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Can digital cognitive behavioral therapy for insomnia improve functional health, psychological well-being, and sleep-related quality of life, and does a reduction in insomnia symptoms mediate these potential improvements?
In a 2-arm, parallel-group randomized clinical trial that included 1711 persons, digital cognitive behavioral therapy significantly improved insomnia symptoms, functional health, psychological well-being, and sleep-related quality of life at 4, 8, and 24 weeks after initiation of treatment. Improvements at 8 and 24 weeks were mediated by improvements in insomnia at week 4 and 8, respectively.
Treating insomnia with digital cognitive behavioral therapy could be a therapeutic pathway for addressing self-reported health, well-being, and quality of life.
Digital cognitive behavioral therapy (dCBT) is a scalable and effective intervention for treating insomnia. Most people with insomnia, however, seek help because of the daytime consequences of poor sleep, which adversely affects quality of life.
To investigate the effect of dCBT for insomnia on functional health, psychological well-being, and sleep-related quality of life and to determine whether a reduction in insomnia symptoms was a mediating factor.
Design, Setting, and Participants
This online, 2-arm, parallel-group randomized trial comparing dCBT for insomnia with sleep hygiene education (SHE) evaluated 1711 participants with self-reported symptoms of insomnia. Participants were recruited between December 1, 2015, and December 1, 2016, and dCBT was delivered using web and/or mobile channels plus treatment as usual; SHE comprised a website and a downloadable booklet plus treatment as usual. Online assessments took place at 0 (baseline), 4 (midtreatment), 8 (posttreatment), and 24 (follow-up) weeks. Programs were completed within 12 weeks after inclusion.
Main Outcomes and Measures
Primary outcomes were scores on self-reported measures of functional health (Patient-Reported Outcomes Measurement Information System: Global Health Scale; range, 10-50; higher scores indicate better health); psychological well-being (Warwick-Edinburgh Mental Well-being Scale; range, 14-70; higher scores indicate greater well-being); and sleep-related quality of life (Glasgow Sleep Impact Index; range, 1-100; higher scores indicate greater impairment). Secondary outcomes comprised mood, fatigue, sleepiness, cognitive failures, work productivity, and relationship satisfaction. Insomnia was assessed with the Sleep Condition Indicator (range: 0-32; higher scores indicate better sleep).
Of the 1711 participants included in the intention-to-treat analysis, 1329 (77.7%) were female, mean (SD) age was 48.0 (13.8) years, and 1558 (91.1%) were white. Use of dCBT was associated with a small improvement in functional health compared with SHE (adjusted difference [95% CI] at week 4, 0.90 [0.40-1.40]; week 8, 1.76 [1.24-2.28]; week 24, 1.76 [1.22-2.30]) and psychological well-being (adjusted difference [95% CI] at week 4, 1.04 [0.28-1.80]; week 8, 2.68 [1.89-3.47]; week 24, 2.95 [2.13-3.76]), and with a large improvement in sleep-related quality of life (at week 4, −8.76 [−11.83 to −5.69]; week 8, –17.60 [−20.81 to −14.39]; week 24, −18.72 [−22.04 to −15.41]) (all P < .01). A large improvement in insomnia mediated these outcomes (range mediated, 45.5%-84.0%).
Conclusions and Relevance
Use of dCBT is effective in improving functional health, psychological well-being, and sleep-related quality of life in people reporting insomnia symptoms. A reduction in insomnia symptoms mediates these improvements. These results confirm that dCBT improves both daytime and nighttime aspects of insomnia, strengthening existing recommendations of CBT as the treatment of choice for insomnia.
isrctn.org identifier: ISRCTN60530898
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Accepted for Publication: August 4, 2018.
Corresponding Author: Colin A. Espie, PhD, Sleep & Circadian Neuroscience Institute, Nuffield Department of Clinical Neurosciences, University of Oxford, Sir William Dunn School of Pathology, South Parks Road, Oxford OX1 3RE, United Kingdom (firstname.lastname@example.org).
Published Online: September 25, 2018. doi:10.1001/jamapsychiatry.2018.2745
Author Contributions: Dr Espie had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Espie, Kyle, Gordon, Drake, Siriwardena, Cape, Ong, Sheaves, Foster, Freeman, Costa-Font, Luik.
Acquisition, analysis, or interpretation of data: Emsley, Kyle, Gordon, Drake, Costa-Font, Marsden, Luik.
Drafting of the manuscript: Espie, Emsley, Kyle, Marsden, Luik.
Critical revision of the manuscript for important intellectual content: Espie, Emsley, Kyle, Gordon, Drake, Siriwardena, Cape, Ong, Sheaves, Foster, Freeman, Costa-Font, Luik.
Statistical analysis: Emsley, Marsden.
Administrative, technical, or material support: Kyle, Gordon, Siriwardena, Sheaves, Freeman, Luik.
Supervision: Espie, Gordon, Costa-Font.
Conflict of Interest Disclosures: Dr Espie reports being a cofounder, chief medical officer, and shareholder of and receiving salary from Big Health Ltd and being a developer of Sleepio. Drs Kyle and Drake report receiving nonfinancial support from Big Health Ltd (provision of Sleepio for use in clinical trials). Dr Cape reports providing clinical advice and support to Sleepio and receiving payment from Big Health Ltd. Dr Ong reports receiving nonfinancial support from Big Health Ltd (provision of Sleepio for use in clinical trials), providing consultancy support for Sleepio, and receiving payment from Big Health Ltd. Dr Sheaves reports providing monthly support for an online discussion forum run by Sleepio and receiving payment from Big Health Ltd. Dr Freeman reports being a cofounder of the University of Oxford spinout company, Oxford VR; receiving nonfinancial support from Big Health Ltd (provision of Sleepio for use in clinical trials); and being supported by an NIHR Research Professorship. Dr Luik held a research position at the University of Oxford during the conduct of the study that was funded by Big Health Ltd. No other conflicts were reported.
Funding/Support: The study was funded by Big Health Ltd. The work was supported in part by the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, NIHR Oxford Health Biomedical Research Centre, NIHR Biomedical Research Centre at South London, Maudsley National Health Service (NHS) Foundation Trust, King’s College London, and the Dr Mortimer & Theresa Sackler Foundation.
Role of the Funder/Sponsor: Big Health Ltd was involved in the design and conduct of the study; collection, management, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. The funder was not involved in the analysis of the data. Other funders had no role in the design and conduct of the study, collection of the data, data analysis, management, interpretation, or review or approval of the manuscript.
Disclaimer: The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. Dr Freeman is supported by an NIHR Research Professorship.
Meeting Presentation: This paper was presented at the 24th Congress of the European Sleep Research Society; September 25, 2018; Basel, Switzerland.
Additional Contribution: Alasdair Henry, PhD, Big Health Ltd, helped with formatting the manuscript, which was performed as part of his regular duties; he was not additionally compensated. Sleepio was provided to participants at no cost. The study was conducted at the University of Oxford, Sleep & Circadian Neuroscience Institute. The University of Oxford has a memorandum of understanding with Big Health for the conduct of joint research.
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