Sleep Disturbances Impact Web-Based CBT Outcomes

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Nicotine addicted teen boy falling asleep with cigarette in bed risk of accident
The researchers of this study explored the impact of a blended approach (bCBT) that included both face-to-face CBT and iCBT on patients with major depressive disorder and insomnia.

The negative impact of sleep disturbances on the benefit of cognitive behavioral therapy (CBT) in people with major depressive disorder (MDD) applies to face-to-face CBT, internet-based CBT, and a hybrid approach according to a recent study in the Journal of Medical Internet Research.

Previous studies showed insomnia, a common MDD symptom, may double the risk of MDD nonremission in patients receiving CBT.

Internet-based, guided, self-help CBT (iCBT) is effective for treating depressive symptoms and helps alleviate some of the cost barriers of traditional face-to-face therapy. However, MDD patients who experience sleep disturbances don’t receive the full benefits of the therapy.

The researchers of the current study ( NCT02542891) explored the impact of a blended approach (bCBT) that included both face-to-face CBT and iCBT on MDD patients with insomnia.

The researchers obtained their data from the E-COMPARED study: a 2-arm, parallel, randomized controlled, noninferiority trial. It recruited 943 patients from primary care facilities across 9 European countries that examined blended CBT for depression. The study included participants aged 18 years or older who met the diagnostic criteria for MDD. The control group in the current analysis received treatment as usual (TAU), which varied between patients.

Of all the participants, 81% reported some type of insomnia. The seriousness of insomnia did not change depression symptom severity from baseline to 12-month follow-up. However, the effect of baseline sleep disturbances had little effect on the TAU but did have an effect on the bCBT group (β=.49, 95% CI 0.22-0.76). A secondary analysis showed similar results: significant impact for the bCBT group (OR 1.18, 95% CI 1.02-1.38) but not for the TAU group (OR 0.94, 95% CI 0.82-1.08).

Overall, the researchers found that sleep disturbances had an impact on treatment outcomes in patients receiving bCBT and higher baseline sleep problems indicated a decreased treatment response in the bCBT group. The researchers’ findings represent “an important addition to the existing literature on sleep disturbance symptoms and MDD treatment,” they state.

While the study design and large sample size were strengths, the study lacked a dedicated insomnia measure. They also included hypersomnia even though few participants experienced this symptom.

However, the study results indicate that “extra attention to comorbidity such as sleep disturbance symptoms…might be important when treating depression with bCBT in routine care.”


Jensen ES, Ladegaard N, Mellentin AI, et al. Effect of sleep disturbance symptoms on treatment outcome in blended cognitive behavioral therapy for depression (E-COMPARED study): secondary analysisJ Med Internet Res. 2022;24(3):e30231. Published online March 21, 2022. doi:10.2196/30231