From the Editor

It’s one of the most common patient complaints: I can’t sleep.

What many of our patients aspire to…

Insomnia affects 6 to 10% of the population. It’s a common problem – and often chronic. But are we mishandling insomnia?

In a two-part, two-week series, we look at the latest in insomnia research.

Last week. Fewer Pills, More Therapy. The new Clinical Practice Guidelines.

This week. Insomnia, Is There an App for That? The GoodNight Study.

This week, turning to a new paper from The Lancet Psychiatry, we consider an online insomnia program to prevent depression relapse.


Depression Relapse and Sleep

“Effectiveness of an online insomnia program (SHUTi) for prevention of depressive episodes (the GoodNight Study): a randomised controlled trial”

Helen Christensen et al., The Lancet Psychiatry, April 2016


Major depressive disorder is preventable in 25% of cases with use of cognitive behaviour therapy (CBT). However, prevention of depression is hugely challenging. Most depression cases have an onset in young people unaware that they are at risk; furthermore, the causal pathways are poorly understood and are not associated with any specific biomedical or psychosocial marker, doctors do not routinely detect depression risk, help seeking is low, and CBT can be difficult to access.

One promising strategy to prevent depression in people at risk might be to target insomnia, in view of the high co-occurrence of the two disorders. Evidence suggests that insomnia is associated with, but distinct from, depression, and is also linked to other psychiatric and behavioural disorders, such as schizophrenia, anxiety, and suicide.

Nevertheless, depression is the highest comorbid disorder: 35–47% of people with insomnia have clinically significant depression and 60–84% of people with major depressive disorder have significant insomnia symptoms.

Helen Christensen

So opens a new paper published in The Lancet Psychiatry.

The authors are clear in their goal: “we did the GoodNight Study to establish whether insomnia could be a primary preventive target for individuals with high depression symptomatology, but not meeting criteria for a diagnosis of major depressive disorder.” They thus target insomnia – but with a twist. They use an Internet-based intervention: SHUTi, which focuses on sleep, not mood or anxiety.

They chose an Internet intervention because of the ease of dissemination and, also, because studies suggest that 17% of patients don’t seek help for this mental health problem because of stigma.

Here’s what the authors did:

· Essentially, they did a randomized controlled trial involving adults, targeting depressive symptoms with website-based intervention (vs. a control website), and using social media advertising for recruitment.

· Initial inclusion criteria included subclinical depression and the presence of insomnia (using PHQ-9 and Bergen Insomnia Scale). A telephone administered interview (MINI) was then done to confirm the insomnia diagnosis.

· Exclusion criteria included bipolar, schizophrenia, and sleep disorders other than insomnia; also: shift work, pregnancy, and unreliable Internet access.

· Patients were assigned to SHUTi or HealthWatch. “SHUTi provides six sequential modules consisting of an overview of insomnia, and two behavioural modules focusing on sleep restriction and stimulus control, cognitive restructuring, sleep hygiene, and relapse prevention. An 11 item daily sleep diary is required to advance from the first to the second module so the system can establish an algorithmically defined sleep window.” The HealthWatch program “has no specific mental health or sleep-related content and is not associated with therapeutic reductions in depression, and can therefore be regarded as an excellent control condition. Modules contained information about environmental health, nutrition, heart health, activity, medication, oral health, blood pressure and cholesterol, calcium, and back pain…”

· Scales were used to measure patients symptoms at 6 weeks and 6 months.

· Statistical analysis was done, including an ANOVA analysis.

Here’s what the authors found:

· Between April 30, 2013, and June 9, 2014, 1149 participants were randomly assigned to receive SHUTi (n=574) or HealthWatch (n=575).

· 581 (51%) participants completed the study program assessments at 6 weeks and 504 (44%) participants completed 6 months’ follow-up.

· At baseline, levels of employment, education, depression severity, anxiety, and sleep disturbance were similar between the two groups. For the record, on average, participants were more female than male, completed high school, and worked full time.

· At 6 weeks and 6 month follow-up, depression symptoms were significantly reduced from baseline in patients in the SHUTi group compared with those in the HealthWatch group. See figure below:

· And, At 6 weeks and 6 month follow-up, the mean PHQ-9 score for patients receiving the SHUTi intervention was no longer in the depressed range, whereas the score for patients in the HealthWatch group registered in the lower range of mild depression. (!) Between-group effect sizes (Cohen’s d): 0.69 at 6 weeks and 0.48 at 6 months.

· There were 22 cases of depression: about 2% (nine) in the SHUTi group and about 2% (or 13) in the HealthWatch group. Thus, stastistically speaking, SHUTi had no superior effect on diagnosis of major depressive disorder. (!)

The authors note:

Our findings show that an internet-based intervention for insomnia effectively reduced symptoms of depression in people with insomnia and subclinical depression at the end of the intervention and at 6 months’ follow-up, taking participants in the SHUTi group from a status of mild depression to one of no depression, according to PHQ-9 categories. This effect persisted even after elimination of the insomnia item on the PHQ-9, taking account of differential dropout and participant preference.

Some thoughts:

· There is much to like here.

· Depression is an episodic illness, yes, but it’s a chronic episodic illness. Any study that looks at ways of reducing relapse of depression is good. Targeting sleep? Interesting – and frankly practical.

· And the approach is innovative and clever: a website-based CBT-Insomnia.

· But I’m a bit skeptical of Internet-delivered care without therapist support or feedback (“therapist guidance” – to use the term in the literature). SHUTi doesn’t offer much beyond a self-help book, albeit with clear, evidenced-based material. I note the high drop-out rate.

· I also wonder if the results are coloured by the method of recruitment. Consider: participants were found using social media advertising. My point: the participants were already invested in online resources.

· Is this a criticism of this approach? Far from it. Depression relapse is too common and a web-based approach is a useful tool in the toolkit. But website-based CBT-Insomnia isn’t for everyone.

Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.