by Joye C. Anestis
It has been a while since I made a contribution to my series evaluating alternative treatment delivery mechanisms. In a previous article, I examined available evidence for online treatments geared toward preventing eating disorders. Today I am focusing on online interventions to treat primary insomnia. Cognitive-behavioral therapy and other behavioral treatments are already considered empirically-supported treatments (ESTs)...but can these therapies be adapted into an online format and thus, theoretically, reach a maximum number of folks who need them? Unfortunately, online interventions for insomnia have not been as extensively researched as other conditions.
In the most recent (2009) investigation of this question, Lee Ritterband and colleagues randomly assigned adults to a wait-list control group or to the Sleep Healthy Using the Internet, or SHUTi, intervention. SHUTi is a structured internet intervention based on standard CBT for insomnia (check it out at www.shuti.net). Clients complete 6 core modules, including stimulus control, sleep hygiene, and cognitive restructuring. In an interesting aspect of this program, after the completing of each core, participants receive personalized feedback based on their previous week of sleep diaries. Participants had to meet DSM-IV-TR criteria for primary insomnia, have sleep difficulties for at least 6 months and for at least 3 nights per week, report significant daytime impairments due to sleep problems, and have Internet access. After initial in-person assessments, all participants completed 10 sleep diary entries over two weeks before being notified of their group assignment. Those assigned to SHUTi were then given access to the SHUTi website for the 9-week intervention. After the 9 weeks, all participants (both treatment and control conditions) then completed a 2nd in-person assessment. Those in the treatment group also completed 6-month follow-up assessments. Control participants were given access to SHUTi post-intervention. Results from the study indicate that SHUTi produced statistically significant improvements for the treatment group in comparison to the control group. Treatment gains included score reductions on the Insomnia Severity Index, a valid and reliable index of the severity of sleep problems, at both post-treatment and 6-month follow-up; clinically significant change on the Insomnia Severity Index; and, based on the sleep diary data, significant improvements for wake after sleep onset, sleep efficiency, and number of nighttime awakenings for those who received SHUTi.
Only one other study has examined an online intervention for insomnia. Published in 2004, Lars Strom and colleagues randomly assigned participants to either a cognitive-behavioral self-help program or a wait-list control group. The program was developed and administered in Sweden. Like the previous study, the 5-week online sleep management program contained the key features of a CBT program for insomnia. The results of this study were not as promising as those in the Ritterband study. The treatment group demonstrated improvement on a number of measures, but the control group, who only received information about the study and completed sleep diaries and questionnaires, also improved on several measures. Strong between-group differences were found on only one measure, the Dysfunctional Beliefs and Attitudes about Sleep Scale.
It is difficult to draw conclusions about the efficacy of online CBT for insomnia at the present time based on these 2 findings. I'm hopeful that more interventions of this kind are being examined...given that many people are reluctant to seek out a therapist to assist with mental conditions for a variety of reasons (e.g., feelings of shame, social stigma, financial reasons), internet interventions as well as other alternative treatment delivery systems demonstrate great promise in making treatments already determined to be effective in a standard therapeutic format more accessible to the public.
Look for the next installment of this series soon...
Joye Anestis is a doctoral candidate in clincial psychology at Florida State University.
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