Internet-Delivered Cognitive Behavioral Therapy to Treat Insomnia: A Systematic Review and Meta-Analysis

Abstract

Background: Insomnia is of major public health importance. While cognitive behavioral therapy is beneficial, in-person treatment is often unavailable. We assessed the effectiveness of internet-delivered cognitive behavioral therapy for insomnia.

Objectives: The primary objectives were to determine whether online cognitive behavioral therapy for insomnia could improve sleep efficiency and reduce the severity of insomnia in adults. Secondary outcomes included sleep quality, total sleep time, time in bed, sleep onset latency, wake time after sleep onset, and number of nocturnal awakenings.

Data sources: We searched PubMed/MEDLINE, the Cumulative Index to Nursing and Allied Health Literature, PsycInfo, Cochrane Library, Embase, and the Web of Science for randomized trials.

Methods: Studies were eligible if they were randomized controlled trials in adults that reported application of cognitive behavioral therapy for insomnia via internet delivery. Mean differences in improvement in sleep measures were calculated using the Hartung-Knapp-Sidik-Jonkman method for random effects meta-analysis.

Results: We found 15 trials, all utilizing a pretest-posttest randomized control group design. Sleep efficiency was 72% at baseline and improved by 7.2% (95% CI: 5.1%, 9.3%; p<0.001) with internet-delivered cognitive behavioral therapy versus control. Internet-delivered cognitive behavioral therapy resulted in a decrease in the insomnia severity index by 4.3 points (95% CI: -7.1, -1.5; p = 0.017) compared to control. Total sleep time averaged 5.7 hours at baseline and increased by 20 minutes with internet-delivered therapy versus control (95% CI: 9, 31; p = 0.004). The severity of depression decreased by 2.3 points (95% CI: -2.9, -1.7; p = 0.013) in individuals who received internet-delivered cognitive behavioral therapy compared to control. Improvements in sleep efficiency, the insomnia severity index and depression scores with internet-delivered cognitive behavioral therapy were maintained from 4 to 48 weeks after post-treatment assessment. There were no statistically significant differences between sleep efficiency, total sleep time, and insomnia severity index for internet-delivered versus in-person therapy with a trained therapist.

Conclusion: In conclusion, internet-delivered cognitive behavioral therapy is effective in improving sleep in adults with insomnia. Efforts should be made to educate the public and expand access to this therapy. Registration Number, Prospero: CRD42015017622.

Fig 1. PRISMA Flow Diagram for the Systematic Review of Internet-Delivered Cognitive Behavioral Therapy to Treat Insomnia.

Fig 2. Mean Differences in Sleep Efficiency between Internet-Delivered Cognitive Behavioral Therapy for Insomnia and Wait List.

Fig 3. Mean Differences in Total Sleep Time between Internet-Delivered Cognitive Behavioral Therapy for Insomnia and Wait List.

Fig 4. Mean Differences in Sleep Onset Latency between Internet-Delivered Cognitive Behavioral Therapy for Insomnia and Wait List.

Fig 5. Mean Differences in Wake Time after Sleep Onset between Internet-Delivered Cognitive Behavioral Therapy for Insomnia and Wait List.

Fig 6. Mean Differences in Insomnia Severity Index between Internet-Delivered Cognitive Behavioral Therapy for Insomnia and Wait List.

Fig 7. Mean Differences in Depression between Internet-Delivered Cognitive Behavioral Therapy for Insomnia and Wait List.

Fig 8. Mean Differences in Sleep Measures between Internet-Delivered Cognitive Behavioral Therapy for Insomnia and Control after Long-Term Follow-up.

Fig 9. Mean Differences in Insomnia Severity Index between Internet-Delivered Cognitive Behavioral Therapy for Insomnia and Wait List after Long-Term Follow-up.

Fig 10. Mean Differences in Sleep Measures between Internet-Delivered and In-Person Cognitive Behavioral Therapy for Insomnia.

Fig 11. Standardized Mean Differences in Dysfunctional Belief and Attitudes about Sleep, comparing Internet-Delivered Cognitive Behavioral Therapy for Insomnia and Wait List.