Can the internet cure insomnia?
By Laura Schocker

BBC News Magazine
Wednesday, 26 August 2009 14:38 UK

One out of 10 Britons can’t fall asleep at night. But do new online
treatments for insomnia mean a cure is just a few clicks away?

Midnight’s not so bad. Some quick number crunching and you figure you can
still get six hours of shut-eye before facing the morning.

Two in the morning is a little bleaker. You’re down to four hours – and
that’s if sleep comes right away.

At three, those glowing red numbers on the alarm clock seem to be screaming
one thing: "You’re not getting more than three hours tonight."

By four, you’re ready to give up, grab a laptop and while away the remaining
hours with some mindless web surfing. But maybe it’s not such a bad idea –
that computer screen could just be the solution for insomniacs.

Help with sleeplessness is available on the NHS, but places can be limited
and waiting lists long. But these are free, and the online courses are
currently offered on a commercial basis from the United States.

Number watching

It’s a promise that reads rather like an e-mail spam subject: "End sleepless
nights once and for all – at home." But over the past few years, researchers
have been developing internet-based courses designed to do exactly that.

Now some US studies claim that on-screen therapy may be just as effective as
face-to-face cognitive behavioural therapy.

Everyone who has had a few bad nights of sleep knows the folk remedies.
Drink warm milk, take a hot bath, sip herbal tea, or count sheep.

No luck? It used to seem like the only option was to hope sleep would come,
or to place yourself on a waiting list for a cognitive behavioural
therapist, suffering through wakeful nights and groggy days in the meantime.

"We’re talking about the most common mental health problem in the UK, and
probably the world," says Colin Espie, director of the University of Glasgow
Sleep Centre. "But less than half of people with insomnia mention it to
their doctors."

Many feel insomnia is too trivial to mention to their GP, or they think it’s
something they can manage on their own, says Derk-Jan Dijk, Professor of
Sleep and Physiology at the University of Surrey.

"It’s a cultural thing that sleep is not important," he says. "You may not
want to admit that you didn’t sleep very well during the night because you
were worried about that meeting with your manager."

And even if people are ready to talk about it, they may not have the
resources to do so. Millions of people in the UK have chronic insomnia, but
only several hundred psychologists are trained in this type of therapy. The
NHS is working to make treatment easier to find. The Department of Health
says more than 800 cognitive behavioural therapists are now in training, and
3,600 are expected to be trained by 2011.

And online treatments may have the potential to ease this pressure. It’s a
little more modern than, say, sheep counting, but researchers are focused on
bringing insomnia treatment to the internet. It’s about accessibility, says
Dr Espie, who has examined the approach taken by online courses.

To the masses

With online automated courses, therapy that is typically only available on
an individual or small group basis can be multiplied to reach many more,
says Dr Richard Bedrosian, an American researcher who developed an online
insomnia program.

"We’re trying to provide the service to as many people as we can," he says.
"You can offer these things to millions of people almost as easily as you
can offer them to dozens of people."

Yet whether it’s dozens or millions, how, exactly, do these courses attempt
to tackle insomnia?

These typically take several weeks, include downloadable lessons and,
ultimately, mimic the doctor/patient relationship.

"I basically took the treatment programme that we delivered in a
face-to-face format and turned it into an online format," says Gregg Jacobs,
an insomnia specialist at the University of Massachusetts Medical School,
and founder of an online therapy programme.

Dr Jacobs’ five-lesson, five-week course starts by teaching patients about
insomnia and then offers goals for each week ahead. Patients learn to keep
to a sleep schedule, reduce negative thoughts about sleep and practise
relaxation techniques for day and for night.

"It’s a very safe, very anonymous way of treating their insomnia," he says
of the $25 course.

In week one, for instance, participants learn to give the minute-by-minute
clock watching a rest.

Week two is spent establishing a regular rising time – a tough task for
insomniacs who try to binge on sleep over the weekends to make up for those
sleepless weeknights.

But a bit of commitment – remembering to only lie down when drowsy, to use
the bed for sleep only so no reading or TV watching, and to never spend more
than 20 or 30 minutes awake in bed – can eventually regulate sleep. Dr
Jacobs says about 75% of his patients report significant improvement.

With success rates similar to face-to-face interventions, will online
treatments become a widespread and viable option?

"In many ways, they have advantages over face-to-face care, certainly in the
ability to reach larger audiences and reduce travel time," says Lee
Ritterband, a psychologist at the University of Virginia Health System, who
developed a nine-week online course for a university study. His findings
were published in July’s issue of the Archives of General Psychiatry, a
medical journal.

The advantages are reflected in the numbers, says Dr Ritterband. About
three-quarters of the participants – who all had moderate to severe insomnia
at the start – finished the course without diagnosable insomnia.

Patients also saw improvements in how long it took to fall asleep, how long
they stayed asleep, and how many times they woke through the night.

A similar study at the University of Manitoba in Winnipeg, Canada, also had
similar findings, published earlier this year in the medical journal Sleep.
Some 80% of participants noticed an improvement in their insomnia.

Some experts aren’t yet convinced, though. While Dr Espie, of the University
of Glasgow Sleep Centre, says automated systems can help make insomnia
treatment widely available, others think effective treatment requires the
human touch.

"I’m a bit sceptical. I think many people with insomnia really would like to
have more human contact than they would over the internet," says Jim Horne,
director of the Sleep Research Centre at Loughborough University. "The more
personal the approach between the person who is the sufferer and the
therapist, the better."

TIPS FOR GETTING TO SLEEP

Stay positive – if you worry about not sleeping, you won’t sleep
Good sleepers try to stay awake – don’t dwell on falling asleep
One bad night isn’t the end of good sleeping patterns – there’s always
tomorrow

>From Colin Espie, University of Glasgow Sleep Centre

TREATING INSOMNIA

Don’t nap – the bed shouldn’t be for anything but sleep and sex
Don’t stay in bed longer than 20 minutes. If you’re not asleep, get up and
do something else until you feel tired
Create a pre-sleep routine, like taking a bath or watching TV

>From University of Virginia