Guided internet-based cognitive behavioral therapy for insomnia: Health-economic evaluation from the societal and public health care perspective alongside a randomized controlled trial

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  • Claudia Buntrock
  • Dirk Lehr
  • Filip Smit
  • Hanne Horvath
  • Matthias Berking
  • Kai Spiegelhalder
  • Heleen Riper
  • David Daniel Ebert

BACKGROUND: The evidence base for internet-based cognitive behavioral therapy for insomnia (iCBT-I) is firm; however, little is known about iCBT-I's health-economic effects.

OBJECTIVE: This study aimed to evaluate the cost-effectiveness and cost-utility of iCBT-I in reducing insomnia among schoolteachers.

METHODS: Schoolteachers (N=128) with clinically significant insomnia symptoms and work-related rumination were randomized to guided iCBT-I or a wait list control group, both with unrestricted access to treatment as usual. Health care use, patient and family expenditures, and productivity losses were self-assessed and used for costing from a societal and a public health care perspective. Costs were related to symptom-free status (score <8 on the insomnia severity index) and quality-adjusted life years (QALYs) gained. Sampling error was handled using nonparametric bootstrapping.

RESULTS: Statistically significant differences favoring the intervention group were found for both health outcomes (symptom-free status yes or no: β=.30; 95% CI 0.16-0.43; QALYs: β=.019, 95% CI 0.01-0.03). From a societal perspective, iCBT-I had a 94% probability of dominating the wait list control for both health outcomes. From a public health care perspective, iCBT-I was more effective but also more expensive than the wait list control, resulting in an incremental cost-effectiveness ratio of €650 per symptom-free individual. In terms of QALYs, the incremental cost-effectiveness ratio was €11,285. At a willingness-to-pay threshold of €20,000 per QALY gained, the intervention's probability of being cost-effective was 89%.

CONCLUSIONS: Our trial indicates that iCBT could be considered as a good value-for-money intervention for insomnia.

TRIAL REGISTRATION: German Clinical Trial Registry: DRKS00004700;


Original languageEnglish
Article numbere25609
JournalJournal of Medical Internet Research
Issue number5
Publication statusPublished - 24.05.2021

Bibliographical note

This was not an industry-supported study. The European Union funded this study (European Regional Development Fund: ZW6-80119999 and CCI 2007DE161PR001). The funder did not have a role in study design; data collection, analysis, and interpretation of results; or the decision to publish the study results.

©Claudia Buntrock, Dirk Lehr, Filip Smit, Hanne Horvath, Matthias Berking, Kai Spiegelhalder, Heleen Riper, David Daniel Ebert. Originally published in the Journal of Medical Internet Research (, 24.05.2021.

    Research areas

  • Behavior, Cognitive behavioral therapy, Cost-effectiveness, Cost-utility, Economic evaluation, Economics, ICBT-I, Insomnia, Internet-based cognitive behavioural therapy, Perspective, Public health, Sleep
  • Psychology
  • Health sciences