Internet-based Cognitive Behavioral Therapy For Insomnia(ICBT-i): Meta-Analysis And Randomized Controlled Trials

Background and purposeRecently,the curing to insomnia mainly contains drug therapy(sedative hypnotic drug)and cognitive behavioral therapy.The drug therapy takes the advantages that it works quickly,relieve insomnia symptom quickly and has a better short term curative effect.But in the long term use of drug,patients suffer unpleasant effects including dependence to drugs,damage to cognitive functions and heavy rebound phenomenon after drug suspension.A lot of researches show that short term CBT(4 to 8 weeks)is as good as curing with sedative drugs and hypnotics,no cognitive damage and drug dependence found in long term therapy and curative duration lasts longer.So,CBT is the first therapy to cure insomnia.CBT mainly contains stimulus control therapy,sleep restriction therapy,sleep health education,cognitive therapy and relaxation therapy.However,in hospital work,it is not popular to carry out traditional face to face CBT.It is not because of curative effect but long curative duration,high curing expense,lack of therapists and difference on patients locations etc.which affect the carry out of CBT.With the rapid development of internet and its help,internet cognitive based therapy(ICBT)realized the flexible implementation of CBT,came over the limitation of time and space,resolved the problem that there is a lot of patients and much more less therapists available.So,ICBT became an important method to cure insomnia.But the curative effect of ICBT differs based on different researches and the differences between traditional face to face CBT,drugs therapy and ICBT remains unknown.This paper plans to do a systematic evaluation and Meta analyze on ICBT curative effect to insomnia;to provide a medicine support for ICBT;to understand the curative effect on insomnia by comparing the improvement to sleeping parameters,anxious and depression with ICBT,traditional face to face CBT and taking Zolpidem.Material and methodMeta analysis: searching PubMed,Cochrane Library,EMBASE and Psyc INFO database,the searching time set as from the database setup time to July 2015.Select papers to implement system evaluation and Meta analysis according to inclusion and exclusion criterion.The criterion is: 1)the basic situation of papers: first author,publishing time,sampling size,female percentage,average value and standard deviation of age,the scale of anxious and depression,diagnostic criteria for insomnia,nations;2)the number of dropout cases in experimental group and control group after interference;3)the interference methods(including sleep restriction,stimulus control,relaxation,sleep health education and cognitive therapy etc.)and durtion of experimental group,the methods and time of control group,interviewing time;4)the research indicator: sleep onset latency(SOL),wake after sleep onset(WASO),total sleep time(TST),sleep efficiency(SE),number of awakenings(NOA),time in bed(TIB),Insomnia Severity Index(ISI),anxious scoring,depression scoring.The screening of papers and selecting of documents are implemented by 2 researchers independently.They discuss and resolve disagreements when they occur.Software Rev Man5.2 and Stata 13.0 are adopted to execute meta analysis.Randomized controlled trials: 85 cases of insomnia were collected in sleep psychology and neurology department of Daping Hospital form June 2015 to August 2015 which according Diagnostic and Statistical Manual of Mental Disorders Fifth Edition(DSM-5)and randomly divied into the ICBT group(n=30 cases),CBT group(n=28 cases)and Zolpidem group(n=27 cases).Records patients information(including name,age,sex,marital status,education,occupation,past history of other diseases,a history of drug addiction,the use of sedative-hypnotics,etc.).Patients with continuous recording of sleep diaries(including SOL,TST,TIB,SE,WASO and NOA,etc.)for 8 weeks.The levels of anxiety and depression were measured with Hamilton Depression Scale(HAMD)and Hamilton Anxiety Scale(HAMA)in pre-intervention,4th week and post-intervention.Statistical analysis was performed by SPSS 18.0 software.ResultMeta analysis showed: A total of 1147 potentially relevant records were retrieved,13 records that comprised 14 studies were included.Fourteen studies reported the date of SOL,TST,and SE,10 studies reported WASO,8 reported ISI and depression scale,6 reported anxiety scale,and 4 studies reported TIB.The effect size of ICBT-i on TST,SOL,SE,WASO,NOA,TIB,and ISI were 21.86,18.29,9.27%,21.26,0.51,14.83,and 6.02,respectively.The effect size of depression and anxiety were 0.40 and 0.34.Randomized controlled clinical trials showed: Compared with before treatment TST,SOL,SE,WASO,NOA and TIB significantly improved in three groups at fourth week and post-intervention,the levels of anxiety and depression were significantly lower and the difference were statistically significant(P <0.05).At fourth week,the difference of TST,SE,WASO in ICBT group were higher than zolpidem group,SE was lower than CBT group,WASO was higher than CBT group and the difference were statistically significant(P <0.05).At post-intervention,the level of anxiety and depression in CBT group and ICBT group were lower than zolpidem group.In addition to the level of depression,the difference of SOL,TST,TIB,SE,WASO,NOA and anxiety in ICBT group and CBT group was not statistically significant(P> 0.05).ConclusionSystematic Review and Meta-analysis results show that ICBT for insomnia not only have improvement on SOL,TST,TIB,SE,WASO and NOA,but also have a effect of anxiety and depression.The treatment is worthy of clinical.Randomized controlled clinical trial results show that,the speed of insomnia improve in ICBT was slow than medication,but at post-intervention,the efficacy of ICBT is superior to medication and equal with CBT.