Internet Intervention for Insomnia
Q & A Session with Frances Thorndike, PhD
Center for Behavioral Medicine Research at The University of Virginia Health System

What are you studying?
Our NIMH-funded research examines the feasibility of using the Internet to deliver a well-validated, face-to-face, cognitive-behavioral treatment for insomnia. We hypothesize that the intervention will ultimately improve overall sleep as well as mood state and cognitive functioning, which can deteriorate due to sleep loss and fatigue.

Why study insomnia?
Virtually everyone is affected by sleep difficulties at one time or another, and surveys suggest that more adults are experiencing sleep problems on a regular basis. In 2005, the National Sleep Foundation conducted a national survey of adults and concluded that approximately half (54%) of Americans sampled reported experiencing at least one of the four main symptoms of insomnia (trouble falling asleep, problems with waking during the night, waking too early and having difficulty falling back to sleep, feeling unrefreshed upon waking) at least a few nights each week. Furthermore, 33% reported experiencing at least one of these symptoms almost every night during the past year, and 24% of all adults interviewed said that their sleep problems had a negative impact on their daily lives. In addition to being a source of worry, physical discomfort, and moodiness, the estimated annual cost for the treatment of insomnia is in the billions (Stoller, 1997; Stoller, 1994), and approximately 56,000 automobile accidents are attributed to insomnia and fatigue each year (National Institutes of Health, 1998, April).

Fortunately for those with insomnia, cognitive-behavioral therapy (CBT) has been found to have significant short-term and long-term benefits. In fact, experts at the 2005 NIH State-of-the-Science Conference on insomnia concluded that, while medications can be helpful in the short-term for situational insomnia, CBT may offer longer lasting effects for those with chronic insomnia. However, while CBT is often the treatment of choice, availability of CBT for insomnia is limited by many factors, including lack of trained clinicians, poor geographical distribution of knowledgeable professionals, expense, and inaccessibility to treatment due to work schedules and competing commitments. In fact, there are only about 150 board certified sleep medicine specialists with a Ph.D. (Smith, 2001). And, the demand for psychologists who have an expertise in treatment of insomnia is expected to grow (Smith, 2001). To help meet this need for treatment of insomnia, NIMH funded this study to develop and evaluate the feasibility of a more accessible, potentially cost-effective, alternative treatment: an Internet intervention for insomnia.

Why use the Internet to provide treatment?
The Internet has become an important source of healthcare and medical information. As of November 2004, 80% of US adult Internet users, or 95 million Americans, had searched for health related information on the Internet, making this act of looking for health information the third most popular online activity, after email (93%) and researching a product or service before buying it (83%)(Fox & Fallows, 2003). Two-thirds of Internet users had searched for a specific disease or medical problem, and just over half (51%) had searched for information about a particular treatment or procedure (Fox, 2005). The availability of extensive amounts of medical information on the Internet has important implications for the future of our health care system.

What is an Internet intervention and how does it work?
The vast majority of health related websites are informational (Fox & Fallows, 2003; Rabasca, 2000); however, a growing minority of sites provide health interventions which patients can use to self-treat or use in conjunction with face-to-face treatment. Such Internet health interventions are usually behavioral treatments that have been operationalized and transformed for delivery across the Internet. They are typically highly structured; at least semi-self guided; based on effective face-to-face interventions; personalized and tailored to the user; interactive; enhanced with graphics, animations, audio, and possibly video; and designed to allow follow-up and feedback (Ritterband et al., 2003).

While most Internet interventions differ in various ways, there are similarities across programs. Typically, the user enters information about himself or herself into the program. The user then receives some general information about the problem and the components of treatment. The user may also enter additional information about his/her current health status, which can begin the tailoring process. Based on responses from the user, pertinent information and/or treatment recommendations are made available. Users are encouraged to follow these recommendations and to enter follow-up information, providing further personalization of treatment. Symptoms are tracked with the expectation that they will lessen over time.

What are the potential benefits of an Internet intervention?
Internet interventions may lower some of the barriers associated with traditional face-to-face treatments. The inconvenience of scheduling appointments, missing work or school, and traveling to and from a clinician’s office may be decreased by offering an intervention over the Internet since treatment can be available when and where the patient desires. Moreover, Internet interventions enable the presentation of information in rich detail, using audio, video, and animated graphics to promote greater depth of knowledge and understanding of a disorder and its treatment. Internet-based treatment interventions may reduce the total time of treatment, as patients may be able to proceed more quickly through treatment rather than having to wait for subsequent clinician visits. Finally, the financial cost of treatment may be reduced since fewer clinician visits may be needed, and treatment efficacy may be enhanced because patients feel empowered.

How will the current trial be conducted?
During the initial phase, traditional CBT for insomnia (Morin, 1993), including the behavioral, cognitive, and educational aspects, was operationalized and transformed for an Internet intervention system. The program is called SHUTi (Sleep Healthier Using the Internet) and it is in the final stages of development. Pilot testing in scheduled to being this summer, 2006. Forty participants will be randomized (20 will receive the Internet program right away, and 20 will serve as wait-list controls before receiving the program) and assessed before and after the eight-week treatment intervention. Both the pre- and post-treatment assessment batteries will include measures of sleep (self-report diaries and actigraphy), psychological distress, cognitive functioning, and cost-effectiveness. Focus groups will also be held after the program to obtain the participants thoughts and experiences about their use of the Internet intervention. Based on the findings, the system will then be optimized by revising and upgrading necessary aspects of the program to improve overall treatment success.

Who is involved?
I work with an interdisciplinary research group experienced in the areas of Internet interventions (PI: Dr. Lee Ritterband), insomnia (Drs. Charles Morin, Linda Gonder-Frederick), cognitive functioning (Drs. Jeffrey Barth, Scott Bender, Jason Freeman), web development (Mr. Jonathan Sletten), and database integration (Mr. John Ashenfelter). Core members of this team have been successfully developing Internet interventions for the past nine years.

To learn more about our insomnia Internet intervention program, contact Frances Thorndike at fthorndike@virginia.edu.

References:
Fox, S. (May 17, 2005). Health information online. Washington, D.C.: Pew Internet and American Life Project.

Fox, S., & Fallows, D. (July 16, 2003). Internet health resources. Washington, D.C.: Pew Internet and American Life Project.

Morin, C. M. (1993). Insomnia: Psychological assessment and management. New York: The Guilford Press.

National Institutes of Health. (2005). NIH state-of-the-science conference statement on manifestations and management of chronic insomnia in adults. http://consensus.nih.gov/2005/2005InsomniaSOS026html.htm.

National Institutes of Health. (1998, April). Drowsy driving and automobile crashes. A report prepared by the national highway traffic safety administration for the U.S. department of health and human services. Washington, DC: U.S. Department of Health and Human Services.

National Sleep Foundation. (2005). 2005 Sleep in America poll. Washington DC: National Sleep Foundation.

Rabasca, L. (2000). Taking telehealth to the next step. Monitor on Psychology, 31, 37.

Ritterband, L. M., GonderFrederick, L. A., Cox, D. J., Clifton, A. D., West, R. W., & Borowitz, S. M. (2003). Internet interventions: In review, in use, and into the future. Professional Psychology: Research and Practice, 34(5), 527-534.

Smith, D. (2001, October). Sleep psychologists in demand. Monitor on Psychology, 32(9), 36-39.

Stoller, M. K. (1997). The socio-economics of insomnia: The materials and the methods. European Psychiatry, 12(1), 41s-48s.

Stoller, M. K. (1994). Economic effects of insomnia. Clinical Therapeutics, 16(5), 873-97; discussion 854.