In what scientists are calling “the largest randomized controlled trial of a psychological intervention for a mental health concern,” researchers found that treating insomnia using cognitive-behavioral therapy (CBT), delivered online, appears to improve a variety of mental health concerns. Addressing sleep issues led to improvement in depression, anxiety, and psychotic symptoms such as paranoia and hallucinations.
“This trial indicates the importance of sleep difficulties for mental health in the general population and the need for a reconsideration in clinical services of the priority given to improving sleep,” the researchers write.
The study authors gathered thousands of college students who were experiencing insomnia, and randomized half of them to receive an online CBT treatment called “Sleepio.” They found that not only did participants receiving the therapy improve their sleeping habits, but they were also significantly less likely to experience paranoia, hallucinations, depression, and anxiety.
The research was led by Daniel Freeman, affiliated with the Department of Psychiatry at the University of Oxford, Warneford Hospital, and the Oxford Health National Health Service Trust in the United Kingdom, and the study was published in The Lancet Psychiatry. Freeman and his team assigned 3755 college students–at 26 different universities in the UK–to receive either usual care or online CBT for insomnia.
All of the students were experiencing insomnia. Some of the students exhibited varying levels of depressive, anxious, or psychotic symptoms. The researchers collected data at the beginning of the intervention, at three weeks, at ten weeks (the end of the treatment), and at a 22-week follow-up to determine if results held true for months after the intervention.
There was a high drop-out rate for the online CBT group—only 69% of the students even logged on for a single session, while just 50% received two sessions. By the 6th session, only 18% took part. Even with this drop-out rate, the difference between groups was significant.
The sleep of the group receiving the treatment improved considerably. “After treatment, 54 (62%) of 733 individuals in the treatment group [compared to] 326 (29%) of 1142 individuals in the control group scored outside the clinical cutoff for insomnia.”
The reductions in psychotic experiences, depression, and anxiety, and increases in functioning and psychological well-being were lower, but still significant. The measure for depression (PHQ-9) includes questions regarding sleep, energy, and appetite, so it is unsurprising that these improved. However, the measures of anxiety (GAD-7), paranoia (GPTS), hallucinations (SPEQ), and prodromal psychosis (PQ-16) do not include such questions, so such improvement is further evidence of the impact of sleep on these experiences.
Additionally, those who received CBT for insomnia also showed substantial improvement in measures of daily functioning (WSAS) and psychological well-being (WEMWBS).
Interestingly, the insomnia treatment appeared to increase scores on the Altman scale for measuring mania; however, this could be due to increased energy from improved sleep.
Freeman and his colleagues write that although sleep problems are often viewed as a symptom of mental health concerns, they may, in fact, be a cause of mental health concerns. Sleep problems are associated with almost every mental health diagnosis, including depression, anxiety, and psychosis.
The researchers write that causality can be inferred by manipulating the variable that is theorized to cause the changes while controlling the other variables between groups. That is, the researchers attempted to treat sleep problems in one group, and then compare the experiences of paranoia, hallucinations, depressive symptoms, and anxious symptoms, between the groups. If sleep is a cause of these symptoms, the group that receives successful insomnia treatment should also experience decreases on all those other variables.
After doing this procedure, the researchers write that “Early changes in sleep explain approximately half of the total […] changes in psychotic experiences by the end of treatment” when including paranoia and hallucinations as outcome measures. That is, resolving sleep problems made a very large difference in the psychotic outcomes between the two groups. According to the authors, “These outcomes lend further support to the causal pathway hypothesis proposed in this study.”
The researchers also attempted to examine the possibility of reverse causation. They analyzed the data to determine if changes in paranoia and hallucinations within the first three weeks explained the variance in sleep at the end of the study. They found that paranoia and hallucinations each appeared to explain about 3% of the variance. This small variance suggests that resolving sleep problems has a considerable impact on reducing psychotic experiences, but that the reducing psychotic experiences does not seem to impact sleep substantially.
It is important to note that the study sample was predominantly White and female and that they were university students. It is thus unclear whether the results would generalize to other groups. Additionally, this was not a clinical sample. It is unclear whether this effect would hold true to those with symptoms associated with severe depression, anxiety, or psychotic experiences.
Nonetheless, since sleep problems are associated so strongly with most psychiatric diagnoses, treating those issues with the top recommended method–CBT–is a no-brainer. And if that can help reduce the severity of mental health concerns, possibly eliminating the need for riskier treatments such as medication, so much more the better.
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Freeman, D., Sheaves, B., Goodwin, G. M., Yu, L.-M., Nickless, A., Harrison, P. J. . . . Espie, C. A. (2017). The effects of improving sleep on mental health (OASIS): A randomised controlled trial with mediation analysis. The Lancet Psychiatry, 4(10), 749–758. doi: http://dx.doi.org/10.1016/S2215-0366(17)30328-0 (Link)
“…paranoia, hallucinations, depression, and anxiety….” as far as I know, nobody has ever died from lack of sleep.
People do die of ‘lack of sleep’.
Rats totally deprived of sleep die. There is no reason to presume that the same wouldn’t happen to a human being.
I would imagine that all sorts of so-called “mental disorders” also might only be disruption of one’s sleep patterns, but the case is still out on that one.
https://io9.gizmodo.com/can-you-die-from-sleep-deprivation-1684235719
I will never be able to prove it but I feel that being on psych meds long term destroyed my sleep cycle which lowered my immune system which caused lymphoma. Obviously, I am alive 🙂 but I don’t believe for a minute that people can’t die from lack of sleep since when that situation occurs, it destroys people’s health.
As far as online CBT-i, that seems to be the non-drug one size fits all solution. Not saying it doesn’t help people but unfortunately, sleep professionals seem to wrongly think it is the solution for all sleep problems when it isn’t.
If you were on antipsychotics, they probably helped you get lymphoma by raising your estrogen levels in addition to depriving you of natural sleep.
bcharris,
No, I was on a cocktail of antidepressants and a stimulant for years. But that is interesting about what antipsychotics do.
Some of those drugs lower estrogen, and raise prolactin. This is why men grow breasts from Risperdal. Women miss periods causing bone thinning. Some anti-d’s cause raised prolactin also.
REM sleep is affected by “antipsychotics”.https://www.ncbi.nlm.nih.gov/pubmed/18840034
People with a hammer justifying their use of a hammer.
My worst nightmare is being in the prison-that-isnt-a-prison called a hospital. and in prison they don’t or cant force you to take poison for a figurative illness.
Maybe nightmares of previous “treatment” and possible future “treatment” are keeping people from sleeping well.
Sleep disorder can effect different organs like the liver and result in a certain amount toxicity which would effect the brain and create memory problems and everything else. But in the Normal way of looking at things – there’s no genuine “mental illness” attached to this.
Fiachra,
I complained to a former sleep doc about listing my sleep issue, including sleep apnea, as a psychiatric diagnosis, and her response was that the medical records software program gave her no choice but to designate it that way. And on other medical history forms, I have seen sleep issues listed under the psychiatric category. It galls me big time.
“Nonetheless, since sleep problems are associated so strongly with most psychiatric diagnoses, treating those issues with the top recommended method–CBT–is a no-brainer.”
I don’t agree. The study shows TCB is superior to “usual care”, but the usual care may possibly be inferior to no treatment. In addition, CBT may possibly be inferior to a neutral stimulus from a medical point of view, for example the remittance of a sum of money.
“Psychic treatments” are too expensive, the minimum is they are more effective than just giving their value in money. In the opposite case, it is better, in theory, to give the money directly, or to do nothing.
The “gold standard” for measuring depression that was used (the PHQ9) is the property of Pfizer pharmaceuticals. It’s as invalid and unreliable as it comes over and above the glaring conflict of interest. This, combined with a completely restricted population makes the finding all about how a university was paid to do more research which is worthless. It’s almost guaranteed that the results wont apply to most people.
The simplicity of CBT is very alluring – lets “reduce symptoms” and problem solved. Unfortunately this approach leaves no room to explore the possibility that “symptoms” actually serve a purpose
Another no brainer study. Loss of sleep almost always precedes psychotic episodes, and anyone deprived of sleep for long enough will start to hallucinate. But of course, the DSM is “cause neutral” – God forbid we should actually try to UNDERSTAND why a person is acting as they are!
Exactly!
“Another no brainer study.”
Indeed. What next? Good nutrition helps to alleviate symptoms?
That would be a SHOCKING revelation!
Again, nothing here about damage to ability to sleep FROM drugs. The drugs cause physical damage, resulting in complete or partial inability to sleep. For many, the damage is permanent. I’m not convinced CBT is the answer for organ damage. And as usual, the drug companies aren’t owning up to this.
I have known, or known of people who resorted to opiates due to inability to sleep. There are cases documented of severe insomnia that resulted in death.
Seeing as Sleepio doesn’t involve seeing a doctor I checked it out. I found that most of the introductory questions don’t even apply to my situation. I got a zero for sleep score which is the worst possible. I guess it doesn’t work for organ damage. I’ve called many sleep clinics anonymously and they refuse to acknowledge damage from drugs. Oh well.
Most people I know who have ended up with drug damage affecting sleep resorted to staying on drugs long term or permanently.
The Sleepio program is based on a book by Colin Espie. The book is much cheaper than the computerized program!
If you want to get Sleepio for free, you can sign up for a research study or get it through your workplace (if you have one). If you sign up you’ll receive an email saying if they can’t find a study for you after 60 days you will be offered a discount on the program.
What I end up doing, at least once or twice a week is to cancel my activities for the day because I am too sleep-deprived to function. I back out of an awful lot of commitments on pretense that I am “sick.” It is embarrassing.
Julie,
Thank you for precisely nailing the issues. It greatly made my day that someone like you understands what is going on.
I know what you mean about backing out of commitments. Fortunately, when I do it with a friend, she is very understanding.
I am not surprised at all that sleep centers don’t acknowledge damage by drugs. Heck, I have had sleep docs recommend drugs that were related to the ones that I feel destroyed my sleep system.
AA, thanks for validating. I am having trouble getting anyone to own up to being victimized by this. I suspect that this is because most people either die, give up entirely, or go back to drugs, legal or illegal, out of desperation. And they don’t want to admit to such things.
My latest attack on this is to get a light box because as far as I can tell the problem worsened when cold weather hit and I was forced to spend more time indoors. I end up walking the dog before dawn or after sundown. I’ve never tried one of these devices before but a friend used one and swore by it. These are supposed to keep you awake during the day and asleep at night. Better than sleeping with a machine I don’t need nor want.
Hi Julie,
Hmm, I am wondering if people don’t want to scare folks into believing that psych meds cause permanent damage. That is a debate that constantly comes up in the psych withdrawal community.
Good luck with the light box. Unfortunately, it has not kept me awake during the day and too much use causes agitation.
That is great you don’t need a cpap machine. Unfortunately, I do as confirmed by a home and two full-scale studies.
Exactly, AA. I don’t hang with the “withdrawal” community much as I am sick of the drug-based focus on here and of course over there. As I say in my book that’s just about finished, you can stop the drugs and be over with withdrawal but still be very much a mental patient if you don’t shake the treatment-induced dependency. What good does getting off drugs do if you can’t do anything on your own? That and trauma from the so-called treatment, especially incarceration, are the larger damages. Too much focus on the drugs distracts us from the basic human rights issues. I am saddened that MIA ignores this stuff, but that’s the way most of this community is. I suspect that’s because a lot of psychologists hang here and want to keep on doing what they’re doing. It’s a business…..
It’s the mental health movement, Julie. I’ve seen the enemy, and the mental health movement is that enemy. There are these figures that say a certain percentage of the population ‘suffers’ from ‘untreated’, often ‘undiagnosed’, “mental illness”, and, therefore, the problem is ‘access to care’. “Access to care” has become one angle utilized by those ready to play the violence card, and it’s also become a gateway into the mental health/disability field for so-called “peer” careerists. Substance abuse is one thing, system abuse another, only, there are two definitions at work here, there are victims of the system, on the one hand, and there are beneficiaries of the systems, too, and some of those “beneficiaries” might better be described as system abusers (i.e. addicts). Independence from the system has never been high on the agenda of people pushing that system, and it is even less so today, now that evading treatment is seen as an indication of a “stigmatizing” attitude. The system, a supposed hospital system, has ceased to be about getting people out of that system (i.e. “well”). 20 % of the population, more or less, is reputed to have bought the idea of having a “mental illness”. Apparently, to top it all off, it’s a very successful business as well.