CBT via Telehealth or In-Person: Which Is Best for Insomnia?

Telehealth can be effective for delivering cognitive-behavioral therapy for insomnia (CBT-I) ― and is not inferior to in-person treatment, new research suggests.

Results from a study of 60 adults with insomnia disorder showed no significant between-group difference at 3-month follow-up between those assigned to receive in-person CBT-I and those assigned to telehealth CBT-I in regard to change in score on the Insomnia Severity Index (ISI).

In addition, both groups showed significant change compared with a wait-list group, indicating that telehealth was not inferior to the in-person mode of delivery, the investigators note.

“The take-home message is that patients with insomnia can be treated with cognitive-behavioral treatment for insomnia by video telehealth without sacrificing clinical gains,” study investigator Philip Gehrman, PhD, Department of Psychiatry, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, told Medscape Medical News.

“This fits with the broader telehealth literature that has shown that other forms of therapy can be delivered this way without losing efficacy, so it is likely that telehealth is a viable option for therapy in general,” he said.

The findings were published online August 24 in The Journal of Clinical Psychiatry.

Telehealth “Explosion”

Although CBT-I is the recommended intervention for insomnia, “widespread implementation of CBT-I is limited by the lack of clinicians who are trained in this treatment,” the investigators note. There is a “need for strategies to increase access, particularly for patients in areas with few healthcare providers.”

Telehealth is a promising technology for providing treatment, without the necessity of having the patient and the practitioner in the same place. There has been an “explosion” in its use because of restrictions necessitated by the COVID-19 pandemic. However, the “rapid deployment of telehealth interventions did not allow time to assess this approach in a controlled manner,” so it is possible that this type of communication might reduce treatment efficacy, the investigators note.

Previous research suggests that telehealth psychotherapeutic treatments in general are not inferior to in-person treatments. One study showed that CBT-I delivered via telehealth was noninferior to in-person delivery. However, that study did not include a control group.

“I have been doing telehealth clinical work for about 10 years, so way before the pandemic pushed everything virtual,” Gehrman said. “But when I would talk about my telehealth work to other providers, I would frequently get asked whether the advantages of telehealth (greater access to care, reduced travel costs) came at a price of lower efficacy.”

Gehrman said he suspected that telehealth treatment was just as effective and wanted to formally test this impression to see whether he was correct.

The investigators randomly assigned 60 adults (mean age, 32.72 years; mean ISI score, 17.0; 65% women) with insomnia disorder to in-person CBT-I (n = 20), telehealth-delivered CBT-I (n = 21), or to a wait-list control group (n = 19). For the study, insomnia disorder was determined on the basis of DSM-5 criteria.

Most participants had completed college or postgraduate school (43% and 37%, respectively) and did not have many comorbidities.

The primary outcome was change on the ISI. Other assessments included measures of depression, anxiety, work and social adjustment, fatigue, and medical outcomes. Participants also completed a home unattended sleep study using a portable monitor to screen participants for obstructive sleep apnea.

Both types of CBT-I were delivered over 6 to 8 weekly sessions, with 2-week and 3-month posttreatment follow-ups.

An a priori margin of -3.0 points was used in the noninferiority analysis, and all analyses were conducted using mixed-effects models, the authors explain.

Necessary Evil?

In the primary noninferiority analyses, the mean change in ISI score from baseline to 3-month follow-up was -7.8 points for in-person CBT-I, -7.5 points for telehealth, and -1.6 for wait list.

The difference between the CBT-I groups was not statistically significant (t 28 = -0.98, P = .33).

“The lower confidence limit of this between-group difference in the mean ISI changes was greater than the a priori margin of -3.0 points, indicating that telehealth treatment was not inferior to in-person treatment,” the investigators write.

Although there were significant improvements on most secondary outcome measures related to mood/anxiety and daytime functioning, the investigators found no group differences.

The findings suggest that the benefits of telehealth, including increased access and reduced travel time, “do not come with a cost of reduced efficacy,” the researchers write.

The study was conducted prior to the COVID-19 pandemic, the investigators note. However, the results “underscore that the use of telehealth during the pandemic is not a ‘necessary evil,’ but rather a means of providing high quality care while reducing risks of exposure,” they write.

Benefits, Fidelity Maintained

Commenting on the study for Medscape Medical News, J. Todd Arnedt, PhD, professor of psychiatry and neurology and co-director of the Sleep and Circadian Research Laboratory, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, said it is “one of the first studies to clearly demonstrate that the benefits and fidelity of CBT for insomnia, which is most commonly delivered in-person, can be maintained with telehealth delivery.”

Arnedt is also director of the Behavioral Sleep Medicine Program and was not involved in the study. He said the findings “support the use of this modality by providers to expand access to this highly effective but underutilized insomnia treatment.”

Additionally, telehealth delivery of CBT-I “offers a safe and effective alternative to in-person care for improving insomnia and associated daytime consequences and has the potential to reduce healthcare disparities by increasing availability to underserved communities,” Arnedt said.

However, the investigators point out that the utility of this approach for underserved communities needs further investigation. A study limitation was that the participants were “generally healthy and well educated.”

In addition, further research is needed to see whether the findings can be generalized to individuals who have “more complicated health or socioeconomic difficulties,” they write.

The study was funded by a grant from the American Sleep Medicine Foundation and the Doris Duke Charitable Foundation Clinical Scientist Development Award. Gehrman has received research funding from Merck, Inc, is a consultant to WW, and serves on the scientific advisory board of Eight Sleep. The other authors’ disclosures are listed in the original article. Arnedt reports no relevant financial relationships but notes that he was the principal investigator of a similar study run in parallel to this one that was also funded by the American Academy of Sleep Medicine Foundation at the same time.

J Clin Psychiatry. Published online August 24, 2021. Abstract

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