Brief History and Importance
Interest for delivering psychological services through digital media began in the 1990s (Luik et al., 2019). Initial efforts focused on publishing self-help manuals on the Internet, and has become increasingly complex in terms of programming sophistication and the diversity of products offered (e.g., apps, websites, telehealth services). The term digital covers a full spectrum of electronic services delivered online through the Internet or mobile devices (e.g., apps, text messaging). Cognitive Behavioral Therapy for Insomnia (CBT-I) lends itself to digital delivery services because the treatment is highly structured.
Digital delivery of CBT-I over the past decade falls into three main categories: supportive digital CBT-I, therapist-guided digital CBT-I, and fully automated digital CBT-I. Digital services in the supportive category are used to support face-to-face therapy and tend to be more limited regarding automation. Examples include the use of the CBT-I coach app or technology used to deliver telehealth services. Digital services in the therapist-guided category refers to actual treatment content being delivered through a webpage or a mobile app (e.g., text, image, videos, audio or animations). The key difference is that in this category, the digital services are supported by a clinical professional that the patient can interact with as necessary. Finally, digital services in the fully automated category are provided without any human support. This category represents the most sophisticated digital programming, allowing for personalization through algorithms to individually tailor all aspects of the program (e.g., personalized feedback). The efforts to develop and expand digital delivery of CBT-I is important considering research estimates that despite the high prevalence of insomnia, only 37% report consulting a healthcare provider for their sleep problems (Luik et al., 2019). Additionally, literature on CBT-I also cites the lack of trained healthcare professionals as another critical barrier to accessing this highly recommended and effective treatment. Finally, offering digitally-based services has also been cited within help-seeking literature as a strategy to reduce stigma associated with accessing psychological care.
Overview of Findings for Digital CBT-I
Given the expanding development of digital services for CBT-I, it is worthwhile to review key findings from the growing literature. Results from meta-analytic studies demonstrate both short- and long-term efficacy for digital CBT-I. On average, findings revealed sleep onset latency (SOL) decreasing by 18.41 minutes (95% CI 13.60 to 23.21), total sleep time (TST) increasing by 22.3 minutes (95% CI 16.38 to 28.23), sleep efficiency (SE) increased by 9.58% (95% CI 7.30% to 11.85%), wake after sleep onset decreased by 22.31 minutes (95% CI 13.50 to 31.11), and scores on the Insomnia Severity Index (ISI) decreased by 5.88 points (95% CI 4.29 to 7.46). Furthermore, SOL, WASO, TST, and SE demonstrated statistically significant improvements six months post-treatment (Y-yaun et al., 2016). Luik et al., (2019) in their review of literature found sustained effects for digital CBT-I up to 1.5 years.
Beyond the treatment of insomnia, digital CBT-I was found to reduce depressive symptoms with medium to large effect sizes, small to moderate effects for anxiety, and small effect for individuals with psychotic symptoms. Some literature has also found small effect sizes for digital CBT-I reducing cognitive complaints and improving cognitive performance (Luik et al., 2019). Beyond these clinical outcomes, there is some evidence that automated support (i.e., event-based or time-based reminders) is beneficial in terms of improving treatment adherence versus no reminders (Horsch et al., 2017). Additionally, there is some evidence that using the CBT-I Coach app with face-to-face therapy resulted in a lower drop-out rate and greater homework adherence in a randomized control trial compared to the non-app patient group (Gould et al, 2019). More research is needed to examine how digital services could increase treatment adherence and reduce attrition so people could benefit from this highly effective treatment.
Summary of Empirically Supported Digital CBT-I Resources
Digital CBT-I resources can be placed into three main categories: supportive, therapist-guided, and fully automated. This blog will be briefly highlight a resource in each category that has received empirical support through peer-reviewed publications.
Supportive Digital CBT-I: CBT-I Coach
Initially developed by the Veteran Affairs National Center for PTSD, the CBT-I Coach app was designed as a tool to help military personnel struggling with chronic insomnia from PTSD in 2013. The app is free and features include psychoeducation, assessment tools like sleep diaries and the ISI, sleep prescription recommendation, reminders for sleep diary logs and sleep hygiene practices, and additional relaxation exercises. Studies examining clinician’s use of the app with patients cited greater treatment adherence and overall improved outcomes as strengths of this digital service (Gould et al. 2019). Patients reported the app to be user friendly and cited the ability to record and track their sleep as the most helpful aspects of the app. More information can be found at: https://mobile.va.gov/app/cbt-i-coach
Therapist-Guided or Fully Automated: SHUTi
Sleep Healthy Using The Internet or SHUTi, was developed by Dr. Charles Morin and Dr. Lee Ritterband in 2012. The program includes six interactive lessons over a six week period. The program provides patients with personalized sleep schedule, sleep diaries, Fitbit integration, printable reference materials, interactive quizzes and homework. Currently, the program is only open for clinical trials and not available for consumer purchase. More information can be found at: http://www.myshuti.com/
Fully Automated: Sleepio
Created by Dr. Colin Espie and launched in 2012, Sleepio is a six week course requiring users to log-on weekly for a 20 minutes session with an animated character called The Prof. Users practice techniques, complete sleep diaries, have access to educational materials, relaxation MP3s, progress reports, email reminders, and access to an online user community in between sessions. Users start by completing a questionnaire and based on their responses, Sleepio will provide a tailored program. This program may be covered by health insurance companies, or users may be able to participate in a research study and receive free access, otherwise there is a fee to access the materials. More information can be found at: https://www.sleepio.com/
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Timothy E. Rogers, Ph.D., is a Senior Military Internship Behavioral Health Psychologist with the Center for Deployment Psychology at Uniformed Services University of the Health Sciences in Bethesda, MD. Dr. Rogers is based at Wilford Hall Ambulatory Surgical Center at Lackland AFB, TX.
Gould, C. E., Kok, B. C., Ma, V. K., Zapata, A. M. L., Owen, J. E., & Kuhn, E. (2019). Veterans Affairs and the Department of Defense mental health apps: A systematic literature review. Psychological Services, 16(2), 196-207. doi: 10.1037/ser000289
Luik, A. I., van der Zweerde, T., van Straten, A., & Lancee, J. (2019). Digital Delivery of Cognitive Behavioral Therapy for Insomnia. Current psychiatry reports, 21(7), 50. doi:10.1007/s11920-019-1041-0
Ye, Y. Y., Chen, N. K., Chen, J., Liu, J., Lin, L., Liu, Y. Z., … Jiang, X. J. (2016). Internet-based cognitive-behavioural therapy for insomnia (ICBT-i): a meta-analysis of randomized controlled trials. BMJ open, 6(11), e010707. doi:10.1136/bmjopen-2015-010707