Online CBT for Insomnia Also Cuts Paranoia, Hallucinations

Deborah Brauser

October 23, 2017

Online cognitive-behavioral therapy (CBT) for insomnia effectively treats the sleep disorder and also dramatically reduces the subsequent occurrence of psychotic symptoms, including paranoia and hallucinations, as well as symptoms of other mental health disorders, such as anxiety and depression, new research shows.

The randomized OASIS (Oxford Access for Students Improving Sleep) trial, which included almost 3800 university students with sleep problems, showed that those who received CBT experienced a 50% reduction in insomnia scores at 10 weeks. In addition, they had mean 4- and 2-point score reductions on paranoia and hallucination scales, respectively. These outcomes were all significantly better than outcomes for participants who received usual care.

Furthermore, mistrust scores in the CBT group decreased by 25%, anxiety and depression scores each decreased by 20%, and happiness levels increased by 10%.

"This clinical trial presents an open-and-shut case ― getting our shut-eye improves psychological health. Sleeping well helps shift our blues, reduces our fears, and makes us happier," lead author Daniel Freeman, PhD, Department of Psychiatry, University of Oxford and Warneford Hospital, United Kingdom, told Medscape Medical News.

Dr Daniel Freeman

In other words, "nighttime sleep success brings a cascade of daytime benefits," he added.

The findings are published in the October issue of Lancet Psychiatry.

Benefits for the Mind

Noting the importance of treating insomnia, Dr Freeman pointed out its potential impact with respect to many other emotional and psychological difficulties.

"The intriguing implication is that in the wake of treating sleep problems, there may be multiple benefits for the mind."

To definitively establish what these benefits may be, the investigators conducted "what may well be the largest randomized clinical trial in mental health research," said Dr Freeman.

The investigators note that CBT is recommended in clinical guidelines as first-line treatment for insomnia and that digital forms of this intervention have been shown to be effective.

Between March 2015 and February 2016, 3755 students with insomnia, defined as having a score of 16 or lower on the Sleep Condition Indicator (SCI), from 26 UK universities were enrolled into the OASIS trial.

All were randomly assigned to receive 10 weeks of digital CBT (n = 1891; 72% women; mean age, 24.8 years) or usual care (n = 1864; 71% women; mean age, 24.6 years).

The interactive, Webbased, insomnia-focused intervention, known as Sleepio, included six 20-minute CBT sessions presented by an animated therapist. Self-completed daily sleep diaries ensured that the program provided tailored advice.

Usual care, which was administered to the control group, consisted of the current care that a participant was receiving. "The amount of treatment input was likely to be minimal, with prescription of medication for a small proportion," the researchers write. This group was also given the option of participating in Sleepio after their last study assessment.

All of the study participants completed online assessments of the primary outcomes of insomnia, paranoia, and hallucinations at baseline, at 3 weeks, at 10 weeks (end of study), and at 3-month/22-week follow-up.

Insomnia was measured on a scale of 0 to 32 (32 was defined as the best sleep) on the eight-item SCI-8; paranoia was measured on part B of the Green et al Paranoid Thought Scales (GPTS); and hallucinations were measured on a scale of 0 (not at all) to 5 (more than once a day) on the Specific Psychotic Experiences Questionnaire-Hallucinations subscale (SPEQ).

Secondary outcomes included scores on the Insomnia Severity Index (ISI), the Disturbing Dreams and Nightmare Severity Index, the Prodromal Questionnaire for psychotic experiences, the nine-item version of the Patient Health Questionnaire, the seven-item version of the Generalized Anxiety Disorder Scale, the Altman Mania Scale, the Warwick-Edinburgh Mental Wellbeing Scale, and the Work and Social Adjustment Scale.

There was a 50% dropout rate, which was greater in the CBT group than in the control group. However, "baseline scores for the three primary outcomes...were not associated with later missingness."

A Causal Link to Psychosis

At baseline, for the treatment group, the unadjusted mean insomnia score on the SCI-8 was 9.9. This improved to a mean of 18.08 at 10 weeks (signifying better sleep). Paranoia scores on the GPTS decreased from 25.4 to 21.06, and hallucination scores on the SPEQ decreased from 5.3 to 3.12.

In addition, the digital CBT intervention was associated with significantly greater improvements in all three primary outcomes at 3, 10, and 22 weeks vs usual care (all comparisons, P < .0001).

Table. Differences in Primary Outcomes for CBT vs Usual-Care Groups

Outcomes at 3 Weeks Adjusted Difference (95% CI*)
Improved insomnia scores 2.62 (2.19 - 3.06)
Reduced paranoia scores -1.81 (-2.49 to -1.13)
Reduced hallucination scores -0.79 (-1.15 to -0.42)
Outcomes at 10 Weeks  
Improved insomnia scores 4.78 (4.29 - 5.26)
Reduced paranoia scores -2.22 (-2.98 to -1.45)
Reduced hallucination scores -1.58 (-1.98 to -1.18)
Outcomes at 22 Weeks  
Improved insomnia scores 4.81 (4.29 - 5.33)
Reduced paranoia scores -2.78 (-3.60 to -1.96)
Reduced hallucination scores -1.56 (-1.99 to -1.14)
*95% CI, 95% confidence interval


At weeks 10 and 22, the treatment group also demonstrated significantly greater reductions in nightmares, prodromal psychosis symptoms, depression, anxiety, and insomnia on the ISI than the control group ― and they showed greater improvements in well-being and functioning (all comparisons, P < .0001).

The treatment group was significantly less likely to have a depressive episode or an anxiety disorder or to be at "ultra-high risk of psychosis" than the usual-care group. However, they were found to have a small yet sustained increase in mania symptoms and to be at greater risk of having a manic episode.

Overall, the results provide "strong evidence that insomnia is a causal factor in the occurrence of psychotic experiences," write the investigators.

However, they note that because the study population was made up of students, further testing is required to determine whether the results are generalizable.

Still, they write that "the results are likely to apply to the wider adult population. We used a treatment developed for adults, which was not modified for students."

"For too long, insomnia has been trivialized as merely a symptom, languishing way down in...problems to be tackled. However, how well we sleep might actually play a role in our mental health," Dr Freeman noted in a release.

He added that getting sufficient sleep should be seen as just as important as eating a healthy diet or going to the gym regularly.

"Typically, the assessment and treatment of sleep problems are an afterthought in the training of mental health professionals. This inattention then gets taken into clinical practice, so that too few patients get their problems taken seriously," he told Medscape Medical News.

"We think the treatment of sleep problems should actually be front and center in mental health services."

A Growing Concern

"Insomnia and mental health disorders are growing public health concerns," Tea Lallukka, PhD, Finnish Institute of Occupational Health in Helsinki, Finland, and Børge Sivertsen, PhD, PsyD, Regional Center for Child and Youth Mental Health and Child Welfare, Uni Research Health, Bergen, Norway, write in an accompanying editorial.

"Furthermore, both...typically emerge during adolescence, highlighting the significance of early detection and prevention efforts," they add.

The current study's findings showcase "the potential benefits of the implementation of easily available and low-cost internet therapies for insomnia" and support the view that insomnia can be a causal factor in mental health problems, they write.

The editorialists add that further research is needed to address some of the study's limitations, including the need for additional population groups, longer follow-ups, and further analysis of patient subgroups to better elucidate treatment aspects.

Still, "the evidence...suggests that treatment of insomnia has potential in the improvement of [students'] overall mental health and wellbeing, and online therapy is an effective strategy in reaching wide numbers of participants," write Dr Lallukka and Dr Sivertsen.

The study was supported by the Wellcome Trust. Dr Freeman has received grants from the Wellcome Trust and nonfinancial support in the form of the trial's sleep treatment from Sleepio. He has also received grants from the UK National Institute of Health Research and personal fees from Oxford Virtual Reality. The original article includes a full listing of disclosures for the other study authors. The editorialists have disclosed no relevant financial relationships.

Lancet Psychiatry. 2017;4:734-735 and 749-758. Full text, Editorial

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