Digital CBT Improves Insomnia, Anxiety, and Depression in Pregnant Women

Digital cognitive behavioral therapy (CBT) is an effective, scalable, safe, and acceptable intervention for improving insomnia symptoms in pregnant women at less than 28 weeks’ gestation, according to findings published in JAMA Psychiatry.

Jennifer N. Felder, PhD, from the Osher Center for Integrative Medicine at the University of California, San Francisco, and colleagues conducted a randomized clinical trial to evaluate the effectiveness of digital CBT in 208 adult women (mean age, 33.6±3.7 years) who were pregnant for up to 28 weeks’ gestation and either reported elevated insomnia symptom severity or met the criteria for an insomnia disorder. Participants were randomized to receive either digital CBT (n=105) or standard treatment (n=103) for insomnia.

Digital CBT involved 6 weekly remote sessions (available via website or iOS app), each lasting approximately 20 minutes. This approach comprised sleep restriction, stimulus control, relaxation techniques, cognitive therapy, and sleep hygiene and education. Participants completed the Insomnia Severity Index at 10 weeks (postintervention) and 18 weeks (follow-up) after randomization; they used diaries to log their own sleep efficiency, duration, quality, and caseness. Women receiving standard treatment had no limits placed on the receipt of nonstudy treatments, including medication and psychotherapy.

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A total of 68 women (64.8%) completed all 6 sessions. The mean gestational age was 17.6±6.3 weeks at baseline, and the majority of participants were white (66.3%) and married or cohabiting (94.2%). The sample also largely represented a high socioeconomic status, with 86.5% having a college degree and 67.8% earning $100,000 or more per year. Both groups experienced 3 adverse events each, mainly miscarriages.

Compared to women who received standard treatment, those who received digital CBT experienced greater improvements in insomnia symptom severity from baseline to postintervention (time-by-group interaction, difference = −0.36; 95% CI, −0.48 to −0.23; χ2 = 29.8; P <.001; d = −1.03). The digital CBT group had significantly higher remission rates as well (44.0% vs 22.3%; P =.002). Furthermore, alongside greater reductions in secondary sleep outcomes in the digital CBT group, participants in the experimental condition also experienced significantly reduced depressive (difference, -0.21; 95% CI, -0.30 to -0.11; P <.001) and anxiety (difference, -0.188; 95% CI, -0.26 to -0.10; P <.001) symptoms. Improvements from baseline to follow-up were similar to those from baseline to postintervention.

The study may be limited by the fact that participants were mostly wealthy, white, and highly educated; results may differ for patients from other backgrounds.

“Although more women randomized to receive digital CBT-I experienced remission in insomnia symptoms compared with those randomized to receive standard treatment, most women continued to experience at least subthreshold symptoms,” the investigators noted. The findings may be promising since anxiety and depressive symptoms improved alongside insomnia for the digital CBT intervention, which is highly scalable, low risk, and effective.


Felder JN, Epel ES, Neuhaus J, Krystal AD, Prather AA. Efficacy of digital cognitive behavioral therapy for the treatment of insomnia symptoms among pregnant women: a randomized clinical trial [published online January 22, 2020]. JAMA Psychiatry. 2020;77(5):1‐9.