BALTIMORE—Cognitive behavioral therapy for insomnia (CBT-I) is an effective treatment, but a scarcity of trained clinicians has limited patients’ access to it. Telehealth and Internet-based platforms could broaden access to CBT-I, and investigators presented research on the efficacy of these methods of administration at the 32nd Annual Meeting of the Associated Professional Sleep Societies.
CBT-I by Telehealth Is Noninferior to In-Person CBT-I
Philip Gehrman, PhD, Associate Professor of Psychology at the University of Pennsylvania and the Philadelphia VA Medical Center, and colleagues conducted a cluster-randomized trial to determine whether group CBT-I delivered by telehealth was noninferior to CBT-I delivered in person. Eligible participants were veterans with posttraumatic stress disorder (PTSD) and an Insomnia Severity Index (ISI) score of 15 or higher. The investigators randomized 95 participants in groups of six to eight to group CBT-I in person or by telehealth. The primary outcome was the change in ISI score from baseline to the three-month follow-up. Dr. Gehrman and colleagues defined treatment inferiority as a difference of greater than two points on the ISI score.
Philip Gehrman, PhD
Participants’ mean age was 55.6, about 91% of the sample was male, and 42.2% of the sample was African American. The study population generally was overweight and had severe PTSD. Approximately half of the population was receiving one or more psychotropic medication. Forty-six participants were randomized to in-person CBT-I, and 49 were randomized to CBT-I delivered by telehealth.
At three months, the mean change in ISI score was 6.48 for in-person CBT-I and 4.45 for telehealth CBT-I. The difference between groups was outside of the prespecified margin of inferiority, and the researchers concluded that CBT-I delivered by telehealth was noninferior to in-person CBT-I.
The overall effectiveness of both methods of administration was modest, said Dr. Gehrman. The effect size might be greater in a group with fewer comorbidities or in a group that received more treatment sessions, he added. Nevertheless, the results “demonstrate that CBT-I can be effective even in a complex patient population,” he concluded.
SHUTi May Be Inferior to In-Person CBT-I
The online CBT-I intervention Sleep Healthy Using the Internet (SHUTi) has reduced insomnia with effect sizes similar to those of traditional CBT-I. No researchers had compared the two techniques directly, however. Håvard Kallestad, PhD, a clinical psychologist at Saint Olav’s Hospital in Trondheim, Norway, and colleagues examined whether SHUTi was a noninferior treatment for insomnia, compared with in-person CBT-I.
Håvard Kallestad, PhD
Eligible participants were 18 or older, had a diagnosis of insomnia, had been referred to a sleep clinic, and had access to a computer and adequate computer skills. Participants were randomized to in-person CBT-I or SHUTi. The primary outcome was ISI score, and three therapists assessed participants’ outcomes at baseline, after treatment, and at six months. They defined noninferiority as a difference between treatments of 2 or fewer points on ISI score.
Dr. Kallestad and colleagues randomized 52 participants to in-person CBT-I and 49 to SHUTi. Mean duration of insomnia was about 13 years. Approximately 60% of participants were currently using sleep medication, and about 90% had had previous treatment with sleep medication. After treatment, two patients in the in-person group and five in the SHUTi group were lost to follow-up. At six months, four participants in the in-person group and eight in the SHUTi group were lost to follow-up.
Both study arms had significantly lower ISI scores after treatment and at six months. After treatment, the mean ISI score in the in-person group was 5.1 points lower than in the SHUTi group, indicating that SHUTi was inferior at that time. At six months, mean ISI score was 3.3 points lower in the in-person group than in the SHUTi group. Because part of the confidence interval overlapped with the noninferiority margin, the result was inconclusive.
After treatment, the response rate was 70% in the in-person group and 43% in the SHUTi group. The remission rate was 52% in the in-person group and 18% in the SHUTi group. At six months, the response rate was 65% for the in-person group and 46% for the SHUTi group. The remission rate was 56% in the in-person group and 24% in the SHUTi group.
“SHUTi did not have the same effectiveness in this patient sample, compared with previous studies,” said Dr. Kallestad. One reason could be that previous studies included self-selected participants, rather than patients who had been referred to a sleep clinic. Also, the researchers interviewed all participants at baseline, and SHUTi might have seemed “more limited” in comparison with the interview, Dr. Kallestad concluded.