Digital Cognitive Behavioral Therapy (dCBT) for Insomnia: a State-of-the-Science Review
Curr Sleep Medicine Rep
Digital Cognitive Behavioral Therapy (dCBT) for Insomnia: a State-of-the-Science Review
Annemarie I. Luik 0 1
Simon D. Kyle 0 1
Colin A. Espie 0 1
0 Big Health Ltd , London , UK
1 Sleep and Circadian Neuroscience Institute, Nuffield Department of Clinical Neurosciences, University of Oxford , OMPI G, South Parks Road, Oxford OX1 3RE , UK
2 Colin A. Espie
Purpose of Review Over the past decade, digital solutions have been developed to support the dissemination of Cognitive Behavioral Therapy (CBT). In this paper, we review the evidence for and implications of digital CBT (dCBT) for insomnia. Recent Findings We propose three categories of dCBT, which differ in the amount of clinician time needed, level of automatization, costs, and scalability: dCBT as support, guided dCBT, and fully automated dCBT. Consistent evidence has been published on the effectiveness of dCBT to address insomnia disorder, in a variety of populations, with effects extending into well-being. Important gaps in the literature are identified around moderators and mediators of dCBT, costeffectiveness, and the implementation of dCBT. Summary The evidence base for dCBT is rapidly developing and already suggests that dCBT for insomnia is effective. However, further science and digital innovation is required to realize the full potential of dCBT and address important clinical questions.
Insomnia; Cognitive Behavioral Therapy; Digital CBT
Introduction
The ubiquitous nature of web and smartphone technology has
changed our lives in every way imaginable, including offering
new approaches to the evaluation and treatment of many
disorders. Over the past decade, digital solutions, for example via
web and mobile devices, have been developed to support the
dissemination of Cognitive Behavioral Therapy (CBT). These
are of particular interest to the insomnia field because CBT
has emerged as the recommended first-line therapy for
insomnia [
1
]. Correspondingly, perhaps the 5-year period ending in
December 2016 saw a substantial increase in published
papers, with approximately one paper featuring digital CBT
(dCBT) for insomnia published per month, whereas less than
a handful of articles were published prior to 2012.
Undoubtedly, therefore, the evidence base has substantially
increased. However, CBT for insomnia, in whichever form,
still faces a lot of challenges such as costs and scalability [
2,
3
]. Similar to the dissemination of conventional CBT, the
dissemination of dCBT remains limited.
What Is BDigital CBT^ for Insomnia?
CBT has traditionally been a face-to-face talking therapy,
delivered in a direct one-to-one relationship between patient and
therapist. It also has been demonstrated that CBT can be
provided successfully as a group therapy [
4
], in large workshops
[
5
], as a self-help bibliotherapy [
6
], or by telephone [
7
]. These
methods reflect attempts at Bscaling^ CBT to meet the
population need. However, they are by no stretch sufficient if our
ambition is to make CBT as ubiquitous as pharmacotherapy. It
is in fact a perfectly reasonable ambition to provide CBT to
the tens of millions of people who might benefit, considering
that CBT’s evidence base is stronger than that of
pharmacotherapy—the problem is that providing CBT to a large
population is not even remotely feasible using traditional
methods of dissemination. Potentially, technology can bridge
that feasibility gap, with digital solutions offering the
possibility of true scalability.
Although several terms have been used to describe
technological advances, for example internet CBT (iCBT),
computerized CBT (cCBT), electronic CBT (eCBT), or online CBT
(oCBT), we have suggested that the field recognizes and
evolves towards the term Bdigital CBT (dCBT)^ to reflect
the contemporary spectrum of digital technology, rather than
one specific, and most likely historical aspect (e.g. computer
or internet) that will soon enough be lost in the mists of time
[
3
]. There can be little doubt that the pace of change in this
digital age will afford unrelenting opportunity for the
dissemination of dCBT. The corollary to this, however, is that all
forms of dCBT will be perpetually out of date unless they
remain at the forefront of digital innovation. Consequently, it
will not be the provenance, content, validation, or outcome
data associated with any particular dCBT program that
determines its longevity but its level of execution. For clinicians
and patients wherever they may be to have ready and
sustained access to high quality, engaging, and effective
CBT, we need both clinical excellence and creative genius,
as illustrated in Fig. 1.
Supportive to Fully Automated dCBT
For convenience, to present a model of how CBT may be
offered using technology, and to summarize progress in the
field to date, we will use the term dCBT for all interventions,
but the reader should note that the literature to date comprises
everything from optimized web sites through t (...truncated)