Effect of Culturally Tailored, Internet-Delivered Cognitive Behavioral Therapy for Insomnia in Black Women
Authors: Eric S. Zhou, Lee M. Ritterband, Traci N. Bethea, Yvonne P. Robles, Timothy C. Heeren, Lynn Rosenberg
Journal: JAMA Psychiatry (2022)

<h3>Importance</h3> Black women are at risk for insomnia disorder. Despite interest in addressing sleep health disparities, there is limited research investigating the efficacy of criterion-standard treatment (cognitive behavioral therapy for insomnia [CBT-I]) among this racial minority population. <h3>Objective</h3> To compare the efficacy of a standard version of an internet-delivered CBT-I program, a culturally tailored version, and a sleep education control at improving insomnia symptoms. <h3>Design, Setting, and Participants</h3> In this single-blind, 3-arm randomized clinical trial, participants in a national, longitudinal cohort (Black Women’s Health Study [BWHS]) were recruited between October 2019 and June 2020. BWHS participants with elevated insomnia symptoms were enrolled and randomized in the current study. <h3>Interventions</h3> Participants were randomized to receive (1) an automated internet-delivered treatment called Sleep Healthy Using the Internet (SHUTi); (2) a stakeholder-informed, tailored version of SHUTi for Black women (SHUTi-BWHS); or (3) patient education (PE) about sleep. <h3>Main Outcomes and Measures</h3> The primary outcome was insomnia severity (Insomnia Severity Index [ISI]). Index score ranged from 0 to 28 points, with those scoring less than 8 points considered to not have clinically significant insomnia symptoms and a score of 15 points or higher suggesting insomnia disorder. An ISI score reduction of more than 7 points was considered a clinically significant improvement in insomnia symptoms. The SHUTi-BWHS program was hypothesized to be more effective at significantly decreasing insomnia severity compared with the SHUTi program and PE. <h3>Results</h3> A total of 333 Black women were included in this trial, and their mean (SD) age was 59.5 (8.0) years. Those randomized to receive either SHUTi or SHUTi-BWHS reported significantly greater reductions in ISI score at 6-month follow-up (SHUTi: −10.0 points; 95% CI, −11.2 to −8.7; SHUTi-BWHS: −9.3 points; 95% CI, −10.4 to −8.2) than those randomized to receive PE (−3.6 points; 95% CI, −4.5 to −2.1) (<i>P</i> &lt; .001). Significantly more participants randomized to SHUTi-BWHS completed the intervention compared with those randomized to SHUTi (86 of 110 [78.2%] vs 70 of 108 [64.8%];<i>P</i> = .008). Participants who completed either intervention showed greater reductions in insomnia severity compared with noncompleters (−10.4 points [95% CI, −11.4 to −9.4] vs −6.2 points [95% CI, −8.6 to −3.7]). <h3>Conclusions and Relevance</h3> In this randomized clinical trial, both the SHUTi and SHUTi-BWHS programs decreased insomnia severity and improved sleep outcomes more than PE. The culturally tailored SHUTi-BWHS program was more effective at engaging participants with the program, as a greater proportion completed the full intervention. Program completion was associated with greater improvements in sleep. <h3>Trial Registration</h3> ClinicalTrials.gov Identifier:NCT03613519