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By ANITA HAMILTON Anita Hamilton Mon Jun 1, 1:40 am ET
Getting a decent night's sleep shouldn't be such a crapshoot. But for an
estimated 30% of American adults who suffer from at least occasional insomnia,
nightfall is no guarantee of slumber.
To combat wakefulness, Americans filled more than 50 million prescriptions in
2008 for sleeping pills like Ambien, and spent more than $600 million on
over-the-counter sleep-inducing supplements such as melatonin and valerian
root. Others seek medical treatment or psychological therapy to get to sleep,
while the rest of us accept our nocturnal tossing and turning as just another
of life's unavoidable nuisances, and gulp an extra cup of coffee the next
morning to compensate. (See the Year in Health, from A to Z.)
But despite our best efforts, about 10% of Americans still suffer from
persistent insomnia (defined as difficulty initiating or maintaining sleep) -
namely falling asleep or being functionally impaired by sleepiness during the
day - and researchers continue to search for its causes and cure. Now a new
study in the journal Sleep suggests a surprising treatment for the sleepless:
the Internet. Web-based treatments have emerged for all kinds of bad habits and
disorders, such as overeating, smoking, depression - and insomnia. (Read "Can a
Sleep Disorder Predict Parkinson's?")
Compared with face-to-face counseling or medical treatments, online therapies
are typically simpler and less expensive. Major health insurers like Blue Cross
and Aetna even offer Web-based anti-insomnia programs for free (you can check
out the retail versions at cbtforinsomnia.com or myselfhelp.com for as little
as $20). And there's growing evidence that online therapy really works: in the
new Sleep study, 81% of participants who completed a five-week, online program
for insomnia reported improvement in sleep.
"There may be some unique things that you get from an Internet program, like
the feeling that you are really in the driver's seat," says the study's author,
Norah Vincent, a clinical psychologist, who adds that many of the 40
participants who completed her multimedia program reported both better sleep
quality and less daytime fatigue than a control group. "People like to have
autonomy in solving problems. I think it motivates them more," she says. (Read
"Online Helpdesk.")
Based on cognitive behavioral therapy techniques, Vincent's virtual therapy
combines videos, text and audio clips to teach the sleepless everything about
good sleep hygiene, from how to relax the body before getting into bed to how
not to stress out when you fail to doze off right away. (One of the worst
things you can do when you can't fall asleep is to lie there and dwell on the
consequences of not getting enough sleep.) Participants were asked to keep
digital sleep diaries and complete practice the techniques that were
demonstrated onscreen. They were also allowed to download audio clips of a
sleep therapist and an actor in a staged, one-on-one session and listen to them
on their iPods.
While prior studies have shown that online therapy can help alleviate insomnia,
little research has compared it directly with other approaches. Vincent's
study, on the other hand, found that 35% of those who received online treatment
reported that they were "much" or "very much" improved compared with 50% of
those who received in-person group therapy using the same behavioral cognitive
approach at Vincent's sleep clinic at the University of Manitoba in Canada. The
benefit of the online strategy, of course, is that it can work for people who
don't have access to face-to-face therapy.
Some proponents of online therapy say it may actually be more effective than
in-person counseling. "You don't have to worry about personalities, and you can
go over the material over and over," notes Gregg Jacobs, an insomnia specialist
at the University of Massachusetts Medical School, who has offered a
self-guided, online program for the past two years. Since patients don't have
to make time for in-office appointments and can proceed at their own pace,
Web-based programs have the potential to reach a much broader audience.
But computer counseling has its detractors, particularly when it fails to get
at the root of patients' sleep issues. "There is only so far you can go with
it," notes Dr. S.K. Mostafavi, who runs the Advanced Sleep Medicine Services
chain of sleep clinics in Southern California and has served as a sleep "guru"
for the popular weight-loss reality show The Biggest Loser. Online therapy can
be helpful as an educational tool, says Mostafavi, but cautions, "you don't
have the benefit of talking to a professional and finding out what is causing
the insomnia." (Insomnia may be a side effect of an underlying condition, such
as anxiety, Alzheimer's, arthritis or asthma, or it can result simply from poor
sleep habits, like failing to keep a regular bedtime.) Vincent concedes that
patients who have deeper problems - those who are depressed or suicidal - or
have trouble concentrating are unlikely to benefit from the program.
As digital therapy evolves, "one of the tricks is to identify who will respond
best to online treatment," notes Dr. Michael Sateia, director of sleep medicine
at Dartmouth-Hitchcock Psychiatric Associates in Lebanon, N.H. "Sleep medicine
is still in its childhood, and for decades we have lived in a culture where
pharmacological therapies have been the mainstay. But we are beginning to
change that mentality." Sateia's center, for example, recently hired a nurse
practitioner to offer more affordable group therapy as an alternative to
individual counseling by a psychiatrist.
One area that has been studied extensively is the benefits of cognitive
behavioral therapy compared with those of medication. A recent study in the
Journal of the American Medical Association found that while cognitive therapy
alone or a combination of cognitive therapy and medication worked equally well
to treat insomnia in the short term, patients fared better over the long term
with talk therapy alone. "Cognitive therapy should be a first line approach,"
notes the study's lead author, Charles Morin, "but many people do not have
access to it."
With demand far outstripping supply for therapists trained to treat sleep
problems, online programs are "a very innovative and cost-effective way of
looking at insomnia therapy," says Morin. There may be no single cure-all for
sleeplessness, but such promising alternatives should help more night owls wake
in the morning feeling refreshed.