Getting a decent night's sleep shouldn't be such a crapshoot. But for the estimated 30% of American adults who suffer from at least occasional insomnia, nightfall is no guarantee of slumber.
To combat wakefulness, Americans filled more than 50 million prescriptions in 2008 for sleeping pills like Ambien and spent more than $600 million on over-the-counter sleep-inducing supplements such as melatonin and valerian root. Others seek medical treatment or psychological therapy to get to sleep, while the rest of us accept our nocturnal tossing and turning as just another of life's unavoidable nuisances and gulp an extra cup of coffee the next morning to compensate.
But despite our best efforts, about 10% of Americans still suffer from persistent insomnia (defined as difficulty initiating or maintaining sleep) — namely, falling asleep or being functionally impaired by sleepiness during the day — and researchers continue to search for its causes and cure. Now a new study in the journal Sleep suggests a surprising treatment for the sleepless: the Internet. Web-based treatments have emerged for all kinds of bad habits and disorders, such as overeating, smoking, depression — and insomnia.
Compared with face-to-face counseling or medical treatments, online therapies are typically simpler and less expensive. Major health insurers like Blue Cross and Aetna even offer Web-based anti-insomnia programs for free. And there's growing evidence that online therapy really works: in the new Sleep study, 81% of participants who completed a five-week, online program for insomnia reported improvement in sleep.
"There may be some unique things that you get from an Internet program, like the feeling that you are really in the driver's seat," says the study's author, clinical psychologist Norah Vincent, who adds that many of the 40 participants who completed her multimedia program reported both better sleep quality and less daytime fatigue than did a control group. "People like to have autonomy in solving problems. I think it motivates them more," she says.
Based on cognitive-behavioral-therapy techniques, Vincent's virtual therapy combines videos, text and audio clips to teach the sleepless everything about good sleep hygiene, from how to relax the body before getting into bed to how not to stress out when you fail to doze off right away. (One of the worst things you can do when you can't fall asleep is lie there and dwell on the consequences of not getting enough sleep.) Participants in her study were asked to keep digital sleep diaries and practice the techniques that were demonstrated onscreen. They were also allowed to download audio clips of a sleep therapist and an actor in a staged one-on-one session and listen to them on their iPods.
While prior studies have shown that online therapy can help alleviate insomnia, little research has compared it directly with other approaches. Vincent's study, on the other hand, found that 35% of those who received online treatment reported that they were "much" or "very much" improved, compared with 50% of those who received in-person group therapy using the same behavioral-cognitive approach at Vincent's sleep clinic at the University of Manitoba in Canada. The benefit of the online strategy, of course, is that it can work for people who don't have access to face-to-face therapy.
Some proponents of online therapy say it may actually be more effective than in-person counseling. "You don't have to worry about personalities, and you can go over the material over and over," notes Gregg Jacobs, an insomnia specialist at the University of Massachusetts Medical School, who has offered a self-guided online program for the past two years. Since patients don't have to make time for in-office appointments and can proceed at their own pace, Web-based programs have the potential to reach a much broader audience.
But computer counseling has its detractors, particularly when it fails to get at the root of patients' sleep issues. "There is only so far you can go with it," notes Dr. S.K. Mostafavi, who runs the Advanced Sleep Medicine Services chain of sleep clinics in Southern California and has served as a sleep "guru" for the popular weight-loss reality show The Biggest Loser. Online therapy can be helpful as an educational tool, says Mostafavi, but he cautions, "You don't have the benefit of talking to a professional and finding out what is causing the insomnia." (Insomnia may be a side effect of an underlying condition, such as anxiety, Alzheimer's, arthritis or asthma, or it can result simply from poor sleep habits, like failing to keep a regular bedtime.) Vincent concedes that patients who have deeper problems — those who are depressed or suicidal — or have trouble concentrating are unlikely to benefit from the program.
As digital therapy evolves, "one of the tricks is to identify who will respond best to online treatment," notes Dr. Michael Sateia, director of sleep medicine at Dartmouth-Hitchcock Psychiatric Associates in Lebanon, N.H. "Sleep medicine is still in its childhood, and for decades we have lived in a culture where pharmacological therapies have been the mainstay. But we are beginning to change that mentality." Sateia's center, for example, recently hired a nurse practitioner to offer more affordable group therapy as an alternative to individual counseling by a psychiatrist.
One area that has been studied extensively is the benefits of cognitive-behavioral therapy vs. those of medication. A recent study in the Journal of the American Medical Association found that while cognitive therapy alone or in combination with medication worked equally well to treat insomnia in the short term, patients fared better over the long term with talk therapy alone. "Cognitive therapy should be a first-line approach," says the study's lead author, Charles Morin, "but many people do not have access to it."
With demand far outstripping supply for therapists trained to treat sleep problems, online programs are "a very innovative and cost-effective way of looking at insomnia therapy," says Morin. There may be no single cure-all for sleeplessness, but such promising alternatives should help more night owls wake in the morning feeling refreshed.
