Background: Sleep complaints are among the most prevalent health concerns, especially among workers, which may lead to adverse effects on health and work. Internet-delivered cognitive behavioral therapy for insomnia (iCBT-I) offers the opportunity to deliver effective solutions on a large scale. The efficacy of iCBT-I for clinical samples has been demonstrated in recent meta-analyses, and there is evidence that iCBT-I is effective in the working population with severe sleep complaints. However, to date, there is limited evidence from randomized controlled trials that iCBT-I could also be an effective tool for universal prevention among the general working population regardless of symptom severity. Although increasing evidence suggests that negatively toned cognitive activity may be a key factor for the development and maintenance of insomnia, little is known about how iCBT-I improves sleep by reducing presleep cognitive activity.
Objective: This study aimed to examine the efficacy of a self-help internet-delivered recovery training, based on principles of iCBT-I tailored to the work-life domain, among the general working population. General and work-related cognitive activities were investigated as potential mediators of the intervention's effect.
Methods: A sample of 177 workers were randomized to receive either the iCBT-I (n=88) or controls (n=89). The intervention is a Web-based training consisting of six 1-week modules. As the training was self-help, participants received nothing but technical support via email. Web-based self-report assessments were scheduled at baseline, at 8 weeks, and at 6 months following randomization. The primary outcome was insomnia severity. Secondary outcomes included measures of mental health and work-related health and cognitive activity. In an exploratory analysis, general and work-related cognitive activities, measured as worry and work-related rumination, were investigated as mediators.
Results: Analysis of the linear mixed effects model showed that, relative to controls, participants who received iCBT-I reported significantly lower insomnia severity scores at postintervention (between-group mean difference -4.36; 95% CI -5.59 to - 3.03; Cohen d=0.97) and at 6-month follow-up (between-group difference: -3.64; 95% CI -4.89 to -2.39; Cohen d=0.86). The overall test of group-by-time interaction was significant (P<.001). Significant differences, with small-to-large effect sizes, were also detected for cognitive activity and for mental and work-related health, but not for absenteeism. Mediation analysis demonstrated that work-related rumination (indirect effect: a1b1=-0.80; SE=0.34; 95% boot CI -1.59 to -0.25) and worry (indirect effect: a2b2=-0.37; SE=0.19; 95% boot CI -0.85 to -0.09) mediate the intervention's effect on sleep.
Conclusions: A self-help Web-based recovery training, grounded in the principles of iCBT-I, can be effective in the general working population, both short and long term. Work-related rumination may be a particularly crucial mediator of the intervention's effect, suggesting that tailoring interventions to the workplace, including components to reduce the work-related cognitive activity, might be important when designing recovery interventions for workers.
Trial registration: German Clinical Trials Register DRKS00007142; https://www.drks.de/DRKS00007142.
Keywords: Web-based, cognitive behavioral therapy; e-mental-health; insomnia; mediators; occupational health.
©Doerte Behrendt, David Daniel Ebert, Kai Spiegelhalder, Dirk Lehr. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 07.01.2020.
Conflict of interest statement
Conflicts of Interest: DL and DDE are stakeholders in the Institute for Online Health Training, which aims to transfer scientific knowledge related to this research into routine health care. DB and KS have no conflicts of interest to declare.
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