Secondary Psychiatric Care Patients’ Experiences of Internet CBT for Insomnia – a Qualitative Study

doi:10.21203/rs.3.rs-1742347/v1

Download PDF

Research Article

Secondary Psychiatric Care Patients’ Experiences of Internet CBT for Insomnia – a Qualitative Study

https://doi.org/10.21203/rs.3.rs-1742347/v1

This work is licensed under a CC BY 4.0 License

You are reading this latest preprint version

Background: Insomnia is very common, especially among psychiatric patients in secondary care. It is experienced as a 24h problem affecting several domains of life. Cognitive behavioural therapy for insomnia (CBT-I) is widely regarded as the first-line treatment and often improves comorbid disorders. Despite this, many patients are not offered CBT-I. Internet based CBT for insomnia (iCBT-I) is just as good as face-to-face treatments and could considerably increase availability. However, it is unclear whether iCBT-I is suitable for patients with more severe and comorbid psychiatric illnesses in secondary care.

Methods: Eleven Swedish participants (24-68 years old) in outpatient secondary psychiatric care who underwent iCBT-I treatment were interviewed. The semi-structured interviews were analysed using content analysis. The purpose was to map their experiences, motivation and suggestions for improvement.

Results: Prior to the treatment, most participants were highly motivated to take the opportunity to address their insomnia. The treatment was perceived as well-structured and interesting. The most difficult aspect was counteracting the fatigue. It was also hard to continue the treatment when faced with major life events. During this phase, contact with the therapist motivated them to continue the treatment. Several desired more face-to-face meetings. It was also motivating to gain insights into and a sense of control over sleep. Several described better sleep, improved daily routines, a more predictable everyday life and increased energy. Daytime well-being was improved in some, partly because they had more energy but also because they filled their days with more activities.

Conclusions: The treatment has the potential to be very useful in secondary psychiatric care where insomnia is common and affects comorbid disorders. Psychiatric patients might have more difficulties continuing with iCBT-I treatment, but those who manage to complete the program have a good chance of obtaining benefit. Additional social support and other adjustments may enhance treatment outcomes. Participants' stories are particularly valuable, as therapists and treatment developers receive less feedback from patients in internet-based treatments compared to face-to-face treatments.

Insomnia

Sleep

iCBT-I

CBT

internet

online

comorbid

psychiatric

secondary care

motivation

In the fifth edition of the Diagnostic and Statistical Manual for mental disorders, DSM-5, insomnia is defined as ”a predominant complaint of dissatisfaction with sleep quantity or quality” pertaining to initiating or maintaining sleep or early-morning awakening causing “clinically significant distress or impairment in social, occupational, educational, academic, behavioural, or other important areas of functioning” [1, p. 362]. It is experienced as a 24h problem that affects several domains of life [5].

Insomnia is a common problem with a point prevalence of 6–15% in the general population [26]. It may also be caused by various mental or medical disorders. Irrespective of whether insomnia is caused by other disorders, it is a problem that requires independent clinical attention [20, 9].

A qualitative review of patients with insomnia found that there was often a mismatch between the patients’ perspective and that of healthcare professionals regarding the nature and treatment of the problems. Patients frequently experienced that healthcare professionals focused too much on medications and sleep hygiene [5].

Cognitive behaviour therapy for insomnia (CBT-I) is a treatment that in addition to sleep hygiene includes stimulus control, sleep restriction, cognitive therapy and relaxation. It is regarded as the first-line treatment for insomnia by many organisations and guideline panels [24, 25, 27]. CBT-I has a similar effect to pharmacological treatment in short-term treatment and has been found to be more effective in the long term [28, 14]. CBT-I has also been shown to be effective in improving sleep for patients with psychiatric comorbidity such as anxiety and depression [17, 9]. Despite this, many patients are not offered CBT-I.

Delivering CBT-I in internet format (iCBT-I) could considerably increase its availability. Such a format is more time-efficient for the therapist (10–15 minutes/week) and patients can take part in the treatment at their own pace, irrespective of their geographical location and time of day.

The results from meta-analyses of iCBT-I provide support for improved sleep in both short and long-term follow-ups [12, 13]. In previous studies participants have generally been recruited from the general population via the media [22]. The studies of iCBT-I conducted in psychiatric populations also show good results with reduced comorbid anxiety and depression [4, 13]. Most of these studies have focused on insomnia patients with comorbid depression. There are fewer studies of iCBT-I among a broader population of psychiatric patients. One issue raised is that the need for therapist support may be greater for patients with comorbid depression [2]. There are some signs that therapist support is particularly important in written self-help CBT for insomnia compared to other CBT treatments [15], but it is unclear if this also applies to internet-based treatment.

Qualitative studies can be used to investigate how patients experience iCBT-I treatment. A qualitative study of iCBT-I that included patients in secondary psychiatric care focused on treatment completers [11]. The results indicated that the treatment benefitted participants who were goal-directed, liked graphic interpretations and were intrinsically motivated to improve their overall health. Acceptance of problems related to insomnia as well as of negative emotions and cognitions also seemed to facilitate a good outcome among patients with comorbid depression [8].

One qualitative study of iCBT-I focused on negative experiences of and reasons for not completing the treatment in patients with substance use disorder and insomnia [18]. The difficulties reported were that the treatment was regarded as time-consuming as many had competing demands (“it´s not like something you can do on the run, it´s something you have to actually pencil in on your schedule”), that it lacked individualization, that it was boring and that the format was similar to schoolwork.

Research Aim

To evaluate the outcome of an internet-based CBT treatment for insomnia in psychiatric secondary care using interviews with patients who had undergone such treatment.

Research Questions

What are the participants’ expectations before undergoing iCBT-I treatment?
What are the participants’ experiences of the treatment?
How do the participants think the treatment can be improved?

Design and Participants

A qualitative approach was used. Eleven participants were interviewed about their experiences of iCBT-I treatment. The treatment contained best CBT-I practice components [24]. It was specially adjusted to psychiatric patients by means of more videos, briefer information and focus on the core components, i.e., sleep restriction and stimulus control. These components consist of behavioural changes aimed at creating sleep pressure and stabilising circadian rhythms. The treatment also includes information and writing exercises aimed at altering sleep-related misconceptions and reducing worry. Relaxation exercises are offered to minimise pre-sleep arousal. The treatment took about 8 weeks for each participant, with one module per week. The participants received therapist support through written messages once a week and phone calls if they had been inactive for a couple of weeks. The six therapists involved in the treatment were licensed psychologists or CBT-therapists, all of whom had received iCBT-I treatment training and supervision.

The treatment and interviews were carried out in clinical practice settings in Gothenburg, Sweden, during spring and summer 2019. Gothenburg is a city with a population of 600,000, making it the second largest city in Sweden. Three adult outpatient secondary care psychiatric clinics at Sahlgrenska University Hospital were included; two general psychiatric clinics and one opioid substitution treatment clinic. More information on the implementation and context of this particular iCBT-I treatment is provided in Banck & Bernhardsson [6].

In the present study, patients with insomnia were asked to participate after initial screening. Participants were included if they had mild to severe insomnia (> 11 on Insomnia Severity Index), and no other sleep-wake disorders (e.g., sleep apnoea, narcolepsy, hypersomnia) or specific psychiatric disorders (e.g., bipolar disorder, epilepsy, psychosis) that needed special treatment. In addition to insomnia, many of the participants had other diagnoses such as anxiety disorders, depression, neuropsychiatric disorders, personality disorders and medical co-morbidities. Participants with opioid substitution treatment had maintenance therapy and no other substance use disorder.

All patients who started the treatment were invited to participate in interviews. No intentional selection took place. Seventeen patients were invited but six were not available or declined to be interviewed. Thus, eleven participants were interviewed; eight women and three men aged 24–68 years (mean: 39 years). Half of the participants completed all eight modules. For more information on the participants, see Table 1. All interviews were semi-structured and conducted over the telephone. The interviews lasted between 17 and 32 minutes (mean: 25 min).

Table 1

*Participants.*
Participants	Male/Female	Completed modules (8 models in total)
1	F	8
2	F	6
3	F	8
4	F	8
5	F	3
6	F	8
7	F	7
8	F	8
9	M	2
10	M	8
11	M	6

Interviews and Analysis

The topics covered in the interviews were motivation prior to the treatment, experiences of the treatment, evaluation of the therapy as well as the internet format and how comorbid psychiatric problems interacted with the treatment (see the interview guide in the appendix). The topics remained the same throughout the study.

The interviews, transcriptions and coding were performed by FNS, a clinical psychologist with education in and experience of CBT-I treatment as well as a basic university education in research methodology. FS had the main responsibility for the study and had no previous relationship with any of the participants but was a colleague of three of the six therapists.

A content analysis was conducted [19]. The de-identified interviews were transcribed verbatim. The de-identification did not affect the meaning of the data. When the researchers had familiarized themselves with the content of the transcribed material, the data were condensed and the manifest meaning coded. Threads of meaning were identified throughout the data, which were analysed and abstracted into categories, subcategories, themes and subthemes, after which they were compared with the transcription for further analysis and validation. The interpretation was inductive and empathetic in that it was open-ended and exploratory with the aim of understanding the participants’ experiences and perspectives. Saturation was considered to be achieved after eleven interviews, as the last three interviews fitted into the previous categories and themes and did not provide any new information. The entire material was then related to the context and compared with the literature to enable further reflection. CBT theory [10, 16] was applied to understand the therapeutic process. The authors discussed the coding framework and themes at regular intervals. Awareness of and supervision to prevent distortions and misconceptions of the material were prioritized. The themes were discussed with a third PhD researcher (AJ) who has vast experience of qualitative research. The four themes were finally divided into 14 subthemes. These are described in Table 2.

Table 2

*Themes and Subthemes*
Themes	Subthemes
Participating in the Internet Treatment	Perceptions of the Basic Structure and Content
	Relating to the Treatment Content
	Therapist Support
	Individual Adjustments
	Persistence with or Dropout from the Treatment
Dealing with Sleep Problems	Experience of Sleep Problems
	New Perspectives on Sleep
	Difficulties Counteracting Fatigue
	Getting Started with New Habits and Routines
Perceptions of Motivation, Responsibility and Demands	Motivation Before and during Treatment
Perceptions of Motivation, Responsibility and Demands	The participants’ perceptions of Demand and their Own Responsibility during the Treatment
Influence on Every-Day Life	Impact of the Treatment on Overall Mental Health
	Daytime Behavioural Activation
	Impact on Relationships

Participating in the Internet Treatment

Perceptions of the basic structure and content. The internet format was perceived as structured, clear, flexible and with a good flow. The participants appreciated not having to travel back and forth to meetings and being able to carry out the treatment at any time – even at night. However, the sleep diary could sometimes be complicated, unclear and lack certain aspects. Another issue raised was the need for a more cheerful web design and a more positive atmosphere in the videos. The treatment as such was not experienced as technically complicated.

The participants repeatedly expressed that the information about sleep problems was interesting, instructive and clear. Although most of it was already familiar to them, it aroused their curiosity and provided insight.

Participants who had impaired cognition read the material several times. One participant with dyslexia asked for the text to be read aloud.

Relating to the treatment content. Most participants could relate to the treatment content. The part that dealt with worries was often mentioned by the participants, as some of them reported feeling confirmed by their worries being raised and addressed. Others thought that there was too much information about worries – “it is pointless getting excited about it!" (1) and asked for more examples of thoughts when lying awake.

Therapist support. The therapists sent messages to their patients via the treatment platform. They also contacted the participants by phone if they had been inactive for a couple of weeks, which motivated them to continue changing their habits. The participants were mostly satisfied with the support they received from the therapists, but would have liked even more support. They requested face-to-face meetings to obtain feedback, motivation, follow-up, the opportunity to ask more questions or because it becomes "something else when you also meet face-to-face at some point" (8).

Individual adjustments. Some skipped the sleep restriction section, perhaps the most difficult, but at the same time one of the most effective parts of the treatment. Participants often changed the pace or took breaks during this difficult section, which could make the treatment feel less demanding and more suited to their individual needs. Skipping sections was also seen as avoidance associated with negative emotions.

Persistence with or dropout from the treatment. There was a wide variation in treatment persistence. Some dropped out after a couple of modules, others remained for half of the treatment, while most completed the main part of it. The general impression of the treatment ranged from "I was probably not the right person for this particular treatment" (5) or it "went so-so" (1) to "it was one of the best things I've done for myself in my life" (7). Most were satisfied with the treatment.

A daily link to the treatment consisted of writing the sleep diary, which sometimes lacked continuity. One participant logged "in on Friday night and filled in for the whole week", which made it confusing and "difficult to maintain after a while" (2).

Those who dropped out early usually said other major events got in the way, e.g., separation from their partner, major surgery or starting a new job after unemployment.

One participant found it difficult that a large part of her treatment occurred during her holidays. She thought it would be "easier to do it when you have some kind of everyday life with routines" (8),

Of the participants who completed the treatment, several continued to work with it after the eight weeks had ended by printing the material, logging in and starting over or just continuing to apply the lessons in their everyday life.

Dealing With Sleep Problems

Experience of sleep problems. Many described chronic insomnia. Some related it to other problems such as pain, brain fatigue and anxiety. One participant with anxiety found it "very difficult to find peace and fall asleep, because then the thoughts come". She was "afraid to fall asleep" (5), which became a barrier to completing the treatment. Those who were helped by the treatment described that they fell asleep faster, slept heavier and longer, had fewer awakenings and were more rested during the day. Some mentioned that they became less anxious and had a "more relaxed attitude" (8) when unable to sleep at night but also during the day.

New perspectives on sleep. The treatment provided the participants with insights and perspectives on their sleep. Even those who finished the treatment early described that their attitude changed after reading the first module that dealt with myths about sleep. Those who completed the treatment described major changes in perspective due to both the information provided and their own experiences.

Participants described having a clearer picture of how they actually slept thanks to the sleep diary and diagrams. One insight was that even if they had slept poorly, they were nevertheless able to cope with the following day, which had a calming effect.

Difficulties counteracting fatigue. The treatment involved tasks in which the participants were encouraged to counteract fatigue – getting out of bed despite extreme tiredness, trying to stay awake to build up sleep pressure and not sleeping during the day. These experiences were difficult and often described as a burden. It was not easy getting out of bed "when the whole body is dog-tired but you still cannot go to asleep" (1). The participants could relate their tiredness to aspects such as hormonal changes and brain fatigue. Another participant asked for more suggestions on activities she could perform to stay awake. Although it was hard, in retrospect some saw it as part of the process. It was "difficult at first not to fall asleep in the daytime" (2) and "a completely different routine than what you are used to, so it's no wonder you find it difficult" (2).

Getting started with new habits and routines. Participants who noticed progress in the treatment mentioned that they knew what to do if they were unable to sleep, which they considered one of the most helpful parts of the treatment, as it provided a sense of control. They gave many examples of if X happens, I’ll do Y or talked more generally about having "found routines". These routines made the evenings, nights and mornings more predictable. One participant described routines as creating "some sort of schedule to go by" (8). Another stated that she "didn't see certain things before" but now she both sees and "fixes it as best I can" (7). "When you should do something, you think back and like yeah, that is what she said" (1). One participant expressed that it was "stabilizing" to be instructed to "do these things, think about this" (11).

It was not always easy to implement the new habits. Some days they felt incapable of trying. They could be stressed, feel listless and lose their motivation. This alternated with days when they tested to see if the treatment produced any results. One participant only read the texts for a month before reluctantly making some attempts to implement the changes of habit she had read about. She developed more motivation when she noticed that the changes worked – "At first everything honestly seemed very ridiculous. You just can’t believe it – you force yourself to do certain things" (7).

Perceptions of Motivation, Responsibility and Demands

Motivation before and during treatment. The participants were generally highly motivated before starting the treatment. The motivation was mainly derived from the fact that they wanted to overcome their sleep problems. Some mentioned that they wanted to cease taking their sleep medication and "do something yourself" (8). Another common source of motivation was their impression that those who provided the information about the treatment firmly believed in it themselves.

The most common cause of doubt was whether they would be able to complete the treatment. They recalled previous experiences of not accomplishing things due to having failed or forgotten.

One person had no motivation whatsoever before the treatment because she had previously tested several other methods and "didn't think anything could help me" (7) and “some things don't work at first or it's so ridiculous" (7). "It was my psychiatrist or psychologist who wanted me to try. And I thought OK, I’ll give it a try” (7). Another source of ambivalence was mentioned by a participant who had become accustomed to her chronic insomnia and did not want to upset the current status quo. After thinking about it, she decided to take part in the treatment because "I can only learn more that might be useful to me" (3).

When the participants had been inactive for a while the therapists contacted them, which the participants described as motivating. Another common source of motivation was experiencing progress in everyday life and following one’s sleep diagrams.

The participants’ perceptions of demands and their own responsibility during the treatment. Compared to face-to-face treatment, internet treatment was generally perceived as requiring a higher degree of self-responsibility. Some thought it suited them well, while others considered it too hard. The most demanding part was changing everyday habits rather than the amount of text and videos. The autonomy involved in using the internet format was experienced by some as a burden.

For others the internet format was perceived as less demanding compared to face-to-face treatment. One participant who was not very motivated before the treatment agreed to take part because the internet format made it easier as he was free to do it at his own pace, thus creating less stress.

Influence on Everyday Life

Impact of the treatment on overall mental health. Those who reported enhanced overall mental health mainly explained that it was due to having more energy because of improved sleep. It also seemed to be related to the new routines and activities during the day. Some also mentioned that they had become "calmer" as well as "feeling safer" (11), with an increased belief that "the body takes care of itself" (6) and now had "better self-confidence" by "daring to cope" (2).

There were also several who stated that better sleep did not affect their lives in general, "not much unfortunately, not much. No more than that I get to sleep" (4).

Participants who had major difficulties and those who dropped out early sometimes described increased negative emotions - one "clanks down pretty much on oneself" even though "there wasn't much I needed to do really" (5). "As I said, I am very disappointed that I was not able to do it fully" (1). They pointed out, however, that the treatment did not have an overall negative impact on them, although their anxiety and depressed mood increased as a result of encountering various difficulties.

Daytime Behavioural activation. The days were sometimes filled with activities such as "meeting my friends" (2), "doing a workout"(1) or just changing into "ordinary clothes" (7). These were ways to get the day started, counteract fatigue and become more tired in the evening – “to stay awake you have to activate yourself. And then you automatically try to go out for a walk or something just to do something” (1).

Improved sleep sometimes provided more energy and strength in the daytime. The participants described being "more alert" (8), able to "work better during the day" (2), “withstand a little more" (7) as well as feeling "more alive today, that my life has some quality" (7).

As participants developed more consistent sleep patterns they found it easier to plan their days - "there's more order in my life. I can plan the days now, like what I should do. Before I didn't know how I felt. I didn't know if I could manage it the next day" (7).

Not all participants managed to activate themselves. One felt that the hardest part was "to activate yourself during the day, I haven't got to that yet" (4).

Impact on relationships. Those who mentioned that relationships were affected by the treatment described positive changes. It was easier to relate to others and take initiatives when they had more energy.

Prior to the treatment the participants’ motivation was usually high as they considered it a good opportunity to deal with their insomnia. Doubts mainly arose due to previous experiences of being unable to complete similar programs. Those who completed most of the treatment reported gaining new routines that gave insights and a sense of control of sleep. These experiences motivated them to proceed. Phone calls and messages from the therapist were also motivating. The internet format was regarded as well-structured and easily accessible, although generally perceived as requiring a higher degree of personal responsibility than face-to-face treatment. Some stated that this suited them well, while others requested more therapist support. The hardest parts were counteracting the fatigue and engaging in sleep restriction. Many participants were reluctant to continue the difficult tasks, and dropouts were especially frequent during sleep restriction. Other causes of dropout were life events, e.g., major surgery and separation. Dropout could cause disappointment and self-criticism but was not perceived to have any negative impact in the long term. Many of those who completed most of the treatment described improved sleep at night and increased energy during the day, making it easier to socialize and be more active. These activities in themselves increased the participants’ quality of life.

Comparison with Existing Literature

In addition to insomnia, most participants in the iCBT-I treatment also suffered from depression. Behavioural activation in combination with CBT-I has been highlighted as an appropriate treatment for those with both diagnoses [10]. A treatment focused solely on insomnia also seems to work well for depression [7]. Several participants in the present study reported increased energy during the day. They also activated themselves to perk up. A more stable sleep pattern made it easier to plan activities. From a depression treatment perspective, this can be interpreted as behavioural activation [23]. A central part of behavioural activation is becoming active despite lacking the desire or energy. In the present study, it is possible that the ability of the participants to counteract both their general and their depressive fatigue was strengthened.

In a previous qualitative study of iCBT-I treatment, participants who were goal-directed and had an intrinsic motivation to improve their overall health benefitted the most [11]. In the present study the participants generally regarded the internet format as requiring more of their own responsibility compared to face-to-face treatment. This personal responsibility may be a beneficial consequence of internet-based treatments, which indicates the need for more such treatments. However, it also implies that patients with low self-efficacy might experience big barriers, which is more likely in secondary psychiatric care. Solutions aimed at overcoming such barriers may be needed and should be communicated during the recruitment to the treatment, so that more patients will feel that they have a good chance of achieving their goal. Solutions might include a higher availability of therapist support, group discussions among patients to share experiences, more positive reinforcement and other kinds of support. Ideally, the support provided should enhance the patient’s personal responsibility.

Therapist support in the form of written self-help for insomnia has been found to be especially important compared to self-help in other psychological treatments [15]. However, in one study the need for therapist support in iCBT-I treatments was only found in those who, in addition to insomnia, had moderate to severe depression. Participants with no or low depression seemed to improve regardless of support [21]. The participants in the present study were satisfied with the support they received but also requested more face-to-face therapist support. As discussed by Farrand & Woodford [15], there are many other factors that influence the effectiveness of treatment, and it is possible that therapist support is a solution that receives too much attention. However, Lancee et al. [21] demonstrated the likelihood that those with both depression and insomnia actually need more support, especially guidance in the treatment process. In the present study, the participants contributed a variety of suggestions of how the treatment could be supplemented with more face-to-face support. In previous studies, internet forums have also been proposed [11]. The ePsychiatry unit at Sahlgrenska University hospital [6], where the internet treatment was designed, changed its recommendations after this study was completed. They recommended that the therapists should make a follow-up face-to-face call (video call or in real life) after about four weeks. This is during the sleep restriction phase, a time when dropouts are common. Another change in recommendations was to exclude patients with severe depression (defined as 22 or more points on the Patient Health Questionnaire-9, PHQ-9). They saw large improvements among patients with low or moderate depression, but no improvement and high drop-out rates (2 out of 3) among patients with severe depression.

Strengths and Limitations

One strength of the study is that it was conducted in an everyday clinical context at three different sites. As the treatment is new, it has been carefully evaluated within the organization by many different professional categories.

There was probably a selection bias in that those who could benefit from the treatment were more willing to be interviewed. A third of the patients who were contacted did not want to be interviewed. Some mentioned that they had dropped out early and did not think they could contribute much to the study. The sample had a greater proportion of participants who completed treatment, and thus fewer participants who experienced failures were interviewed.

Eight women and three men were interviewed. There is no known reason for this imbalance, but selection bias cannot be ruled out.

Another limitation was that the questions about motivation for initiating treatment were posed after the treatment had been completed. Some may have had difficulty remembering and the answers were probably coloured by their experiences of the treatment.

Only two persons were involved in the coding and analysis, which increases the risk of bias. A third researcher with vast experience of qualitative research also read and commented on the material.

Possible implications

There are few qualitative studies of internet-based CBT treatments for insomnia in patients in a secondary psychiatric care setting. As insomnia is very common in this group, participants' stories are valuable.

The study may increase understanding of the treatment from the patients’ perspective. Therapists in internet treatments receive less feedback from patients compared to face-to-face treatments. The study can be used in developing similar future treatments and guide therapists in recruiting patients and delivering treatments.

As could be anticipated, patients’ progress in the program varied. Psychiatric comorbidities sometimes, but far from always, hindered completion of the treatment. After screening and basic exclusion, the patients themselves are probably the best judges of whether the treatment is suitable for them. However, according to the ePsychiatry unit that developed this treatment, patients with severe comorbid depression have a low likelihood of success and can therefore be excluded.

For most patients, additional support and individual adjustments may enhance treatment outcomes.

The treatment was useful for many of the participants interviewed in this study. It provided new routines that gave insights and a sense of control over sleep. Improved sleep at night often led to increased energy during the day, making it easier to be with others and to be more active. The treatment has the potential to increase the overall quality of life both at night and during the day. Sleep is an essential, but often neglected, component of many aspects of good psychiatric health. The internet format could considerably increase the availability of this treatment, which is highly relevant in secondary psychiatric care, where insomnia is common and affects comorbid disorders. Although this treatment can be very helpful, it was not without disadvantages. The important sleep restriction intervention was regarded as difficult by many. Dropouts were especially frequent during this intervention. Other causes of dropout were significant life events, e.g., major surgeries and separations. Psychiatric patients might have more difficulties continuing with an iCBT-I treatment, but those who manage to proceed stand a good chance of deriving benefit. The higher degree of personal responsibility required has both benefits and pitfalls. Experiences of successful outcomes may improve self-efficacy. However, more support might be required to make more patients willing to give it a try and to succeed.

In internet-based treatments, the therapists receive less feedback from patients compared to face-to-face treatments, making the participants' stories in this study particularly valuable.

CBT: Cognitive Behavioural Therapy

CBT-I: Cognitive Behavioural Therapy for Insomnia

iCBT-I: Internet based Cognitive Behavioural Therapy for Insomnia

Availability of data and materials

The datasets generated and analysed are not publicly available due to content that could potentially identify the participants. They are, however, available from the corresponding author on reasonable request.

Ethical approval and consent to participate

The study was conducted with adherence to ethical standards [3] and approved by the Swedish Ethical Review Authority (No. 2019-01356). Recordings, names, consent forms and questionnaires were stored in accordance with Sahlgrenska University Hospital routines. Routines were also developed to address potential difficult or critical situations during the treatment.

Participants completed informed consent forms before participating. The transcriptions were de-identified. This de-identification did not affect the content of the data or quotation.

Consent for publication

Not applicable.

Authors' contributions

The authors designed the study and interview guide together. The interviews, transcriptions, coding and most manuscript drafting were carried out by FNS. The authors discussed the coding framework, themes and manuscript at regular intervals. Both authors edited and approved the final manuscript. FS had the main responsibility for the study.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

Competing Interests

The authors declare that they have no competing interests.

Acknowledgements

We would like to thank the participants for their contribution to the study. We would also like to thank Annika Jakobsson, Alf Bengtsson, Kajsa Skoglund and Mikael Mide for comments on the manuscript.

American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-5. Arlington, VA: American Psychiatric Publishing; 2013.
Dyrberg H, Juel A, Kragh M. Experience of treatment and adherence to Cognitive Behavioral Therapy for insomnia for patients with depression: An interview study [Internet]. Vol 19, Behav Sleep Med. Taylor & Francis. 2021. 481–91. Available from: http://dx.doi.org/10.1080/15402002.2020.1788033
World Medical Association. Declaration of Helsinki: Ethical Principles for Medical Research Involving Humans Subjects. [Internet]. Ferney-Voltaire: World Medical Association; 2019. [cited 2019 Jun 28] Available from: https://www.wma.net/policies-post/wma-declaration-of-helsinki-ethical-principles-for-medical-research-involving-human-subjects/
Ye Y, Zhang Y, Chen J, Liu J, Li X, Liu Y, et al. Internet-Based Cognitive Behavioral Therapy for Insomnia (ICBT-i) Improves Comorbid Anxiety and Depression—A Meta-Analysis of Randomized Controlled Trials [Internet]. Courvoisier DS, editor. Vol. 10, PLOS ONE. Public Library of Science (PLoS); 2015. p. e0142258. Available from: http://dx.doi.org/10.1371/journal.pone.0142258
Araújo T, Jarrin DC, Leanza Y, Vallières A, Morin CM. Qualitative studies of insomnia: Current state of knowledge in the field [Internet]. Vol. 31, Sleep Medicine Reviews. Elsevier BV; 2017. p. 58–69. Available from: http://dx.doi.org/10.1016/j.smrv.2016.01.003
Kadesjö Banck J, Bernhardsson S. Experiences from implementation of internet-delivered cognitive behaviour therapy for insomnia in psychiatric health care: a qualitative study applying the NASSS framework [Internet]. Vol. 20, BMC Health Services Research. Springer Science and Business Media LLC; 2020. Available from: http://dx.doi.org/10.1186/s12913-020-05596-6
Blom K, Jernelöv S, Kraepelien M, Bergdahl MO, Jungmarker K, Ankartjärn L, et al. Internet Treatment Addressing either Insomnia or Depression, for Patients with both Diagnoses: A Randomized Trial [Internet]. Vol. 38, Sleep. Oxford University Press (OUP); 2015. p. 267–77. Available from: http://dx.doi.org/10.5665/sleep.4412
Blom K, Jernelöv S, Lindefors N, Kaldo V. Facilitating and hindering factors in Internet-delivered treatment for insomnia and depression [Internet]. Vol. 4, Internet Interventions. Elsevier BV; 2016. p. 51–60. Available from: http://dx.doi.org/10.1016/j.invent.2016.03.004
Taylor DJ, Pruiksma KE. Cognitive and behavioural therapy for insomnia (CBT-I) in psychiatric populations: A systematic review [Internet]. Vol. 26, International Review of Psychiatry. Informa UK Limited; 2014. p. 205–13. Available from: http://dx.doi.org/10.3109/09540261.2014.902808
Carney CE, Posner D. Cognitive behavior therapy for insomnia in those with depression: a guide for clinicians. New York, NY: Routledge; 2015.
Chan C, West S, Glozier N. Commencing and Persisting With a Web-Based Cognitive Behavioral Intervention for Insomnia: A Qualitative Study of Treatment Completers [Internet]. Vol. 19, Journal of Medical Internet Research. JMIR Publications Inc.; 2017. p. e37. Available from: http://dx.doi.org/10.2196/jmir.5639
Cheng SK, Dizon J. Computerised Cognitive Behavioural Therapy for Insomnia: A Systematic Review and Meta-Analysis [Internet]. Vol. 81, Psychotherapy and Psychosomatics. S. Karger AG; 2012. p. 206–16. Available from: http://dx.doi.org/10.1159/000335379
Soh HL, Ho RC, Ho CS, Tam WW. Efficacy of digital cognitive behavioural therapy for insomnia: a meta-analysis of randomised controlled trials [Internet]. Vol. 75, Sleep Medicine. Elsevier BV; 2020. p. 315–25. Available from: http://dx.doi.org/10.1016/j.sleep.2020.08.020
Riemann D, Perlis ML. The treatments of chronic insomnia: A review of benzodiazepine receptor agonists and psychological and behavioral therapies [Internet]. Vol. 13, Sleep Medicine Reviews. Elsevier BV; 2009. p. 205–14. Available from: http://dx.doi.org/10.1016/j.smrv.2008.06.001
Farrand P, Woodford J. Impact of support on the effectiveness of written cognitive behavioural self-help: A systematic review and meta-analysis of randomised controlled trials [Internet]. Vol. 33, Clinical Psychology Review. Elsevier BV; 2013. p. 182–95. Available from: http://dx.doi.org/10.1016/j.cpr.2012.11.001
Hedman E, Carlbring P, Ljótsson B, Andersson G. Internetbaserad psykologisk behandling. Stockholm: Natur & Kultur; 2014.
Ho FY-Y, Chan CS, Lo W-Y, Leung JC-Y. The effect of self-help cognitive behavioral therapy for insomnia on depressive symptoms: An updated meta-analysis of randomized controlled trials [Internet]. Vol. 265, Journal of Affective Disorders. Elsevier BV; 2020. p. 287–304. Available from: http://dx.doi.org/10.1016/j.jad.2020.01.062
Hermes ED, Merrel J, Clayton A, Morris C, Rowe M. Computer-based self-help therapy: A qualitative analysis of attrition [Internet]. Vol. 25, Health Informatics Journal. SAGE Publications; 2016. p. 41–50. Available from: http://dx.doi.org/10.1177/1460458216683536
Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness [Internet]. Vol. 24, Nurse Education Today. Elsevier BV; 2004. p. 105–12. Available from: http://dx.doi.org/10.1016/j.nedt.2003.10.001
Khurshid KA. Comorbid insomnia and psychiatric disorders: An update. Innov Clin Neurosci. 2018;15(3–4):28–32.
Lancee J, Sorbi MJ, Eisma MC, van Straten A, van den Bout J. The Effect of Support on Internet-Delivered Treatment for Insomnia: Does Baseline Depression Severity Matter? [Internet]. Vol. 45, Behavior Therapy. Elsevier BV; 2014. p. 507–16. Available from: http://dx.doi.org/10.1016/j.beth.2014.02.012
Lindefors N, Andersson, G, editor(s). Guided internet-based treatments in psychiatry. 1st ed. Cham, Switzerland: Springer International Publishing; 2016.
Mazzucchelli T, Kane R, Rees C. Behavioral activation treatments for depression in adults: A meta-analysis and review. [Internet]. Vol. 16, Clinical Psychology: Science and Practice. American Psychological Association (APA); 2009. p. 383–411. Available from: http://dx.doi.org/10.1111/j.1468-2850.2009.01178.x
Morin CM, Espie CA. Insomnia: A Clinical Guide to Assessment and Treatment. Boston, MA: Springer Science + Business Media; 2004
Morin CM, Inoue Y, Kushida C, Poyares D, Winkelman J. Endorsement of European guideline for the diagnosis and treatment of insomnia by the World Sleep Society [Internet]. Vol. 81, Sleep Medicine. Elsevier BV; 2021. p. 124–6. Available from: http://dx.doi.org/10.1016/j.sleep.2021.01.023
Ohayon MM. Epidemiological Overview of sleep Disorders in the General Population [Internet]. Vol. 2, Sleep Medicine Research. Korean Society of Sleep Medicine; 2011. p. 1–9. Available from: http://dx.doi.org/10.17241/smr.2011.2.1.1
Qaseem A, Kansagara D, Forciea MA, Cooke M, Denberg TD. Management of Chronic Insomnia Disorder in Adults: A Clinical Practice Guideline from the American College of Physicians [Internet]. Vol. 165, Annals of Internal Medicine. American College of Physicians; 2016. p. 125. Available from: http://dx.doi.org/10.7326/M15-2175
Riemann D, Baglioni C, Bassetti C, Bjorvatn B, Dolenc Groselj L, Ellis JG, et al. European guideline for the diagnosis and treatment of insomnia [Internet]. Vol. 26, Journal of Sleep Research. Wiley; 2017. p. 675–700. Available from: http://dx.doi.org/10.1111/jsr.12594
Riemann D, Perlis ML. The treatments of chronic insomnia: A review of benzodiazepine receptor agonists and psychological and behavioral therapies [Internet]. Vol. 13, Sleep Medicine Reviews. Elsevier BV; 2009. p. 205–14. Available from: http://dx.doi.org/10.1016/j.smrv.2008.06.001

No competing interests reported.

AppendixNicolaisenSidnFSpakFSecondaryPsychiatricCarePatientsExperiencesofInternetCBTforInsomniaaQualitativeStudy.docx

Download PDF

Editorial decision: Major revision
18 Jul, 2022
Reviews received at journal
14 Jul, 2022
Reviews received at journal
07 Jul, 2022
Reviewers agreed at journal
27 Jun, 2022
Reviewers invited by journal
25 Jun, 2022
Editor assigned by journal
20 Jun, 2022
Editor invited by journal
17 Jun, 2022
Submission checks completed at journal
17 Jun, 2022
First submitted to journal
09 Jun, 2022

You are reading this latest preprint version

Secondary Psychiatric Care Patients’ Experiences of Internet CBT for Insomnia – a Qualitative Study

Status:

Version 1

Abstract

Background

Research Aim

Research Questions

Method

Design and Participants

Interviews and Analysis

Results

Participating in the Internet Treatment

Dealing With Sleep Problems

Perceptions of Motivation, Responsibility and Demands

Influence on Everyday Life

Discussion

Comparison with Existing Literature

Strengths and Limitations

Possible implications

Conclusions

Abbreviations

Declarations

References

Additional Declarations

Supplementary Files

Status:

Version 1