QUESTION

I've read that online cognitive behavioral therapy can help with insomnia, but I'd like to know how well it works before I make the investment in one of these programs. (I've never tried any kind of therapy before.)

ANSWER

With so much self-help available online for free, it can be hard to know when paying for a program makes sense. But the effectiveness of Internet-based cognitive behavioral therapy for insomnia, or Internet-based CBTI, backed by more than a decade of research, makes it valuable for many people who struggle to get needed sleep. In fact, these programs can be downright economical compared to office visits with a therapist—should you be fortunate enough to even have a therapist nearby who practices CBTI. Researchers in the field began to develop Internet-based programs starting in the early 2000s precisely because there aren't enough therapists trained in CBTI to care for the millions of people with insomnia who could benefit from it. Two expert-created programs in particular have been studied extensively: SHUTi, which starts at $149 for 26 weeks of access, and Sleepio, which costs $400 for a year. (Some insurance plans will cover the costs—check with your provider.) Each program guides you through a CBTI course similar to what you’d experience in one-on-one therapy sessions that help you get rid of your insomnia naturally, safely and effectively.

HOW IT WORKS

Internet-based programs focus on core CBTI techniques like…
  • Sleep restriction: Confining sleep to a set number of nighttime hours
  • Stimulus control: Improving your environment to weed out distractions like electronic devices
  • Sleep hygiene: Developing habits that encourage restorative sleep
  • Cognitive restructuring: Changing any negative thoughts you have about sleep
  • Relapse prevention: Keeping insomnia from coming back.
An online sleep diary is one of the key elements of SHUTi, which was developed at University of Virginia, notes Lee M. Ritterband, PhD, professor in the department of psychiatry and neurobehavioral sciences center and one of the program’s creators. As part of it, you answer questions about your previous night’s sleep, and SHUTi provides tailored recommendations based on your responses. Using the diary is mandatory at the start of the program, and continuing to use it as you move through the program can improve your results. The SHUTi program is divided into "cores." The first one, for instance, covers general insomnia issues, goal setting and your expectations. The second focuses on sleep restriction and stimulus control. A new core becomes available one week after you complete the previous one. Here are some of the helpful behavior changes you might expect to make…
  • Stay up later and get up earlier. For example, if you typically turn in around 10 pm, you might be instructed to stay up until midnight and then wake up at 5 am. This is a part of sleep restriction therapy designed to increase your “drive” for sleep so that you’ll be able to fall asleep more quickly and stay asleep.
  • Avoid napping, again to make you more tired at bedtime.
  • Use your bed for sleep and sex only. This is part of stimulus control designed to help you connect your bed in your mind as a place mainly for sleep.
  • Keep a regular sleep and wake schedule—getting up and going to sleep at the same times each day, weekends included. Other good sleep hygiene habits include avoiding caffeine and alcohol before bedtime and keeping your bedroom cool (between 60 and 67 degrees).
  • Get out of bed and do something relaxing if after 20 or 30 minutes you’re still awake—even if it’s 3 am.
Don’t be too surprised if you find yourself more tired (if that’s possible) at first as you work to build better sleep habits.

HOW WELL IT WORKS

Cognitive behavioral therapy for insomnia is very effective. A comprehensive research review of studies on Internet-based versions, published in PLOS ONE, found that it was just as effective as in-person treatment. What's more, it didn't carry the stigma that some people still think is attached to getting therapy. A study done in Sweden and published in Sleep found that results can last for at least three years. Internet-based CBTI can also be helpful in ways that go well beyond better sleep. For instance, a large study using Sleepio, published in The Lancet Psychiatry, found that in addition to improving insomnia, the program helped ease mental health problems including anxiety, depression and paranoia. Other research found SHUTi very effective for anxiety and depression and found it could help prevent full-fledged depression in people whose insomnia has led to depressive symptoms. Another study found that SHUTi could reduce fatigue as well as insomnia in breast cancer survivors (and cancer patients struggle with sleep issues at twice the rate of the general population). Just getting under way is a clinical trial to look at SHUTi’s effectiveness on adults over age 55 (if you'd like to be considered for the trial, go to SHUTiOasis.org and fill out the interest form). The bottom line: Like any other type of CBTI, you’ll need to put in the effort to get the best results—but online cognitive behavioral therapy can indeed help with your insomnia. Need more sleep advice? Check out…