Getting A Good Night's Sleep With Online Therapy

You can do almost anything on the Internet these days. What about getting a good night’s sleep?

It might be possible, some researchers say. Web-based programs to treat insomnia are proliferating, and two small but rigorous studies suggest that online applications based on cognitive behavioral therapy can be effective.

“Fifteen years ago, people would have thought it was crazy to get therapy remotely,” said Bruce Wampold, a professor of counseling psychology at the University of Wisconsin. “But as we do more and more things electronically, including have social relationships, more therapists have come to believe that this can be an effective way to deliver services to some people.”

The first controlled study of an online program for insomnia was published in 2004. But the results were hard to interpret, because they showed similar benefits for those who used the program and those in the control group. The two new studies, from researchers in Virginia and in Canada, advance the evidence that such programs can work.

In the Virginia study, called SHUTi, patients enter several weeks of sleep diaries, and the program calculates a window of time during which they are allowed to sleep. Patients limit the time they spend in bed to roughly the hours that they have actually been sleeping.

The goal is to consolidate sleep, then gradually expand its duration — the same technique that would be used in face-to-face therapy, said Lee Ritterband, a psychologist at the University of Virginia, who developed the program.

Stella Parolisi, 65, a registered nurse in Virginia and a patient in the study, said sticking to the restricted sleep schedule was hard, “but toward the end, it started to pay off.”

“Before, if I was exhausted, I would try to get to bed earlier and earlier, which was the wrong thing,” she said. “It just gave me more time to toss and turn.”

But after using the program, she began to sleep for at least one four-hour stretch a night.

The SHUTi program, which spans nine weeks, advises patients to get out of bed if they wake and are unable to return to sleep for more than 15 minutes. It also uses readings, vignettes, animation and interactive exercises to help patients deal with factors that interfere with sleep. For example, the program helps patients manage anxious thoughts, like the idea that they cannot function without eight solid hours of sleep. It also reinforces the message that they should not do work or watch TV in bed, should limit the light in the bedroom and should avoid stimulants like caffeine late in the day.

In a small, randomized, controlled study, which included 45 adults, those who were assigned to try the online program reported significantly greater increases in sleep efficiency and decreases in nighttime wakefulness than those who remained on the waiting lists.

Specifically, participants’ sleep efficiency, a measure of the proportion of time spent asleep relative to the total time in bed, improved by 16 percent and their nighttime wakefulness (minutes awake during the night) decreased by 55 percent; neither measure changed significantly for the control group. The findings appeared last month in The Archives of General Psychiatry.

“The outcomes were very impressive, almost unbelievable,” said Jack Edinger, a psychologist at Duke University Medical Center.

The Canadian study tested a five-week program that also emphasized sleep restriction, controlling negative thoughts and avoiding stimuli like light and noise in the bedroom. It also included readings, and audio and video clips to teach and reinforce its messages.

Led by Norah Vincent, a psychologist at the University of Manitoba, the study included 118 adults who were randomly assigned to complete the program or remain on a waiting list.

“I liked that it was over the Internet,” said one participant, Kelly Lawrence, 51, of Winnipeg, “because when you don’t get your sleep you don’t want to have to get up and go to appointments. You don’t want to be out there on the roads.”

The online format made it easier to work around child care and other responsibilities, and to “pause the program and go back to something any time I needed to,” she added.

Thirty-five percent of those who completed the program described their insomnia as “much improved” or “very much improved,” compared with just 4 percent of those who remained on the waiting list. The findings were published in June in the journal Sleep.

Dr. Ritterband says he plans to make the online program publicly available, though not until after further study. Dr. Vincent also said she planned to commercialize her program, charging participants roughly $20 to $30.

Other online programs offering cognitive behavioral therapy for sleeplessness include CBTforinsomnia.com, developed and run by Gregg Jacobs, an insomnia specialist at University of Massachusetts Medical School, and “Overcoming Insomnia,” created by HealthMedia, a company based in Michigan.

In-person cognitive behavioral therapy is not readily available to many of the sleepless, whether because they do not have access to a trained therapist or because their schedules make it hard to keep the appointments.

“The sleep community recognizes that if everyone with insomnia showed up on our doorstep today, we wouldn’t be able to help them all,” said Lawrence Epstein, an instructor at Harvard Medical School and medical director of Sleep HealthCenters in Boston.

Still, Dr. Wampold, of Wisconsin, said some people were bound to be skeptical of online therapy. Therapists who tend to see “the interpersonal relationship between patient and clinician as a key source of motivation and change are likely to be suspicious,” he said.

For many insomniacs, he said, “the actual sleep disturbance is just an indication of more or other problems that need to be addressed.”

“And you can’t do that,” he added, “without more clinician contact and flexibility.”

New York Times 8/11/09