Efficacy of internet-delivered cognitive-behavioral therapy for insomnia - A systematic review and meta-analysis of randomized controlled trials

Improvements of adolescent psychopathology after insomnia treatment: results from a randomized controlled trial over 1 year

BACKGROUND

Adolescent insomnia can be treated effectively with cognitive behavioural therapy for insomnia (CBTI). However, little is known about effects of CBTI on psychopathology in adolescents. This study aimed to investigate whether (a) CBTI improves psychopathology in Internet- (IT) and face-to-face group treatment (GT) compared to waitlist (WL), (b) improvement in psychopathology can be attributed to reduced insomnia, (c) improvement in psychopathology remains stable for up to 1 year.

METHODS

One hundred and sixteen participants (age = 15.6 years, 25% males) with DSM-5 insomnia, were randomly assigned to IT, GT or WL.

CLINICAL TRIAL REGISTRATION

http://www.controlledtrials.com (ISRCTN33922163). Assessments of psychopathology, insomnia and objectively and subjectively measured sleep occurred at baseline, post-treatment, and at 2-, 6- and 12-month follow-up. Multilevel and mediation analyses were run to test hypotheses. The CBTI protocol, 'Sleeping Smart' for both IT and GT consisted of six weekly sessions and a booster session after 2 months.

RESULTS

Psychopathology symptoms, insomnia and sleep problems as measured by actigraphy and sleep logs decreased substantially in IT and GT compared with WL at 2-month follow-up with medium to large effect sizes (ESs). Psychopathology symptoms remained stable or further improved for up to 12-month follow-up. ESs at 12-month follow-up for IT and GT were respectively: affective (d = -0.87 and -0.97), anxiety (d = -0.81 for IT), somatic (d = -0.38 and d = -0.52), oppositional (d = -0.42 for GT) and attention deficit hyperactivity disorder (ADHD) problems (d = -0.47 and -0.46). Mediation analyses indicated that reduction of insomnia symptoms after CBTI fully mediated the effects of CBTI on affective and anxiety problems, and partially mediated the effect on ADHD problems.

CONCLUSIONS

This is the first study demonstrating that Internet and face-to-face CBT for insomnia achieves long-term reduction in adolescent psychopathology and does so by improving insomnia. This finding can have profound implications for youth mental health care.

Internet- and Mobile-Based Psychological Interventions: Applications, Efficacy, and Potential for Improving Mental Health

Abstract. The majority of mental health disorders remain untreated. Many limitations of traditional psychological interventions such as limited availability of evidence-based interventions and clinicians could potentially be overcome by providing Internet- and mobile-based psychological interventions (IMIs). This paper is a report of the Taskforce E-Health of the European Federation of Psychologists’ Association and will provide an introduction to the subject, discusses areas of application, and reviews the current evidence regarding the efficacy of IMIs for the prevention and treatment of mental disorders. Meta-analyses based on randomized trials clearly indicate that therapist-guided stand-alone IMIs can result in meaningful benefits for a range of indications including, for example, depression, anxiety, insomnia, or posttraumatic stress disorders. The clinical significance of results of purely self-guided interventions is for many disorders less clear, especially with regard to effects under routine care conditions. Studies on the prevention of mental health disorders (MHD) are promising. Blended concepts, combining traditional face-to-face approaches with Internet- and mobile-based elements might have the potential of increasing the effects of psychological interventions on the one hand or to reduce costs of mental health treatments on the other hand. We also discuss mechanisms of change and the role of the therapist in such approaches, contraindications, potential limitations, and risk involved with IMIs, briefly review the status of the implementation into routine health care across Europe, and discuss confidentiality as well as ethical aspects that need to be taken into account, when implementing IMIs. Internet- and mobile-based psychological interventions have high potential for improving mental health and should be implemented more widely in routine care.

Evaluation of an Internet-Based Behavioral Intervention to Improve Psychosocial Health Outcomes in Children With Insomnia (Better Nights, Better Days): Protocol for a Randomized Controlled Trial

BACKGROUND

Up to 25% of 1- to 10-year-old children experience insomnia (ie, resisting bedtime, trouble falling asleep, night awakenings, and waking too early in the morning). Insomnia can be associated with excessive daytime sleepiness and negative effects on daytime functioning across multiple domains (eg, behavior, mood, attention, and learning). Despite robust evidence supporting the effectiveness of behavioral treatments for insomnia in children, very few children with insomnia receive these treatments, primarily due to a shortage of available treatment resources.

OBJECTIVE

The Better Nights, Better Days (BNBD) internet-based program provides a readily accessible electronic health (eHealth) intervention to support parents in providing evidence-based care for insomnia in typically developing children. The purpose of the randomized controlled trial (RCT) is to evaluate the effectiveness of BNBD in treating insomnia in children aged between 1 and 10 years.

METHODS

BNBD is a fully automated program, developed based on evidence-based interventions previously tested by the investigators, as well as on the extant literature on this topic. We describe the 2-arm RCT in which participants (500 primary caregivers of children with insomnia residing in Canada) are assigned to intervention or usual care.

RESULTS

The effects of this behavioral sleep eHealth intervention will be assessed at 4 and 8 months postrandomization. Assessment includes both sleep (actigraphy, sleep diary) and daytime functioning of the children and daytime functioning of their parents. Results will be reported using the standards set out in the Consolidated Standards of Reporting Trials statement.

CONCLUSIONS

If the intervention is supported by the results of the RCT, we plan to commercialize this program so that it is sustainable and available at a low cost to all families with internet access.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02243501; https://clinicaltrials.gov/show/NCT02243501 (Archived by WebCite at http://www.webcitation.org/6x8Z5pBui).

Digitally-delivered cognitive-behavioural therapy for youth insomnia: A systematic review

Sleep disturbance is common among young people, with consequences for academic, emotional and behavioural development. Cognitive-behavioural therapy for insomnia (CBT-I) is efficacious, yet it is costly and not available to many who need it. Digitally-delivered CBT-I (eCBT-I) has the potential to overcome these barriers. The purpose of this systematic review was to identify studies which report on the efficacy or effectiveness of eCBT-I for young people with sleep disturbance. Electronic databases were systematically searched and three studies met inclusion criteria. Two studies used the same online intervention for adolescents with insomnia symptoms, while the other was conducted in a college sample of individuals who opted into a stress-management study. Results showed that eCBT-I improved sleep efficiency, sleep quality, sleep-onset latency and total sleep time with effect sizes ranging from 0.17-1.30 (Cohen's d). This suggests that eCBT-I is a promising intervention for young people, but more studies are needed to verify the conditions under which it is most effective.

Working alliance with an avatar: How far can we go with internet interventions?

OBJECTIVE

To examine the working alliance between users and an avatar and users' treatment expectations in an unguided Internet intervention for the treatment of insomnia.

METHODS

The sample included participants from the treatment condition (N = 29) of a randomised controlled trial. The task and goal subscales of the Working Alliance Inventory Short Revised (WAI-SR) were applied in week three. Five items of the Bern Post-Session Report and one question about the extent to which users had missed a human therapist were administered after each session. Treatment expectations were measured with the Credibility Expectancy Questionnaire (CEQ), and the Insomnia Severity Index (ISI) was used as the primary outcome measure.

RESULTS

The mean scores for the WAI-SR task and goal subscales were relatively high (M = 3.24, SD = 0.79; M = 3.16, SD = 0.91, respectively). The mean score of the five Bern Post-Session Report items remained stable over time, but some users increasingly indicated that they missed a real therapist over the course of the intervention, with a strong linear effect (t(87) = 3.16, p < 0.01). ISI chance score was predicted by the mean score of the Bern Post-Session Report (b = -0.3.83, t(21.80) = -2.97, p < 0.01), missing a human therapist (b = -0.0.13, t(20.47) = -2.72, p = 0.01) and the CEQ (b = 0.18, t(19.03) = -2.69, p = 0.01), but not by WAI-SR task and goal subscales.

CONCLUSIONS

Results indicate that users established a working alliance with the avatar. The affective bond remained stable over time, but towards the end of the intervention some users indicated that they missed having a human therapist. Affective bond and missing a real therapist predicted symptom change.

Internet-delivered cognitive-behavioral therapy for insomnia and comorbid symptoms

BACKGROUND

Cognitive-behavioral therapy for insomnia (CBTi) is considered the standard treatment. The internet has proven to be a useful and successful tool of providing CBTi. However, few studies have investigated the possible effect of unguided internet-delivered CBTi (ICBTi) on comorbid psychological symptoms and fatigue.

METHODS

Based on a randomized controlled trial, we investigated whether unguided ICBTi had an effect on comorbid psychological symptoms. Adults with insomnia (n = 181; 67% women; mean age 44.9 years [SD 13.0]) were randomized to ICBTi (n = 95) or to an online patient education condition (n = 86) for a nine-week period.

RESULTS

The results from mixed linear modelling yielded medium to large between-group effect sizes from pre- to post-treatment for symptoms of anxiety or depression (d = -0.57; 95% CI = 0.79-0.35) and fatigue (d = 0.92; 95% CI = 1.22-0.62). The ICBTi group was reassessed at a 6-month non-randomized follow-up, and the completing participants had on the average a significant increase (from the post-assessment) on symptoms of anxiety or depression, while the reduction in symptoms of fatigue (on post-assessment) was maintained. However, due to high dropout attrition and no control group data, caution should be made regarding the long-term effects. In conclusion, the present findings show that unguided ICBTi positively influence comorbid symptoms in the short-term, thereby emphasizing the clinical relevance of unguided ICBTi.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02261272.

Delivering digital cognitive behavioral therapy for insomnia at scale: does using a wearable device to estimate sleep influence therapy?

Contemporary developments, such as digital Cognitive Behavioral Therapy (CBT) and wearable devices estimating sleep, could support the implementation of CBT for insomnia at a large scale. We assessed what characterizes those users who connected a wearable device to the program to estimate sleep diary variables, and whether connecting a wearable device affected insomnia symptom improvement, related well-being, and program interaction. In total, 3551 users (63% female, mean age 44.50 ± 14.78 years) of a dCBT program who completed a post-therapy survey, including 378 users (10.6%) who used a device, were selected. Within-subject, pre-therapy to post-therapy, the Sleep Condition Indicator (SCI, 7 Items) was used to assess insomnia. Two-item measures (depression, anxiety) and single item measures (perceived stress, life satisfaction, work productivity) of well-being were analyzed, in addition to program interaction. For all participants, insomnia symptoms significantly improved following dCBT (t(3504) = 83.33, p < 0.001; Cohen's d = 1.45), as did depression and anxiety symptoms, perceived stress, life satisfaction and work productivity. Those who did not connect a device reported better sleep and less affected work productivity (all p < .001) than those who did connect a device at baseline and post-treatment; nevertheless treatment effects were largely similar for the two groups. Those who connected a device interacted more with additional program components. In conclusion, improvements in insomnia after completing dCBT are similar in persons choosing to wear a wearable device to estimate sleep and persons completing a subjective sleep diary. Potentially, use of wearable devices can facilitate treatment for those who struggle to complete daily diaries.

Randomised controlled trial on the effect of internet-delivered computerised cognitive-behavioural therapy on patients with insomnia who remain symptomatic following hypnotics: a study protocol

INTRODUCTION

Insomnia has severe consequences for health. Primary care physicians in Japan commonly provide hypnotics, which is far from optimal. The recommended treatment for insomnia is cognitive-behavioural therapy (CBT). Access to trained therapists, however, is limited. Rather than face-to-face CBT, several researchers have studied internet-delivered computerised CBT (ICBT). This paper describes the study protocol for a randomised controlled trial (RCT) to evaluate effectiveness and feasibility of our newly developed five-step ICBT as an adjunct to usual care (UC) compared with UC alone for patients with insomnia who remain symptomatic following hypnotics.

METHODS AND ANALYSIS

This proposed exploratory RCT comprises two parallel groups (ICBT+UC and UC alone) consisting of 15 participants each (n=30) diagnosed with insomnia who remain symptomatic after pharmacotherapy. We aim to evaluate the effectiveness of six intervention weeks. The primary outcome of insomnia severity will be the Pittsburgh Sleep Quality Index (PSQI) at week 6. Secondary outcomes include sleep onset latency, total sleep time, sleep efficiency extracted from PSQI, current feeling of refreshment and perceived soundness of sleep measured using visual analogue scale, number of awakenings, anxiety by Hospital Anxiety and Depression Scale, depression by Center for Epidemiologic Studies Depression Scale and quality of life by Euro Qol-5D. All measures will be assessed at weeks 0 (baseline), 6 (postintervention) and 12 (follow-up), and intention-to-treat analysis will be applied. The statistical analysis plan has been developed considering design of field materials.

ETHICS AND DISSEMINATION

This study will be conducted at the academic outpatient clinic of Chiba University Hospital, Japan. Ethics approval was granted by the Institutional Review Board of Chiba University Hospital. All participants will be required to provide written informed consent. The trial will be implemented and reported in accordance with Consolidated Standards of Reporting Trials recommendations.

TRIAL REGISTRATION NUMBER

UMIN000021509; Pre-results.

Insomnia and cognitive behavioural therapy-how to assess your patient and why it should be a standard part of care

Hippocrates recognized the importance of asking about sleep as long ago as 400 BC when he wrote "sleep and watchfulness, both of them when immoderate, constitute disease". Disrupted sleep for any reason has immediate and long term consequences on physical and mental health. Insomnia disorder ("immoderate watchfulness") remains the commonest sleep disorder in primary and secondary care with an estimated 5-10% of the adult population affected. While it is commonly comorbid with other physical and mental health problems, the new diagnostic classification has been helpfully simplified such that it is considered a disorder in itself. If it is the patient's main concern, it warrants treatment. Patients and health professionals have often had limited teaching about effective strategies for insomnia which leaves many untreated and insomnia can be unfairly perceived as a challenging symptom to manage. The first line treatment is now well established as insomnia-specific cognitive behavioural therapy (CBTi) in the most recent US and European treatment guidelines. Over 25 years of high quality research have shown evidence for sustained improvements in sleep in those with insomnia alone or insomnia comorbid with other conditions. This is a simple CBT to deliver with better and safer outcomes than prescription hypnotics. Therefore, this review will cover the initial assessment of insomnia, including insomnia mimics, the selection of patients for treatment and the key components of CBT therapy. Finally, the review will cover evidence for different modes of delivery (online, self, help, group or individual face to face) in a variety of clinical settings.

A systematic review and meta-analysis of cognitive and behavioral interventions to improve sleep health in adults without sleep disorders

Many adults without a diagnosed sleep disorder report poor sleep health, which is defined by dissatisfactory levels of sleep duration, sleep quality, or the timing of sleep. No previous review has summarized and described interventions targeting poor sleep health in this population. This meta-analysis aimed to quantify the efficacy of behavioral and cognitive sleep interventions in adults with poor sleep health, who do not have a sleep disorder. Electronic databases (Medline, Embase, PsycInfo, Cinahl) were searched with restrictions for age (18-64 y) and English language full-text, resulting in 18,009 records being screened and 592 full-texts being assessed. Eleven studies met inclusion criteria, seven of which reported a measure of overall sleep health (Pittsburgh sleep quality index [PSQI]). Following appraisal for risk of bias, extracted data were meta-analyzed using random-effects models. Meta-analyses showed interventions had a medium effect on sleep quality (Hedge's g = -0.54, [95% confidence interval (CI)] -0.90 to -0.19, p < 0.01). Baseline sleep health was the only significant effect moderator (p = 0.01). The most frequently used intervention components were stress management and relaxation practice, stimulus control, sleep hygiene, and exercise. Interventions targeting cognitive and behavioral self-regulation improve sleep quality in adults without clinical sleep disorder.

Cognitive mechanisms of sleep outcomes in a randomized clinical trial of internet-based cognitive behavioral therapy for insomnia

OBJECTIVE

The aim of this study was to investigate in a randomized clinical trial the role of sleep-related cognitive variables in the long-term efficacy of an online, fully automated cognitive behavioral therapy intervention for insomnia (CBT-I) (Sleep Healthy Using the Internet [SHUTi]).

METHOD

Three hundred and three participants (M_age = 43.3 years; SD = 11.6) were randomly assigned to SHUTi or an online patient education condition and assessed at baseline, postintervention (nine weeks after baseline), and six and 12 months after the intervention period. Cognitive variables were self-reported internal and chance sleep locus of control, dysfunctional beliefs and attitudes about sleep (DBAS), sleep specific self-efficacy, and insomnia knowledge. Primary outcomes were self-reported online ratings of insomnia severity (Insomnia Severity Index), and sleep onset latency and wake after sleep onset from online sleep diaries, collected 12 months after the intervention period.

RESULTS

Those who received SHUTi had, at postassessment, higher levels of insomnia knowledge (95% confidence interval [CI] = 0.10-0.16) and internal sleep locus of control (95% CI = 0.04-0.55) as well as lower DBAS (95% CI = 1.52-2.39) and sleep locus of control attributed to chance (95% CI = 0.15-0.71). Insomnia knowledge, chance sleep locus of control, and DBAS mediated the relationship between condition and at least one 12-month postassessment sleep outcome. Within the SHUTi condition, changes in each cognitive variable (with the exception of internal sleep locus of control) predicted improvement in at least one sleep outcome one year later.

CONCLUSION

Online CBT-I may reduce the enormous public health burden of insomnia by changing underlying cognitive variables that lead to long-term changes in sleep outcomes.

Australasian Sleep Association position statement regarding the use of psychological/behavioral treatments in the management of insomnia in adults

Insomnia disorder is a high prevalence condition with a high disease burden, which, left untreated, can increase risk of poorer health outcomes. Due to Insomnia's tendency towards having a chronic course, long-term treatment approaches are required to reduce the impact of Insomnia over time. After reviewing the available literature, The Australasian Sleep Association (ASA) recommends Cognitive Behavior Therapy for Insomnia (CBT-I) as a first line treatment in the management of Insomnia. The ASA notes that in addition to CBT-I, there is emerging evidence for the use of Mindfulness Based Therapy for Insomnia when used in combination with behavioural techniques (MBT-I). CBT-I should be used whenever possible, and medications should be limited to the lowest necessary dose and shortest necessary duration. CBT-I, whilst the most effective long-term treatment, does not work for everybody across all circumstances, so there will be circumstances in which other treatments are required (e.g., pharmacotherapy). Improving access to CBT-I is an important issue which will involve raising awareness of the effectiveness of CBT-I, increasing the number of trained practitioners, and the development of effective low intensity treatments that can be offered in the first instance.

Clarifying the Concept of Adherence to eHealth Technology: Systematic Review on When Usage Becomes Adherence

BACKGROUND

In electronic health (eHealth) evaluations, there is increasing attention for studying the actual usage of a technology in relation to the outcomes found, often by studying the adherence to the technology. On the basis of the definition of adherence, we suggest that the following three elements are necessary to determine adherence to eHealth technology: (1) the ability to measure the usage behavior of individuals; (2) an operationalization of intended use; and (3) an empirical, theoretical, or rational justification of the intended use. However, to date, little is known on how to operationalize the intended usage of and the adherence to different types of eHealth technology.

OBJECTIVE

The study aimed to improve eHealth evaluations by gaining insight into when, how, and by whom the concept of adherence has been used in previous eHealth evaluations and finding a concise way to operationalize adherence to and intended use of different eHealth technologies.

METHODS

A systematic review of eHealth evaluations was conducted to gain insight into how the use of the technology was measured, how adherence to different types of technologies was operationalized, and if and how the intended use of the technology was justified. Differences in variables between the use of the technology and the operationalization of adherence were calculated using a chi-square test of independence.

RESULTS

In total, 62 studies were included in this review. In 34 studies, adherence was operationalized as "the more use, the better," whereas 28 studies described a threshold for intended use of the technology as well. Out of these 28, only 6 reported a justification for the intended use. The proportion of evaluations of mental health technologies reporting a justified operationalization of intended use is lagging behind compared with evaluations of lifestyle and chronic care technologies. The results indicated that a justification of intended use does not require extra measurements to determine adherence to the technology.

CONCLUSIONS

The results of this review showed that to date, justifications for intended use are often missing in evaluations of adherence. Evidently, it is not always possible to estimate the intended use of a technology. However, such measures do not meet the definition of adherence and should therefore be referred to as the actual usage of the technology. Therefore, it can be concluded that adherence to eHealth technology is an underdeveloped and often improperly used concept in the existing body of literature. When defining the intended use of a technology and selecting valid measures for adherence, the goal or the assumed working mechanisms should be leading. Adherence can then be standardized, which will improve the comparison of adherence rates to different technologies with the same goal and will provide insight into how adherence to different elements contributed to the outcomes.

Sleep Treatment Outcome Predictors (STOP) Pilot Study: a protocol for a randomised controlled trial examining predictors of change of insomnia symptoms and associated traits following cognitive-behavioural therapy for insomnia in an unselected sample

INTRODUCTION

Cognitive-behavioural therapy for insomnia (CBT-I) leads to insomnia symptom improvements in a substantial proportion of patients. However, not everyone responds well to this treatment, and it is unclear what determines individual differences in response. The broader aim of this work is to examine to what extent response to CBT-I is due to genetic and environmental factors. The purpose of this pilot study is to examine feasibility of a design to test hypotheses focusing on an unselected sample, that is, without selection on insomnia complaints, in order to plan a larger behavioural genetics study where most participants will likely not have an insomnia disorder.

METHODS AND ANALYSIS

A two parallel-group randomised controlled trial is being conducted across three London universities. Female students (minimum age 18 years) enrolled on a psychology programme at one of the three sites were invited to participate. The target number of participants to be recruited is 240. Following baseline assessments, participants were randomly allocated to either the treatment group, where they received weekly sessions of digital CBT-I for 6 weeks, or the control group, where they completed an online puzzle each week for 6 weeks. Follow-up assessments have taken place mid-intervention (3 weeks) and end of intervention (6 weeks). A 6-month follow-up assessment will also occur. Primary outcomes will be assessed using descriptive statistics and effect size estimates for intervention effects. Secondary outcomes will be analysed using multivariate generalised estimating equation models.

ETHICS AND DISSEMINATION

The study received ethical approval from the Research Ethics and Integrity subcommittee, Goldsmiths, University of London (application reference: EA 1305). DNA sample collection for the BioResource received ethical approval from the NRES Committee South Central-Oxford (reference number: 15/SC/0388). The results of this work shall be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT03062891; Results.

FORECAST - A cloud-based personalized intelligent virtual coaching platform for the well-being of cancer patients

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The challenges of cancer patients and the benefits of coaching are presented.

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Evidence of impact of coaching on the well being of cancer patients is presented.

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A cloud-based personalized intelligent virtual coaching platform for the well-being of cancer patients is proposed.

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Technology acceptance of the platform is presented, based on validation trials.

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Future work is discussed.

Well-being of cancer patients and survivors is a challenge worldwide, considering the often chronic nature of the disease. Today, a large number of initiatives, products and services are available that aim to provide strategies to face the challenge of well-being in cancer patients; nevertheless the proposed solutions are often non-sustainable, costly, unavailable to those in need, and less well-received by patients. These challenges were considered in designing FORECAST, a cloud-based personalized intelligent virtual coaching platform for improving the well-being of cancer patients. Personalized coaching for cancer patients focuses on physical, mental, and emotional concerns, which FORECAST is able to identify. Cancer patients can benefit from coaching that addresses their emotional problems, helps them focus on their goals, and supports them in coping with their disease-related stressors. Personalized coaching in FORECAST offers support, encouragement, motivation, confidence, and hope and is a valuable tool for the wellbeing of a patient.

Three-Year Follow-Up Comparing Cognitive Behavioral Therapy for Depression to Cognitive Behavioral Therapy for Insomnia, for Patients With Both Diagnoses

This 3-year follow-up compared insomnia treatment to depression treatment for patients with both diagnoses. Forty-three participants were randomized to either treatment, in the form of Internet-delivered therapist-guided cognitive behavior therapy (CBT), and 37 (86%) participants provided primary outcome data at the 3-year follow-up. After 3 years, reductions on depression severity were similar in both groups (between-group effect size, d = 0.33, p = .45), while the insomnia treatment had superior effects on insomnia severity (d = 0.66, p < .05). Overall, insomnia treatment was thus more beneficial than depression treatment. The implication for practitioners, supported by previous research, is that patients with co-occurring depression and insomnia should be offered CBT for insomnia, in addition to medication or psychological treatment for depression.

[Internet- and mobile-based approaches : Psycho-social diagnostics and treatment in medical rehabilitation]

Technology-based approaches for psychosocial diagnostics and interventions provide an attractive opportunity to optimize medical rehabilitation. Based on an Internet- and mobile-based assessment of existing functional health impairments, appropriate planning, implementation of corresponding courses of action as well as outcome assessment can take place. This can be implemented in the form of Internet- and mobile-based interventions (IMI).The present article provides an overview of the basic knowledge of IMI and their evidence base both in general and in particular for their use in medical rehabilitation. Important aspects of internet and mobile-based psycho-social diagnostics are discussed subsequently. Finally, an outlook for the use of Internet- and mobile-based diagnostics and interventions in medical rehabilitation is given.

The effects of improving sleep on mental health (OASIS): a randomised controlled trial with mediation analysis

BACKGROUND

Sleep difficulties might be a contributory causal factor in the occurrence of mental health problems. If this is true, improving sleep should benefit psychological health. We aimed to determine whether treating insomnia leads to a reduction in paranoia and hallucinations.

METHODS

We did this single-blind, randomised controlled trial (OASIS) at 26 UK universities. University students with insomnia were randomly assigned (1:1) with simple randomisation to receive digital cognitive behavioural therapy (CBT) for insomnia or usual care, and the research team were masked to the treatment. Online assessments took place at weeks 0, 3, 10 (end of therapy), and 22. The primary outcome measures were for insomnia, paranoia, and hallucinatory experiences. We did intention-to-treat analyses. The trial is registered with the ISRCTN registry, number ISRCTN61272251.

FINDINGS

Between March 5, 2015, and Feb 17, 2016, we randomly assigned 3755 participants to receive digital CBT for insomnia (n=1891) or usual practice (n=1864). Compared with usual practice, the sleep intervention at 10 weeks reduced insomnia (adjusted difference 4·78, 95% CI 4·29 to 5·26, Cohen's d=1·11; p<0·0001), paranoia (-2·22, -2·98 to -1·45, Cohen's d=0·19; p<0·0001), and hallucinations (-1·58, -1·98 to -1·18, Cohen's d=0·24; p<0·0001). Insomnia was a mediator of change in paranoia and hallucinations. No adverse events were reported.

INTERPRETATION

To our knowledge, this is the largest randomised controlled trial of a psychological intervention for a mental health problem. It provides strong evidence that insomnia is a causal factor in the occurrence of psychotic experiences and other mental health problems. Whether the results generalise beyond a student population requires testing. The treatment of disrupted sleep might require a higher priority in mental health provision.

FUNDING

Wellcome Trust.

Trajectories of change and long-term outcomes in a randomised controlled trial of internet-based insomnia treatment to prevent depression

BACKGROUND

Insomnia treatment using an internet-based cognitive-behavioural therapy for insomnia (CBT-I) program reduces depression symptoms, anxiety symptoms and suicidal ideation. However, the speed, longevity and consistency of these effects are unknown.

AIMS

To test the following: whether the efficacy of online CBT-I was sustained over 18 months; how rapidly the effects of CBT-I emerged; evidence for distinct trajectories of change in depressive symptoms; and predictors of these trajectories.

METHOD

A randomised controlled trial compared the 6-week Sleep Healthy Using the Internet (SHUTi) CBT-I program to an attention control program. Adults (N=1149) with clinical insomnia and subclinical depression symptoms were recruited online from the Australian community.

RESULTS

Depression, anxiety and insomnia decreased significantly by week 4 of the intervention period and remained significantly lower relative to control for >18 months (between-group Cohen's d=0.63, 0.47, 0.55, respectively, at 18 months). Effects on suicidal ideation were only short term. Two depression trajectories were identified using growth mixture models: improving (95%) and stable/deteriorating (5%) symptoms. More severe baseline depression, younger age and limited comfort with the internet were associated with reduced odds of improvement.

CONCLUSIONS

Online CBT-I produced rapid and long-term symptom reduction in people with subclinical depressive symptoms, although the initial effect on suicidal ideation was not sustained.

DECLARATION OF INTEREST

P.J.B. has received grants from the National Health and Medical Research Council (NHMRC) during the conduct of the study. H.C. has received grants from the NHMRC and the Australian Research Council during the conduct of the study. L.M.R. receives research funding from the National Institutes of Health (NIH) that, in part, focuses on insomnia. F.P.T. and L.M.R. have equity ownership in BeHealth Solutions (Charlottesville, VA, USA), a company that develops and makes available products related to the research reported in this manuscript. BeHealth Solutions has licensed the SHUTi program and the software platform on which it was built from the University of Virginia. The terms of this arrangement have been reviewed and approved by the University of Virginia in accordance with its conflict of interest policy. N.G. has received grants from the NHMRC during the conduct of the study and personal fees from Lundbeck, Servier and Janssen outside the submitted work.

COPYRIGHT AND USAGE

© The Royal College of Psychiatrists 2017. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.

Sleep and Dreaming in Posttraumatic Stress Disorder

PURPOSE OF REVIEW

Sleep disturbances are core features of posttraumatic stress disorder (PTSD). This review aims to characterize sleep disturbances, summarize the knowledge regarding the relationships between trauma exposure and sleep difficulties, and highlight empirically supported and/or utilized treatments for trauma-related nightmares and insomnia.

RECENT FINDINGS

Trauma-related nightmares and insomnia, and other sleep disorders, are frequently reported among trauma survivors. The roles of fear of sleep, REM density, and decreased parasympathetic activity are beginning to inform the relationship between trauma exposure and sleep difficulties. Additionally, the potential adaptive role of sleep loss immediately following a traumatic experience is being recognized. Interventions targeting these sleep disturbances show promise in reducing symptoms. Research in understanding the role of sleep on the development, course, and treatment of PTSD is expanding. Longitudinal investigations are needed to further elucidate these relationships and identify treatments most effective in ameliorating symptoms.

A Smartphone App for Adolescents With Sleep Disturbance: Development of the Sleep Ninja

BACKGROUND

Sleep disturbances are common in young people and have consequences for academic, social, emotional, and behavioral development. The most effective treatment is cognitive behavioral therapy for insomnia (CBT-I), with evidence suggesting that it is efficacious even when delivered digitally.

OBJECTIVE

There are no commercially available digitally delivered CBT-I programs for use by young people. The aim of this project was to develop a smartphone app that delivers CBT-I to young people to improve sleep.

METHODS

To inform the development of the app, young people (N=21) aged between 12 and 16 years attended one of the 3 focus groups (each with 4-10 participants). These focus groups were conducted at different stages of the development process such that the process could be iterative. Participants were asked the reasons why they might use an app to help them sleep, the kinds of features or functions that they would like to see in such an app, and any concerns they may have in using the app. Data were analyzed using a thematic analysis approach. Of the issues discussed by the participants, the researchers selected themes associated with content, functionality, and accessibility and user experience to examine, as these were most informative for the app design process.

RESULTS

In terms of content, young people were interested in receiving information about recommended sleep guidelines and personalized information for their age group. They reported that keeping a sleep diary was acceptable, but they should be able to complete it flexibly, in their own time. They reported mixed views about the use of the phone's accelerometer. Young people felt that the functionality of the app should include elements of game playing if they were to remain engaged with the app. Flexibility of use and personalized features were also desirable, and there were mixed views about the schedule of notifications and reminders. Participants reported that for the app to be accessible and usable, it should be from a trusted developer, have engaging aesthetics, have a layout that is easy to navigate, not rely on Internet coverage, and preferably be free. Participants felt that being able to conceal the purpose of the app from peers was an advantage and were willing to provide personal information to use the app if the purpose and use of that information was made clear. Overall, participants endorsed the use of the app for sleep problems among their age group and reported motivation to use it.

CONCLUSIONS

The Sleep Ninja is a fully-automated app that delivers CBT-I to young people, incorporating the features and information that young people reported they would expect from this app. A pilot study testing the feasibility, acceptability, and efficacy of the Sleep Ninja is now underway.

Long sleep duration and health outcomes: A systematic review, meta-analysis and meta-regression

We examined the dose-response relationship between long sleep duration and health outcomes including mortality and the incidence of diabetes mellitus, hypertension, cardiovascular diseases, stroke, coronary heart diseases, obesity, depression and dyslipidemia. We collected data from 5,134,036 participants from 137 prospective cohort studies. For the independent variable, we categorized participants at baseline as having long sleep duration or normal sleep duration. Risk ratios (RRs) for mortality and incident health conditions during follow-up were calculated through meta-analyses of adjusted data from individual studies. Meta-regression analyses were performed to investigate the association between each outcome and specific thresholds of long sleep. Long sleep was significantly associated with mortality (RR, 1.39; 95% CI, 1.31-1.47), incident diabetes mellitus (1.26, 1.11-1.43), cardiovascular disease (1.25, 1.14-1.37), stroke (1.46, 1.26-1.69), coronary heart disease (1.24, 1.13-1.37), and obesity (1.08, 1.02-1.15). Long sleep was not significantly related to incident hypertension (1.01, 0.95-1.07). Insufficient data were available for depression and dyslipidemia. Meta-regression analyses found statistically significant linear associations between longer sleep duration and increased mortality and incident cardiovascular disease. Future studies should address whether the relationship between long sleep and health outcomes is causal and modifiable.

Effects of digital Cognitive Behavioural Therapy for Insomnia on cognitive function: study protocol for a randomised controlled trial

BACKGROUND

The daytime effects of insomnia pose a significant burden to patients and drive treatment seeking. In addition to subjective deficits, meta-analytic data show that patients experience reliable objective impairments across several cognitive domains. While Cognitive Behavioural Therapy for Insomnia (CBT-I) is an effective and scalable treatment, we know little about its impact upon cognitive function. Trials of CBT-I have typically used proxy measures for cognitive functioning, such as fatigue or work performance scales, and no study has assessed self-reported impairment in cognitive function as a primary outcome. Moreover, only a small number of studies have assessed objective cognitive performance, pre-to-post CBT-I, with mixed results. This study specifically aims to (1) investigate the impact of CBT-I on cognitive functioning, assessed through both self-reported impairment and objective performance measures, and (2) examine whether change in sleep mediates this impact.

METHODS/DESIGN

We propose a randomised controlled trial of 404 community participants meeting criteria for Insomnia Disorder. In the DISCO trial (D efining the I mpact of improved S leep on CO gnitive function (DISCO)) participants will be randomised to digital automated CBT-I delivered by a web and/or mobile platform (in addition to treatment as usual (TAU)) or to a wait-list control (in addition to TAU). Online assessments will take place at 0 (baseline), 10 (post-treatment), and 24 (follow-up) weeks. At week 25, all participants allocated to the wait-list group will be offered digital CBT-I, at which point the controlled element of the trial will be complete. The primary outcome is self-reported cognitive impairment at post-treatment (10 weeks). Secondary outcomes include objective cognitive performance, insomnia severity, sleepiness, fatigue, and self-reported cognitive failures and emotional distress. All main analyses will be carried out on completion of follow-up assessments and will be based on the intention-to-treat principle. Further analyses will determine to what extent observed changes in self-reported cognitive impairment and objective cognitive performance are mediated by changes in sleep. The trial is supported by the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (BRC) based at Oxford University Hospitals NHS Trust and University of Oxford, and by the NIHR Oxford Health BRC.

DISCUSSION

This study will be the first large-scale examination of the impact of digital CBT-I on self-reported cognitive impairment and objective cognitive performance.

TRIAL REGISTRATION

ISRCTN, ID: ISRCTN89237370 . Registered on 17 October 2016.

Is the devil in the detail? A randomised controlled trial of guided internet-based CBT for perfectionism

An internet guided self-help cognitive-behavioural treatment (ICBT) for perfectionism was recently found to be effective (see this issue). Such studies stand in need of replication. The aim of this study was to report the outcomes and predictors of change when the treatment is delivered in a UK setting. A total of 120 people (Mean = 28.9 years; 79% female) were randomised to receive ICBT or wait-list control over 12 weeks (trial registration: NCT02756871). While there were strong similarities between the current study and its Swedish counterpart, there were also important differences in procedural details. There was a significant impact of the intervention on the primary outcome measure (Frost Multidimensional Perfectionism Scale, Concern over Mistakes subscale) and also on the Clinical Perfectionism Questionnaire (between group effect sizes d = 0.98 (95% CI: 0.60-1.36) and d = 1.04 (95% CI: 0.66-1.43) respectively using intent-to-treat analyses). Unlike the Swedish study, there was significant non-engagement and non-completion of modules with 71% of participants completing fewer than half the modules. The number of modules completed moderated the rate of change in clinical perfectionism over time. In conclusion, the study indicates the intervention is effective in a UK setting but highlighted the importance of procedural details to optimise retention.

Digital Cognitive Behavioral Therapy (dCBT) for Insomnia: a State-of-the-Science Review

PURPOSE OF REVIEW

Over the past decade, digital solutions have been developed to support the dissemination of Cognitive Behavioral Therapy (CBT). In this paper, we review the evidence for and implications of digital CBT (dCBT) for insomnia.

RECENT FINDINGS

We propose three categories of dCBT, which differ in the amount of clinician time needed, level of automatization, costs, and scalability: dCBT as support, guided dCBT, and fully automated dCBT. Consistent evidence has been published on the effectiveness of dCBT to address insomnia disorder, in a variety of populations, with effects extending into well-being. Important gaps in the literature are identified around moderators and mediators of dCBT, cost-effectiveness, and the implementation of dCBT.

SUMMARY

The evidence base for dCBT is rapidly developing and already suggests that dCBT for insomnia is effective. However, further science and digital innovation is required to realize the full potential of dCBT and address important clinical questions.

The relationship between mood disorder and insomnia depends on race in US veterans with epilepsy

PURPOSE

Few data exist on race, medical/psychiatric comorbidities, and insomnia symptoms in US veterans with epilepsy. Our aims were to examine 1) whether insomnia symptom prevalence was different between Black and White veterans and 2) whether predictors of insomnia symptoms varied by race.

METHODS

This retrospective, cross-sectional study included veterans evaluated in an epilepsy clinic over the course of 1.5years. Individuals completed standardized assessments for epilepsy and sleep complaints. Insomnia criteria were met by 1) report of difficulty with sleep initiation, maintenance, or premature awakenings accompanied by daytime impairment or 2) sedative-hypnotic use on most days of the month. Demographics, medical/psychiatric comorbidities, and medications were determined per electronic medical record review. Hierarchical multivariable logistic regression analyses were performed to determine if race, medical/mental health comorbidities, and the potential interaction of race with each comorbid condition were associated with insomnia.

RESULTS

Our sample consisted of 165 veterans (32% Black). The unadjusted prevalence of insomnia was not different between Black and White veterans (42% vs 39%, p=0.68). In adjusted analyses, the association between mood disorder and insomnia varied by race. Depressed White veterans had over 11-times higher predicted odds of insomnia (OR 11.4, p<0.001) than non-depressed White veterans, while depressed Black veterans had 4-times higher predicted odds of insomnia (OR 4.1, p=0.06) than non-depressed Black veterans. Although mood disorder diagnosis was associated with insomnia for both racial groups, White veterans had a stronger association between mood disorder diagnosis and insomnia than Black veterans.

CONCLUSIONS

The relationship between mood disorder diagnosis and insomnia was stronger for White than Black veterans with epilepsy. Future studies are needed to explore mental health symptoms and psychosocial determinants of insomnia with larger samples of minority individuals with epilepsy.

Attentional bias modification training for insomnia: A double-blind placebo controlled randomized trial

Background

Attentional bias toward sleep-related information is believed to play a key role in insomnia. If attentional bias is indeed of importance, changing this bias should then in turn have effects on insomnia complaints. In this double-blind placebo controlled randomized trial we investigated the efficacy of attentional bias modification training in the treatment of insomnia.

Method

We administered baseline, post-test, and one-week follow-up measurements of insomnia severity, sleep-related worry, depression, and anxiety. Participants meeting DSM-5 criteria for insomnia were randomized into an attentional bias training group (n = 67) or a placebo training group (n = 70). Both groups received eight training sessions over the course of two weeks. All participants kept a sleep diary for four consecutive weeks (one week before until one week after the training sessions).

Results

There was no additional benefit for the attentional bias training over the placebo training on sleep-related indices/outcome measures.

Conclusions

The absence of the effect may be explained by the fact that there was neither attentional bias at baseline nor any reduction in the bias after the training. Either way, this study gives no support for attentional bias modification training as a stand-alone intervention for ameliorating insomnia complaints.

Guided web-based intervention for insomnia targeting breast cancer patients: Feasibility and effect

BACKGROUND

Insomnia is highly prevalent in breast cancer (BRC) patients, but non-pharmacological treatment is not widely available. The aim of this preliminary study was to investigate whether guided cognitive behavioral therapy via the Internet (I-CBT) is a feasible and effective solution for this undertreated condition in BRC patients, and to investigate who benefits most.

METHODS

An existing evidence based I-CBT sleep intervention (I-Sleep) was adapted for BRC patients. An open mixed methods design was used including qualitative interviews and pre- and post-test questionnaires measuring sleep, fatigue, daily functioning, and psychological distress.

RESULTS

100 of the 171 participants (59%) completed the intervention fully and participants highly valued the intervention (7.5 out of 10). Large to small pre-post effect sizes were found on insomnia severity (d = 1.33) fatigue (d = 0.24), and daytime functioning (d = 0.30). Younger patients and patients with more severe insomnia at baseline benefited most from the intervention.

CONCLUSION

The I-CBT intervention I-Sleep is feasible, well-accepted, and effective for BRC patients who suffer from insomnia, especially for younger patients and those with more severe insomnia.

Mobile Phone-Delivered Cognitive Behavioral Therapy for Insomnia: A Randomized Waitlist Controlled Trial

Background

This study is one of the first randomized controlled trials investigating cognitive behavioral therapy for insomnia (CBT-I) delivered by a fully automated mobile phone app. Such an app can potentially increase the accessibility of insomnia treatment for the 10% of people who have insomnia.

Objective

The objective of our study was to investigate the efficacy of CBT-I delivered via the Sleepcare mobile phone app, compared with a waitlist control group, in a randomized controlled trial.

Methods

We recruited participants in the Netherlands with relatively mild insomnia disorder. After answering an online pretest questionnaire, they were randomly assigned to the app (n=74) or the waitlist condition (n=77). The app packaged a sleep diary, a relaxation exercise, sleep restriction exercise, and sleep hygiene and education. The app was fully automated and adjusted itself to a participant’s progress. Program duration was 6 to 7 weeks, after which participants received posttest measurements and a 3-month follow-up. The participants in the waitlist condition received the app after they completed the posttest questionnaire. The measurements consisted of questionnaires and 7-day online diaries. The questionnaires measured insomnia severity, dysfunctional beliefs about sleep, and anxiety and depression symptoms. The diary measured sleep variables such as sleep efficiency. We performed multilevel analyses to study the interaction effects between time and condition.

Results

The results showed significant interaction effects (P<.01) favoring the app condition on the primary outcome measures of insomnia severity (d=–0.66) and sleep efficiency (d=0.71). Overall, these improvements were also retained in a 3-month follow-up.

Conclusions

This study demonstrated the efficacy of a fully automated mobile phone app in the treatment of relatively mild insomnia. The effects were in the range of what is found for Web-based treatment in general. This supports the applicability of such technical tools in the treatment of insomnia. Future work should examine the generalizability to a more diverse population. Furthermore, the separate components of such an app should be investigated. It remains to be seen how this app can best be integrated into the current health regimens.

Trial Registration

Netherlands Trial Register: NTR5560; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=5560 (Archived by WebCite at http://www.webcitation.org/6noLaUdJ4)

Internet-Delivered Health Interventions That Work: Systematic Review of Meta-Analyses and Evaluation of Website Availability

BACKGROUND

Due to easy access and low cost, Internet-delivered therapies offer an attractive alternative to improving health. Although numerous websites contain health-related information, finding evidence-based programs (as demonstrated through randomized controlled trials, RCTs) can be challenging. We sought to bridge the divide between the knowledge gained from RCTs and communication of the results by conducting a global systematic review and analyzing the availability of evidence-based Internet health programs.

OBJECTIVES

The study aimed to (1) discover the range of health-related topics that are addressed through Internet-delivered interventions, (2) generate a list of current websites used in the trials which demonstrate a health benefit, and (3) identify gaps in the research that may have hindered dissemination. Our focus was on Internet-delivered self-guided health interventions that did not require real-time clinical support.

METHODS

A systematic review of meta-analyses was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (PROSPERO Registration Number CRD42016041258). MEDLINE via Ovid, PsycINFO, Embase, Cochrane Database of Systematic Reviews, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) were searched. Inclusion criteria included (1) meta-analyses of RCTs, (2) at least one Internet-delivered intervention that measured a health-related outcome, and (3) use of at least one self-guided intervention. We excluded group-based therapies. There were no language restrictions.

RESULTS

Of the 363 records identified through the search, 71 meta-analyses met inclusion criteria. Within the 71 meta-analyses, there were 1733 studies that contained 268 unique RCTs which tested self-help interventions. On review of the 268 studies, 21.3% (57/268) had functional websites. These included evidence-based Web programs on substance abuse (alcohol, tobacco, cannabis), mental health (depression, anxiety, post-traumatic stress disorder [PTSD], phobias, panic disorders, obsessive compulsive disorder [OCD]), and on diet and physical activity. There were also evidence-based programs on insomnia, chronic pain, cardiovascular risk, and childhood health problems. These programs tended to be intensive, requiring weeks to months of engagement by the user, often including interaction, personalized and normative feedback, and self-monitoring. English was the most common language, although some were available in Spanish, French, Portuguese, Dutch, German, Norwegian, Finnish, Swedish, and Mandarin. There were several interventions with numbers needed to treat of <5; these included painACTION, Mental Health Online for panic disorders, Deprexis, Triple P Online (TPOL), and U Can POOP Too. Hyperlinks of the sites have been listed.

CONCLUSIONS

A wide range of evidence-based Internet programs are currently available for health-related behaviors, as well as disease prevention and treatment. However, the majority of Internet-delivered health interventions found to be efficacious in RCTs do not have websites for general use. Increased efforts to provide mechanisms to host "interventions that work" on the Web and to assist the public in locating these sites are necessary.

[Internet-based interventions in the treatment of mental disorders : Overview, quality criteria, perspectives]

BACKGROUND

Mental disorders are frequently not or only insufficiently treated. Internet-based interventions offer the potential of closing the existing gaps in the treatment of mental disorders; however, it is very difficult for patients and providers to choose from the numerous interventions available.

OBJECTIVE

The aim of this study was to develop a set of quality criteria that can help patients and care providers to identify recommendable internet-based interventions.

METHODS

A selective literature search was carried out and the existing evidence on internet-based interventions in the treatment of mental disorders was collated. A panel of experts then developed quality criteria based on existing models for the systematic assessment of telemedicine applications.

RESULTS

Internet-based interventions are effective in the treatment of a broad range of mental disorders. The best evidence is available for depression and anxiety disorders. A set of criteria is proposed for the evaluation of available internet-based interventions using a checklist. These criteria have to be developed further with input from other stakeholders.

DISCUSSION

When taking these quality criteria into account, evidence-based interventions available on the internet can make an important contribution to improvement of the care of patients with mental disorders.

A Single Arm Pilot Trial of Brief Cognitive Behavioral Therapy for Insomnia in Adolescents with Physical and Psychiatric Comorbidities

STUDY OBJECTIVES

The majority of adolescents with chronic insomnia have physical health or psychiatric comorbidities; insomnia is also associated with greater negative daytime symptoms (e.g., depressive symptoms) and reduced overall health-related quality of life (HRQOL). However, to date, there has been limited attention to treatment of insomnia in this population. The purpose of this study was to determine the preliminary efficacy of a brief cognitive behavioral therapy for insomnia (CBT-I) intervention on sleep, psychological symptoms, and HRQOL outcomes in adolescents with insomnia and co-occurring physical or psychiatric comorbidities.

METHODS

We conducted a single arm pilot trial in which 40 youth (mean age = 14.93, standard deviation = 1.89) with insomnia and physical or psychiatric comorbidities (e.g., depression, chronic pain, anxiety, gastrointestinal problems) received CBT-I in four individual treatment sessions over 4 to 6 w. Adolescents completed 7 days of wrist actigraphy and self-report measures of insomnia, sleep quality and behaviors, psychological symptoms, and HRQOL outcomes at pretreatment, immediate posttreatment, and 3-mo follow-up.

RESULTS

CBT-I was associated with improvements in self-reported measures of sleep including insomnia symptoms, sleep quality, sleep hygiene, pre-sleep arousal, and sleep onset latency. Psychological symptoms and HRQOL also improved. Effects were generally sustained at 3-mo follow-up.

CONCLUSIONS

CBT-I may be efficacious for adolescents with co-occurring physical and mental health comorbidities; future randomized controlled trials are needed to test the effect of CBT-I on sleep, psychological symptoms, and HRQOL and to evaluate maintenance of treatment effects over longer time periods.

Sitting Time, Physical Activity and Sleep by Work Type and Pattern-The Australian Longitudinal Study on Women's Health

Data from the Australian Longitudinal Study on Women's Health were used to examine how work was associated with time spent sleeping, sitting and in physical activity (PA), in working women. Young (31-36 years; 2009) and mid-aged (59-64 years; 2010) women reported sleep (categorised as shorter ≤6 h/day and longer ≥8 h/day) and sitting time (work, transport, television, non-work computer, and other; summed for total sitting time) on the most recent work and non-work day; and moderate and vigorous PA (categorised as meeting/not meeting guidelines) in the previous week. Participants reported occupation (manager/professional; clerical/sales; trades/transport/labourer), work hours (part-time; full-time) and work pattern (shift/night; not shift/night). The odds of shorter sleep on work days was higher in both cohorts for women who worked shift or night hours. Longer sitting time on work days, made up primarily of sitting for work, was found for managers/professionals, clerical/sales and full-time workers. In the young cohort, clerical/sales workers and in the mid-aged cohort, full-time workers were less likely to meet PA guidelines. These results suggest multiple behaviour interventions tailored to work patterns and occupational category may be useful to improve the sleep, sitting and activity of working women.

Efficacy and safety of acupuncture treatment on primary insomnia: a randomized controlled trial

OBJECTIVE

The objective of this study was to evaluate the efficacy and safety of acupuncture treatment for primary insomnia.

METHODS

We conducted a single-center, single-blinded, and randomized controlled clinical trial. Seventy-two patients with primary insomnia were randomly assigned into two groups - the acupuncture group, who received acupuncture treatment, and the control group, who received sham acupuncture treatment. The treatment was given three times a week for four weeks. Patients were asked to wear sleep monitors and complete questionnaires every two weeks for a total of eight weeks. The primary outcome was the Insomnia Severity Index (ISI). The secondary outcomes were sleep parameters including sleep efficiency (SE), sleep awakenings (SA) and total sleep time (TST) recorded by the Actigraphy, as well as scores of the Self-Rating Anxiety Scale (SAS) and the Self-Rating Depression Scale (SDS).

RESULTS

Compared with pretreatment baseline, patients in both groups had varying degrees of improvements in their sleep conditions. Paired t-test showed that there was a significant difference in all indicators in the acupuncture group before and after acupuncture treatment. One-way analysis of covariance adjusted for baseline scores indicated that the ISI improved dramatically in the acupuncture group at two weeks post-treatment (F = 11.3, p = 0.001), four weeks post-treatment (F = 33.6, p < 0.001), 2 weeks follow-up (F = 39.4, p < 0.001) and four weeks follow-up (F = 34.1, p < 0.001). Similar significant improvements can also be observed in the SE, TST and SDS scores. Although no differences in SA and SAS were shown between the two groups until the end of the treatment, remarkable decrements in SA and SAS were found in the acupuncture treatment group after the two-week and four-week follow-ups.

CONCLUSION

Acupuncture treatment is more effective than sham acupuncture treatment in increasing insomnia patients' sleep quality and improving their psychological health.

TRIAL REGISTRATION

Chinese Clinical Trial Registry: Chi CTR-TRC-14004859.

Clinical Practice Guideline for the Pharmacologic Treatment of Chronic Insomnia in Adults: An American Academy of Sleep Medicine Clinical Practice Guideline

INTRODUCTION

The purpose of this guideline is to establish clinical practice recommendations for the pharmacologic treatment of chronic insomnia in adults, when such treatment is clinically indicated. Unlike previous meta-analyses, which focused on broad classes of drugs, this guideline focuses on individual drugs commonly used to treat insomnia. It includes drugs that are FDA-approved for the treatment of insomnia, as well as several drugs commonly used to treat insomnia without an FDA indication for this condition. This guideline should be used in conjunction with other AASM guidelines on the evaluation and treatment of chronic insomnia in adults.

METHODS

The American Academy of Sleep Medicine commissioned a task force of four experts in sleep medicine. A systematic review was conducted to identify randomized controlled trials, and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) process was used to assess the evidence. The task force developed recommendations and assigned strengths based on the quality of evidence, the balance of benefits and harms, and patient values and preferences. Literature reviews are provided for those pharmacologic agents for which sufficient evidence was available to establish recommendations. The AASM Board of Directors approved the final recommendations.

RECOMMENDATIONS

The following recommendations are intended as a guideline for clinicians in choosing a specific pharmacological agent for treatment of chronic insomnia in adults, when such treatment is indicated. Under GRADE, a STRONG recommendation is one that clinicians should, under most circumstances, follow. A WEAK recommendation reflects a lower degree of certainty in the outcome and appropriateness of the patient-care strategy for all patients, but should not be construed as an indication of ineffectiveness. GRADE recommendation strengths do not refer to the magnitude of treatment effects in a particular patient, but rather, to the strength of evidence in published data. Downgrading the quality of evidence for these treatments is predictable in GRADE, due to the funding source for most pharmacological clinical trials and the attendant risk of publication bias; the relatively small number of eligible trials for each individual agent; and the observed heterogeneity in the data. The ultimate judgment regarding propriety of any specific care must be made by the clinician in light of the individual circumstances presented by the patient, available diagnostic tools, accessible treatment options, and resources. We suggest that clinicians use suvorexant as a treatment for sleep maintenance insomnia (versus no treatment) in adults. (WEAK). We suggest that clinicians use eszopiclone as a treatment for sleep onset and sleep maintenance insomnia (versus no treatment) in adults. (WEAK). We suggest that clinicians use zaleplon as a treatment for sleep onset insomnia (versus no treatment) in adults. (WEAK). We suggest that clinicians use zolpidem as a treatment for sleep onset and sleep maintenance insomnia (versus no treatment) in adults. (WEAK). We suggest that clinicians use triazolam as a treatment for sleep onset insomnia (versus no treatment) in adults. (WEAK). We suggest that clinicians use temazepam as a treatment for sleep onset and sleep maintenance insomnia (versus no treatment) in adults. (WEAK). We suggest that clinicians use ramelteon as a treatment for sleep onset insomnia (versus no treatment) in adults. (WEAK). We suggest that clinicians use doxepin as a treatment for sleep maintenance insomnia (versus no treatment) in adults. (WEAK). We suggest that clinicians not use trazodone as a treatment for sleep onset or sleep maintenance insomnia (versus no treatment) in adults. (WEAK). We suggest that clinicians not use tiagabine as a treatment for sleep onset or sleep maintenance insomnia (versus no treatment) in adults. (WEAK). We suggest that clinicians not use diphenhydramine as a treatment for sleep onset and sleep maintenance insomnia (versus no treatment) in adults. (WEAK). We suggest that clinicians not use melatonin as a treatment for sleep onset or sleep maintenance insomnia (versus no treatment) in adults. (WEAK). We suggest that clinicians not use tryptophan as a treatment for sleep onset or sleep maintenance insomnia (versus no treatment) in adults. (WEAK). We suggest that clinicians not use valerian as a treatment for sleep onset or sleep maintenance insomnia (versus no treatment) in adults. (WEAK).

Commencing and Persisting With a Web-Based Cognitive Behavioral Intervention for Insomnia: A Qualitative Study of Treatment Completers

Background

Computerized cognitive behavioral therapy for insomnia (CCBT-I) has a growing evidence base as a stand-alone intervention, but it is less clear what factors may limit its acceptability and feasibility when combined with clinical care.

Objective

The purpose of this study was to explore barriers and facilitators to use of an adjunctive CCBT-I program among depressed patients in a psychiatric clinic by using both quantitative and qualitative approaches.

Methods

We conducted the qualitative component of the study using face-to-face or telephone interviews with participants who had enrolled in a clinical trial of a CCBT-I program as an adjunctive treatment in a psychiatric clinical setting. In line with the grounded theory approach, we used a semistructured interview guide with new thematic questions being formulated during the transcription and data analysis, as well as being added to the interview schedule. A range of open and closed questions addressing user experience were asked of all study participants who completed the 12-week trial in an online survey.

Results

Three themes emerged from the interviews and open questions, consistent with nonadjunctive CCBT-I implementation. Identification with the adjunctive intervention’s target symptom of insomnia and the clinical setting were seen as key reasons to engage initially. Persistence was related to factors to do with the program, its structure, and its content, rather than any nonclinical factors. The survey results showed that only the key active behavioral intervention, sleep restriction, was rated as a major problem by more than 15% of the sample. In this clinical setting, the support of the clinician in completing the unsupported program was highlighted, as was the need for the program and clinical treatment to be coordinated.

Conclusions

The use of a normally unsupported CCBT-I program as an adjunctive treatment can be aided by the clinician’s approach. A key behavioral component of the intervention, specific to insomnia treatment, was identified as a major problem for persistence. As such, clinicians need to be aware of when such components are delivered in the program and coordinate their care accordingly, if the use of the program is to be optimized.

ClinicalTrial

Australian and New Zealand Clinical Trials Registry ACTRN12612000985886; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=362875&isReview=true (Archived by WebCite at http://www.webcitation.org/6njjhl42X)

Prevention of Mental Health Disorders Using Internet- and Mobile-Based Interventions: A Narrative Review and Recommendations for Future Research

Although psychological interventions might have a tremendous potential for the prevention of mental health disorders (MHD), their current impact on the reduction of disease burden is questionable. Possible reasons include that it is not practical to deliver those interventions to the community en masse due to limited health care resources and the limited availability of evidence-based interventions and clinicians in routine practice, especially in rural areas. Therefore, new approaches are needed to maximize the impact of psychological preventive interventions. Limitations of traditional prevention programs could potentially be overcome by providing Internet- and mobile-based interventions (IMIs). This relatively new medium for promoting mental health and preventing MHD introduces a fresh array of possibilities, including the provision of evidence-based psychological interventions that are free from the restraints of travel and time and allow reaching participants for whom traditional opportunities are not an option. This article provides an introduction to the subject and narratively reviews the available evidence for the effectiveness of IMIs with regard to the prevention of MHD onsets. The number of randomized controlled trials that have been conducted to date is very limited and so far it is not possible to draw definite conclusions about the potential of IMIs for the prevention of MHD for specific disorders. Only for the indicated prevention of depression there is consistent evidence across four different randomized trial trials. The only trial on the prevention of general anxiety did not result in positive findings in terms of eating disorders (EDs), effects were only found in post hoc subgroup analyses, indicating that it might be possible to prevent ED onset for subpopulations of people at risk of developing EDs. Future studies need to identify those subpopulations likely to profit from preventive. Disorders not examined so far include substance use disorders, bipolar disorders, stress-related disorders, phobic disorders and panic disorder, obsessive-compulsive disorder, impulse-control disorders, somatic symptom disorder, and insomnia. In summary, there is a need for more rigorously conducted large scale randomized controlled trials using standard clinical diagnostic instruments for the selection of participants without MHD at baseline and the assessment of MHD onset. Subsequently, we discuss future directions for the field in order to fully exploit the potential of IMI for the prevention of MHD.

Group vs. Individual Treatment for Acute Insomnia: A Pilot Study Evaluating a "One-Shot" Treatment Strategy

Background: Despite undeniable evidence for the efficacy and effectiveness of Cognitive Behaviour Therapy for Insomnia (CBT-I), the potential for its widespread dissemination and implementation has yet to be realised. A suggested reason for this is that traditional CBT-I is considered too burdensome for deployment, in its current form, within the context of where it would be most beneficial—Primary Care. One strategy, aimed to address this, has been to develop briefer versions of CBT-I, whilst another has been to deliver CBT-I in a group format. An alternative has been to attempt to address insomnia during its acute phase with a view to circumventing its progression to chronic insomnia. The aim of the present study was to compare a brief version of CBT-I (one-shot) when delivered individually or in groups to those with acute insomnia. Method: Twenty-eight individuals with acute insomnia (i.e., meeting full DSM-5 criteria for insomnia disorder for less than three months) self-assigned to either a group or individual treatment arm. Treatment consisted of a single one-hour session accompanied by a self-help pamphlet. Subjects completed measures of insomnia severity, anxiety and depression pre-treatment and at one-month post-treatment. Additionally, daily sleep diaries were compared between pre-treatment and at the one-month follow up. Results: There were no significant between group differences in treatment outcome on any sleep or mood measures although those in the group treatment arm were less adherent than those who received individual treatment. Furthermore, the combined (group and individual treatment arms) pre-post test effect size on insomnia symptoms, using the Insomnia Severity Index, was large (d = 2.27). Discussion: It appears that group treatment is as efficacious as individual treatment within the context of a “one shot” intervention for individuals with acute insomnia. The results are discussed with a view to integrating one-shot CBT-I in Primary Care.

Understanding and Promoting Effective Engagement With Digital Behavior Change Interventions

This paper is one in a series developed through a process of expert consensus to provide an overview of questions of current importance in research into engagement with digital behavior change interventions, identifying guidance based on research to date and priority topics for future research. The first part of this paper critically reflects on current approaches to conceptualizing and measuring engagement. Next, issues relevant to promoting effective engagement are discussed, including how best to tailor to individual needs and combine digital and human support. A key conclusion with regard to conceptualizing engagement is that it is important to understand the relationship between engagement with the digital intervention and the desired behavior change. This paper argues that it may be more valuable to establish and promote "effective engagement," rather than simply more engagement, with "effective engagement" defined empirically as sufficient engagement with the intervention to achieve intended outcomes. Appraisal of the value and limitations of methods of assessing different aspects of engagement highlights the need to identify valid and efficient combinations of measures to develop and test multidimensional models of engagement. The final section of the paper reflects on how interventions can be designed to fit the user and their specific needs and context. Despite many unresolved questions posed by novel and rapidly changing technologies, there is widespread consensus that successful intervention design demands a user-centered and iterative approach to development, using mixed methods and in-depth qualitative research to progressively refine the intervention to meet user requirements.

Internet-Based Cognitive Behavioral Therapy for Insomnia: A Health Economic Evaluation

STUDY OBJECTIVES

Lost productivity caused by insomnia is a common and costly problem for employers. Although evidence for the efficacy of Internet-based cognitive behavioral therapy for insomnia (iCBT-I) already exists, little is known about its economic effects. This study aims to evaluate the cost-effectiveness and cost-benefit of providing iCBT-I to symptomatic employees from the employer's perspective.

METHODS

School teachers (N = 128) with clinically significant insomnia symptoms and work-related rumination were randomized to guided iCBT-I or a waitlist-control-group, both with access to treatment as usual. Economic data were collected at baseline and 6-mo follow-up. We conducted (1) a cost-effectiveness analysis with treatment response (Reliable Change [decline of 5.01 points] and Insomnia Severity Index < 8 at 6-month follow-up) as the outcome and (2) a cost-benefit analysis. Because both analyses were performed from the employer's perspective, we focused specifically on absenteeism and presenteeism costs. Statistical uncertainty was estimated using bootstrapping.

RESULTS

Assuming intervention costs of €200 ($245), cost-effectiveness analyses showed that at a willingness-to-pay of €0 for each positive treatment response, there is an 87% probability that the intervention is more cost effective than treatment as usual alone. Cost-benefit analyses led to a net benefit of €418 (95% confidence interval: -593.03 to 1,488.70) ($512) per participant and a return on investment of 208% (95% confidence interval: -296.52 to 744.35). The reduction in costs was mainly driven by the effects of the intervention on presenteeism and to a lesser degree by reduced absenteeism.

CONCLUSIONS

Focusing on sleep improvement using iCBT-I may be a cost-effective strategy in occupational health care.

CLINICAL TRIALS REGISTRATION

Title: Online Recovery Training for Better Sleep in Teachers with High Psychological Strain. German Clinical Trial Register (DRKS), URL: https://drks-neu.uniklinik-freiburg.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00004700. Identifier: DRKS00004700.

COMMENTARY

A commentary on this article appears in this issue on page 1767.