JMIR Publications

ABSTRACT

Background:

Insomnia is a prevalent condition with significant health, societal, and economic impacts. Cognitive Behavioral Therapy for Insomnia (CBTI) is recommended as the first-line treatment. With limited accessibility to in-person delivered CBTI (ipCBTI), electronically delivered (eHealth) CBTI (eCBTI), ranging from telephone- and videoconference delivered interventions to fully automated web-based programs and mobile applications, has emerged as an alternative. However, the relative efficacy of eCBTI compared to ipCBTI has not been conclusively determined.

Objective:

To test the comparability of eCBTI and ipCBTI through a systematic review and meta-analysis of equivalence based on randomized trials directly comparing the two delivery formats.

Methods:

A comprehensive search across multiple databases was conducted, leading to the identification and analysis of 15 unique randomized head-to-head comparisons of ipCBTI and eCBTI. Data on sleep and non-sleep outcomes were extracted and subjected to both conventional meta-analytical methods and equivalence testing based on predetermined equivalence margins derived from previously suggested minimal important differences (MIDs). Supplementary Bayesian analyses were conducted to determine the strength of the available evidence.

Results:

The meta-analysis included 15 studies with a total of 1,100 participants. Conventional comparisons generally favored ipCBTI. However, the effect sizes were small, and the two delivery formats were statistically significantly equivalent for most sleep and non-sleep outcomes. Additional within-group analyses showed that both formats led to statistically significant improvements in insomnia severity, sleep quality, and secondary outcomes like fatigue, anxiety, and depression. Heterogeneity analyses highlighted the role of treatment duration and drop-out rates as potential moderators of the differences in treatment efficacy.

Conclusions:

eCBTI and ipCBTI were found to be statistically significantly equivalent for treating insomnia for most examined outcomes, indicating eCBTI as a clinically relevant alternative to ipCBTI. This supports the expansion of eCBTI as a viable option to increase accessibility to effective insomnia treatment. Nonetheless, further research is needed to address the limitations noted, including the high risk of bias in some studies and the potential impact of treatment duration and drop-out rates on efficacy.