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Self-help for insomnia: encouraging results and some available resources

I've written three blog posts about sleep in the last three months - "'Sleep well and live better: overcoming insomnia using CBT'- a workshop with Colin Espie", "The links between sleep disturbance and depression" and "Is short duration sleep a problem or is it just disturbed sleep that leads to increased mortality risk?  A personal exploration".  It is clear that many people struggle with sleep difficulties and that this is associated with a network of other problems.  A recent paper that highlighted this for me was a North American study of nearly 5,000 policeman - "Sleep disorders, health, and safety in police officers" - which very worryingly reported that "26.1% reported falling asleep while driving at least 1 time a month".  Further findings included "those respondents who screened positive for a sleep disorder vs those who did not had a higher rate of reporting that they had made a serious administrative error (17.9% vs 12.7%; adjusted odds ratio [OR], 1.43) ... of making an error or safety violation attributed to fatigue (23.7% vs 15.5%; adjusted OR, 1.63); and of exhibiting other adverse work-related outcomes including uncontrolled anger toward suspects (34.1% vs 28.5%; adjusted OR, 1.25), absenteeism (26.0% vs 20.9%; adjusted OR, 1.23), and falling asleep during meetings (14.1% vs 7.0%; adjusted OR, 1.95)."   We can extend these findings to people working in other kinds of jobs all over the country.  Sobering ...

A genuinely encouraging sign though is that self-help treatments for insomnia delivered in printed form or on computer can make state-of-the-art interventions widely and cheaply available.  A paper that's just been published - "Internet-delivered or mailed self-help treatment for insomnia? A randomized waiting-list controlled trial" - makes this point clearly, stating "Cognitive Behavioral Therapy (CBT) is effective in reducing insomnia complaints, but the effects of self-help CBT have been inconsistent. The aim of this study was to determine the effectiveness of self-help for insomnia delivered in either electronic or paper-and-pencil format compared to a waiting-list. Participants kept a diary and filled out questionnaires before they were randomized into electronic (n=216), paper-and-pencil (n=205), or waiting-list (n=202) groups. The intervention consisted of 6 weeks of unsupported self-help CBT, and post-tests were 4, 18, and 48 weeks after intervention. At 4-week follow-up, electronic and paper-and-pencil conditions were superior (p < .01) compared to the waiting-list condition on most daily sleep measures (Δd=0.29-0.64), global insomnia symptoms (Δd=0.90-1.00), depression (Δd=0.36-0.41), and anxiety symptoms (Δd=0.33-0.40). The electronic and paper-and-pencil groups demonstrated equal effectiveness 4 weeks after treatment (Δd=0.00-0.22; p>.05). Effects were sustained at 48-week follow-up. This large-scale unsupported self-help study shows moderate to large effects on sleep measures that were still present after 48 weeks. Unsupported self-help CBT for insomnia therefore appears to be a promising first option in a stepped care approach."  It's worth noting that the electronic computer-delivered treatment in this study was deliberately kept simple, so the authors commented "Participants in the electronic condition received the intervention and the diary online. However, in order to get a clear comparison, the electronic condition consisted of a simple website that did not include interaction or individual tailoring that is often employed in Internet interventions. This means that the paper-and-pencil intervention of the paper-and-pencil condition was essentially digitalized and fitted to a website format." 

A further paper also published this year - "Efficacy of a behavioral self-help treatment with or without therapist guidance for co-morbid and primary insomnia - a randomized controlled trial" - suggests that guided self-help for insomnia is more effective than "pure" self-help with no therapist input.  The paper's abstract reads "BACKGROUND: Cognitive behavioral therapy is treatment of choice for insomnia, but availability is scarce. Self-help can increase availability at low cost, but evidence for its efficacy is limited, especially for the typical insomnia patient with co-morbid problems. We hypothesized that a cognitive behaviorally based self-help book is effective to treat insomnia in individuals, also with co-morbid problems, and that the effect is enhanced by adding brief therapist telephone support. METHODS: Volunteer sample; 133 media-recruited adults with insomnia. History of sleep difficulties (mean [SD]) 11.8 [12.0] years. 92.5% had co-morbid problems (e.g. allergy, pain, and depression). Parallel randomized (block-randomization, n>21) controlled "open label" trial; three groups - bibliotherapy with (n=44) and without (n=45) therapist support, and waiting list control (n=44). Assessments before and after treatment, and at three-month follow-up. Intervention was six weeks of bibliotherapeutic self-help, with established cognitive behavioral methods including sleep restriction, stimulus control, and cognitive restructuring. Therapist support was a 15-minute structured telephone call scheduled weekly. Main outcome measures were sleep diary data, and the Insomnia Severity Index. RESULTS: Intention-to-treat analyses of 133 participants showed significant improvements in both self-help groups from pre to post treatment compared to waiting list. For example, treatment with and without support gave shorter sleep onset latency (improvement minutes [95% Confidence Interval], 35.4 [24.2 to 46.6], and 20.6 [10.6 to 30.6] respectively), and support gave a higher remission rate (defined as ISI score below 8; 61.4%), than bibliotherapy alone (24.4%, p's<.001). Improvements were not seen in the control group (sleep onset latency 4.6 minutes shorter [-1.5 to 10.7], and remission rate 2.3%). Self-help groups maintained gains at three-month follow-up. CONCLUSIONS: Participants receiving self-help for insomnia benefited markedly. Self-help, especially if therapist-supported, has considerable potential to be as effective as individual treatment at lower cost, also for individuals with co-morbid problems."

As a therapist I often start any sleep intervention I provide by introducing my client to Professor Colin Espie's fine book "Overcoming Insomnia and Sleep Problems: A Self-Help Guide Using Cognitive Behavioral Techniques".  Downloadable sleep diaries and other material that support this intervention can be found on the "Sleep ... & fatigue" page of this website.  There has been an exciting development in provision of this material with the recent launch of a specialised website that delivers a "state of the art" CBT intervention in all-singing-all-dancing style - see http://www.sleepio.com/.  Unfortunately the six week online course currently costs £49.99 - but the good news is that anyone interested can try the first week free of charge so they can make an informed decision whether to buy into the whole course or not.  The website states "Sleepio is a self-help course designed to help you overcome poor sleep, by using evidence-based cognitive and behavioural therapy (CBT) techniques, up-to-date expert sleep information, and community support. Each weekly online session is tailored to you automatically and presented by ‘The Prof', your virtual sleep expert.  The course requires effort from the user over a number of weeks for the techniques to be effective, but when followed correctly they can help you dramatically improve poor and disrupted sleep - whether it has lasted weeks, months or even years."


Encouragingly, Colin Espie has performed a randomized controlled trial on Sleepio's effectiveness.  A report on the website comments "A total of 164 people with persistent poor sleep (ie. lasting 3 months or longer) took part in the study and were randomly allocated to one of three groups: those given the CBT-based Sleepio course, another given a placebo course using the same online system, and finally a group that received no course at all over the same period. Our online system gathered evaluation data from them all before they started the course (a baseline measure), after completing the course and at a follow-up point eight weeks later. Our results were then analysed so that we could test the effectiveness of the Sleepio course when compared to the placebo group and to the untreated group.  Our results show that the Sleepio course helped around 75% of people with persistent sleep problems to improve their sleep to healthy levels, compared with the placebo and no treatment conditions which had relatively little impact. In research trials it is usual to report average scores, and these averages of course include those who benefitted least as well as those who saw great improvements. Nonetheless we found an average reduction in time taken to fall asleep of 50% and in time spent awake during the night of 60% within the Sleepio group. We also found that people using Sleepio rated their quality of sleep as having more than doubled (a 115% increase) and their energy and daytime wellbeing levels increased by 58% during the daytime. Importantly, these improvements with Sleepio were found to be lasting because effects were maintained at our two month follow up point."

A quick Google search will find other available online courses for insomnia.  The new Sleepio site however is excellent ... a great new resource both for anyone wanting to try the methods on their own and for therapists who want to add this "sleep module" into their overall therapy for a client with sleep difficulties in addition to their other presenting problems. 

And to underline the need for wider availability of effective psychological approaches for insomnia, there is now the just published article "Hypnotics' association with mortality or cancer: a matched cohort study".  Yes, the increased death rates for those using sleeping pills (even antihistamines) are probably "confounded" by unrecognised factors that both raise the rate of insomnia as well as the mortality risk - see the post "The links between sleep disturbance and depression".  However the findings still emphasise the foolishness of not trying to shift from sleep medication to better psychological management whenever possible.

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