: DRKS00028153 ( https://drks.de/search/de/trial/DRKS00028153 ). Registered on 16th May 2023.

The clinical effects of digital cognitive behavioral therapy for insomnia in a heterogenous study sample: results from a randomized controlled trial

STUDY OBJECTIVES

Numerous studies worldwide have reported the beneficial effects of digital cognitive behavioral therapy for insomnia (dCBT-I). However, few focus on real-world study samples that reflect people in regular care. To test whether dCBT-I is suitable within German regular care, we designed a randomized controlled trial recruiting a heterogenous insomnia population.

METHODS

Participants aged ≥18 who met the criteria for insomnia disorder were randomized to 8-weeks dCBT-I + care-as-usual (CAU) or they were set on a waitlist + CAU. The intervention group was followed-up at 6- and 12-months. The primary outcome was self-reported insomnia severity, assessed with the Insomnia Severity Index (ISI) at 8-weeks post-randomization. A one-way ANCOVA with baseline score as a covariate was fitted to determine group differences. Secondary outcomes included measures of daytime functioning, quality of life, depression, anxiety, dreams, and nightmares.

RESULTS

Of the N = 238 participants (67.6% female), age range 19-81 years, n = 118 were randomized to dCBT-I and n = 120 to the control group. At posttreatment, the use of dCBT-I was associated with a large reduction in the ISI (Diffadj = -7.60) in comparison to WLC (d = -2.08). This clinical improvement was also reflected in responder and remission rates. Treatment effects were also observed for daytime functioning, quality of life, symptoms of depression and anxiety (ds = 0.26-1.02) and at long-term follow-up (intervention group only; ds = 0.18-1.65). No effects were found for dream and nightmare frequency.

CONCLUSIONS

This study showed that dCBT-I reduces insomnia symptoms and improves daytime functioning in a heterogenous insomnia population in Germany with sustained long-term treatment effects in the intervention group. Our results underscore the potential of digital health applications, their suitability within regular care, and their role in facilitating widespread implementation of CBT-I as a first-line treatment for insomnia.

Effect of cognitive behavioral therapy for insomnia in workers: A systematic review and meta-analysis of randomized controlled trials

Although cognitive behavioral therapy for insomnia (CBT-I) is recommended as a first-line treatment, its efficacy for workers with insomnia remains unclear. This systematic review and meta-analysis aimed to determine the effectiveness of CBT-I in the management of insomnia symptoms in workers. We searched the literature in three electronic databases, namely PubMed, PsycINFO, and Embase, and included 21 studies in the meta-analysis. Compared with the control group, CBT-I overall resulted in significant improvements in terms of severity of insomnia (g = -0.91), sleep onset latency (g = -0.62), wakefulness after sleep onset (g = -0.60), early morning awakening (g = -0.58), and sleep efficiency (g = 0.71). However, there was no improvement in the total sleep time relative to that in the control group. Furthermore, CBT-I significantly alleviated depressive (g = -0.37) and anxiety (g = -0.35) symptoms and fatigue (g = -0.47) compared with the control group. Our study findings suggest that both web-based and face-to-face CBT-I are effective interventions for managing insomnia symptoms in daytime workers, although it is important to note that only face-to-face CBT-I achieved clinically meaningful changes. The effectiveness of CBT-I for shift workers could not be determined.

Development and Initial Evaluation of Web-Based Cognitive Behavioral Therapy for Insomnia in Rural Family Caregivers of People With Dementia (NiteCAPP): Mixed Methods Study

BACKGROUND

Informal caregivers of people with dementia frequently experience chronic insomnia, contributing to stress and poor health outcomes. Rural caregivers are particularly vulnerable but have limited access to cognitive behavioral therapy for insomnia (CBT-I), a recommended frontline treatment for chronic insomnia. Web-based delivery promises to improve insomnia, particularly for rural caregivers who have limited access to traditional in-person treatments. Our team translated an efficacious 4-session standard CBT-I content protocol into digital format to create NiteCAPP.

OBJECTIVE

This study aimed to (1) adapt NiteCAPP for dementia caregivers to create NiteCAPP CARES, a tailored digital format with standard CBT-I content plus caregiver-focused modifications; (2) conduct usability testing and evaluate acceptability of NiteCAPP CARES' content and features; and (3) pilot-test the adapted intervention to evaluate feasibility and preliminary effects on sleep and related health outcomes.

METHODS

We followed Medical Research Council recommendations for evaluating complex medical interventions to explore user needs and adapt and validate content using a stepwise approach: (1) a rural dementia caregiver (n=5) and primary care provider (n=5) advisory panel gave feedback that was used to adapt NiteCAPP; (2) caregiver (n=5) and primary care provider (n=7) focus groups reviewed the newly adapted NiteCAPP CARES and provided feedback that guided further adaptations; and (3) NiteCAPP CARES was pilot-tested in caregivers (n=5) for feasibility and to establish preliminary effects. Self-report usability measures were collected following intervention. Before and after treatment, 14 daily electronic sleep diaries and questionnaires were collected to evaluate arousal, health, mood, burden, subjective cognition, and interpersonal processes.

RESULTS

The stepped approach provided user and expert feedback on satisfaction, usefulness, and content, resulting in a new digital CBT-I tailored for rural dementia caregivers: NiteCAPP CARES. The advisory panel recommended streamlining content, eliminating jargon, and including caregiver-focused content. Focus groups gave NiteCAPP CARES high usefulness ratings (mean score 4.4, SD 0.79, scored from 1=least to 5=most favorable; score range 4.2-4.8). Multiple features were evaluated positively, including the intervention's comprehensive and engaging information, caregiver focus, good layout, easy-to-access intervention material, and easy-to-understand sleep graphs. Suggestions for improvement included the provision of day and night viewing options, collapsible text, font size options, tabbed access to videos, and a glossary of terms. Pilot-test users rated usefulness (mean score 4.3, SD 0.83; range 4.1-4.5) and satisfaction (mean score 8.4, SD 1.41, scored from 1=least to 10=most satisfied; range 7.4-9.0) highly. Preliminary effects on caregiver sleep, arousal, health, mood, burden, cognition, and interpersonal processes (all P<.05) were promising.

CONCLUSIONS

Adaptations made to standard digital CBT-I created a feasible, tailored digital intervention for rural dementia caregivers. Important next steps include further examination of feasibility and efficacy in a randomized controlled trial with an active control condition, a multisite effectiveness trial, and eventual broad dissemination.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04632628; https://clinicaltrials.gov/ct2/show/NCT04632628.

Does insomnia treatment prevent depression?

Rates of major depressive disorder (MDD) are increasing globally, in part due to the coronavirus disease 2019 pandemic, contributing to disease burden. It has long been known that insomnia is intricately connected with depression as indicated by greater depression severity and lower treatment response. Furthermore, insomnia is a significant risk factor for new-onset depression. Treatment of insomnia is thus a logical target for prevention of incidents and recurrent MDD. This systematic review sought to evaluate the current evidence for the preventive effects of insomnia treatment on depression onset. A database search yielded 186 studies, six of which met criteria for inclusion in this review. All of the studies utilized cognitive behavioral treatment for insomnia (CBT-I) as the target intervention and most delivered treatment via a digital platform. Four of the studies found significantly lower rates of MDD onset in those who received CBT-I compared to a control condition. The two remaining studies failed to confirm these effects in primary analyses but secondary analyses suggested evidence of a preventive effect. There was significant methodologic heterogeneity across studies in terms of sample selection, outcomes, and follow-up periods, limiting the ability to draw firm conclusions. The evidence overall is in the direction of insomnia treatment reducing the risk for onset of MDD, but further research is warranted.

Comparative efficacy of onsite, digital, and other settings for cognitive behavioral therapy for insomnia: a systematic review and network meta-analysis

Given the limited availability and accessibility of onsite cognitive behavioral therapy for insomnia (CBT-I), other CBT-I settings, such as internet-delivered CBT-I (iCBT-I), have been proposed. The primary aim of the study was to compare the efficacy of available CBT-I settings on insomnia severity. A systematic review and frequentist network meta-analysis of available CBT-I settings was performed. PsycINFO, PsycARTICLES, MEDLINE, PubMed, and CINAHL were searched for randomized controlled trials (RCTs) investigating any CBT-I settings in adults with insomnia disorder. The systematic literature search (3851 references) resulted in 52 RCTs. For the primary outcome insomnia severity, all examined CBT-I settings except smartphone-delivered CBT-I yielded significant effects when compared to WL. Large standardized mean differences were found for individual onsite CBT-I (- 1.27;95%CI - 1.70, - 0.84), group-delivered CBT-I (- 1.00;95%CI - 1.42. - 0.59), telehealth (- 1.28;95%CI - 2.06, - 0.50), and guided bibliotherapy (- 0.99;95%CI - 1.67, - 0.32). Both guided iCBT-I (- 0.71;95%CI - 1.18, - 0.24) and unguided iCBT-I (- 0.78;95%CI - 1.18, - 0.38) yielded medium effect sizes. The results underline that health care systems should intensify their efforts to provide synchronously-delivered CBT-I (individual onsite, group-delivered, and telehealth), and particularly individual onsite CBT-I, given its solid evidence base. Medium to large effect sizes for iCBT-I and guided bibliotherapy indicate that self-help settings may be a viable alternative when synchronously-delivered CBT-I is not available.

Four Useful Concepts When Treating Patients With Insomnia: Possibility of Sleep Index-Based Cognitive Behavioral Therapy for Insomnia

Cognitive behavioral therapy for insomnia (CBT-I) is one of the most common treatments for insomnia and is considered as the first-line treatment. People who struggle to fall asleep or stay asleep or those who do not find sleep refreshing can benefit over four to six sessions of CBT-I. Although CBT-I has many benefits, it does have some drawbacks. Therefore, a brief version needs to be developed for use in clinical practice. This study proposes the following concepts that can be readily applied in clinical practice: 1) Concept 1, 17 hours of activity and 7 hours of sleep; 2) Concept 2, discrepancy between desired time in bed and desired total sleep time; 3) Concept 3, time in bed during 24 hours; and 4) Concept 4, taking sleeping pills 7 hours before the waking up time. These concepts based on sleep indices could easily help patients with insomnia and may serve as a foundation for the development of Sleep Index-based CBT-I.

Insomnia disorder: State of the science and challenges for the future

Insomnia disorder comprises symptoms during night and day that strongly affect quality of life and wellbeing. Prolonged sleep latency, difficulties to maintain sleep and early morning wakening characterize sleep complaints, whereas fatigue, reduced attention, impaired cognitive functioning, irritability, anxiety and low mood are key daytime impairments. Insomnia disorder is well acknowledged in all relevant diagnostic systems: Diagnostic and Statistical Manual of the American Psychiatric Association, 5th revision, International Classification of Sleep Disorders, 3rd version, and International Classification of Diseases, 11th revision. Insomnia disorder as a chronic condition is frequent (up to 10% of the adult population, with a preponderance of females), and signifies an important and independent risk factor for physical and, especially, mental health. Insomnia disorder diagnosis primarily rests on self-report. Objective measures like actigraphy or polysomnography are not (yet) part of the routine diagnostic canon, but play an important role in research. Disease concepts of insomnia range from cognitive-behavioural models to (epi-) genetics and psychoneurobiological approaches. The latter is derived from knowledge about basic sleep-wake regulation and encompass theories like rapid eye movement sleep instability/restless rapid eye movement sleep. Cognitive-behavioural models of insomnia led to the conceptualization of cognitive-behavioural therapy for insomnia, which is now considered as first-line treatment for insomnia worldwide. Future research strategies will include the combination of experimental paradigms with neuroimaging and may benefit from more attention to dysfunctional overnight alleviation of distress in insomnia. With respect to therapy, cognitive-behavioural therapy for insomnia merits widespread implementation, and digital cognitive-behavioural therapy may assist delivery along treatment guidelines. However, given the still considerable proportion of patients responding insufficiently to cognitive-behavioural therapy for insomnia, fundamental studies are highly necessary to better understand the brain and behavioural mechanisms underlying insomnia. Mediators and moderators of treatment response/non-response and the associated development of tailored and novel interventions also require investigation. Recent studies suggest that treatment of insomnia may prove to add significantly as a preventive strategy to combat the global burden of mental disorders.

Using network intervention analysis to explore associations between participant expectations of and difficulties with cognitive behavioural therapy for insomnia and clinical outcome: A proof of principle study

BACKGROUND

Research about predictors of response to cognitive behaviour therapy for insomnia (CBT-I) is ongoing. We examined any whether pre-intervention expectations or post-intervention appraisals of difficulties in utilizing face to face (FtF) or digital (dCBT-I) versions of the therapy were associated with outcome.

METHODS

Self-rating data were extracted on 101 adult participants in a recent randomized controlled trial of FtF versus dCBT-I. Network intervention analyses were used to explore any associations between expectations of CBT-I at response at 9 weeks and between post-intervention ratings of difficulties, modality of therapy and response at 9-weeks and at 6-months.

RESULTS

Anticipated and actual difficulties in employing sleep restriction techniques predicted response in all network models. Modality of therapy played a more overt role in the 9-week outcome network, with FtF therapy more robustly associated with response. However, the direct association between FtF therapy and response was not found in the 6-month outcome network. Notable predictors of poor outcome at 9-weeks and 6-month follow-up were difficulties in accommodating CBT-I into work and daily routines and applying the rules of CBT-I.

CONCLUSIONS

This network intervention analysis highlights that self-confidence and ability in undertaking sleep restriction is a key active ingredient of CBT-I. Also, benefits and gains from access to the FtF version of this multi-component therapy were more apparent in the short than the longer term. However, it is important that findings from this proof of principle study are confirmed in further studies.