Digital cognitive behavioral therapy superior to medication for insomnia treatment

Key takeaways:

• Digital cognitive behavioral therapy alone or in combination with medication was more effective than medication alone.
• However, the durability of digital cognitive behavioral therapy was unstable.

After 6 months of treatment, digital cognitive behavioral therapy for insomnia was superior to medication in improving sleep quality, but combining the two has “the potential to optimize outcomes,” according to researchers.

Previous randomized controlled trials (RCTs) have shown that digital cognitive behavioral therapy for insomnia (dCBT-I) is effective in reducing medication intake and decreasing insomnia severity, Menglin Lu, MSc, of Zhejiang University in China, and colleagues wrote.

“Despite the advantages of RCTs in removing the influence of external factors, they are cumbersome and time consuming and often do not match complex clinical scenarios,” they wrote in JAMA Network Open. “Furthermore, there is a lack of systematic analysis regarding dCBT-I engagement, durability and adaptability in the practice setting, which is essential to inform effective and widespread dissemination.”

To learn more, the researchers conducted a China-based retrospective cohort study using 2018 to 2022 data from users of the Good Sleep 365 mobile application.

The cohort consisted of 4,052 participants with insomnia who had a mean age of 44 years; 74.1% of whom were women. Of those, 418 received dCBT-I, 862 received medication therapy and 2,772 received combination therapy. The researchers assessed treatment outcomes using the Pittsburgh Sleep Quality Index, with lower scores indicating better sleep.

Lu and colleagues reported finding response rates in 77.3%, 82% and 76.2% of participants who received dCBT-1 at 1, 3 and 6 months of follow up, respectively. In comparison, of participants who received medication therapy, 55.4% developed responses at 1 and 3 months and 54% developed responses at 6 months.

“The response rate of using dCBT-I in practice settings was comparable with that reported in previous RCTs,” the researchers wrote.

At 6 months, PQSI scores declined from 12.85 to 8.92 points among patients receiving medication therapy; 13.51 to 7.15 points among patients receiving dCBT-I; and 12.92 to 6.98 points among patients receiving both treatments.

“dCBT-I was also more effective for comorbid disorders in comparison with medication, showing consistent superiority from the first month in relief of anxiety, depression, and somatic symptoms,” Lu and colleagues wrote.

However, the researchers observed “insignificant and unstable trends” in outcomes with dCBT-I, which rapidly improved during the first 3 months and then fluctuated.

Such outcomes indicated to the researchers “that the engagement challenge still exists when patients are asked to make major behavioral changes in their daily life.”

“To increase patient engagement with self-help dCBT-I, innovational therapeutic content should be developed and consistently updated to intrigue patients to overhaul their sleep patterns, behaviors, and thoughts,” they wrote.

Lu and colleagues concluded that though combined therapy was associated with improved sleep quality among those with insomnia compared with medication alone, “given the unstable durability of dCBT-I at 6-month follow-up, the design, implementation and delivery of dCBT-I in the practice setting warrants further investigation.”