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      Digital Cognitive Behavioral Therapy (dCBT) for Insomnia: a State-of-the-Science Review

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          Abstract

          Purpose of Review

          Over the past decade, digital solutions have been developed to support the dissemination of Cognitive Behavioral Therapy (CBT). In this paper, we review the evidence for and implications of digital CBT (dCBT) for insomnia.

          Recent Findings

          We propose three categories of dCBT, which differ in the amount of clinician time needed, level of automatization, costs, and scalability: dCBT as support, guided dCBT, and fully automated dCBT. Consistent evidence has been published on the effectiveness of dCBT to address insomnia disorder, in a variety of populations, with effects extending into well-being. Important gaps in the literature are identified around moderators and mediators of dCBT, cost-effectiveness, and the implementation of dCBT.

          Summary

          The evidence base for dCBT is rapidly developing and already suggests that dCBT for insomnia is effective. However, further science and digital innovation is required to realize the full potential of dCBT and address important clinical questions.

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          Cognitive Behavioral Therapy for Chronic Insomnia: A Systematic Review and Meta-analysis.

          James M. Trauer, Mary Y Qian, Joseph Doyle … (2015)
          Because psychological approaches are likely to produce sustained benefits without the risk for tolerance or adverse effects associated with pharmacologic approaches, cognitive behavioral therapy for insomnia (CBT-i) is now commonly recommended as first-line treatment for chronic insomnia.
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            Efficacy of internet-delivered cognitive-behavioral therapy for insomnia - A systematic review and meta-analysis of randomized controlled trials.

            Robert Zachariae, Marlene Lyby, Lee Ritterband … (2015)
            Cognitive-behavioral therapy for insomnia (CBT-I) has been shown efficacious, but the challenge remains to make it available and accessible in order to meet population needs. Delivering CBT-I over the internet (eCBT-I) may be one method to overcome this challenge. The objective of this meta-analysis was to evaluate the efficacy of eCBT-I and the moderating influence of various study characteristics. Two researchers independently searched key electronic databases (1991 to June 2015), selected eligible publications, extracted data, and evaluated methodological quality. Eleven randomized controlled trials examining a total of 1460 participants were included. Results showed that eCBT-I improved insomnia severity, sleep efficiency, subjective sleep quality, wake after sleep onset, sleep onset latency, total sleep time, and number of nocturnal awakenings at post-treatment, with effect sizes (Hedges's g) ranging from 0.21 to 1.09. The effects were comparable to those found for face-to-face CBT-I, and were generally maintained at 4-48 wk follow-up. Moderator analyses showed that longer treatment duration and higher degree of personal clinical support were associated with larger effect sizes, and that larger study dropout in the intervention group was associated with smaller effect sizes. In conclusion, internet-delivered CBT-I appears efficacious and can be considered a viable option in the treatment of insomnia.
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              A randomized, placebo-controlled trial of online cognitive behavioral therapy for chronic insomnia disorder delivered via an automated media-rich web application.

              Janice G Douglas, S Kyle, Colin Espie … (2012)
              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. Randomized, placebo-controlled trial comprising 3 arms: CBT, imagery relief therapy (IRT: placebo), treatment as usual (TAU). Online community of participants in the UK. 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). 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. 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. 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. ISRCTN - 44615689.
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                Author and article information

                Contributors
                Colin A. Espie: +44 (0)1865 618661 , colin.espie@ndcn.ox.ac.uk
                Journal
                Journal ID (nlm-ta): Curr Sleep Med Rep
                Journal ID (iso-abbrev): Curr Sleep Med Rep
                Title: Current Sleep Medicine Reports
                Publisher: Springer International Publishing (Cham )
                ISSN (Electronic): 2198-6401
                Publication date (Electronic): 8 May 2017
                Publication date PMC-release: 8 May 2017
                Publication date (Print): 2017
                Volume: 3
                Issue: 2
                Pages: 48-56
                Affiliations
                [1 ]ISNI 0000 0004 1936 8948, GRID grid.4991.5, Sleep and Circadian Neuroscience Institute, Nuffield Department of Clinical Neurosciences, , University of Oxford, ; OMPI G, South Parks Road, Oxford, OX1 3RE UK
                [2 ]Big Health Ltd, London, UK
                Article
                Publisher ID: 65
                DOI: 10.1007/s40675-017-0065-4
                PMC ID: 5427093
                PubMed ID: 28553574
                SO-VID: 32ebcdd0-d288-48ca-b29b-0bfaf9eaa215
                Copyright © © The Author(s) 2017
                License:

                Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

                History
                Funding
                Funded by: University of Oxford
                Categories
                Subject: Behavioral Therapy (J Edinger, Section Editor)
                Custom metadata
                issue-copyright-statement © Springer International Publishing AG 2017

                Keywords: insomnia,cognitive behavioral therapy,digital cbt
                Data availability:
                Keywords: insomnia, cognitive behavioral therapy, digital cbt

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