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Tackling insomnia may be key to easing mental health issues

Online CBT study shows improvements largely result of better sleep patterns

Caroline White

Thursday, 07 September 2017

Tackling insomnia may be key to easing mental health issues, suggest the results of the largest study* of its kind, published in The Lancet Psychiatry today.

Treating sleeplessness with a digital cognitive behavioural therapy (CBT) programme improved sleep quality and reduced transient paranoia and hallucinations, as well as easing the symptoms of depression and anxiety, the findings showed.

The improvements in mental health were largely a result of better sleep, suggesting that sleep deprivation might have a causal role in the development of some mental health symptoms, say the authors. 

Some 3,755 university students with insomnia were randomly assigned to receive either digital CBT for insomnia (1,891 people) or not (1,864). Both groups had similar rates of interaction with mental health services (18%).

The CBT was delivered via a digital programme called Sleepio, accessible through a web browser. It involves six sessions of 20 minutes each, and includes behavioural, cognitive and educational components, presented by an animated therapist. Participants complete daily sleep diaries throughout, which are used by the programme to tailor the advice provided.

Participants completed online assessments on their levels of insomnia and experiences of paranoia and hallucinations. These were completed at the start of the study, during the therapy (three weeks), at the end of the therapy (10 weeks) and three months later (22 weeks).

At 10 weeks, the sleep intervention had reduced insomnia by 4.78 points (0-32 point scale), and experiences of paranoia and hallucinations by 2.2 and 1.58 points, respectively.

Depression, anxiety, psychological wellbeing, nightmares and perceived functioning also improved in the students on the programme.

The effects on depression and anxiety are consistent with other studies, but more research is needed to confirm these effects, say the authors. Sleep therapy did not affect contact with mental health services, but longer-term monitoring might be needed to test this, they suggest.

Further analyses showed that improvements in sleep accounted for almost 60% of the change in experiences of paranoia and hallucination after treatment.

“Sleeping well can help shift our blues, reduce our fears, and make us happier. When it comes to psychological disorders, sleep problems are very much the poor relation. For too long, insomnia has been trivialised as merely a symptom, languishing way down in the league table of problems to be tackled. However, how well we sleep might actually play a role in our mental health,” says lead author, Professor Daniel Freeman, University of Oxford.

“For many people, insomnia can be part of the complex package of causes of mental health difficulties. If you can sort out your sleep, you could also be taking a significant step forward in tackling a wide range of psychological and emotional problems,” he adds.

The authors note that while some participants may have had a mental health diagnosis, further research is needed to understand whether the findings apply to patients with clinical diagnoses of mental health disorders, or with more severe symptoms of psychosis.

Mental health problems are caused by a wide range of factors, both genetic and environmental, and the findings do not imply that sleep deprivation is the largest cause of psychotic experiences; rather, that it may be a contributing factor in the development of some mental health symptoms.

Similar to other studies using online therapies, the drop-out rate was high at about 50%, and not everyone involved in the trial completed all the sessions (50% accessed at least two sessions, and 18% accessed at six).

In a linked comment,** Dr Tea Lallukka, University of Helsinki, and Professor Børge Sivertsen, Norwegian Institute of Public Health, write: “The findings highlight the potential benefits of the implementation of easily available and low-cost internet therapies for insomnia.

“Treatment of insomnia might help reduce the burden of mental ill health and prevent onset of symptoms such as hallucinations and paranoia. The findings add to our understanding of the significance of insomnia as a causal factor in mental ill health, and corroborate findings from observational studies or smaller trials.”


* Freeman D, Sheaves B, Goodwin GM, et al. The effects of improving sleep on mental health (OASIS): a randomised controlled trial with mediation analysis. The Lancet Psychiatry, September 2017. DOI: 10.1016/S2215-0366(17)30328-0

** Lallukka T, Sivertsen B. Sleep improvement by internet-based cognitive behavioural therapy might help prevent mental health disorders. The Lancet Psychiatry, September 2017. DOI: 10.1016/S2215-0366(17)30360-7

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