Internet and In-Person Cognitive Behavioral Therapy for Insomnia in Military Personnel: A Randomized Clinical Trial

Abstract

Study objectives: Compare in-person and unguided Internet-delivered cognitive behavioral therapy for insomnia (CBTi) with a minimal contact control condition in military personnel.

Methods: A three-arm parallel randomized clinical trial of 100 active duty US Army personnel at Fort Hood, Texas. Internet and in-person CBTi were comparable, except for the delivery format. The control condition consisted of phone call assessments.

Results: Internet and in-person CBTi performed significantly better than the control condition on diary-assessed sleep efficiency (d = 0.89 and 0.53, respectively), sleep onset latency (d = -0.68 and -0.53), number of awakenings (d = -0.42 and -0.54), wake time after sleep onset (d = -0.88 and -0.50), the Insomnia Severity Index (d = -0.98 and -0.51), and the Dysfunctional Beliefs and Attitudes About Sleep Scale (d = -1.12 and -0.54). In-person treatment was better than Internet treatment on self-reported sleep quality (d = 0.80) and dysfunctional beliefs and attitudes about sleep (d = -0.58). There were no differences on self-reported daytime sleepiness or actigraphy-assessed sleep parameters (except total sleep time; d = -0.55 to -0.60). There were technical difficulties with the Internet treatment which prevented tailored sleep restriction upward titration for some participants.

Conclusions: Despite the unique, sleep-disrupting occupational demands of military personnel, in-person and Internet CBTi are efficacious treatments for this population. The effect sizes for in-person were consistently better than Internet and both were similar to those found in civilians. Dissemination of CBTi should be considered for maximum individual and population benefits, possibly in a stepped-care model.

Keywords: Insomnia; cognitive behavior therapy; military; randomized clinical trial; unguided Internet intervention.