Effectiveness of eCBT-I on Improving Mental Health in Chinese Youths With Insomnia

Effectiveness of E-based Cognitive Behavioral Therapy for Insomnia on Improving Mental Health in Chinese Youths With Insomnia: a Large-scale Randomized Control Trial

This study aims to conduct a randomized control trial to validate the treatment effect of e-based cognitive behavioral therapy for Insomnia (e-CBT-I) on insomnia disorder, and explore whether e-CBT-I could prevent depression and suicide in youths with insomnia and subclinical depression. In addition, to further explore the mechanisms underlying the association between insomnia treatments and psychiatric disorders, this study will evaluate whether changes in candidate factors including insomnia symptoms, poor sleep hygiene, sleep-related unhelpful thoughts and maladaptive behaviors, circadian rhythm disruption and chronic sleep deprivation will mediate the effect of e-CBT-I on prevention of depression and suicide.

Study Overview

• Status: Completed
• Conditions: Insomnia
• Intervention / Treatment: Behavioral: e-CBT-I; Behavioral: e-HE

Detailed Description

Previous studies have documented the associations of insomnia with depression and suicide. Currently, researchers have done considerable work to investigate whether e-CBT-I could be effective in improving psychological well-being for adults, and previous studies have confirmed that e-CBT-I is effective in reducing depressive symptoms and suicidal ideation in adult population.

However, such studies have not been established in youths yet. Additionally, it is still unclear that by which mechanisms e-CBT-I might affect mental health, and whether e-CBT-I could reduce the risk of depression and suicide.

This study will be the first specifically designed investigation of the preventive effects of e-CBT-I for depression and suicide in youths, and the first large scale causal test of the relationship between insomnia treatments and psychiatric disorders. The results can be expected to influence care provision for the youth population who are at a life stage of emerging adulthood and vulnerable to psychiatric disorders. Further, because the investigators will be using an e-CBT-I approach, a scalable solution may be demonstrated as both feasible and effective. The findings of this study will show the possibility of developing novel preventive intervention for depression and suicide by targeting insomnia.

• Study Type: Interventional
• Enrollment (Actual): 708
• Phase: Not Applicable

Contacts and Locations

Study Locations

• China
  • Beijing, China
    • Peking University Sixth Hospital
• Hong Kong
  • Hong Kong, Hong Kong
    • Department of psychiatry, Faculty of Medicine, The Chinese University of Hong Kong

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 15 years to 25 years (Child, Adult)
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

1. Native Han youths in Hong Kong and mainland China, aged between15-25
2. A diagnosis of insomnia disorder measured by ICD-10 Classification of Mental and Behavioural Disorders
3. The presence of moderate or severe insomnia measured by a score of 15 or above on ISI
4. The presence of subclinical depression assessed by a score of between 4 and 20 on PHQ-9
5. Access to smartphones
6. Ability to read and understand research protocol

Exclusion Criteria:

1. Shift workers
2. The presence of prominent suicidality (suicide plans and suicide attempts) measured by MINI via telephone interview
3. A reported diagnosis of psychosis, schizophrenia, bipolar disorder, or neurodevelopmental disorders
4. Medical conditions that could cause poor sleep quality and sleep continuity disruption, such as eczema
5. An additional sleep disorder (other than insomnia) that may potentially contribute to a disruption in sleep continuity and quality, such as excessive sleepiness and possible obstructive sleep apnoea
6. The presence of current MDD or a prior episode of MDD within past two months measured by MINI via telephone interview
7. Women during pregnancy or lactation
8. Currently receiving psychological treatment for insomnia provided by a psychologist and/or pharmacological treatment for depression

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Prevention
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: E-based cognitive behavioral therapy for insomnia (e-CBT-I); The e-CBT-I will be delivered by a mobile application (eSleep) developed by BestCare & SuMian BioTech Co., Ltd. which contains a digital, self-paced, and highly interactive programme. It consists of six weekly sessions with animated elements, including an overview of sleep, sleep restriction, stimulus control, cognitive therapy, structured worry time and relapse prevention. Participants will have access to the e-CBT-I treatment for 12 weeks.	Behavioral: e-CBT-I; The e-CBT-I will be delivered through a mobile application (eSleep) with a personal password.
Active Comparator: E-based health education (e-HE); The e-HE, a psychoeducation/information-approach, also consists of six consecutive sessions which contains information about general sleep knowledge, functions of human organs, nutrition, environmental health, brain health, identification and treatments of common diseases, but the contents are not related to any active therapeutic components of cognitive behavioral therapy for insomnia (CBT-I). Participants will have access to the intervention for 12 weeks.	Behavioral: e-HE; The e-HE will be delivered in control though a mobile application (eSleep) with a personal password.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Number of Participants With Major Depressive Disorder	Major depressive disorder will be confirmed by Mini International Neuropsychiatric Interview (MINI).	Up to 12-month follow-up

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change of Depressive Symptoms	Depressive symptoms will be measured by Patient Health Questionnaire-9 (PHQ-9). PHQ-9 is a commonly used self-administered questionnaire to assess depressive symptoms and severity, with a higher total score suggesting more severe depressive symptoms. Scores range from 0 to 27.	Baseline, post-session 2, post-session 4, post-intervention (week 7/at the conclusion of last session), 6- and 12-month follow-up
Change of Insomnia Symptoms	Insomnia symptoms will be measured by Insomnia Severity Index (ISI). ISI is a seven-item self-report measure designed to assess the nature, severity and impact of insomnia, with a higher total score suggesting more severe insomnia symptoms. Scores range from 0 to 28.	Baseline, post-session 2 (week 3/at the conclusion of session 2), post-session 4 (week 5/at the conclusion of session 4), post-intervention (week 7/at the conclusion of last session), 6- and 12-month follow-up
Percentage of Participants in Remission of Insomnia Disorder	Insomnia disorder will be confirmed by International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) Classification of Mental and Behavioural Disorders: Diagnostic Criteria for Research.	Post-intervention (week 7/at the conclusion of last session), 6- and 12-month follow-up

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change of Anxiety Symptoms	Anxiety symptoms will be measured by Generalised Anxiety Disorder 7-item (GAD-7). GAD-7 is a self-report measure of anxiety severity, with a higher total score suggesting more severe anxiety symptoms. Scores range from 0 to 21.	Baseline, post-session 2 (week 3/at the conclusion of session 2), post-session 4 (week 5/at the conclusion of session 4), post-intervention (week 7/at the conclusion of last session), 6- and 12-month follow-up
Percentage of Participants With Suicidality	Suicidality which includes suicidal ideation, suicide plans and suicide attempts will be measured by MINI.	Post-intervention (week 7/at the conclusion of last session), 6- and 12-month follow-up
Change of Suicidal Ideation	Suicidal ideation will be measured by Beck Scale for Suicide Ideation (BSSI). BSSI is a 19-item self-report measure designed to assess suicidality, with higher total scores representing greater. Scores range from 0 to 38.	Baseline, post-intervention, 6- and 12-month follow-up
Change of Daytime Symptoms	Daytime symptoms will be measured by Multidimensional Fatigue Inventory (MFI). MFI is a 20-item self-rated scale on fatigue symptoms. There are three subscales, measuring the physical (possibly scored from 7 to 35), mental (possibly scored from 6 to 30), and spiritual (possibly scored from 7 to 35), dimensions of fatigue. A grand total score can be calculated by summing up the three sub scores. In all cases, a higher score represents higher fatigue symptoms.	Baseline, post-intervention, 6- and 12-month follow-up
Change of Sleep-related Thoughts and Behaviors	Sleep-related thoughts and behaviors will be measured by Brief Version of Dysfunctional Beliefs and Attitudes about Sleep (DBAS-16). DBAS-16 is a 16-item self-report measure designed to evaluate a subset of those sleep related cognition, with a higher score indicating more dysfunctional beliefs and attitudes about sleep. The total score is calculated from the average score of all the items on the scale and could range from 0 to 10.	Baseline, post-intervention, 6- and 12-month follow-up
Change of Circadian Rhythms	Circadian rhythms will be measured by reduced version of Horne and Östberg Morningness-Eveningness Questionnaire (rMEQ). The rMEQ is a 5-item self reported measure used to evaluate circadian rhythm and sleep rhythm patterns in individuals. Individuals scored higher than 17 and lower than 12 were classified as morning-type and evening-type, respectively. Individuals scored between 12 and 17 were classified as intermediate-type. Scores range from 4 to 25.	Baseline, post-intervention, 6- and 12-month follow-up
Change of Subjective Sleep Measure (Time in Bed, TIB)	TIB will be estimated by 7-Day Daily Sleep Diary. 7-Day Daily Sleep Diary is a prospective measure that includes the questions to assess bedtime, time to fall asleep, total length of time awake during the night, number of awakenings during the night, final wake time and rise time, time spent in bed, total sleep time, sleep quality during the previous night (rating 0-10).	Baseline, post-intervention, 6- and 12-month follow-up
Change of Subjective Sleep Measure (Total Sleep Time, TST)	TST will be estimated by 7-Day Daily Sleep Diary. 7-Day Daily Sleep Diary is a prospective measure that includes the questions to assess bedtime, time to fall asleep, total length of time awake during the night, number of awakenings during the night, final wake time and rise time, time spent in bed, total sleep time, sleep quality during the previous night (rating 0-10).	Baseline, post-intervention, 6- and 12-month follow-up
Change of Subjective Sleep Measure (Sleep Onset Latency, SOL)	SOL will be estimated by 7-Day Daily Sleep Diary. 7-Day Daily Sleep Diary is a prospective measure that includes the questions to assess bedtime, time to fall asleep, total length of time awake during the night, number of awakenings during the night, final wake time and rise time, time spent in bed, total sleep time, sleep quality during the previous night (rating 0-10).	Baseline, post-intervention, 6- and 12-month follow-up
Change of Subjective Sleep Measure (Wake After Sleep Onset, WASO)	WASO will be estimated by 7-Day Daily Sleep Diary. 7-Day Daily Sleep Diary is a prospective measure that includes the questions to assess bedtime, time to fall asleep, total length of time awake during the night, number of awakenings during the night, final wake time and rise time, time spent in bed, total sleep time, sleep quality during the previous night (rating 0-10).	Baseline, post-intervention, 6- and 12-month follow-up
Change of Subjective Sleep Measure (Sleep Efficiency, SE)	SE will be estimated by 7-Day Daily Sleep Diary. 7-Day Daily Sleep Diary is a prospective measure that includes the questions to assess bedtime, time to fall asleep, total length of time awake during the night, number of awakenings during the night, final wake time and rise time, time spent in bed, total sleep time, sleep quality during the previous night (rating 0-10).	Baseline, post-intervention, 6- and 12-month follow-up

Collaborators and Investigators

• Sponsor: Chinese University of Hong Kong
• Collaborators: Peking University Sixth Hospital
• Investigators: Study Director: Shirley Xin Li, PhD, Hong Kong University; Principal Investigator: Yun Kwok Wing, MBChB, Chinese University of Hong Kong; Principal Investigator: Lin Lu, PhD, Peking University Sixth Hospital; Study Director: Jihui Zhang, PhD, Chinese University of Hong Kong; Study Director: Le Shi, PhD, Peking University Sixth Hospital

Study record dates

Study Major Dates

• Study Start (Actual): September 5, 2019
• Primary Completion (Actual): January 18, 2024
• Study Completion (Actual): January 18, 2024

Study Registration Dates

• First Submitted: August 15, 2019
• First Submitted That Met QC Criteria: August 22, 2019
• First Posted (Actual): August 28, 2019

Study Record Updates

• Last Update Posted (Actual): March 25, 2025
• Last Update Submitted That Met QC Criteria: November 25, 2024
• Last Verified: November 1, 2024

More Information

Terms related to this study

• Keywords: depression; insomnia; cognitive behavioral therapy; suicide; youth
• Additional Relevant MeSH Terms: Nervous System Diseases; Mental Disorders; Sleep Wake Disorders; Sleep Disorders, Intrinsic; Dyssomnias; Sleep Initiation and Maintenance Disorders
• Other Study ID Numbers: 2019.044

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No