Efficacy of Email-delivered Versus Face-to-face Group Cognitive Behavioral Therapy for Insomnia in Youths: A Randomized Controlled Trial



      The purpose of the study was to compare the efficacy of group-based therapy (GT) and email-delivered self-help (ESH) cognitive behavioral therapy for insomnia (CBT-I) with the wait-list (WL) control group in youths.


      The study involved an assessor-blind, parallel group randomized controlled trial in youths meeting the diagnostic criteria for insomnia disorder. Participants were randomized to one of the three groups (8-week GT, 8-week ESH, or WL). Participants in all three groups were assessed at baseline and after treatment (week 9 for the WL group). The two treatment groups were additionally assessed at one month and six months after the intervention. Treatment effects were examined using linear mixed models.


      A total of 135 youths (mean age: 20.0 ± 2.5 years, female: 67.4%) were recruited. After treatment, both active treatment groups showed significant improvements in insomnia symptoms (GT vs. WL: Cohen's d = −1.03, ESH vs. WL: d = −.63), less presleep arousal (d = −.52 to −1.47), less sleep-related dysfunctional belief (d = −.88 to −1.78), better sleep hygiene practice (d = −.79 to −.84), and improved daytime functioning (d = −.56 to −.96) compared with the WL group. In addition, GT outperformed ESH in improving maladaptive sleep-related beliefs and mood symptoms at post-treatment and 6-month follow-up. A reduction of suicidality with moderate effect size favoring GT emerged at 6-month follow-up.


      Our findings suggested that both group-based and email-delivered CBT-I were effective in treating youth insomnia, but group-based CBT-I showed superior effects on reducing maladaptive beliefs and mood symptoms.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Adolescent Health
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Zhang J.
        • Chan N.Y.
        • Lam S.P.
        • et al.
        Emergence of Sex differences in insomnia symptoms in adolescents: A large-scale school-based study.
        Sleep. 2016; 39: 1563-1570
        • Li S.X.
        • Chan N.Y.
        • Yu M.W.M.
        • et al.
        Eveningness chronotype, insomnia symptoms, and emotional and behavioural problems in adolescents.
        Sleep Med. 2018; 47: 93-99
        • Alvaro P.K.
        • RobertsJ R.M.
        • Harris K.
        A systematic review assessing Bidirectionality between sleep Disturbances, anxiety, and depression.
        Sleep. 2013; 36: 1059-1068
        • Bartel K.A.
        • Gradisar M.
        • Williamson P.
        Protective and risk factors for adolescent sleep: A meta-analytic review.
        Sleep Med Rev. 2015; 21: 72-85
        • Chan N.Y.
        • Zhang J.
        • Tsang C.C.
        • et al.
        The associations of insomnia symptoms and chronotype with daytime sleepiness, mood symptoms and suicide risk in adolescents.
        Sleep Med. 2020; 74: 124-131
        • Sateia M.J.
        • Buysse D.J.
        • Krystal A.D.
        • et al.
        Clinical practice Guideline for the Pharmacologic treatment of Chronic insomnia in adults: An American Academy of sleep medicine clinical practice Guideline.
        J Clin Sleep Med. 2017; 13: 307-349
        • Bastien C.H.
        • Morin C.M.
        • Ouelet M.C.
        • et al.
        Cognitive-behavioral therapy for insomnia: Comparison of individual therapy, group therapy, and telephone consultations.
        J Consult Clin Psychol. 2004; 72: 653-659
        • Liu Y.
        • Zhang J.
        • Lam S.P.
        • et al.
        Help-seeking behaviors for insomnia in Hong Kong Chinese: A community-based study.
        Sleep Med. 2016; 21: 106-113
        • Zachariae R.
        • Lyby M.S.
        • Ritterband L.M.
        • O’Toole M.S.
        Efficacy of internet-delivered cognitive-behavioral therapy for insomnia - a systematic review and meta-analysis of randomized controlled trials.
        Sleep Med Rev. 2016; 30: 1-10
        • Trauer J.M.
        • Qian M.Y.
        • Doyle J.S.
        • et al.
        Cognitive behavioral therapy for Chronic insomnia: A systematic review and meta-analysis.
        Ann Intern Med. 2015; 163: 191-204
        • van Straten A.
        • van der Zweerde T.
        • Kleiboer A.
        • et al.
        Cognitive and behavioral therapies in the treatment of insomnia: A meta-analysis.
        Sleep Med Rev. 2018; 38: 3-16
        • Sweeney G.M.
        • Donovan C.L.
        • March S.
        • Forbes Y.
        Logging into therapy: Adolescent perceptions of online therapies for mental health problems.
        Internet Interventions-the Appl Inf Technology Ment Behav Health. 2019; 15: 93-99
        • Wing Y.K.
        • Chan N.Y.
        • Yu M.W.M.
        • et al.
        A school-based sleep education program for adolescents: A cluster randomized trial.
        Pediatrics. 2015; 135: e635-e643
        • Chan N.Y.
        • Li S.X.
        • Zhang J.
        • et al.
        A prevention program for insomnia in at-risk adoelscents: A randomized controlled study.
        Pediatrics. 2021; 147 (e2020006833)
        • Merikangas K.R.
        • Zhang J.
        • Emsellem H.
        • et al.
        The structured diagnostic interview for sleep patterns and disorders: Rationale and initial evaluation.
        Sleep Med. 2014; 15: 530-535
        • Sheehan D.V.
        • Lecrubier Y.
        • Sheehan K.H.
        • et al.
        The Mini-International Neuropsychiatric interview (M.I.N.I.): The development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10.
        J Clin Psychiatry. 1998; 59 (quiz 4-57): 22-33
        • Trockel M.
        • Manber R.
        • Chang V.
        • et al.
        An e-mail delivered CBT for sleep-health program for college students: Effects on sleep quality and depression symptoms.
        J Clin Sleep Med. 2011; 7: 276-281
        • Chung K.F.
        • KanW K.K.
        • Yeung F.
        Assessing insomnia in adolescents: Comparison of insomnia severity Index, Athens insomnia scale and sleep quality Index.
        Sleep Med. 2011; 12: 463-470
        • Buysse D.J.
        • Reynolds C.F.
        • Monk T.H.
        • et al.
        The Pittsburgh sleep quality Index - a New instrument for psychiatric practice and research.
        Psychiat Res. 1989; 28: 193-213
        • Carney C.E.
        • Buysse D.J.
        • Ancoli-Israel S.
        • Edinger J.D.
        • et al.
        The consensus sleep diary: Standardizing prospective sleep self-monitoring.
        Sleep. 2012; 35: 287-302
        • Berk M.
        • Ng F.
        • Dodd S.
        • et al.
        The validity of the CGI severity and improvement scales as measures of clinical effectiveness suitable for routine clinical use.
        J Eval Clin Pract. 2008; 14: 979-983
        • Morin C.M.
        • Vallieres A.
        • Ivers H.
        Dysfunctional beliefs and attitudes about sleep (DBAS): Validation of a brief version (DBAS-16).
        Sleep. 2007; 30: 1547-1554
        • Peltz J.S.
        • Rogge R.D.
        The moderating role of parents' dysfunctional sleep-related beliefs among associations between adolescents' pre-bedtime conflict, sleep quality, and their mental health.
        J Clin Sleep Med. 2019; 15: 265-274
        • Yang C.M.
        • Lin S.C.
        • Hsu S.C.
        • Cheng C.P.
        Maladaptive sleep hygiene practices in good sleepers and patients with insomnia.
        J Health Psychol. 2010; 15: 147-155
        • Nicassio P.M.
        • Mendlowitz D.R.
        • Fussell J.J.
        • Petras L.
        The phenomenology of the pre-sleep state: The development of the pre-sleep arousal scale.
        Behav Res Ther. 1985; 23: 263-271
        • Klein D.N.
        • Dougherty L.R.
        • Olino T.M.
        Toward guidelines for evidence-based assessment of depression in children and adolescents.
        J Clin Child Adolesc Psychol. 2005; 34: 412-432
        • Chan Y.F.
        • Leung D.Y.
        • Fong D.Y.
        • et al.
        Psychometric evaluation of the Hospital Anxiety and Depression Scale in a large community sample of adolescents in Hong Kong.
        Qual Life Res. 2010; 19: 865-873
        • Joiner Jr., T.E.
        • Pfaff J.J.
        • Acres J.G.
        A brief screening tool for suicidal symptoms in adolescents and young adults in general health settings: Reliability and validity data from the Australian National general practice youth suicide prevention Project.
        Behav Res Ther. 2002; 40: 471-481
        • Smets E.M.
        • Garssen B.
        • Bonke B.
        • De Haes J.C.
        The Multidimensional Fatigue Inventory (MFI) psychometric qualities of an instrument to assess fatigue.
        J Psychosom Res. 1995; 39: 315-325
        • Norup A.
        • Svendsen S.W.
        • Doser K.
        • et al.
        Prevalence and severity of fatigue in adolescents and young adults with acquired brain injury: A nationwide study.
        Neuropsychol Rehabil. 2019; 29: 1113-1128
        • Chung K.F.
        • Yu B.Y.
        • Yung K.P.
        • et al.
        Assessment of fatigue using the Multidimensional Fatigue Inventory in patients with major depressive disorder.
        Compr Psychiatry. 2014; 55: 1671-1678
        • Ravens-Sieberer U.
        • Gosch A.
        • Rajmil L.
        • et al.
        The KIDSCREEN-52 quality of life measure for children and adolescents: Psychometric results from a cross-cultural survey in 13 European countries.
        Value Health. 2008; 11: 645-658
        • Europe T.K.G.
        The KIDSCREEN Questionnaires – quality of life questionnaires for children and adolescents. Handbook.
        Pabst Science Publishers, Lengerich2006
        • Trockel M.
        • Karlin B.E.
        • Taylor C.B.
        • Manber R.
        Cognitive Behavioral Therapy for insomnia with veterans: Evaluation of effectiveness and correlates of treatment outcomes.
        Behav Res Ther. 2014; 53: 41-46
        • de Bruin E.J.
        • Bogels S.M.
        • Oort F.J.
        • Meijer A.M.
        Efficacy of cognitive behavioral therapy for insomnia in adolescents: A randomized controlled trial with internet therapy, group therapy and A waiting list condition.
        Sleep. 2015; 38: 1913-1926
        • Chan N.Y.
        • Zhang J.
        • Yu M.W.M.
        • et al.
        Impact of a modest delay in school start time in Hong Kong school adolescents.
        Sleep Med. 2017; 30: 164-170
        • Cuijpers P.
        • Li J.A.
        • Hofmann S.G.
        • Andersson G.
        Self-reported versus clinician-rated symptoms of depression as outcome measures in psychotherapy research on depression: A meta-analysis.
        Clin Psychol Rev. 2010; 30: 768-778
        • Christensen H.
        • Batterham P.J.
        • Gosling J.A.
        • et al.
        Effectiveness of an online insomnia program (SHUTi) for prevention of depressive episodes (the GoodNight study): A randomised controlled trial.
        Lancet Psychiatry. 2016; 3: 333-341
        • Hamilton J.L.
        • Buysse D.J.
        Reducing suicidality through insomnia treatment: Critical Next Steps in suicide prevention.
        Am J Psychiatry. 2019; 176: 897-899
        • Blake M.J.
        • Sheeber L.B.
        • Youssef G.J.
        • et al.
        Systematic review and meta-analysis of adolescent cognitive-behavioral sleep interventions.
        Clin Child Fam Psychol Rev. 2017; 20: 227-249
        • Farrand P.
        • Woodford J.
        Impact of support on the effectiveness of written cognitive behavioural self-help: A systematic review and meta-analysis of randomised controlled trials.
        Clin Psychol Rev. 2013; 33: 182-195
        • Lancee J.
        • van den Bout J.
        • Sorbi M.J.
        • an Straten A.
        Motivational support provided via email improves the effectiveness of internet-delivered self-help treatment for insomnia: A randomized trial.
        Behav Res Ther. 2013; 51: 797-805
        • Yeung W.F.
        • Chung K.F.
        • Ho F.Y.
        • Ho L.M.
        Predictors of dropout from internet-based self-help cognitive behavioral therapy for insomnia.
        Behav Res Ther. 2015; 73: 19-24
        • Lancee J.
        • van Straten A.
        • Morina N.
        • et al.
        Guided online or face-to-face cognitive behavioral treatment for insomnia: A randomized wait-list controlled trial.
        Sleep. 2016; 39: 183-191
        • Ho F.Y.
        • Chung K.F.
        • Yeung W.F.
        • et al.
        Weekly brief phone support in self-help cognitive behavioral therapy for insomnia disorder: Relevance to adherence and efficacy.
        Behav Res Ther. 2014; 63: 147-156
        • Edmonds M.
        • Hadjistavropoulos H.D.
        • Schneider L.H.
        • et al.
        Who benefits most from therapist-assisted internet-delivered cognitive behaviour therapy in clinical practice? Predictors of symptom change and dropout.
        J Anxiety Disord. 2018; 54: 24-32