CBT for insomnia – the science behind Sleepio

Cognitive Behavioural Therapy (CBT) techniques have been shown in numerous clinical trials to help overcome even long term insomnia. Here Professor Colin Espie explains CBT for insomnia and how the science behind it inspired the Sleepio online sleep improvement programme.

What is CBT for insomnia?

Cognitive Behavioural Therapy, or 'CBTi' for short, trains people to use techniques that address the mental (or cognitive) factors associated with insomnia, such as the 'racing mind', and to overcome the worry and other negative emotions that accompany the experience of being unable to sleep.

Fig 1.
The vicious cycle of poor sleep and how CBT for insomnia can help overcome it.
CBT for insomnia addresses the negative cycle of thoughts, feelings and behaviours underlying insomnia

In addition, CBT helps people with poor sleep establish a healthy sleep pattern. This behavioural element supports people to develop a 'pro-sleep' routine and to achieve strong connection between bed and successful sleep, meaning that falling asleep and staying asleep in bed becomes more automatic and natural.

CBT for insomnia is usually delivered over the course of 6 to 8 weekly face-to-face sessions with a trained therapist, who teaches the person techniques that they can use at home to help themselves improve their sleep. Now online programmes such as Sleepio allow people to access these proven, tailored techniques and receive continuous support, all via the web.

Cognitive behavioural therapy also teaches people how to get a more reliable sleep from night to night. Most poor sleepers have a very unpredictable sleep pattern. They live with uncertainty of what the night will hold for them, compared with good sleepers, who can rely on their sleep being stable and satisfying.

The consequences of improved sleep and less sleep-related worry are that most people who follow a CBT programme for insomnia feel much better during the daytime too. Indeed, many of the techniques that people learn are helpful for the stresses and strains of daily living because they help people feel more organised and more in control in general.


Does CBT for insomnia work?

CBT is what we call an 'evidence-based therapy', meaning that it has been shown to be effective in controlled scientific clinical studies. The earliest research in fact goes back more than 30 years, so several decades of evidence has accumulated to show that CBT can teach people how to fall asleep faster, stay asleep and feel better during the day.

'Randomised Controlled Trials' (or RCTs) are the gold standard method for evaluating whether a treatment is effective. Participants are randomly allocated to receive the treatment in question, no treatment or, in some cases, a placebo (ie. false but convincing) treatment. By comparing differences between groups we can confidently assess whether the real treatment truly works, and confirm that any improvements are not down to chance, some other external factor such as changes in the weather, or to people just believing they will get better. CBT for insomnia has been assessed in over 100 RCTs, and the results show that on average 70% of people with even very long term poor sleep obtain lasting benefit from the treatment.

Scientific studies have also shown that poor sleepers generally would prefer a practical approach based on CBT compared with taking sleeping pills. Indeed, the evidence is that CBT helps most people achieve sustained long-term improvements in their sleep, whereas the effects of sleeping pills are mostly short-term. On the basis of such findings, advisory bodies in the UK, USA and elsewhere advocate CBT as the preferred option for persistent poor sleep problems.


Does the Sleepio course work?

The Sleepio team is committed to an evidence-based model, so that the course can be as effective and as up-to-date as possible. This means that we have an ongoing programme of research to test the effectiveness of what we are offering.

We have recently completed our very first randomised controlled trial (RCT) employing the most rigorous scientific standards. In our study we conducted what is known as a placebo-controlled RCT. That is, we compared CBT not only to a control group who had no treatment, but also to a placebo condition. Since this type of trial tests whether improvements are due to chance or a 'placebo effect' (ie. people feeling better simply because they are being helped in some way or expect to improve) we can be fairly confident of our findings. In addition our trial is the first of its kind in the world to evaluate online CBT for poor sleep in a placebo controlled design.

A total of 164 people with persistent insomnia (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.

Fig 2.
Average reduction in time to fall asleep after using the Sleepio course.
After using the Sleepio CBT course, on average time taken to fall asleep decreases by 50%

We will continue to evaluate Sleepio as time goes on, but we are very pleased that the results from this first study confirm what is reported in the wider scientific literature, that CBT techniques are effective in addressing poor and disrupted sleep. But remember, Sleepio is not intended to address any medical problem. If you have any reason to believe you are suffering from a pre-existing medical condition, or if you frequently struggle to stay awake during the day or fall asleep during the daytime without intending to, then please consult your doctor before starting the Sleepio course.