Which is best for insomnia?


Telehealth may be effective in providing cognitive behavioral therapy for insomnia (CBT-I) and is not inferior to in-person treatment, new research shows.

Results from a study of 60 adults with insomnia showed no significant difference between groups at 3-month follow-up between those assigned to receive CBT-I in person and those assigned to CBT-I from telehealth. regarding the change in score on the Insomnia Severity Index (ISI).

Additionally, both groups showed a significant change from a waitlist group, indicating that telehealth was not inferior to in-person delivery, the investigators note.

“The take-home message is that patients with insomnia can be treated with cognitive behavioral treatment for insomnia through video telehealth without sacrificing clinical gains,” study investigator Philip Gehrman, PhD, Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, said Medscape Medical News.

“This matches the larger telehealth literature which has shown that other forms of therapy can be delivered in this way without losing effectiveness, so it is likely that telehealth is a viable option for therapy in general,” did he declare.

The results were published online August 24 in The Journal of Clinical Psychiatry.

Telehealth “Explosion”

Although CBT-I is the recommended intervention for insomnia, “the large-scale implementation of CBT-I is limited by the lack of clinicians trained in this treatment,” the investigators note. There is a “need for strategies to increase access, especially for patients in areas with few health care providers”.

Telehealth is a promising technology for providing treatment without having to have the patient and practitioner in the same location. There has been an “explosion” in its use due to restrictions imposed by the COVID-19 pandemic. However, the “rapid deployment of telehealth interventions did not allow time to evaluate this approach in a controlled manner,” so it is possible that this type of communication could reduce the effectiveness of treatment, the investigators note.

Previous research suggests that telehealth psychotherapeutic treatments in general are not inferior to in-person treatments. One study showed that CBT-I delivered via telehealth was not inferior to delivery in person. However, this study did not include a control group.

“I’ve been doing clinical telehealth work for about 10 years, so long before the pandemic made it all virtual,” Gehrman said. “But when I talked about my telehealth work to other providers, I was often asked if the benefits of telehealth (better access to care, lower travel costs) came at the cost of less efficiency.”

Gehrman said he suspected the telehealth treatment was just as effective and wanted to formally test that impression to see if he was right.

Researchers randomly assigned 60 adults (mean age, 32.72 years; mean ISI score, 17.0; 65% female) with insomnia to CBT-I in person (n = 20), to CBT -I delivered by telehealth (n = 21), or to a control group on a waiting list (n = 19). For the study, insomnia disorder was determined based on DSM-5 criteria.

Most of the participants had completed college or postgraduate studies (43% and 37%, respectively) and did not have many comorbidities.

The primary outcome measure was the change on the ISI. Other assessments included measures of depression, anxiety, vocational and social adjustment, fatigue, and medical outcomes. Participants also performed an unattended home sleep study using a portable monitor to screen participants for obstructive sleep apnea.

The two types of CBT-I were administered over 6 to 8 weekly sessions, with post-treatment follow-ups of 2 weeks and 3 months.

An a priori margin of -3.0 points was used in the non-inferiority analysis, and all analyzes were conducted using mixed-effects models, the authors explain.

Necessarily wrong?

In the primary non-inferiority analyzes, the mean change in ISI score from baseline to 3-month follow-up was -7.8 points for in-person CBT-I, -7.5 points for telehealth and -1.6 for the waiting list.

The difference between the CBT-I groups was not statistically significant (t 28 = -0.98, P = 0.33).

“The lower confidence limit of this between-group difference in mean ISI changes was greater than the a priori margin of -3.0 points, indicating that telehealth treatment was not inferior to in-person treatment.” , write the investigators.

While there were significant improvements on most secondary outcome measures related to mood / anxiety and daytime functioning, the researchers found no difference between the groups.

The results suggest that the benefits of telehealth, including increased access and reduced travel time, “do not come with a reduced efficiency cost,” the researchers write.

The study was conducted before the COVID-19 pandemic, investigators note. However, the results “underscore that the use of telehealth during the pandemic is not a” necessary evil “, but rather a means of providing high quality care while reducing the risk of exposure,” they write. .

Benefits, loyalty maintained

Commenting on the study of Medscape Medical News, J. Todd Arnedt, PhD, professor of psychiatry and neurology and co-director of the Sleep and Circadian Research Laboratory, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, said it was “one of the first studies to clearly demonstrate that the benefits and fidelity of CBT for insomnia, which is most often administered in person, can be sustained through telehealth. “

Arnedt is also director of the Behavioral Sleep Medicine program and was not involved in the study. He said the results “support the use of this modality by providers to expand access to this highly effective but underused treatment for insomnia.”

Additionally, CBT-I’s telehealth delivery “provides a safe and effective alternative to in-person care to improve insomnia and associated daytime consequences and has the potential to reduce health care disparities by increasing availability for underserved communities, ”said Arnedt.

However, investigators stress that the usefulness of this approach for underserved communities requires further investigation. One limitation of the study was that the participants were “generally healthy and well educated”.

Additionally, more research is needed to see if the findings can be generalized to people who have “more complicated health or socio-economic challenges,” they write.

The study was funded by a grant from the American Sleep Medicine Foundation and the Clinical Scientist Development Award from the Doris Duke Charitable Foundation. Gehrman has received research funding from Merck, Inc, is a consultant for WW and sits on the scientific advisory board of Eight Sleep. Disclosures by other authors are listed in the original article. Arnedt does not report any relevant financial relationships, but notes that he was the principal investigator of a similar study conducted in parallel to this one which was also funded by the American Academy of Sleep Medicine Foundation at the same time.

J Clin Psychiatry. Published online August 24, 2021. Summary

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