Insomnia is very common. About a third of the people in the general population experiences one or more symptoms of poor sleep. About 10 % reports a full insomnia disorder including daytime consequences (Ohayon 2002). These daytime consequences typically refer to subjectively reported impairments in cognitive and emotional functioning such as fatigue, mood swings, and concentration problems (Kyle et al. 2010). Among other things, these impairments lead to increased health-care use and decreased work productivity which in turn leads to high societal costs (Daley et al. 2009a). It has been estimated that poor sleepers cost society about ten times more than good sleepers (Daley et al. 2009b). Moreover, insomnia might be considered a long-term condition: about half of all patients suffer from insomnia for at least 3 years (Morin et al. 2009).

Insomnia also often co-occurs with other mental or medical conditions. Depression and anxiety are two common comorbid conditions (Staner 2010; Baglioni et al. 2011), but insomnia is also associated with cancer, hypertension, and cardiovascular diseases (e.g., Meng et al. 2012; Redline and Foody 2011; Savard and Morin 2011).

The high prevalence of insomnia and its related burden of disease call for widely available, high-quality, and effective treatments. Currently insomnia is most often treated with pharmacotherapy either with benzodiazepines or benzodiazepine receptor agonists (Z-drugs: zolpidem, zopiclone, zaleplon). Several meta-analyses have shown that pharmacotherapy is effective in enhancing sleep in the short run, but it has also been demonstrated that there are negative side effects, especially in the elderly, while long-term consequences risks and benefits are still unknown (Buscemi et al. 2007; Glass et al. 2005).

Various non-pharmacological treatments have been developed as alternatives. These non-pharmacological treatments can be classified as educational (psychoeducation, sleep hygiene), behavioral (relaxation, sleep restriction, stimulus control, paradoxical intention), or cognitive (identifying and challenging dysfunctional thought about sleep; Edinger and Means 2005; Espie 2006; Morin and Espie 2003). Since the 1990s, it has become popular to offer those treatments in (different) combinations. These combinations are referred to as cognitive-behavioral therapy for insomnia (CBTI). See Table 8.2 for an overview of the core components. Next to those core components, the treatment might include relaxation exercises, paradoxical intention (in which the patient is instructed to stay awake during the night), mindfulness exercises, or problem-solving strategies.

Unfortunately, not many patients receive CBTI. One reason is that less than half of all the insomnia patients seek help (Morin et al. 2006a). People with insomnia usually believe that medication is the only existing treatment option. They may be reluctant to take sleep medication and therefore reluctant to seek help. A second reason is that CBT for insomnia is not widely available. Moreover, GPs seldom refer to available psychological services for insomnia even when they do exist (Everitt et al. 2014). Offering CBT through the Internet may help overcome these issues.

As early as in 1979, it was recognized that insomnia treatment might also be delivered in self-help formats (Alperson and Biglan 1979). During the following 30 years, several self-help programs have been developed in different formats such as books, videos, and audiotapes (e.g., Morin et al. 2005; Riedel et al. 1995). This means that patients receive materials in which the different components of cognitive-behavioral therapy are explained. They are stimulated to practice the established CBTI techniques themselves or with brief therapist support.

The first study on Internet-delivered self-help for insomnia appeared in 2004 (Ström et al. 2004). To date we identified ten different programs which have published data on the effectiveness of the program: nine for adult patients with insomnia (Blom et al. 2015a; Espie et al. 2012; Kaldo et al. 2015a; Lancee et al. 2012; Ritterband et al. 2009; Ström et al. 2004; Suzuki et al. 2008; Van Straten et al. 2014; Vincent and Lewycky 2009) and one for adolescent patients (De Bruin et al. 2014).

The ten programs all include the core CBTI components as described in Table 8.2, and some include additional components, e.g., audio files for relaxation and stress management techniques. Even though the content of the programs is not that different, the way the treatments are presented does vary quite a lot. The treatment by Suzuki offers all the CBT elements, but patients can choose which of those they want to try out (at least three). The treatment of De Bruin is offered during fixed weekly online consultations. The treatments by Blom and Kaldo have both fixed and optional elements, with flexible and active online therapist support. The remaining treatments are fixed structured programs which the patients can work through at their own pace. Some of the programs are mostly text based (e.g., Blom, De Bruin, Lancee, Ström, Kaldo, Van Straten), while others make more use of audiovisual clips (e.g., Vincent) or use an array of different elements to make the intervention more attractive. Examples of these elements are quizzes, games, animations, and a virtual therapist (e.g., Espie, Ritterband). The rationale behind a more interactive design, next to offering patients a more pleasurable experience, is to promote better understanding of the information. It is also suggested that it will retain patients in the intervention.

The interventions also vary in the way patients are supported. This varied from no support at all (Lancee, Vincent) to automated support (Espie, Ritterband, Ström, Suzuki) and weekly personal feedback from a coach or therapist (Blom, De Bruin, Van Straten, Kaldo). Support is aimed at helping patients through the program and exercises (i.e., providing optimal sleep windows) and to encourage patients to continue. The automated support was personalized and based on bed times and sleep estimates provided by patients in their sleep diary.

Farah is a 34-year-old woman with insomnia disorder. Her sleeping problems started when her child, now 3 years old, was a baby and needed feeding several times per night. When the baby grew older and started sleeping through most nights, Farah kept waking up three to four times per night and had trouble going back to sleep. After her parental leave, Farah went back to her job as a manager at a construction company. The work entails long hours and a high level of stress. Farah started having trouble falling asleep, in addition to her frequent nighttime awakenings. She found it hard to relax in the evening. She often checked her email late in the evening to get a head start on next day’s work. Her mind was constantly active solving problems, thinking about work and planning their everyday life, making her mentally aroused when trying to sleep. She started worrying a lot about not sleeping and the ramifications of that for her health and performance at work and as a parent. The worrying made it even harder to fall asleep – a catch 22! She was too tired to meet friends and exercise, something she used to do regularly prior to her sleeping problems. Farah has started using sleep medication in order to fall asleep. Her general practitioner (GP) has told her not to use it too frequently, for fear of habituation, and she takes them two or three times per week when she is desperate to sleep. They help her go to sleep, but she still wakes up during the night. It is not a satisfactory solution.

Farah talks to her GP about her issues, and the GP deems online treatment to be suitable for her. He refers her to a mental health service which offers online CBT for insomnia. After filling out an online sleep diary for 1 week, her treatment starts.

Farah logs on to the treatment Internet site and is greeted by a welcome message from her personal online psychologist. The treatment is divided into several chapters, which she can access sequentially, after completing the previous chapter. The treatment consists of educational text to read about insomnia and CBT for insomnia, questions to answer at the end of each chapter on theory and how it applies to her situation, assignments on how to work through the CBT interventions, work sheets to fill out, and a sleep diary that is to be filled out daily throughout treatment.

When Farah has finished a chapter, her writings and answers are automatically sent to her psychologist. The psychologist logs on to the site and looks into Farah’s sleep diary and her writings. The psychologist then gets back to her with advice, answers to questions, and encouragement. Farah is expected to complete on average one chapter per week and can send messages to her psychologist whenever she wants. After a couple of weeks’ treatment, Farah gets a cold, and at the same time her workload increases dramatically due to a colleague’s sick leave. As a result she stops focusing on the ICBT and forgets to log on to the site. When Farah hasn’t been heard from for 1 week, her psychologist sends an online message, asking her how she is doing and motivating her to continue with the treatment. After that, Farah is back on track and continues with the next chapter. She will need another two text messages to remind her in the coming weeks, but she always responds quickly and makes it though the treatment chapters on time.

The treatment focuses on behavioral changes such as sleep restriction, stimulus control, and evening routines. Farah struggles with sleep restriction, since it means she has to stay awake until one in the morning the first week and get up at 6 o’clock. The most difficult part is staying awake in the early evening after putting her child to bed. After online consultation with the psychologist, she decides to start a new evening routine and she asks her husband to support her to stick to the routine. It means that she takes a walk after putting her child to bed, that she and her husband watch some television together, and that she takes a bath before going to bed. Quite soon after she starts adhering to the sleep restriction schedule, she notices that she wakes up less often which encourages her further to stick to the routine. The treatment also encompasses cognitive reappraisal, stress management, and how to cope with, and prevent, sleepiness and fatigue. For example, Farah is encouraged to talk to her manager about reducing her workload, and she takes up running again. She also starts meeting her friends every now and then, even if she feels tired. At the end of the treatment, she makes a plan for the future – how to continue with interventions and look for warning signs of relapse.

When Farah has worked through the complete treatment, her insomnia severity has dropped from severe to mild. At the start it took her around 40 min to fall asleep after going to bed, but this decreased to only 10 min. She also wakes up less frequently and worries less about her sleep problems. Even though her actual sleep time has not increased by much, she feels that her sleep quality is much better and daytime fatigue is much less. She doesn’t use any sleep medication anymore. She believes her sleep time will increase a bit more when she continues with her sleep restriction schedule for a few more weeks after the treatment.