Apps, Online Programs Can Expand Availability of CBT for Insomnia

Mobile apps and Internet programs are expanding the availability of cognitive-behavioral therapy for insomnia (CBT-I), the first-line treatment for this disorder, according to speakers at a symposium on the topic at the joint annual meeting of the American Academy of Sleep Medicine and the Sleep Research Society in Seattle in June.

Sergey Ivanov

The new technology aids data collection and analysis, said Rachel Manber, Ph.D., a professor of psychiatry and behavioral sciences at Stanford University School of Medicine and symposium chair. By offering access to therapy to large numbers of users, she said, this technology also provides new research opportunities.

An estimated 10 to 15 percent of American adults report persistent trouble falling or staying asleep, waking too early, and feeling unrefreshed by sleep. CBT-I offers a constellation of nonpharmacological interventions to ease these symptoms, said Manber, who directs Stanford’s Sleep Health and Insomnia Program. CBT-I aims to help participants learn about factors that enhance sleep, examine beliefs and practices that interfere with sleep, and adopt behaviors that foster sleep.

CBT-I customarily involves individual or group sessions, lasting about one hour per week for four to eight weeks, conducted or supervised by specialists in behavioral sleep medicine. This growing but still small group includes psychiatrists, psychologists, and other health care providers.

CBT-i Coach Can Augment Care Provided By Trained Professionals

At the symposium, Manber described CBT-i Coach, a free app for iPhones and Androids that was jointly developed by Stanford’s School of Medicine, the Department of Veterans Affairs National Center for Post-Traumatic Stress Disorder, and the Department of Defense National Center for Telehealth and Technology. Based on the therapy manual Cognitive Behavioral Therapy for Insomnia in Veterans, the app is used throughout the Veterans Health Administration, Manber said, to augment CBT-I provided by clinicians trained and skilled in delivering CBT-I.

CBT-i Coach users start by recording bedtime, rise time, and other aspects of sleep in a daily diary on their mobile phone. In addition to providing tips on how to strengthen the bed and bedroom as cues for sleep and why limiting time in bed can increase sleep drive and consolidate sleep, the app describes the benefits of using relaxation strategies, such as scheduling a worry time earlier in the day to reduce bedtime rumination. For users troubled by thoughts of trauma that may trigger nightmares, the app includes self-talk messages to ease bedtime anxiety, such as, “I know I’m in a safe place.”

CBT-i Coach also offers users tips on managing the use of caffeine and other substances; they can set reminders, such as the time to stop caffeine and start winding down. The app also provides guidance on letting go of beliefs and practices that undermine sleep, such as the notion that there is little one can do about poor sleep, and urges users to maintain a regular rise time to strengthen their daily sleep/wake rhythm.

Clinicians may prescribe readings or practices specific to an individual’s needs, Manber said. A night-owl with insomnia, for example, may need extra encouragement to maintain a fixed rise time, unwind before bedtime, get morning light exposure, and learn about internal body clocks that govern sleep—all topics reinforced by app content.

Work in progress aims to adapt CBT-i Coach for use as a self-help tool by the general public, Manber said. While in the public domain and free, the app lacks the guidance that a clinician can provide, she noted.

Apps Deliver Personalized CBT-I Recommendations to Users

Several self-help mobile sleep apps on the market offer personalized CBT-I feedback to users.

One such app is SleepRate, which uses a heart rate sensor worn on an elastic band around the chest in sleep to transmit data wirelessly to the user’s phone. The app analyzes heart rate variability to determine when the user falls asleep, awakens, and experiences various sleep stages. It also detects environmental noises that disrupt sleep. Users complete a daily sleep diary on their phone and receive CBT-I recommendations based on their initial assessment period and feedback on their sleep.

Sleepio, a six-week online sleep improvement CBT-I program that relies on sleep data entered manually by users or pulled from tracking devices, also offers users personalized feedback.

Sleepio users tag factors influencing their sleep patterns, such as staying up late or consuming alcohol. Once a week, users interact with an animated therapist, “The Prof,” who reviews sleep progress and offers personalized suggestions for next steps, presenting a menu of options for users to explore.

According to Colin Espie, Ph.D., a professor of sleep medicine at the Sleep and Circadian Neuroscience Institute at the University of Oxford and co-founder of Sleepio, who spoke during the symposium, the program has been downloaded by more than 300,000 people since its launch in 2012. While most Sleepio users take longer than six weeks to complete the program, more than two-thirds stick with it for eight weeks, according to Espie. The majority of those who finish the program report they fall asleep faster, awaken less frequently, and feel more alert in the daytime.

In an analysis of data from 89,000 users, Espie’s group found the experience of lying in bed awake and feeling that sleep is not under one’s control is the strongest predictor of sleep complaints in young adults. This finding, Espie noted, supports the role of cognitive components in CBT-I that address such distress.

Aid to employee health programs

Electronic technology can enhance employee health programs, Michelle Drerup, Psy.D., said at the same symposium.

Drerup, director of behavioral sleep medicine at the Cleveland Clinic Health System, created Go! to Sleep, a six-week interactive mobile phone and web-based CBT-I program, for her organization’s 43,430 employees.

Go! to Sleep aims to help people with short-term or episodic insomnia often associated with stress, she said, and offers physicians and other health care providers an alternative to prescribing hypnotic medications.

After users enter their daily sleep data on their phone or online, they get a sleep efficiency report, along with individualized suggestions to improve their sleep. Daily emails from Drerup, who serves as their “sleep coach,” encourage users to maintain their motivation to adopt healthy sleep habits. Users can also access advice on relaxation practices and other resources.

As of April, Drerup said about 1,500 people had enrolled in the six-week program and 73 percent completed the program within nine weeks, with most reporting improved sleep. Those with persistent sleep problems were invited to participate in group or individual CBT-I in Drerup’s clinic.

Self-help treatment options such as the Go! to Sleep program don’t replace therapist-led interventions, Drerup said, but they may serve as an initial step in treatment.

Drerup currently is training psychiatry residents in CBT-I. “They see patients benefit from this therapy in a relatively short time,” she said. “CBT-I gives psychiatrists a tool other than sleep medications to help patients with psychiatric disorders who also sleep poorly.” ■