Online CBT-I Program May Reduce Depression, Anxiety Symptoms

Participating in an online self-directed cognitive-behavioral therapy for insomnia (CBT-I) program may reduce the risk of depressive episodes in poor sleepers with subclinical levels of depressive symptoms, according to the preliminary results from a large clinical trial.

The GoodNight study enrolled 1,148 Australian adults, aged 18 to 64 years, Frances Thorndike, Ph.D., one of the investigators, told Psychiatric News.

Thorndike, an assistant professor of psychiatry and neurobehavioral sciences at the University of Virginia School of Medicine, is a member of the team that developed the fully automated version of CBT-I called Sleep Healthy Using the Internet (SHUTi) that was used in the study.

“Insomnia is a risk factor for depression, even before a first depressive episode,” Thorndike noted. The study, funded by the National Health and Medical Research Council of Australia, is the first randomized, controlled clinical trial to assess whether online CBT-I can both reduce symptoms of depression and prevent later onset of major depressive episodes, she said.

Starting in April 2013, researchers recruited subjects at risk for depression across Australia using social media, health organizations, newspaper advertisements, and more. Prospective enrollees completed questionnaires about their sleep and mood, and researchers conducted neuropsychiatric and sleep diagnostic interviews by phone with those who met eligibility criteria.

Potential participants then completed online sleep diaries daily for 10 days within a two-week period before being assigned to use SHUTi or a general health education website.

Those in the SHUTi group were asked to report each day when they went to bed, how long they took to fall asleep, how frequently they awakened, when they got out of bed in the morning, how often and how long they napped, how much alcohol they consumed, whether they used sleep aids, and more. They also rated the quality of their sleep.

Based on these reports, the SHUTi system calculated the sleep efficiency of each participant—the percentage of time each spent in bed asleep. The program also assigned each participant an individualized sleep window for each week, specifying bedtime and rise time. Previous studies showed that restricting time in bed, a key component of CBT-I, consolidates sleep and increases sleep efficiency.

SHUTi users also completed interactive sleep education modules, viewing text, graphics, and videos that encouraged them to adopt sleep-promoting behaviors.

People in the control group visited a health education website that mimicked the SHUTi format. Users viewed text and graphics providing weekly interactive updates on nutrition, exercise, blood pressure, cholesterol, and other health topics, but not mental health or sleep. They also completed surveys pertaining to that week’s health topic.

Researchers assessed participants’ depression symptom levels using the Patient Heath Questionnaire-9 (PHQ-9), major depressive episodes using the Mini International Neuropsychiatric Interview, and anxiety symptoms using the Generalized Anxiety Disorder-7 item scale (GAD-7), before and after use of the intervention and again six, 12, and 18 months later.

Analysis of data collected when participants entered the study and at their first six-month assessment found that, after controlling for baseline depression symptoms, adults in the SHUTi group experienced greater reductions in their depression symptoms (PHQ-9 mean change from 8.02 to 3.84) than those in the control group (PHQ-9 change from 7.84 to 5.47). Those in the SHUTi group also experienced greater reductions in anxiety six months after they started the program (GAD-7 change from 5.83 to 3.05) than those in the control group (GAD-7 change from 5.77 to 4.23).

Data for later assessments are being analyzed, and researchers hope to assess participants 36 months after use of the intervention, as well, Thorndike said.

The study is a collaboration between researchers at the Australian National University National Institute for Mental Health Research, the Black Dog Institute, University of New South Wales, University of Sydney Brain and Mind Research Institute, and the University of Virginia. ■