Insomnia treatments:
the evidence for CBTi

The evidence supporting the use of CBTi within Sleepstation

Insomnia is a highly prevalent and costly health problem that often remains untreated despite the availability of effective treatments for insomnia. A specific form of cognitive behavioral therapy (CBT) for insomnia (CBTi) is a well validated treatment for insomnia, with evidence spanning over 30 years. The efficacy of CBTi to improve outcomes in primary and co-morbid insomnia has been repeatedly demonstrated, with improvements in both mental and physical health outcomes. A summary of the key evidence for insomnia treatment, including published evidence for Sleepstation, is outlined below.

There is strong empirical evidence that CBTi is effective and CBTi has been recognised as the first-line treatment for chronic insomnia (National Institutes of Health consensus, British Medical Association). However, the lack of trained therapists and sleep experts prevents widespread availability of this treatment in face-face settings. Sleepstation’s online CBTi programme is an alternative to referring to a sleep clinic for CBTi and/or follow-on prescriptions for sleeping pills and other medications to aid sleep.

Sleepstation can effectively resolve all forms of insomnia. By completing a short questionnaire, those with symptoms of insomnia can find out if Sleepstation could help them overcome their sleep problems for good.

CBTi is effective and long-lasting

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.

Medications are associated with long-term risks

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.

Online CBTi is an efficacious treatment

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.

Sleepstation is highly effective

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.

CBTi can improve mental health

Several RCTs and studies show that understanding and treating disrupted sleep through CBTi could provide a key route to improving mental health. In the largest ever RCT of a psychological treatment for mental health, individuals who received online CBTi showed reduction in insomnia as well as improvements in depression, anxiety, and psychological wellbeing.

Depression increases during menopause, and subclinical depressive symptoms increase risk for major depression. Insomnia is common among postmenopausal women and increases depression-risk in this already-vulnerable population. CBTi and sleep restriction therapy were found to reduce depressive symptoms and dysfunctional beliefs about sleep in postmenopausal women, with CBTi producing superior results.