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Should Internet Cognitive Behavioral Therapy for Insomnia

Be the Primary Treatment Option for Insomnia?
Toward Getting More SHUTi
Andrew D. Krystal, MD, MS; Aric A. Prather, PhD

Insomnia is a prevalent, often debilitating, sleep disorder with

significant consequences for physical health and well-being.
With as many as 50% of adults reporting insomnia symptoms
at least intermittently and up
to 20% of adults meeting diagnostic criteria for insomRelated article
nia disorder, there is an acute
need for effective interventions.1 Treatments established to be
safe and efficacious for this condition include a variety of different medications and cognitive behavioral therapy for insomnia (CBT-I), which focuses on improving homeostatic sleep
drive, standardizing circadian rhythm, breaking any conditioned arousal associated with the nighttime environment, and
reorienting maladaptive cognitions about sleep and ones ability to cope effectively after a night of poor sleep. Of these, CBT-I
has advantages in terms of risks and sustained efficacy.2 Unfortunately, clinicians who have the necessary expertise in delivering CBT-I are scarce, which has led many researchers, as
well as entrepreneurs, to leverage technology to deliver CBT-I
to individuals who are unable or unwilling to meet with a clinician or who prefer the convenience and potentially lower cost
of an internet-based treatment.
Internet-based CBT-I is an attractive solution to challenges of scalability. The developers of the Sleep Healthy
Using the Internet (SHUTi) program have been pioneers in
the rapidly growing space of mobile strategies for treating
insomnia. SHUTi is a fully automated, interactive, and tailored internet-based program that incorporates the welltested principles of CBT-I. In this issue of JAMA Psychiatry,
Ritterband and colleagues3 report that, in a sample of 303
patients with chronic insomnia, those randomized to 9
weeks of SHUTi showed significant improvements in the
symptoms of insomnia, decreases in the number of minutes
awake during the night, and a shorter time to sleep onset at
the postintervention follow-up compared with individuals
randomized to the active control condition (internet-based
patient sleep education). Many of the gains for those using
SHUTi were maintained over time, with 56.6% of SHUTi
participants deemed as insomnia remitters compared with
27.3% in the control condition 1 year after the intervention.
These improvements were similar to those observed in trials
using face-to-face CBT-I, which is impressive. Furthermore,
despite the intervention being completely automated,
adherence was good, with 60.0% of SHUTi participants completing all 6 cores of the program.

One of the biggest challenges to translating findings from

insomnia clinical trials to clinical practice is the reality that the
populations studied in clinical trials lack the psychiatric and
medical comorbidities of those seen in clinic settings. There
have been relatively few rigorous trials of internet-based insomnia therapies carried out in patients with psychiatric or
medical comorbidities.4 As such, it is unclear whether internetbased interventions yield the same gains as those observed
when patients are carefully screened for mental and physical
health problems. In this study, Ritterband and colleagues3 take
an important step in tackling this issue by carrying out the most
robust study to date that enrolled participants with comorbid
psychiatric and medical conditions. Although their study excluded individuals with medium to high suicide risk, severe
depression, bipolar disorder, alcohol or drug abuse in the past
year, and those with medical comorbidities that were likely to
worsen insomnia, their results provide an indication that the
benefits conferred by SHUTi are not diminished by the presence of either psychiatric or medical comorbidities. Still, a true
characterization of how SHUTi performs in patients seen in
clinical practice will require evaluation in a setting where lessstringent eligibility criteria are applied.
On the whole, the findings suggest that SHUTi is a promising treatment option for patients with insomnia. These findings and the potential for rapid widespread use demand that
we address a critical question: Should internet CBT-I be the
first-line treatment for all patients with insomnia? Several issues suggest that it is premature to adopt this position and
speak for restraint.
One important consideration is that the Ritterband and
colleagues3 study only reflects on one particular form of internet CBT-I: the SHUTi system. It cannot be assumed that similar results will be found with any of the many other systems
until this is proven to be the case. The existing literature comprises studies assessing a variety of different treatment systems, each of which must be viewed as speaking only to the
system studied. The CBT-I and internet CBT-I programs should
be viewed as a family of treatments that differ but share things
in common to various degrees.
Another consideration is that, like individuals included in
many studies of internet-based therapies, participants chose
to enroll in a study on internet-based therapy and thus the
sample was preferentially composed of those who prefer this
form of therapy. Consistent with this choice, the study population was skewed toward highly educated persons, white in(Reprinted) JAMA Psychiatry Published online November 30, 2016

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Opinion Editorial

dividuals, and those adept at using the internet. It remains to

be seen whether such interventions will resonate with individuals across socioeconomic strata and racial categories. Internet use is lower among the African American compared with
white populations as is the likelihood of broadband internet
access in the home.5 This difference is particularly salient given
evidence for racial disparities in sleep health.6 If used as a primary intervention, SHUTi would be offered to many people
who would not choose an internet therapy if other options were
available, such as face-to-face CBT-I or medication treatment, and it remains unknown whether SHUTi will be effective in these individuals.
A further consideration is that the true effect size of the
SHUTi vs control intervention difference remains unknown
because, as discussed by Ritterband and colleagues,3 there is
reason to believe that this study was essentially unblinded.
It could be argued that the effect size vs a control treatment
is irrelevant because clinical practice is unblended, making
the SHUTi pre-post difference the critical effect. However,
demonstration of efficacy matters from an ethical point of
view. People with insomnia, health care systems, and insurers are likely going to have to pay fees to use services such as
SHUTi, and they deserve to know the degree to which there

Author Affiliations: Department of Psychiatry,
University of California, San Francisco (Krystal,
Prather); Department of Psychiatry and Behavioral
Sciences, Duke University School of Medicine,
Durham, North Carolina (Krystal).
Corresponding Author: Andrew D. Krystal, MD,
MS, Department of Psychiatry, University of
California, San Francisco, 401 Parnassus Ave,
PO Box 0984-F, San Francisco, CA 94143
Published Online: November 30, 2016.
Conflict of Interest Disclosures: Dr Krystal has
received grants and research support from National
Institutes of Health, Teva, Sunovion, Janssen, and
Jazz, and is a paid consultant for Attentiv, Flamel,
Teva, Jazz, Janssen, Merck, Neurocrine, Otsuka,


is likely to be benefit beyond the improvement derived from

the nonspecific effects of interacting with any internetbased system that one is led to believe will be effective. The
extent to which this consideration is relevant will depend on
the cost of SHUTi, which is currently available on the internet for $135.
Despite reasons for restraint, it seems inevitable that internet CBT-I will be increasingly used as a first-line insomnia
intervention. It also seems likely that the medical community may have little influence on whether, when, and how this
occurs. It is unknown to what extent those who provide treatment will play a role in directing individuals with insomnia to
efficacious internet-based CBT-I systems. There will no doubt
be options available where the ease of access, convenience, and
price will appeal to large numbers of patients, insurers, and
health systems such that many patients may seek out those
who offer treatment only after failing to improve with internet CBT-I. It is, therefore, critical that all such systems made
available as online treatment options for insomnia are tested
in a rigorous way and the results are made available to the public. In this regard, the article by Ritterband and coworkers3
suggests that many of those who choose SHUti will experience lasting improvement.

Pfizer, Lundbeck, Sunovion, and Pernix. No other

disclosures were reported.
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for insomnia intervention with 1-year follow-up:

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JAMA Psychiatry Published online November 30, 2016 (Reprinted)

Copyright 2016 American Medical Association. All rights reserved.

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