Digital Cognitive Behavioral Therapy Proves Cost-Effective for Insomnia

Christopher B. Miller, PhD

Study results from a Markov model analysis suggest that digital cognitive behavioral therapy (CBT) is the most cost-effective treatment for insomnia, particularly in comparison to group CBT, pharmacotherapy, and individual CBT.¹

Ultimately, the findings showed that in comparison to no insomnia treatment, with a net positive monetary benefit of $681.06 every 6 months per individual, confirmed by bootstrap sensitive analysis in 94.7% of simulations. In comparison to the other 3 insomnia treatments, the digital CBT intervention offered the smallest incremental cost-effectiveness ratio, of -$3124.73.

“It is financially prudent and beneficial from a societal perspective to utilize automated digital CBT to treat insomnia at a population scale,” the authors, including Christopher B. Miller, PhD, research lead, Big Health Inc, wrote. The intervention, Sleepio, was developed by Big Health, delivered through a website or iOS app. Its content is based on CBT-Insomnia manuals and includes 5 main components: sleep restriction, stimulus control, cognitive therapy, relaxation techniques, and sleep hygiene/education. It is interactive and includes an animated digital therapist.

Miller et al. used simulated health utility, measured in quality-adjusted life years (QALYs; 1 valued at $50,000), and cost results for a baseline model of 100,000 individuals seeking insomnia therapy, dividing 20,000 to each of the 5 arms assessed. The direct costs of each treatment were assumed to have these values: pharmacotherapy ($444.95), digital CBT ($400), individual CBT ($1044), group CBT ($172.50), and no care ($0).

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“Indirect costs associated with insomnia were also considered. First, we estimated the health expenditures related to insomnia, which are higher than for individuals without insomnia,” Miller et al. wrote. They additionally considered the indirect costs associated with workplace absenteeism (accounting for $549) and presenteeism (accounting for $971).

All told, the mean 6-month QALY levels for all 3 forms of CBT were 0.335, with pharmacotherapy and no treatment reporting 0.329 and 0.322 QALYs, respectively. The total QALYs for the 3 forms of CBT were as follows: digital CBT (6697.03), individual CBT (6697.88), group DBT (6698.34), pharmacotherapy (6575.19), and no treatment (6440.63).

The mean 6-month cost for digital CBT was $2998.86, for individual CBT was $3756.79, and for group DBT was $3035.93. Meanwhile, pharmacotherapy had a mean 6-month cost of $3102.17 and no treatment had a cost of $3038.91. The total 6-month cost for pharmacotherapy was $62,043,416.48, while the cost of no treatment was $60,778.287.00. For digital CBT, individual CBT, and group CBT, those respective total 6-month costs were $59,977,101.41; $75,135,741.76; and $60,718,551.15.

As such, the cost-effectiveness analysis revealed that the net monetary benefit compared to no treatment over 6 months was the aforementioned $681.06 for digital CBT and $273.15 for pharmacotherapy, while individual and group CBT had net benefits of -$74.73 and $647.24, respectively.

“Future work should now focus on providing access to and understand the real-world impact of digital CBT for insomnia at a population scale,” Miller et al. concluded.

Previously, in a trial of more than 200 patients, this digital CBT platform was deemed effective, safe, and acceptable by investigators as an intervention for insomnia symptoms in pregnant women. Additionally, the insomnia therapy, consisting of 6 weekly, 20-minute sessions, appeared to be scalable to a larger population of patients. Those randomized to digital CBT (n = 105) experienced significantly greater improvement in insomnia symptoms, as measured by the total score on the 7-item syndromal measure Insomnia Severity Index (ISI), compared to those who received standard treatment (n = 103), for a difference of −0.36 (95% CI, −0.48 to −0.23; χ2, 29.8; P <.001; d = −1.03).²

As well, the differences from baseline to postintervention for all secondary outcomes, with the exception of sleep duration, were statistically significant for those in the CBT group. Ultimately, the main outcome of insomnia symptom severity decreased by 0.59 for the intervention group compared to 0.23 for the standard treatment group. The secondary outcomes included sleep efficiency, sleep duration, global sleep quality, insomnia caseness, depressive symptom severity, and anxiety symptom severity.

The CBT group experienced a gain in sleep efficiency of 0.84, compared to 0.08 for the standard change group (95% CI, 0.39—1.14; P = .001). Similar results were seen for the intervention group compared to standard of care for global sleep quality (—0.31 vs. –0.02; 95% CI, –0.37 to –0.21; P <.001), insomnia caseness (—0.26 vs. –0.02; 95% CI, –0.35 to –0.12; P <.001). Sleep duration, the only non-significantly different outcome, was improved by 0.03 for the CBT group, compared to 0.002 for the standard of care group (95% CI, −0.002 to 0.67; P = .07).

REFERENCES
1. Darden M, Espie CA, Carl JR, et al. Cost-effectiveness of digital CBT (Sleepio) for insomnia: A Markov simulation model in the United States. Sleep. zsaa223. doi: 10.1093/sleep/zsaa223
2.Felder JN, Epel ES, Neuhaus J, Krystal AD, Prather AA. Efficacy of digital cognitive behavioral therapy for the treatment of insomnia symptoms among pregnant women: A randomized clinical trial. JAMA Psychiatry. Published online January 22, 2020. doi: 10.1001/jamapsychiatry.2019.4491.