Background-The Internet has become a major component to health care and has important implications for the future of the health care system. One of the most notable aspects of the Web is its ability to provide efficient, interactive, and tailored content to the user. Given the wide reach and extensive capabilities of the Internet, researchers in behavioral medicine have been using it to develop and deliver interactive and comprehensive treatment programs with the ultimate goal of impacting patient behavior and reducing unwanted symptoms. To date, however, many of these interventions have not been grounded in theory or developed from behavior change models, and no overarching model to explain behavior change in Internet interventions has yet been published.

Cognitive-behavioral therapy for insomnia (CBT-I) has been shown efficacious, but the challenge remains to make it available and accessible in order to meet population needs. Delivering CBT-I over the internet (eCBT-I) may be one method to overcome this challenge. The objective of this meta-analysis was to evaluate the efficacy of eCBT-I and the moderating influence of various study characteristics. Two researchers independently searched key electronic databases (1991 to June 2015), selected eligible publications, extracted data, and evaluated methodological quality. Eleven randomized controlled trials examining a total of 1460 participants were included. Results showed that eCBT-I improved insomnia severity, sleep efficiency, subjective sleep quality, wake after sleep onset, sleep onset latency, total sleep time, and number of nocturnal awakenings at post-treatment, with effect sizes (Hedges's g) ranging from 0.21 to 1.09. The effects were comparable to those found for face-to-face CBT-I, and were generally maintained at 4-48 wk follow-up. Moderator analyses showed that longer treatment duration and higher degree of personal clinical support were associated with larger effect sizes, and that larger study dropout in the intervention group was associated with smaller effect sizes. In conclusion, internet-delivered CBT-I appears efficacious and can be considered a viable option in the treatment of insomnia.

Context: Insomnia is a major health problem with significant psychological, health, and economic consequences. However, availability to one of the most effective insomnia treatments, Cognitive Behavioral Therapy (CBT), is significantly limited. The Internet may be a key conduit for delivering this intervention. Objective: To evaluate the efficacy of a structured behavioral Internet intervention for adults with insomnia. Design, Setting, and Participants: 45 adults were randomly assigned to an Internet intervention (n=22) or wait-list control group (n=23). 44 eligible participants were included in the analyses (mean age, 44.86±11.03 years; 34 women), who had, on average, a history of sleep difficulties greater than 10 years (10.59±8.89). Intervention: The Internet intervention is based on well-established face-to-face CBT, incorporating the primary components of sleep restriction, stimulus control, sleep hygiene, cognitive restructuring, and relapse prevention. Main Outcome Measure(s): The Insomnia Severity Index (ISI) and daily sleep diary data were used to determine changes in insomnia severity and the main sleep variables, including wake after sleep onset (WASO) and sleep efficiency (SE). Results: Intent-to-treat analyses showed that scores on the ISI significantly improved from 15.73 (95% CI, 14.07-17.39) to 6.59 (95% CI, 4.73-8.45) for the Internet group, but did not change for the control group, 16.27 (95% CI, 14.61-17.94) to 15.50 (95% CI, 13.64-17.36), F (1, 42) = 29.64, p<.001. The Internet group maintained their gains at six month follow-up. Internet participants also achieved significant decreases in WASO (55%; 95% CI, 34%-76%) and increases in SE (16%; 95% CI, 9%-22%) compared to the non-significant control group changes of WASO (8%; 95% CI, −17%-33%) and SE (3%; 95% CI, −4%-9%). Conclusions: Participants who received the Internet intervention for insomnia significantly improved their sleep, whereas the control group did not change. The Internet appears to have considerable potential in delivering a structured behavioral program for insomnia.

Objective Insomnia is a common complaint among cancer survivors. Fortunately, cognitive-behavioral therapy for insomnia (CBT-I) has been shown to be an effective treatment in this population. However, it is rarely implemented given its limited availability. To address this barrier, we examined the ability of an easily-accessible online CBT-I program to improve insomnia symptoms in cancer survivors. Methods Twenty-eight cancer survivors with insomnia were randomly assigned to either an Internet insomnia intervention (n=14) or to a waitlist control group (n=14). The online program, Sleep Healthy Using the Internet, delivers the primary components of CBT-I (sleep restriction, stimulus control, cognitive restructuring, sleep hygiene, and relapse prevention). Pre- and post-assessment data were collected via online questionnaires and daily sleep diaries. Results Participants in the Internet group showed significant improvements at post-assessment compared to those in the control group in overall insomnia severity (F1,26=22.8; P<.001), sleep efficiency (F1,24=11.45; P=.002), sleep onset latency (F1,24=5.18; P=.03), soundness of sleep (F1,24=9.34; P=.005), restored feeling upon awakening (F1,24=11.95; P=.002), and general fatigue (F1,26=13.88; P=.001). Although other group x time interactions were not significant, overall adjusted effect sizes for all sleep variables as well as for fatigue, depression, anxiety, and quality of life ranged from small to large. Conclusions CBT-I delivered through an interactive, individually-tailored Internet intervention may be a viable treatment option for cancer survivors experiencing insomnia.

The provision of health care over the Internet is a rapidly evolving and potentially beneficial means of delivering treatment otherwise unsought or unobtainable. Internet interventions are typically behavioral treatments operationalized and transformed for Web delivery with the goal of symptom improvement. The literature on the feasibility and utility of Internet interventions is limited, and there are even fewer outcome study findings. This article reviews empirically tested Internet interventions and provides an overview of the issues in developing and/or using them in clinical practice. Future directions and implications are also addressed. Although Internet interventions will not likely replace face-to-face care, there is little doubt that they will grow in importance as a powerful component of successful psychobehavioral treatment.

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clinicaltrials.gov Identifier: NCT01438697.

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