Sleep Europe 2026 | MOST trial identifies sleep restriction as the key active component of digital CBT-I for insomnia

So we know that CBT-I works for insomnia disorder and we’ve known this for a long time. We also know that there’s a big issue with adherence and dropout, especially digital versions. So in our MOST trial we wanted to kind of narrow in or focus on what are the most active components in CBT-I and can we maybe optimize the treatment to be more focused on those elements that are mostly active or efficacious. So we conducted this MOST trial. So MOST comes from engineering, where you try to find out based on if you have multiple components, you’re trying to figure out which one is actually adding the most value to your outcome, in this case, treating insomnia. And we did this large trial, combining a lot of different components and different experimental conditions, and then set an optimization criteria, which was a kind of, you have to decide on what is your optimization criteria. In our case, it was a Cohen’s D of 0.25, so a small effect. And basically we look at which of the components in CBT-I delivered through an app that we’ve developed exceed that threshold. And what we find is that the stimulus, sorry, the sleep restriction therapy, which most clinicians know is a very powerful tool, is the one that really exceeds the threshold for optimization, which means that it doesn’t mean that it’s the only active component. It just means that this component really adds value to the protocol or to the program. So in an optimized version where we wanted to maybe even narrow down to only the components that are most active, sleep restriction should definitely be a part of it. And what does this mean for clinicians? Does it mean you shouldn’t do all the other components? Not necessarily because we know that you have to look at the participant and the patient and figure out maybe some participants or patients will gain more from say cognitive therapy or other. But if we wanted to create a very kind of stripped down version, sleep restriction therapy is really the component that is most important.

So sleep restriction is basically trying to reduce time in bed. So we ask participants to only spend time in bed corresponding to the amount of hours they sleep. So basically you don’t want patients or the person with insomnia issues to stay a long time in bed because it will increase the risk of conditioning effects and you will start getting that agitation and anxiety around being in bed. So it’s trying to reduce the time in bed to the total sleep time and then increasing the sleep pressure so when people finally go to bed, they’re really, really tired and then can fall asleep. Our study was basically, of course, a digital version of CBT-I. So first of all, I think there’s a huge potential in digital versions and especially nowadays also with AI and chatbots there’s there’s even more work to be done. But making sure that there’s access to a digital version of CBT-I is the first step and then I guess going forward maybe one could do kind of a step care model of digital components so maybe start with sleep restriction therapy that we know is the most efficacious and then maybe move on to second or third components because we want to kind of keep the burden low on the participants because we know that some of these programs can be very burdensome and people tend to drop out so maybe do kind of a gradual component introduction could be one way to do so.

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