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Editorial
November 30, 2016

Should Internet Cognitive Behavioral Therapy for Insomnia Be the Primary Treatment Option for Insomnia?Toward Getting More SHUTi

Author Affiliations
  • 1Department of Psychiatry, University of California, San Francisco
  • 2Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina
JAMA Psychiatry. Published online November 30, 2016. doi:10.1001/jamapsychiatry.2016.3431

Insomnia is a prevalent, often debilitating, sleep disorder with significant consequences for physical health and well-being. With as many as 50% of adults reporting insomnia symptoms at least intermittently and up to 20% of adults meeting diagnostic criteria for insomnia disorder, there is an acute need for effective interventions.1 Treatments established to be safe and efficacious for this condition include a variety of different medications and cognitive behavioral therapy for insomnia (CBT-I), which focuses on improving homeostatic sleep drive, standardizing circadian rhythm, breaking any conditioned arousal associated with the nighttime environment, and reorienting maladaptive cognitions about sleep and one’s ability to cope effectively after a night of poor sleep. Of these, CBT-I has advantages in terms of risks and sustained efficacy.2 Unfortunately, clinicians who have the necessary expertise in delivering CBT-I are scarce, which has led many researchers, as well as entrepreneurs, to leverage technology to deliver CBT-I to individuals who are unable or unwilling to meet with a clinician or who prefer the convenience and potentially lower cost of an internet-based treatment.

Internet-based CBT-I is an attractive solution to challenges of scalability. The developers of the Sleep Healthy Using the Internet (SHUTi) program have been pioneers in the rapidly growing space of mobile strategies for treating insomnia. SHUTi is a fully automated, interactive, and tailored internet-based program that incorporates the well-tested principles of CBT-I. In this issue of JAMA Psychiatry, Ritterband and colleagues3 report that, in a sample of 303 patients with chronic insomnia, those randomized to 9 weeks of SHUTi showed significant improvements in the symptoms of insomnia, decreases in the number of minutes awake during the night, and a shorter time to sleep onset at the postintervention follow-up compared with individuals randomized to the active control condition (internet-based patient sleep education). Many of the gains for those using SHUTi were maintained over time, with 56.6% of SHUTi participants deemed as insomnia remitters compared with 27.3% in the control condition 1 year after the intervention. These improvements were similar to those observed in trials using face-to-face CBT-I, which is impressive. Furthermore, despite the intervention being completely automated, adherence was good, with 60.0% of SHUTi participants completing all 6 “cores” of the program.

One of the biggest challenges to translating findings from insomnia clinical trials to clinical practice is the reality that the populations studied in clinical trials lack the psychiatric and medical comorbidities of those seen in clinic settings. There have been relatively few rigorous trials of internet-based insomnia therapies carried out in patients with psychiatric or medical comorbidities.4 As such, it is unclear whether internet-based interventions yield the same gains as those observed when patients are carefully screened for mental and physical health problems. In this study, Ritterband and colleagues3 take an important step in tackling this issue by carrying out the most robust study to date that enrolled participants with comorbid psychiatric and medical conditions. Although their study excluded individuals with medium to high suicide risk, severe depression, bipolar disorder, alcohol or drug abuse in the past year, and those with medical comorbidities that were likely to worsen insomnia, their results provide an indication that the benefits conferred by SHUTi are not diminished by the presence of either psychiatric or medical comorbidities. Still, a true characterization of how SHUTi performs in patients seen in clinical practice will require evaluation in a setting where less-stringent eligibility criteria are applied.

On the whole, the findings suggest that SHUTi is a promising treatment option for patients with insomnia. These findings and the potential for rapid widespread use demand that we address a critical question: “Should internet CBT-I be the first-line treatment for all patients with insomnia?” Several issues suggest that it is premature to adopt this position and speak for restraint.

One important consideration is that the Ritterband and colleagues3 study only reflects on one particular form of internet CBT-I: the SHUTi system. It cannot be assumed that similar results will be found with any of the many other systems until this is proven to be the case. The existing literature comprises studies assessing a variety of different treatment systems, each of which must be viewed as speaking only to the system studied. The CBT-I and internet CBT-I programs should be viewed as a family of treatments that differ but share things in common to various degrees.

Another consideration is that, like individuals included in many studies of internet-based therapies, participants chose to enroll in a study on internet-based therapy and thus the sample was preferentially composed of those who prefer this form of therapy. Consistent with this choice, the study population was skewed toward highly educated persons, white individuals, and those adept at using the internet. It remains to be seen whether such interventions will resonate with individuals across socioeconomic strata and racial categories. Internet use is lower among the African American compared with white populations as is the likelihood of broadband internet access in the home.5 This difference is particularly salient given evidence for racial disparities in sleep health.6 If used as a primary intervention, SHUTi would be offered to many people who would not choose an internet therapy if other options were available, such as face-to-face CBT-I or medication treatment, and it remains unknown whether SHUTi will be effective in these individuals.

A further consideration is that the true effect size of the SHUTi vs control intervention difference remains unknown because, as discussed by Ritterband and colleagues,3 there is reason to believe that this study was essentially unblinded. It could be argued that the effect size vs a control treatment is irrelevant because clinical practice is unblended, making the SHUTi pre-post difference the critical effect. However, demonstration of efficacy matters from an ethical point of view. People with insomnia, health care systems, and insurers are likely going to have to pay fees to use services such as SHUTi, and they deserve to know the degree to which there is likely to be benefit beyond the improvement derived from the nonspecific effects of interacting with any internet-based system that one is led to believe will be effective. The extent to which this consideration is relevant will depend on the cost of SHUTi, which is currently available on the internet for $135.

Despite reasons for restraint, it seems inevitable that internet CBT-I will be increasingly used as a first-line insomnia intervention. It also seems likely that the medical community may have little influence on whether, when, and how this occurs. It is unknown to what extent those who provide treatment will play a role in directing individuals with insomnia to efficacious internet-based CBT-I systems. There will no doubt be options available where the ease of access, convenience, and price will appeal to large numbers of patients, insurers, and health systems such that many patients may seek out those who offer treatment only after failing to improve with internet CBT-I. It is, therefore, critical that all such systems made available as online treatment options for insomnia are tested in a rigorous way and the results are made available to the public. In this regard, the article by Ritterband and coworkers3 suggests that many of those who choose SHUti will experience lasting improvement.

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Article Information

Corresponding Author: Andrew D. Krystal, MD, MS, Department of Psychiatry, University of California, San Francisco, 401 Parnassus Ave, PO Box 0984-F, San Francisco, CA 94143 (andrew.krystal@ucsf.edu).

Published Online: November 30, 2016. doi:10.1001/jamapsychiatry.2016.3431

Conflict of Interest Disclosures: Dr Krystal has received grants and research support from National Institutes of Health, Teva, Sunovion, Janssen, and Jazz, and is a paid consultant for Attentiv, Flamel, Teva, Jazz, Janssen, Merck, Neurocrine, Otsuka, Pfizer, Lundbeck, Sunovion, and Pernix. No other disclosures were reported.

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