Insomnia treatments — the evidence for CBTi

There is a large body of evidence, based on over 100 randomised controlled trials (RCTs), for CBTi being an effective and long-lasting treatment for 50%–70% of patients. CBT takes longer than drugs to produce sleep improvements but these improvements are sustained over time. Use of CBTi has been demonstrated to improve most outcomes compared with inactive controls.

The efficacy of Cognitive Behavioural Therapy for insomnia delivered in person has been robustly researched and supported among individuals across all age ranges. CBTi has also been found to be effective for more complex insomnia with comorbid medical and psychiatric conditions.

Pharmacological therapies are widely used in primary care, but there is limited evidence for their benefit in chronic insomnia and increasing evidence that these medications are associated with long-term risks, particularly in an older population.

Antidepressant use for insomnia is widespread, but none is licensed for treatment of insomnia.

A Cochrane review determined that:

The tolerability and safety of antidepressants for insomnia is uncertain due to limited reporting of adverse events. There was no evidence for amitriptyline (despite common use in clinical practice) or for long‐term antidepressant use for insomnia. High‐quality trials of antidepressants for insomnia are needed.

The publications of clinical practice guidelines of multiple international organisations have reached the conclusion that CBTi should be used as the first-line treatment for insomnia. Only when such treatments are not available or not effective should medication be considered for the treatment of persistent insomnia.

The efficacy of CBTi to improve outcomes in primary and co-morbid insomnia patients has been repeatedly demonstrated, with improvements in both mental and physical health outcomes.

Comorbidity between chronic insomnia and depression or anxiety is high, and insomnia is a risk factor for both. Chronic insomnia is also highly co-morbid with most major medical conditions. Comorbidity between insomnia and hypertension ranges from 25% to 44%.

CBTi is effective across a variety of populations, including those with medical and psychological comorbidities. Because CBTi does not carry the risks associated with some sleep medications (e.g. dependency, polypharmacy, cognitive and psychomotor impairment), it is an attractive option for patients with other conditions.

Several small-cohort studies and a number of RCTs have evaluated online CBTi and shown promising results but with varying effect sizes. CBTi tackles factors that maintain insomnia over time, including sleep-related dysfunctional cognitions, behaviours which perpetuate insomnia, and dysregulation of the homeostatic sleep drive.

A systematic review found that internet-delivered CBTi appears efficacious and can be considered a viable option in the treatment of insomnia.

From the evidence outlined above, it is clear that CBTi is an effective intervention, applicable to online delivery. In 2014 we published a review of the effectiveness of Sleepstation compared to other online therapies.

The study found that Sleepstation produced large improvements in our primary endpoint of sleep efficiency. There were also clear improvements in sleep latency, with modest improvements in total sleep time. The majority of participants reported improved sleep quality after completing the Sleepstation programme. Participant feedback was overwhelmingly positive.

Once participants fulfilled criteria for insomnia and had commenced therapy, the attrition rate was low, and compliance with sleep diaries and therapy recommendations was high.

In the years since this study, we have continued to adapt and evolve the Sleepstation programme and, in our most recent study, Sleepstation was found to be three times more engaging than other online CBTi programmes. It is thought that our impressive engagement rates are due to the supported nature of the Sleepstation programme. Sleepstation remains the only online CBTi programme to be fully supported by a team of sleep experts, therapists and coaches.