On August 29th 2016 David DiSalvo published an article on Forbes called: “Reasons For Skepticism About The Latest Online Insomnia Cure”. In the article Mr. DiSalvo raises a few concerns about CBT (Cognitive Behavioral Therapy) and specifically about CBT-I (Cognitive Behavioral Therapy for Insomnia) online programs. Some the concerns raised in the article are quite true. We therefore asked our very own expert, Dr. Anda Baharav, to address them.
The following is Dr. Baharav’s response to Mr. DiSalvo’s article. [Original quotes from the actual article are in bold font].
“The essence of CBT is restructuring negative thought patterns to change behavioral outcomes, so the idea behind CBT-I is to reframe negative thoughts that are triggering insomnia.”
In fact, CBT-I stands for Cognitive Behavioral Therapy CBT for Insomnia and implies not only restructuring of negative thoughts but also and mainly behavioral changes:
- Regarding sleep times and routines such as:
- Bed times and how regular they are
- Wake up times and ranges
- Reconnecting bed with sleep (not with other activities, except sex!)
The rationale for those changes is to increase sleep needs (drive) at a regular time that coincides with the internal biological clock, which rules over sleep and wakefulness.
- Regarding habits that may interfere with sleep such as:
- Caffeinated drinks: those promote alertness
- Alcohol consumption: may induce sleepiness, yet causes sleep disruptions later at night
- Substance use: different substances may either call sleep disruptions or promote alertness
- Time and intensity of exercise: change the core body temperature and increase stress thus late in the day this may delay sleep
- Time of meals: a big meal just before bed time can interfere with sleep, going to sleep hungry is also a sleep disruptor
- Screen and media time: causes sleep deprivation and also the exposure to bright-blue light interferes with the biological clock and delays sleep at night
The rationale to change those habits is to provide the necessary conditions for sufficient duration and good quality sleep.
Insomnia cure: Additional components of CBT for sleep
- Dealing with the sleep environment to make sure it is conducive to sleep: Ambient noise, light and temperature.
- Relaxation: differentiate between an active day and sleep, by adding a buffer zone of activities that allow to slow down before bed time, additional relaxation techniques if needed
- Providing the needed and relevant sleep education that helps with restructuring negative thoughts that trigger Insomnia. This part alone is rarely successful. It works fine in conjunction with behavioral changes that influence the physiological roots of Insomnia.
“That’s right–across all of the studies this study reviewed, the big result was about 20 minutes of additional sleep.”
Insomnia is defined as difficulties falling asleep, maintaining sleep or poor sleep satisfaction based on subjective concern from the sufferers. There are subtypes of this prevalent disorder and CBT-I has been shown to be effective in its treatment (click here to read the study), and is recommended as the first line of treatment for insomnia by the NIH. None of the studies dealing with the efficacy of CBT-I provided by experts suggests that sleep duration increases by hours, 20 minute more sleep is a significant achievement. Studies indicate that falling asleep time decreases by minutes and sleep efficiency increases by a few 2-3 % only with CBT-I, along with improved sleep satisfaction and less daytime symptoms such as sleepiness. Thus the study cited (actually a summary of 15 studies) indicates that internet administered CBT is effective.
“…also learn that the participants in the clinical trials used self-reporting (in sleep diaries) to record their sleep, so we’re assuming they got it right. Maybe they did, maybe they didn’t–but either way, 20 minutes?”
Most CBT-I administered by sleep therapists are based on subjective inputs (questionnaires and self – reported sleep diaries), and sometimes objective information regarding sleep-wake times based on actigraphy (movement loggers).
Self – reporting may indeed be problematic because people usually do not remember what really happened during the night, time perception and memory are normally disturbed during sleep. In this regard, CBT-I provided by sleep therapists is not different from most internet administered cures for Insomnia. Their advantage is that they are scalable, may easily be disseminated and they cost less, than the “classic” ones.
This is why, at Sleeprate, we offer both objective and subjective measures, and we detected a significant decrease in the discrepancies in between the measured and self- reported times simultaneously with the improvement in sleep satisfaction and additional subjective sleep variables. This allows us to overcome the issue of subjective and inaccurate reporting only.
The advantages of Sleeprate monitoring app are:
- Provided in the natural home environment
- Objective measures of sleep
- Subjective measures of sleep
- Stress measurement
- Biofeedback relaxation
- Daily monitoring allows better accuracy than sleep diaries
- Daily and weekly results feedback
- Personalized notifications
- People who stay engaged for 3-4 weeks get better
- Measures ambient noise and snoring
- Provides indicators for possible sleep apnea
“Beyond that, it’s also worth asking whether computer-assisted CBT really delivers on the promises made for it. Some studies offer support, but others taking a broader view of the practice call into question whether the results are significant or sustainable. When compared to in-person therapy, results for the online version are less than stellar for treatment of depression and other major psychiatric disorders. And even if patients receive initial benefits, they’re less likely to stick with the programs over time.”
We realize that therapy is only the first step and that once improvement is obtained, we have to offer continued support. Therefore, we’re developing a maintenance module that can be activated after the person has improved their sleep through the therapy, and which will detect the relapse of insomnia symptoms, inform the user, and guide them to take steps to prevent the relapse.
Regarding secondary morbidities (depression, other mood/psychiatric problems), improving sleep may alleviate some of the symptoms, as has been shown in studies (see here). Thus Sleeprate can supplement psychiatric therapy (it does not replace it).
To sum up, while Mr. DiSalvo raises some valid points regarding Internet insomnia therapies and the inaccuracy of self-reporting, I hope I have been able to show the evidence-based positive effect of CBT and specifically CBT-I when performed properly, especially when combined with objective measurements.
We also agree that a partial solution may be insufficient, as Mr. DiSalvo claims. That’s why so much effort has gone into developing and validating a full solution that combines sleep monitoring, assessment, and maintenance, using a combination of self-reporting and scientific empirical measurements. This may well prove to be the best tool to allow you to take back control of your sleep and so truly improve your life.