Self-help cognitive-behavioral therapy for insomnia (CBT-I) is an acceptable, low-intensity treatment in a stepped care model for insomnia. We tested the application of self-help CBT-I in a Chinese population. 312 participants with self-report of insomnia associated with distress or daytime impairment 3 or more nights per week for at least 3 months were randomized to self-help CBT-I with telephone support (SHS), self-help CBT-I (SH) and waiting-list (WL). The program was Internet-based with treatment materials delivered once per week, and lasted for 6 consecutive weeks, while the telephone support was limited to 15 min weekly. Mixed-effects analyses found significant group by time interaction in sleep and sleep-related cognitions at immediate and 4-week posttreatment. Post-hoc pairwise comparison with WL revealed that both SHS and SH had significantly higher sleep efficiency at immediate (p = .004 and p = .03, respectively) and 4-week posttreatment (p = .002 and p = .02, respectively) and lower insomnia and dysfunctional beliefs scores. The SHS group had additional improvements in sleep onset latency and sleep quality. Benefits with self-help CBT-I were maintained at 12-week posttreatment, but attrition rate was about 35%. Internet-based self-help CBT-I was effective and acceptable for treating insomnia in the Chinese population. A brief telephone support further enhanced the efficacy.
Insomnia is recognized as one of the most common sleep complaint, with a prevalence of 6–15% in the general population suffering from insomnia symptoms accompanied by daytime consequences (Ohayon, 2011). Insomnia is associated with cognitive, social and emotional impairments (Léger et al., 2010). Additionally, insomnia is a risk factor for suicide, depression, anxiety disorders, substance and drug abuse, decreased immune functioning and cardiovascular disease (Taylor, Lichstein, & Durrence, 2003). From a societal perspective, insomnia brings heavy burden to the sufferers and the public (Léger & Bayon, 2010). A Canadian study showed that the total annual cost of insomnia was estimated at $6.6 billion, including direct and indirect expenses, and was equivalent to average per-person cost of $5010 for individuals with insomnia syndrome compared to $421 for good sleepers (Daley, Morin, LeBlanc, Grégoire, & Savard, 2009).
Although pharmacological agents are commonly prescribed to treat insomnia, their use is limited by concern regarding long-term efficacy and potential for abuse, dependence and adverse effects (National Institutes of Health, 2005). Cognitive-behavioral therapy for insomnia (CBT-I) which includes sleep hygiene education, stimulus control, sleep restriction, cognitive restructuring and relaxation training and aims at changing dysfunctional beliefs and maladaptive behaviors associated with sleep has been shown to be efficacious (Morin et al., 2006). CBT-I and pharmacological treatment were found to have comparable efficacy in short term, but further and long-term improvement was only detected in individuals receiving CBT-I (Riemann & Perlis, 2009). Furthermore, greater acceptance of CBT-I, relative to pharmacological treatment, has been reported; therefore, CBT-I seems to be a better choice (Morin et al., 1992 and Morin et al., 1999). However, CBT-I has remained underutilized perhaps due to lack of availability of CBT service and the time-intensive nature of the treatment (Bluestein et al., 2011 and Stinson et al., 2006).
Faced with the limitations of CBT-I, a stepped care model has been proposed (Espie, 2009). Self-help CBT-I is recommended as the least restrictive evidence-based entry step of the treatment model. With the advance of information technology, recent studies have used the Internet for the delivery of self-help material. Internet-based CBT-I has been shown to be effective and acceptable, and it has the benefits of low cost and convenience of access (Espie et al., 2012 and Lancee et al., 2012). Another line of research suggests that self-help CBT-I with therapist support seems to be more effective than self-help CBT-I alone (van Straten & Cuijpers, 2009). However, data on Internet-based self-help CBT-I, benefits of therapist support, and application in non-Western population are still limited.
The primary objective of this study was to develop and test an Internet-based Chinese-language self-help CBT-I program. Another objective was to compare self-help CBT-I with and without weekly brief telephone support. Our hypotheses were that self-help CBT-I would be superior to waitlist control in the short-term treatment of insomnia and telephone support would enhance adherence and efficacy of self-help CBT-I.
