Elsevier

Journal of Affective Disorders

Volume 266, 1 April 2020, Pages 305-310
Journal of Affective Disorders

Research paper
Self-guided online cognitive behavioural therapy for insomnia: A naturalistic evaluation in patients with potential psychiatric comorbidities

https://doi.org/10.1016/j.jad.2020.01.143Get rights and content

Highlights

  • Unguided iCBT-I produced significant improvements in participants’ insomnia symptom severity, psychological distress, and general wellbeing.

  • 65% of participants who reported pre-treatment insomnia severity at clinical levels remitted following treatment with unguided iCBT-I.

  • Adherence to the iCBT-I program was markedly higher than other unguided iCBT programs when accessed in naturalistic settings.

  • Unguided iCBT-I can be successfully disseminated to the public in a naturalistic setting.

Abstract

Background

Insomnia is the most prevalent sleep disorder worldwide, and regularly co-occurs with anxiety and depression. Cognitive behavioural therapy is the gold standard treatment for insomnia (CBT-I), however demand for treatment providers drastically exceeds supply. Internet-delivered programs for insomnia (iCBT-I) improve treatment access. However the effects of unguided iCBT-I for individuals with comorbidities within a naturalistic setting remains unexplored. We developed a novel unguided iCBT-I program and evaluated its impact on insomnia, psychological distress, and wellbeing when accessed by the public.

Methods

317 participants experiencing insomnia for over 3 months enrolled in the program. The program consisted of 4 lessons delivered online with automated web support. Insomnia symptoms, psychological distress, and general wellbeing were assessed at lesson 1 and 4. Intention-to-treat linear mixed models were used to examine effects on insomnia, distress, and wellbeing.

Results

Participants experienced large (g = 1.11) and significant reductions in insomnia, moderate (g = 0.55) and significant reductions in distress, and small (g = 0.37) but significant improvements in wellbeing. 65% of participants who reported pre-treatment insomnia severity at clinical levels remitted following treatment.

Limitations

To examine the program in a naturalistic setting, we did not employ a control group or follow participants beyond the completion of treatment.

Conclusions

Unguided iCBT-I is effective for individuals in the community who experience insomnia and are likely experiencing comorbid mental health problems. These effects in the absence of guided contact strengthen the utility of unguided iCBT-I as a scalable and cost-effective method of disseminating treatments for this disorder.

Introduction

Insomnia is the most prevalent sleep disorder worldwide, affecting approximately 9% of the general population regularly and 30% occasionally (Ohayon, 2002; Morin et al., 2006a). Chronic insomnia interferes with an individual's overall health and quality of life (National Institutes of Health, 2005; Meisinger et al., 2005; Laugsand et al., 2011; Khurshid, 2018) and is associated with substantial socioeconomic burden, including increased absenteeism (Léger et al., 2006) and greater utilization of healthcare services (Daley et al., 2009). Insomnia also regularly co-occurs with mental disorders, particularly anxiety and depression (Ohayon, 2007; Harvey et al., 2008). Indeed, longitudinal studies have found that insomnia increases the risk of depression and anxiety onset (Breslau et al., 1996; Ohayon and Roth, 2003; Roane and Taylor, 2008; Neckelmann et al., 2007) and recurrence (Jansson-Frojmark and Lindblom, 2008). Additionally, insomnia reduces improvements in anxiety and depression following psychological treatment (Okajimi and Chen, 2017), and increases the risk of recurrence of major depression following psychotherapy or psychotherapy-pharmacotherapy combinations (Dombrovski et al., 2008; Troxel et al., 2012). Given the negative psychosocial outcomes of insomnia independent of and when comorbid with anxiety and depression, and the widespread prevalence of the disorder, effective and scalable treatments need to be made available.

Cognitive behavioural therapy is considered the gold standard treatment for insomnia (CBT-I: Morin et al., 2006b; Wilson et al., 2010), with known effectiveness in clinical samples (Okajima et al., 2011; Traumer et al., 2015). Recent studies also indicate that CBT-I reduces depression (Harvey et al., 2015; Cunningham and Shapiro, 2018) and anxiety symptom severity when comorbid with insomnia (Belleville et al., 2011; Gellis and Gehrman, 2011; Talbot et al., 2014). Despite the effectiveness of CBT-I, this treatment is not easily accessible in face-to-face settings, owing to long wait lists, lengthy travel times, and the demand for CBT-I providers drastically exceeding supply (see Koffel et al., 2018 for a review of treatment barriers). For instance, a recent survey identified just 752 CBT-I specialists worldwide, with 88% of these disproportionately concentrated in the USA (Thomas et al., 2016). As a result, internet-delivered CBT programs for insomnia (iCBT-I) have been developed to improve access to treatment.

In research settings, guided (facilitated by a clinician or technician) and unguided (self-guided and automated) iCBT-I has been shown to be efficacious in improving chronic insomnia, decreasing sleep onset latency (SOL), while increasing total sleep time (TST) and sleep efficiency (Ritterband et al., 2009; Espie et al., 2012; Thiart et al., 2015; Christensen et al., 2016). RCTs have also demonstrated that iCBT-I can improve insomnia when comorbid with both anxiety and depression (Ye et al., 2015), and reduce depression and anxiety symptoms in adults with insomnia (Christensen et al., 2016; Gosling et al., 2018). However, given the limited specialized workforce and the need for scalable care, it is important to examine whether the positive effects of iCBT-I are maintained when accessed outside of research settings, and particularly when administered without guidance.

Currently, there is scant research in this area. Preliminary research, however, is positive. Luik et al. (2017) examined the effects of iCBT-I in routine clinical care and demonstrated significant improvements in insomnia, depression, and anxiety symptom severity. Adherence was high, with 73% of patients completing between 4 and 6 sessions. However, the intervention was not unguided, with six support calls made between an eTherapy coordinator and patients (Luik et al., 2017). Unguided iCBT-I in a UK community has been examined under randomised controlled conditions by Espie et al. (2012), who found that iCBT-I produced greater improvements in insomnia symptom severity and sleep parameters (e.g. sleep efficiency) relative to treatment as usual and imagery relief therapy. Again, treatment adherence was high, with 82% completing all 6 sessions (Espie et al., 2012). However it should be noted that Espie et al. (2012) excluded applicants who reported experiencing either “poor” or “very poor” physical or mental health. This limits the generalizability of their findings as the majority of insomniac patients have physical and mental comorbidities (Ohayon, 2002), as the authors of the study highlight (Espie et al., 2012). While Espie et al. (2012) and Luik et al. (2017) provide important advances in the literature on iCBT-I in the community, further research into the effects of unguided iCBT-I in more representative insomniac populations (i.e. those with potential comorbidities) within a naturalistic setting is clearly indicated.

In order to increase access to iCBT-I in the community, and address barriers of lengthy wait and travel times and too few CBT-I providers, we developed a completely self-help and unguided iCBT-I program called the ThisWayUp Managing Insomnia program. This study aimed to first, evaluate the feasibility and impact of the Managing Insomnia program on insomnia symptomology when accessed by the public in a naturalistic setting. Second, we assessed the effects of the program on patients’ psychological distress and general wellbeing as markers of probable cases of psychiatric comorbidity (Andrews and Slade, 2001). By doing so, we could examine whether the outcomes of previous iCBT-I research generalize to a broader population of individuals with insomnia who have probable comorbidities, where comorbidity is known to be associated with higher levels of disability (Andrews, Slade and Issakidis, 2002). Based on the broader iCBT literature (Andrews et al., 2018), we hypothesised that the program would produce moderate to large effect size reductions in insomnia symptoms and psychological distress, as well as improvements in general wellbeing.

Finally, we examined adherence to the program. The extent to which patients would adhere to (i.e. complete all lessons of) the Managing Insomnia program was exploratory, as this was the first evaluation of this program. Nonetheless, we hypothesised that adherence would be lower than what has been observed in RCTs of unguided programs (Espie et al., 2012). This was because there are robust data showing that when other iCBT programs for depression and anxiety (i.e. not those specific to insomnia) are disseminated in routine clinical care, adherence is lower than rates observed under randomised controlled conditions (Williams and Andrews, 2013; Newby et al., 2013; 2014; 2017; Hobbs et al., 2017; Morgan et al., 2017; Hobbs et al., 2018). Although this is not specific to iCBT – face-to-face interventions also have lower adherence in real-world settings versus in RCTs – this trend may be exacerbated for unguided iCBT programs. For example, Morgan et al. (2017) found that only 13.83% of users completed a purely self-guided course for anxiety and depression in a naturalistic setting [vs. 89% in a guided RCT and 33–47.3% in guided routine care (Newby et al., 2013, 2014)]. It is therefore important to quantify adherence to iCBT-I when accessed by the public in a purely self-guided format and naturalistic setting. To our knowledge, this is the first study to assess the effects of and adherence to a purely self-help and unguided iCBT-I program when accessed by the public in a naturalistic setting and by patients with potential psychiatric comorbidities.

Section snippets

Participants

The sample comprised of 317 participants who enrolled in the Managing Insomnia program on the ThisWayUp website (www.thiswayup.org.au) between June 2017 and April 2018. ThisWayUp is an online treatment service providing treatments for anxiety and depressive disorders, and chronic diseases, which is a joint initiative of St Vincent's Hospital, Sydney and the University of New South Wales, Australia. Participants who self-identified as experiencing insomnia for at least 3 months enrolled

Demographic characteristics

Two thirds of the sample were female (n = 212/317) and on average, participants were aged in their mid-forties (R = 18–80; M(SD)=44.54(14.77); Mdn(IQR) = 44(33–56)). 78.55% of the sample provided their postcode. Of these participants, 69.48% resided in major Australian cities. The remainder resided in regional, rural or remote areas.

Baseline symptom severity

Prior to treatment, 5.99% of the sample reported insomnia symptoms that were not clinically significant (n = 19/317) and 23.97% reported insomnia symptoms that were

Discussion

This study was the first to investigate the effectiveness of an unguided internet-based CBT for Insomnia program in a naturalistic setting among a sample characterised by probable psychiatric comorbidities. This iCBT-I program produced significant improvements in participants’ insomnia symptom severity, psychological distress, and general wellbeing. The majority of participants who completed all lessons of the program remitted with treatment. Adherence to the program was moderate. These

Funding

Financial Disclosure: This research was partially funded by a grant from St Vincent's Hospital, Sydney Australia. Non-financial Disclosure: none. There were no conflicts of interest.

Author statement

All authors have participated sufficiently in the conception and design of this work or the analysis and interpretation of the data, as well as the writing of the manuscript. All authors believe the manuscript represents valid work and approve it for publication.

Contributors

ABG and ECM, with the assistance of MJH, identified the hypotheses and methodology for the current study. ABG carried out the literature review and drafted the main sections of the manuscript. MJH undertook the statistical analyses and interpretation of the findings. ABG wrote the initial draft manuscript and all authors read, redrafted, and approved the final manuscript.

Declaration of Competing Interest

Financial Disclosure: This research was partially funded by a grant from St Vincent's Hospital, Sydney Australia. Non-financial Disclosure: none. There were no conflicts of interest.

Acknowledgements

ABG and EM, with the assistance of MJH, identified the hypotheses and methodology for the current study. ABG carried out the literature review and drafted the main sections of the manuscript. MJH undertook the statistical analyses and interpretation of the findings. ABG wrote the initial draft manuscript and all authors read, redrafted, and approved the final manuscript.

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