Internet-Based CBT-I Ineffective as Population Health Approach for Insomnia

Stephen F. Derose, MD, MSHS

A recent study concluded that a population health approach to treating insomnia with internet-based cognitive behavioral therapy for insomnia (ICBT-I) was ineffective, as engagement in the program was low and did not initiate a reduction in health care visits or use of insomnia medication.¹

The pragmatic trial had a hybrid design and enrolled a total of 136,630 individuals with insomnia (diagnosed or insomnia medication dispensation) or at high risk of insomnia (diagnosed with anxiety or depression). Participants were randomized into either the intervention arm to be treated with an ICBT-I program (n = 66,712), or the usual-care arm to attend in-person classes on insomnia (n = 66,690).

Over the course of 12 months, investigators evaluated the dispense of insomnia medication and the amount of provider encounters, finding no difference between the intervention and usual care arm. A total of 638 participants (0.96%) accessed the ICBT-I program, Sleepio, within 8 weeks of outreach, whereas 505 participants (0.76%) attended 1 or more in-person Sleep Well, Live Well sessions.

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“Our study suggests that a population-based approach to insomnia using ICBT-I can be implemented, but potentially with low engagement,” lead author Stephen F. Derose, MD, MSHS, physician, sleep medicine, Baystate Health, Springfield, research scientist, department of research and evaluation, Kaiser Permanente Southern California, Pasadena, et al wrote. “Additional strategies may be necessary to improve population reach, such as better targeting of patients with symptoms through a focus on recent insomnia diagnoses or automated EHR note analyses, more intensive outreach to patients, identifying potential individual barriers such as concern over side effects and the time involved, and developing effective strategies to enhance patient engagement such as spousal involvement.”

When comparing the 2 arms—establishing control for baseline utilization by matching participants accessing ICBT-I compared to participants from the usual-care arm—investigators found no relative risk (RR) differentiation in insomnia medication dispensation (RR, 1.03; 95% CI, 0.91-1.17). There was also no significant difference in combined medication outcomes or provider visits (RR, 0.97; 95% CI, 0.89-1.06). Observing the risk of outcomes, the only difference between the groups was a higher risk or sleep medicine and psychiatry visits for those accessing ICBT-I, compared to those who did not attend any in-person classes (RR, 1.30; 95% CI, 1.07-1.57). Investigators also found that those without an insomnia diagnosis or medication at baseline also saw an increased risk of sleep medicine and psychiatry visits (RR, 1.38; 95% CI, 1.11-1.72). 

Notably, ICBT-I users saw statistically significant improvements in sleep-onset latency (14-minute reduction), total sleep time (30-minute increase), wake after seep onset (9-minute reduction), and overall sleep efficiency (8% improvement).

Patients were enrolled from March 13, 2018, through June 19, 2018. Participants who attended the in-person sessions tended to be older, non-Hispanic White or Asian, had a recent diagnosis of insomnia or sleep medication dispensed, as well as more provider visits and medications in the year preceding the trial.

“While we hoped for higher participation in ICBT-I, Sleepio enrollment was low (~1%) using our population outreach processes. This participation rate was not substantially different from Sleep Well, LiveWell class engagement, which was itself typical of enrollment in other health education classes after population outreach through mailings and public notices in our health system,” Derose et al wrote. “Given that proportionally more participants with insomnia accessed the ICBT-I program, a strategy to increase program engagement, albeit by limiting outreach, is to focus on patients with active insomnia rather than other at-risk populations.”

Existing limitations included the study’ hybrid design and the fact that participants accessing ICBT-I also consented to the collection of additional sleep-related data. Bias may have been introduced due to self-selection and lack of knowledge as to which matched controls would have engaged with ICBT-I if given the option. 

FIGURE. Key Recommendations for Behavioral/Psychological Treatments for Chronic Insomnia

These findings slightly contrast what prior studies have suggested about the effectiveness of CBT-I, though other assessments did not utilize a web-based intervention. In June 2021, the American Academy of Sleep Medicine presented recommendations, developed by a task force of experts, on the clinical practice use of behavioral and psychological treatments for chronic insomnia disorder in adults, with a strong recommendation for cognitive behavioral therapy for insomnia (CBT-I) based on exciting evidence of its efficacy. The task force also included 6 other interventions, including brief therapies for insomnia, stimulus control, sleep restriction therapy, relaxation therapy, and sleepy hygiene, all of which were conditional recommendations (FIGURE).² 

REFERENCE
1. Derose SF, Rozema E, Chen A, Shen E, Hwang D, Manthena P. A population health approach to insomnia using internet-based cognitive behavioral therapy for insomnia. J Clin Sleep Med. 2021;17(8):1675–1684. doi:10.5664/jcsm.9280
2. Edinger JD, Arnedt JT, Bertisch SM, et al. Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2021;17(2). doi: 10.5664/jcsm.8986