Comparative efficacy of digital cognitive behavioral therapy for insomnia: A systematic review and network meta-analysis

An online behavioral self-help intervention rapidly improves acute insomnia severity and subjective mood during the coronavirus disease-2019 pandemic: a stratified randomized controlled trial

STUDY OBJECTIVES

Stressful life events, such as the coronavirus disease-2019 (COVID-19) pandemic, can cause acute insomnia. Cognitive behavioral therapy for acute insomnia is effective but is both time and resource-intensive. This study investigated if an online behavioral self-help intervention, which has been successfully used alongside sleep restriction for acute insomnia, reduced insomnia severity and improved mood in acute insomnia. This study also assessed good sleepers to explore if a "sleep vaccination" approach was feasible.

METHODS

In this online stratified randomized controlled trial, 344 participants (103 good sleepers and 241 participants with DSM-5 acute insomnia) were randomized to receive the intervention/no intervention (good sleepers) or intervention/intervention after 28 days (poor sleepers). Insomnia severity was assessed using the ISI (primary outcome), and anxiety and depression using the GAD-7/PHQ-9 (secondary outcomes) at baseline, 1 week, 1 month, and 3-month follow-up.

RESULTS

In people with acute insomnia, relative to baseline, there were significant reductions in ISI (dz = 1.17), GAD-7 (dz = 0.70), and PHQ-9 (dz = 0.60) scores at 1-week follow-up. ISI, GAD-7, and PHQ-9 scores were significantly lower at all follow-up time points, relative to baseline. Subjective diary-derived sleep continuity was unaffected. No beneficial effects on sleep or mood were observed in good sleepers.

CONCLUSIONS

An online behavioral self-help intervention rapidly reduces acute insomnia severity (within 1 week), and benefits mood in people with acute insomnia. These beneficial effects are maintained up to 3 months later. Although the use of the intervention is feasible in good sleepers, their subjective sleep was unaffected.

CLINICAL TRIAL REGISTRATION

Testing an early online intervention for the treatment of disturbed sleep during the COVID-19 pandemic; prospectively registered at ISRCTN on 8 April 2020 (identifier: ISRCTN43900695).

Promoting sleep health during pregnancy for enhancing women's health: a longitudinal randomized controlled trial combining biological, physiological and psychological measures, Maternal Outcome after THERapy for Sleep (MOTHERS)

BACKGROUND

Sleep is vital for maintaining individuals' physical and mental health and is particularly challenged during pregnancy. More than 70% of women during the gestational period report insomnia symptoms. Sleep dysfunction in the peripartum increases the risk for a cascade of negative health outcomes during late pregnancy, birth, and postpartum. While psychological interventions are considered the first line treatment for sleep difficulties, they are still scarcely offered during pregnancy and there is a lack of longitudinal research combining psychological and physiological indices.

METHODS

The present protocol outlines a randomized controlled trial aimed at testing the long-term effectiveness of an automatized digitalized psychoeducational intervention for insomnia for expectant mothers complaining insomnia symptoms without comorbidity. Outcomes include physiological, hormonal, and subjective indices of maternal psychopathology, stress, and emotional processes, and sleep and wellbeing of the family system. The trial is part of a longitudinal study evaluating expectant mothers from early pregnancy (within the 15th gestational week) to 6-months postpartum through 6 observational phases: baseline (BSL), 6- and 12-weeks from BSL (FU1-FU2), 2-to-4 weeks after delivery (FU3), and 3- and 6-months after delivery (FU4-5). We plan to recruit 38 women without sleep difficulties (Group A) and 76 women with sleep difficulties (Group B). Group B will be randomly assigned to digital psychological control intervention (B1) or experimental psychoeducational intervention targeting insomnia (B2). At 3 time points, an ecological-momentary-assessment (EMA) design will be used to collect data on sleep and emotions (diaries), sleep-wake parameters (actigraphy) and stress reactivity (salivary cortisol). We will also test the DNA methylation of genes involved in the stress response as biomarkers of prenatal poor sleep. Information on partner's insomnia symptoms and new-borns' sleep will be collected at each stage.

DISCUSSION

The proposed protocol aims at testing an easily accessible evidence-based psychoeducational intervention for expectant mothers to help them improving sleep, health, and wellbeing in the peripartum. The results could improve the understanding and management of sleep difficulties and peripartum depression.

TRIAL REGISTRATION

The study protocol has been registered on 22 April 2024 with ClinicalTrials.gov Protocol Registration and Results System (PRS), ID: NCT06379074.

PROTOCOL VERSION

April 23, 2024.

Investigating non-inferiority of internet-delivered versus face-to-face cognitive behavioural therapy for insomnia (CBT-I): a randomised controlled trial (iSleep well)

BACKGROUND

Insomnia is a highly prevalent disorder associated with numerous adverse health outcomes. Cognitive behavioural therapy for insomnia (CBT-I) is recommended as first-line treatment by clinical guidelines but is accessible to only a minority of patients suffering from insomnia. Internet-delivered CBT-I (iCBT-I) could contribute to the widespread dissemination of this first-line treatment. As there is insufficient evidence regarding non-inferiority, this study directly aims to compare therapist-guided internet-delivered versus face-to-face CBT-I in terms of insomnia severity post-treatment. Furthermore, a health-economic evaluation will be conducted, and potential benefits and disadvantages of therapist-guided iCBT-I will be examined.

METHODS

This study protocol describes a randomised controlled two-arm parallel-group non-inferiority trial comparing therapist-guided iCBT-I with face-to-face CBT-I in routine clinical care. A total of 422 patients with insomnia disorder will be randomised and treated at 16 study centres throughout Germany. Outcomes will be assessed at baseline, 10 weeks after randomisation (post), and 6 months after randomisation (follow-up). The primary outcome is insomnia severity measured using the Insomnia Severity Index. Secondary outcomes include depression-related symptoms, quality of life, fatigue, physical activity, daylight exposure, adverse events related to treatment, and a health-economic evaluation. Finally, potential moderator variables and several descriptive and exploratory outcomes will be assessed (e.g. benefits and disadvantages of internet-delivered treatment).

DISCUSSION

The widespread implementation of CBT-I is a significant healthcare challenge. The non-inferiority of therapist-guided iCBT-I versus face-to-face CBT-I will be investigated in an adequately powered sample in routine clinical care, with the same therapeutic content and same level of therapist qualifications provided with both interventions. If this trial demonstrates the non-inferiority of therapist-guided iCBT-I, healthcare providers may be more confident recommending this treatment to their patients, contributing to the wider dissemination of CBT-I.

TRIAL REGISTRATION

Trial registration number in the German Clinical Trials Register: DRKS00028153 ( https://drks.de/search/de/trial/DRKS00028153 ). Registered on 16th May 2023.

The relationships between insomnia, nightmares, and dreams: A systematic review

Insomnia and nightmares are both prevalent and debilitating sleep difficulties. The present systematic review aims to document the relationships between insomnia and nightmares in individuals without a concomitant psychopathology. The relationships between insomnia and dreams are also addressed. PsycINFO and Medline were searched for papers published in English or French from 1970 to March 2023. Sixty-seven articles were included for review. Most results support positive relationships between insomnia variables and nightmare variables in individuals with insomnia, individuals with nightmares, the general population, students, children and older adults, and military personnel and veterans. These positive relationships were also apparent in the context of the COVID-19 pandemic. Some psychological interventions, such as Imagery Rehearsal Therapy, might be effective in alleviating both nightmares and insomnia symptoms. Regarding the relationships between insomnia and dreams, compared with controls, the dreams of individuals with insomnia are characterized by more negative contents and affects. The results show that insomnia and nightmares are connected and may be mutually aggravating. A model is proposed to explain how insomnia might increase the likelihood of experiencing nightmares, and how nightmares can in turn lead to sleep loss and nonrestorative sleep.

Treatment effect heterogeneity of cognitive behavioral therapy for insomnia - A meta-analysis

Investigation of the heterogeneity of the treatment effect (HTE) might guide the optimization of cognitive behavioral therapy for insomnia (CBT-I). This study examined HTE in CBT-I thereby analyzing if treatment setting, control group, different CBT-I components, and patient characteristics drive HTE. Randomized controlled trials investigating CBT-I were included. Bayesian random effect meta-regressions were specified to examine variances between the intervention and control groups regarding post-treatment symptom severity. Subgroup analyses analyzing treatment setting and control groups and covariate analysis analyzing treatment components and patient characteristics were specified. No significant HTE in CBT-I was found for the overall data set, settings and control groups. The covariate analyses yielded significant results for baseline severity and the treatment component relaxation therapy. Thus, this study identified potential causes for HTE in CBT-I for the first time, showing that it might be worthwhile to further examine possibilities for precision medicine in CBT-I.

Treating comorbid insomnia in patients enrolled in therapist-assisted transdiagnostic internet-delivered cognitive behaviour therapy for anxiety and depression: A randomized controlled trial

Transdiagnostic Internet-delivered cognitive behaviour therapy (ICBT) for patients experiencing anxiety and depression can produce large improvements in symptoms. Comorbid insomnia is common among individuals seeking treatment for anxiety and depression, yet transdiagnostic ICBT rarely targets insomnia and many ICBT patients report that symptoms of insomnia remain after treatment. This trial explored the impact of including a brief intervention for insomnia alongside an existing transdiagnostic ICBT course that included brief weekly therapist assistance. Patients were randomly assigned to receive either the Standard transdiagnostic (n = 75) or a Sleep-Enhanced course (n = 142), which included information on sleep restriction and stimulus control. Intent-to-treat analyses using generalized estimating equation (GEE) showed significant, large reductions in all primary outcomes (insomnia: d = 0.96, 95 % CI [0.68, 1.24]; depression: d = 1.04, 95 % CI [0.76, 1.33]; and anxiety: d = 1.23, 95 % CI [0.94, 1.52]) from pre-treatment to post-treatment, with changes maintained at 3-months. Patients assigned to the Sleep-Enhanced course reported larger reductions in insomnia than patients in the Standard transdiagnostic course (Cohen's d = 0.31, 95 % CI [0.034, 0.60]) at post-treatment but no significant between-group differences in any of the primary outcomes were found at follow-up. Patient-reported adherence to sleep restriction guidelines (p = .03), but not stimulus control instructions (p = .84) was associated with greater reductions in insomnia symptoms during the course. Overall, patients who received the Sleep-Enhanced course were satisfied with the materials and most patients reported making sleep behaviour changes. The trial results demonstrate that including a brief intervention targeting insomnia can be beneficial for many patients who enroll in ICBT primarily for symptoms related to anxiety and depression.

Acceptance and Commitment Therapy, Combined with Bedtime Restriction, versus Cognitive Behavioral Therapy for Insomnia: A Randomized Controlled Pilot Trial

INTRODUCTION

Cognitive behavioral therapy for insomnia (CBT-I) is the current first-line treatment for insomnia. However, rates of nonresponse and nonremission are high and effects on quality of life are only small to moderate, indicating a need for novel treatment developments. We propose that Acceptance and Commitment Therapy (ACT) addresses core pathophysiological pathways of insomnia. ACT therefore has the potential to improve treatment efficacy when combined with bedtime restriction, the most effective component of CBT-I. The aim of this study was to compare the efficacy of ACT for insomnia combined with bedtime restriction (ACT-I) and CBT-I in improving insomnia severity and sleep-related quality of life.

METHODS

Sixty-three patients with insomnia disorder (mean age 52 years, 65% female, 35% male) were randomly assigned to receive either ACT-I or CBT-I in a group format. The primary outcomes were insomnia severity (Insomnia Severity Index) and sleep-related quality of life (Glasgow Sleep Impact Index). Outcomes were assessed before randomization (T0), directly after treatment (T1), and at 6-month follow-up (T2).

RESULTS

The results indicated significant, large pre-to-post improvements in both groups, for both primary and secondary outcomes. Improvements were maintained at the 6-month follow-up. However, there was no significant group by time interactions in linear mixed models, indicating an absence of differential efficacy. On a subjective treatment satisfaction scale, patients in the ACT-I group indicated significantly greater satisfaction with their improvement of several aspects of health including their energy level and work productivity.

CONCLUSIONS

The results suggest that ACT-I is feasible and effective, but not more effective than CBT-I for the improvement of insomnia severity and sleep-related quality of life. Future studies are needed to assess whether ACT-I is noninferior to CBT-I and to shed light on mechanisms of change in both treatments.

Digital cognitive behavioural therapy for patients with insomnia and depression: A systematic review and meta-analysis

WHAT IS KNOWN ON THE SUBJECT

Sleep problems are common among those with depression, and there is increasing evidence that sleep problems should be addressed during treatment simultaneously rather than treating depression alone. The first-line treatment for insomnia is cognitive behavioural therapy for insomnia (CBT-I), due to a lack of well-trained therapists and patient time constraints (travelling, work), CBT-I has not been popularized. The development of digital cognitive behavioural therapy for insomnia (dCBT-I) is making the treatment more accessible.

WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE

Interventions for dCBT-I were significantly better than other control conditions in both reducing insomnia and improving depression in patients with depression and insomnia comorbidities. The effect was found to be related to the duration of the intervention and the severity of insomnia before the intervention and therapist-involved dCBT-I has less shedding than self-help.

WHAT ARE THE IMPLICATIONS FOR PRACTICE

It's important for mental health practitioners to realize that insomnia in depressed people needs to be treated. Future trials may explore the effectiveness of therapist-guided dCBT-I in depressed populations and analyse the cost-effectiveness of this treatment.

ABSTRACT

Aim The aim of the study was to systematically identify and synthesize the evidence for the effectiveness of digital cognitive behavioural therapy in insomnia with comorbid depression. Design Systematic review and metaanalysis. Methods A search was conducted on five English and four non-English databases from the inception of the databases to November 2023. This review adhered to the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-analysis Statement 2020 and the included studies were evaluated using version 2 of the Cochrane risk of bias tool. This review examined sleep-related outcomes, including insomnia severity and sleep diaries, along with psychological outcomes, such as depression. We conducted a meta-analysis of each outcome using a random effects model. Heterogeneity was assessed by the I2 statistic. Results A total of seven articles with 1864 participants were included in this review. The results showed that the digital cognitive behavioural therapy group demonstrated a statistically significant amelioration in the severity of insomnia symptoms, as well as a reduction in depressive symptomatology compared with the control groups. The post-intervention effect was found to be related to the duration of the intervention and the severity of insomnia before the intervention. Conclusions Digital cognitive behavioural therapy for insomnia application in patients with depression and insomnia was demonstrated to be effective, less time-consuming and more accessible. Relevance to Clinical Practice We may consider incorporating nurses into treatment plans and conducting nurse-led interventions in specific programs. In the future, nurses may be able to provide exclusive digital behavioural therapy for insomnia to patients with depression to achieve greater effectiveness.

The Sleepio After Cancer (SAC) study. Digital cognitive behavioural therapy for insomnia (dCBT-I) in women cancer patients - Trial protocol of a randomised controlled trial

AIMS

This study will assess the efficacy of digital CBT for insomnia (dCBT-I) compared to sleep hygiene education (SHE) for the management of insomnia in women with cancer.

BACKGROUND

30% of patients with cancer meet insomnia diagnostic criteria and this can be detrimental to health outcomes. Insomnia disorder comprises a dissatisfaction with sleep quantity or quality characterized by difficulty initiating sleep, frequent awakenings, or early morning wakening without the ability to return to sleep, at least 3 nights per week, for at least 3 months, causing significant impairment or distress in areas of functioning.

METHODS

We will recruit 308 women with a current or prior cancer diagnosis who are currently experiencing insomnia; defined as a score of 16 or less on the Sleep Condition Indicator (SCI). Participants will be randomised to dCBT-I or SHE. dCBT-I will be delivered online via 6 sessions. SHE will be provided in an online format. Assessments of sleep and other related parameters, through validated questionnaires, will be taken at 12 and 24 weeks following intervention. Once 24 week assessments are completed, participants will crossover to the alternate arm (either SHE or dCBT-I) and undergo a final assessment at week 36.

OUTCOMES

The primary outcome will be the mean continuous change in SCI score in the intervention arm compared to the control arm at 24 weeks. Additionally, the proportion of women with an SCI > 16 at 24 weeks will be assessed. Secondary outcomes include fatigue, sleep related quality of life, depression, anxiety, and hot flush interference.

REGISTRATION

This study is registered on ClinicalTrials.gov with number NCT05816460.

Disseminating cognitive behavioural therapy (CBT) for insomnia at scale: capitalising on the potential of digital CBT to deliver clinical guideline care

Cognitive behavioural therapy (CBT) is the recommended first-line treatment for insomnia. However, guideline care is very seldom available and most patients receive no treatment, or less effective second-line pharmacotherapy or sleep hygiene, neither of which are evidence-based for chronic insomnia. The primary challenge for CBT has been supply. There are not enough therapists to meet the enormous demand. We must accelerate clinician training, but this approach can never be sufficient, even with abbreviated, efficient therapies. Fortunately, however, the treatment landscape has also changed dramatically. Fully-automated digital CBT (dCBT) has emerged as a safe, effective, and scalable treatment delivery format. dCBT is software only, so it can be disseminated as readily and widely as sleep medication. Moreover, dCBT can be integrated into services. Just as medications can be delivered through health professionals and health systems, approved dCBT programmes can be the same. However, an ecosystem of psychologically-based care should not necessitate a medical prescription model. Our proposed stepped care framework, comprises both population health and clinical health service initiatives, enabling universal access to guideline care for insomnia. The diverse ways in which CBT may be delivered (in-person, face-to-face, using telehealth, group therapy, digitally) can operate congruently and efficiently to optimise treatment for people at all levels of complexity and need. With safe and clinically effective dCBT products now set to become established as treatments, clearly differentiated from wellness apps, there is potential to rapidly transform insomnia services and, for the first time, to deliver clinical guideline care at international scale.

The European Insomnia Guideline: An update on the diagnosis and treatment of insomnia 2023

Progress in the field of insomnia since 2017 necessitated this update of the European Insomnia Guideline. Recommendations for the diagnostic procedure for insomnia and its comorbidities are: clinical interview (encompassing sleep and medical history); the use of sleep questionnaires and diaries (and physical examination and additional measures where indicated) (A). Actigraphy is not recommended for the routine evaluation of insomnia (C), but may be useful for differential-diagnostic purposes (A). Polysomnography should be used to evaluate other sleep disorders if suspected (i.e. periodic limb movement disorder, sleep-related breathing disorders, etc.), treatment-resistant insomnia (A) and for other indications (B). Cognitive-behavioural therapy for insomnia is recommended as the first-line treatment for chronic insomnia in adults of any age (including patients with comorbidities), either applied in-person or digitally (A). When cognitive-behavioural therapy for insomnia is not sufficiently effective, a pharmacological intervention can be offered (A). Benzodiazepines (A), benzodiazepine receptor agonists (A), daridorexant (A) and low-dose sedating antidepressants (B) can be used for the short-term treatment of insomnia (≤ 4 weeks). Longer-term treatment with these substances may be initiated in some cases, considering advantages and disadvantages (B). Orexin receptor antagonists can be used for periods of up to 3 months or longer in some cases (A). Prolonged-release melatonin can be used for up to 3 months in patients ≥ 55 years (B). Antihistaminergic drugs, antipsychotics, fast-release melatonin, ramelteon and phytotherapeutics are not recommended for insomnia treatment (A). Light therapy and exercise interventions may be useful as adjunct therapies to cognitive-behavioural therapy for insomnia (B).

Exercise regimens for improved sleep quality in adult breast cancer survivors: systematic review and network meta-analysis

OBJECTIVE

The relative efficacy of exercise regimens for improving sleep quality in adult breast cancer survivors remains unknown. This network meta-analysis aimed to compare the efficacy of various exercise regimens for improving sleep quality in adult breast cancer survivors.

METHODS

This study searched four electronic databases for relevant literature from inception to 18 July 2023. Randomised controlled trials reporting the effects of exercise on sleep quality in adults with breast cancer were included. A random-effects network meta-analysis based on the frequentist framework was performed.

RESULTS

In total, 35 trials including 3374 breast cancer survivors were included. Compared with usual care, endurance training combined with resistance training significantly improved sleep quality (standardised mean differences (SMDs) = -0.97; 95% CI = -1.50 to -0.43; certainty of evidence=moderate) (p<0.05). Endurance training combined with resistance training (SMDs: -1.42; 95% CIs: -2.31 to -0.53; moderate) achieved superior sleep quality results compared with stretching exercises (p<0.05). The surface under the cumulative ranking curve analysis indicated that endurance training combined with resistance training was ranked as the top effective treatment among other exercise regimens for improving sleep quality in breast cancer survivors (71%).

CONCLUSIONS

Endurance training combined with resistance training is effective in improving sleep quality in adult breast cancer survivors. Our results provide evidence that exercise can improve sleep quality in adult breast cancer survivors.

Cognitive behavioural therapy for insomnia disorder: Extending the stepped care model

Despite cognitive behaviour therapy for insomnia (CBT-I) being the first-line intervention for the disorder, it is often not readily available to patients in need. The stepped care model (SCM) represents an approach to facilitating efficient and wide-ranging provision of evidence-based care to those with insomnia. The SCM reflects a pyramid of therapeutics based on CBT-I gradually increasing in clinical intensity and addressing clinical complexity. By applying CBT-I through the SCM it is hoped that the treatment gap can be bridged such that not only more patients can be reached, but that clinical resource can be more effectively distributed, with patients receiving more tailored care as needed. Nevertheless, this should not be done at the risk of a lower quality of care being offered, and high-standard training for clinicians and scrutiny of non-clinician led interventions remains important. As national health laws within European countries have substantial differences, the application of the SCM as it relates to the treatment of insomnia may be challenged by contrasting interpretations. In order that the SCM is appropriately implemented: (a) only evidence-based CBT-I treatments should be promoted within the model; (b) clinicians involved in SCM should be suitably qualified to offer CBT in general, and have appropriate further training in CBT-I; (c) professionals involved in interventions not included in the SCM, but related to it, such as preventive and educational programmes, diagnostic procedures, and pharmacological treatments, should also have good knowledge of the SCM in order to promote correct allocation to the appropriate interventional step.

Effects of a digital cognitive behavioral therapy for insomnia on sleep and alcohol consumption in heavy drinkers: A randomized pilot study

BACKGROUND

Insomnia is a well-established, prospective risk factor for Alcohol Use Disorder. Thus, targeting sleep problems could serve as a novel and efficacious means of reducing problematic drinking. Here, we examined the potential utility of a well-validated, interactive, easy to use, self-paced digital cognitive behavioral therapy for insomnia program. In a randomized, single-blind pilot study, we examined the impact of treatment with Sleep Healthy Using the Internet (SHUTi) on drinking and sleep outcomes in a sample of heavy drinkers with insomnia.

METHODS

Heavy drinking men (n = 28) and women (n = 42) with insomnia were randomly assigned to complete either the SHUTi program or a control patient education program. Subjective measures of sleep and alcohol use were administered at baseline, immediately following completion of the intervention, 3 months post-intervention, and 6 months post-intervention. Sleep outcomes were assessed using the Insomnia Severity Index and Pittsburgh Sleep Quality Index. Drinking outcomes were assessed using the 30-Day Timeline Follow-Back calendar. We used linear mixed effects models to compare groups on both insomnia and drinking outcomes.

RESULTS

Data from all 70 subjects (SHUTI: n = 40; control: n = 30) were analyzed. Linear mixed effects models showed that SHUTi significantly reduced insomnia symptoms (p = 0.01) and drinking outcomes (ps < 0.05) more than the control condition over time. Trend-level effects on sleep quality (p = 0.06) were also observed. No adverse events were reported.

CONCLUSIONS

Improving sleep may be an effective treatment intervention for reducing hazardous drinking in at-risk individuals. Further, findings provide preliminary support for the implementation of an easily accessible health behavior intervention with significant public health impact in a high-risk population.

Effects of digital sleep interventions on sleep and psychological health during the COVID-19 pandemic: A systematic review and meta-analysis

BACKGROUND

Various digital sleep interventions have been implemented to address sleep and psychological complications during the coronavirus disease 2019 (COVID-19) pandemic. However, the characteristics and effectiveness of digital sleep interventions on sleep and psychological outcomes for people with sleep problems during the COVID-19 pandemic are unknown.

METHODS

The protocol of this systematic review and meta-analysis was registered on PROSPERO (ID: CRD42022325662), seven databases were searched from December 2019 to June 2023. Reference lists from digital sleep reviews were also identified and selected. Two reviewers independently screened eligible articles and extracted data. Quality appraisal was undertaken by two independent reviewers using the Cochrane Risk-of-Bias Tools. Data synthesis was conducted using fixed- or random-effects model based on the results of the heterogeneity test.

RESULTS

A total of 20 studies were identified, including nine randomised controlled trials (RCTs) and 11 non-RCTs, involving 3860 participants. Meta-analyses showed that digital sleep interventions significantly improve sleep quality, insomnia, and depression during the COVID-19 pandemic. Subgroup analysis showed that interventions of more than four weeks, healthcare workers as participants, and relaxation therapies may have the advantage of improving sleep quality. Most non-RCTs supported the efficacy of digital sleep interventions on sleep and psychological health.

CONCLUSION

Digital sleep interventions during the COVID-19 pandemic had significant effectiveness in improving sleep and psychological outcomes for people with sleep problems. More structured and personalised digital sleep interventions should be designed, and other diverse digital technologies could be used to improve sleep and psychological disorders.

Digital cognitive behaviour therapy for insomnia in individuals with self-reported insomnia and chronic fatigue: A secondary analysis of a large scale randomized controlled trial

Insomnia is associated with fatigue, but it is unclear whether response to cognitive behaviour therapy for insomnia is altered in individuals with co-occurring symptoms of insomnia and chronic fatigue. This is a secondary analysis using data from 1717 participants with self-reported insomnia in a community-based randomized controlled trial of digital cognitive behaviour therapy for insomnia compared with patient education. We employed baseline ratings of the Chalder Fatigue Questionnaire to identify participants with more or fewer symptoms of self-reported chronic fatigue (chronic fatigue, n = 592; no chronic fatigue, n = 1125). We used linear mixed models with Insomnia Severity Index, Short Form-12 mental health, Short Form-12 physical health, and the Hospital Anxiety and Depression Scale separately as outcome variables. The main covariates were main effects and interactions for time (baseline versus 9-week follow-up), intervention, and chronic fatigue. Participants with chronic fatigue reported significantly greater improvements following digital cognitive behaviour therapy for insomnia compared with patient education on the Insomnia Severity Index (Cohen's d = 1.36, p < 0.001), Short Form-12 mental health (Cohen's d = 0.19, p = 0.029), and Hospital Anxiety and Depression Scale (Cohen's d = 0.18, p = 0.010). There were no significant differences in the effectiveness of digital cognitive behaviour therapy for insomnia between chronic fatigue and no chronic fatigue participants on any outcome. We conclude that in a large community-based sample of adults with insomnia, co-occurring chronic fatigue did not moderate the effectiveness of digital cognitive behaviour therapy for insomnia on any of the tested outcomes. This may further establish digital cognitive behaviour therapy for insomnia as an adjunctive intervention in individuals with physical and mental disorders.

Effect of cognitive behavioral therapy for insomnia in workers: A systematic review and meta-analysis of randomized controlled trials

Although cognitive behavioral therapy for insomnia (CBT-I) is recommended as a first-line treatment, its efficacy for workers with insomnia remains unclear. This systematic review and meta-analysis aimed to determine the effectiveness of CBT-I in the management of insomnia symptoms in workers. We searched the literature in three electronic databases, namely PubMed, PsycINFO, and Embase, and included 21 studies in the meta-analysis. Compared with the control group, CBT-I overall resulted in significant improvements in terms of severity of insomnia (g = -0.91), sleep onset latency (g = -0.62), wakefulness after sleep onset (g = -0.60), early morning awakening (g = -0.58), and sleep efficiency (g = 0.71). However, there was no improvement in the total sleep time relative to that in the control group. Furthermore, CBT-I significantly alleviated depressive (g = -0.37) and anxiety (g = -0.35) symptoms and fatigue (g = -0.47) compared with the control group. Our study findings suggest that both web-based and face-to-face CBT-I are effective interventions for managing insomnia symptoms in daytime workers, although it is important to note that only face-to-face CBT-I achieved clinically meaningful changes. The effectiveness of CBT-I for shift workers could not be determined.

A randomized controlled trial of a multi-dimensional intervention to improve CPAP use and self-efficacy

OBJECTIVES

To assess the utility of a tailored intervention program to improve continuous positive airway pressure (CPAP) use and self-efficacy in individuals with obstructive sleep apnea (OSA).

METHODS

81 participants (mean age 52.1 ± 11.6 years; 35 females) with OSA were randomized to either a multi-dimensional intervention (PSY CPAP, n = 38) or treatment as usual (TAU CPAP, n = 43). The intervention included a psychoeducation session prior to CPAP initiation, a booster psychoeducation session in the first weeks of commencing CPAP, follow-up phone calls on days 1 and 7, and a review appointment on day 14. CPAP use was compared between the PSY CPAP and TAU CPAP groups at 1 week, 1 month, and 4 months. Self-efficacy scores (risk perception, outcome expectancies, and CPAP self-efficacy) were compared between groups following the initial psychoeducation session and again at 1 month and 4 months.

RESULTS

CPAP use was higher in the PSY CPAP group compared to the TAU CPAP group for all time points (p = .02). Outcome expectancies improved significantly over time in PSY CPAP participants (p = .007). Change in risk perception was associated with CPAP use at 1 week (p = .02) for PSY CPAP participants. However, risk perception did not mediate the effect between group and CPAP use at 1 week.

CONCLUSIONS

Interventions designed to increase self-efficacy and administered prior to CPAP initiation, repeated in the early stages of CPAP therapy, and combined with a comprehensive follow-up regime are likely to improve CPAP use. Sustained improvement in CPAP use is the ultimate goal but remains to be investigated.

Can adding personalized rule-based feedback improve the therapeutic effect of self-help digital cognitive behavioral therapy for insomnia in young adults?

INTRODUCTION

Cognitive-behavioral therapy for insomnia (CBT-I) is recommended as the first-line treatment for insomnia, but low accessibility and relatively high cost limits the dissemination of the treatment. Several forms of digital CBT-I have been developed to increase the accessibility and shown to be effective; however, the treatment effect may be restricted by the lack of interaction within the treatment. The current study examines whether the therapeutic effects of self-help digital CBT-I could be enhanced by adding simple rule-based personalized feedback.

METHOD

Ninety-two young adults with self-reported insomnia were randomly assigned to three groups: a self-help group (SH, n = 31), who received an eight-session email-delivered CBT-I program; a feedback group (FB, n = 31), who went through the same CBT-I program with personalized feedback; and a waitlist group (WL, n = 30). The Insomnia Severity Index (ISI) was used as the primary outcome measure, and the 16-item version of the Dysfunctional Beliefs and Attitudes about Sleep Scale (DBAS-16), Sleep Hygiene Practice Scale (SHPS), and sleep diary were used as the secondary outcome measures. Treatment satisfaction and adherence were also compared between the treatment groups.

RESULTS

Both the SH and FB groups showed significantly more improvements in insomnia severity, sleep-related beliefs, and sleep hygiene behaviors than the WL group. Sleep onset latency and sleep efficiency in the sleep diary were also significantly improved after treatment. None of these effects significantly differed between the two treatment groups. Nonetheless, participants in the FB group reported higher treatment satisfaction than those in the SH group.

CONCLUSION

This study supports the effectiveness of email-delivered self-help CBT-I for young adults with insomnia. Furthermore, while adding simple personalized feedback may not have an additional effect on sleep per se, it can enhance treatment satisfaction. This simple intervention shows promise in addressing sleep disturbance in young adults.

The beneficial effects of integrating a personalized telephone-delivered component into digital cognitive behavioral therapy for insomnia in a large, hospital-based population

OBJECTIVES

Although digital cognitive behavior therapy for insomnia (D-CBTI) has been shown to be a viable treatment for insomnia, lacking flexibility of response and direct practitioner-to-patient contact and comfort potentially limited its efficacy. Integrating personalized telephone sessions into D-CBTI may overcome these obstacles, potentially providing additional clinical benefit to chronic insomnia patients. We evaluate the clinical effectiveness of telephone plus D-CBTI (TD-CBTI) versus D-CBTI alone.

METHODS

Insomnia patients were selected consecutively from the Sleep Medicine Center, West China Hospital from March 2020 to February 2021. Insomnia was defined by Diagnostic and Statistical Manual for Mental Disorders criteria with symptoms lasting ≥3 months. Standard D-CBTI was administered through the APP "SUMIAN," which provided fully automated, interactive and standard CBTI over six weekly treatments. TD-CBTI added weekly 10-15 min personalized telephone-based sessions to D-CBTI.

RESULTS

One hundred and seven patients received D-CBTI and 465 patients received TD-CBTI. Pre-to posttreatment differences of ISI and most sleep diary reported sleep indexes were comparable between groups. However, TD-CBTI patients showed significantly increased odds of SE based remission (167%, OR = 2.67, 95% CI 1.34-5.23), and significantly increased odds of reduction of sleep medications (352%, OR = 4.52, 95% CI 1.27-10.05).

CONCLUSIONS

This study demonstrates that integration of personalized telephone sessions into D-CBTI treatment, provides increased clinical benefit to insomnia patients, particularly for successful discontinuation of sleep medications.

Paradoxic Intention as an Adjunct Treatment to Cognitive Behavioral Therapy for Insomnia

Paradoxic intention (PI) was one of the first psychological interventions for insomnia. Historically, PI has been incorporated in cognitive behavioral therapy for insomnia (CBT-I) or delivered as a sole intervention for insomnia. PI instructions have varied over the years, but a common denominator is the instruction to try to stay awake in bed for as long as possible. This article reviews and discuss treatment rationales and theoretic frameworks for PI, the current evidence base for PI, its clinical relevance, and considerations needed when PI is used as an adjunct treatment to CBT-I, or as a second-line intervention for insomnia.

Comparative efficacy of onsite, digital, and other settings for cognitive behavioral therapy for insomnia: a systematic review and network meta-analysis

Given the limited availability and accessibility of onsite cognitive behavioral therapy for insomnia (CBT-I), other CBT-I settings, such as internet-delivered CBT-I (iCBT-I), have been proposed. The primary aim of the study was to compare the efficacy of available CBT-I settings on insomnia severity. A systematic review and frequentist network meta-analysis of available CBT-I settings was performed. PsycINFO, PsycARTICLES, MEDLINE, PubMed, and CINAHL were searched for randomized controlled trials (RCTs) investigating any CBT-I settings in adults with insomnia disorder. The systematic literature search (3851 references) resulted in 52 RCTs. For the primary outcome insomnia severity, all examined CBT-I settings except smartphone-delivered CBT-I yielded significant effects when compared to WL. Large standardized mean differences were found for individual onsite CBT-I (- 1.27;95%CI - 1.70, - 0.84), group-delivered CBT-I (- 1.00;95%CI - 1.42. - 0.59), telehealth (- 1.28;95%CI - 2.06, - 0.50), and guided bibliotherapy (- 0.99;95%CI - 1.67, - 0.32). Both guided iCBT-I (- 0.71;95%CI - 1.18, - 0.24) and unguided iCBT-I (- 0.78;95%CI - 1.18, - 0.38) yielded medium effect sizes. The results underline that health care systems should intensify their efforts to provide synchronously-delivered CBT-I (individual onsite, group-delivered, and telehealth), and particularly individual onsite CBT-I, given its solid evidence base. Medium to large effect sizes for iCBT-I and guided bibliotherapy indicate that self-help settings may be a viable alternative when synchronously-delivered CBT-I is not available.

Mining the Influencing Factors and Their Asymmetrical Effects of mHealth Sleep App User Satisfaction From Real-world User-Generated Reviews: Content Analysis and Topic Modeling

BACKGROUND

Sleep disorders are a global challenge, affecting a quarter of the global population. Mobile health (mHealth) sleep apps are a potential solution, but 25% of users stop using them after a single use. User satisfaction had a significant impact on continued use intention.

OBJECTIVE

This China-US comparison study aimed to mine the topics discussed in user-generated reviews of mHealth sleep apps, assess the effects of the topics on user satisfaction and dissatisfaction with these apps, and provide suggestions for improving users' intentions to continue using mHealth sleep apps.

METHODS

An unsupervised clustering technique was used to identify the topics discussed in user reviews of mHealth sleep apps. On the basis of the two-factor theory, the Tobit model was used to explore the effect of each topic on user satisfaction and dissatisfaction, and differences in the effects were analyzed using the Wald test.

RESULTS

A total of 488,071 user reviews of 10 mainstream sleep apps were collected, including 267,589 (54.8%) American user reviews and 220,482 (45.2%) Chinese user reviews. The user satisfaction rates of sleep apps were poor (China: 56.58% vs the United States: 45.87%). We identified 14 topics in the user-generated reviews for each country. In the Chinese data, 13 topics had a significant effect on the positive deviation (PD) and negative deviation (ND) of user satisfaction. The 2 variables (PD and ND) were defined by the difference between the user rating and the overall rating of the app in the app store. Among these topics, the app's sound recording function (β=1.026; P=.004) had the largest positive effect on the PD of user satisfaction, and the topic with the largest positive effect on the ND of user satisfaction was the sleep improvement effect of the app (β=1.185; P<.001). In the American data, all 14 topics had a significant effect on the PD and ND of user satisfaction. Among these, the topic with the largest positive effect on the ND of user satisfaction was the app's sleep promotion effect (β=1.389; P<.001), whereas the app's sleep improvement effect (β=1.168; P<.001) had the largest positive effect on the PD of user satisfaction. The Wald test showed that there were significant differences in the PD and ND models of user satisfaction in both countries (all P<.05), indicating that the influencing factors of user satisfaction with mHealth sleep apps were asymmetrical. Using the China-US comparison, hygiene factors (ie, stability, compatibility, cost, and sleep monitoring function) and 2 motivation factors (ie, sleep suggestion function and sleep promotion effects) of sleep apps were identified.

CONCLUSIONS

By distinguishing between the hygiene and motivation factors, the use of sleep apps in the real world can be effectively promoted.

Elevated insomnia symptom severity in university students: The role of sexual orientation and internalizing symptoms

Objectives: Sexual minority (SM) individuals experience a disproportionate health burden relative to their heterosexual peers; however, less is known about their experience of insomnia. Participants: The sample consisted of a subset of students, N = 1543, Mage = 21.25 years, SD = 3.95, in the 2019-2020 Healthy Minds Study. Adjusting for non-response weights, approximately 16.95% of the sample identified as a sexual minority. Methods: Participants completed measures of insomnia (Insomnia Severity Index) and psychopathology symptoms (PHQ-9 for depression and GAD-7 for generalized anxiety). Results: Sexual orientation was significantly positively associated with insomnia severity, such that SM students exhibited higher insomnia symptom severity, B = 1.71, SE = 0.35, p < .001, 95% CI [1.01, 2.40]. Including depression and anxiety symptom severity in the model completely attenuated this effect. Conclusions: Insomnia symptoms in SM students may be understood in the context of internalizing symptoms; however, study design precluded examining causal pathways.

Embedding digital sleep health into primary care practice: A triangulation of perspectives from general practitioners, nurses, and pharmacists

Introduction

While digital health interventions (DHIs) can potentially address the unmet needs for sleep health services, little is known about their implementation in practice. The current study aimed to explore primary care health providers' attitudes and beliefs towards DHIs for sleep and implementation into practice.

Methods

A cross-sectional online survey was administered to Australian primary care health professionals: general practitioners (GPs), community nurses, and community pharmacists. Semi-structured interviews were conducted within a sub-sample of participants exploring their experiences with DHIs and perceived barriers/facilitators for embedding DHIs into primary care. Semi-structured interviews were thematically analysed using the framework approach to contextualise survey findings.

Results

Ninety-six surveys were returned (GPs  =  36, nurses = 30, and pharmacists = 30) and 45 interviews conducted (GPs  =  17, nurses = 14, and pharmacists  =  14). From the survey, GPs were more likely to endorse familiarity (p  =  0.009) and use (p < 0.001) of sleep DHIs in clinical practice than pharmacists and nurses. GPs were more interested in utilising the diagnostic features within a sleep DHI (p  =  0.009) compared to other professionals. Thematic analysis of the interviews revealed three major themes, contextualised by profession: (1) Scope for DHIs in Current Practice, (2) Practice Gaps and Training Needs, and (3) Envisioning a Model of Care Using Sleep DHIs. While DHIs can potentially improve care, greater clarity of care pathways and reimbursement structures are needed for integration into practice.

Conclusion

Primary care health professionals highlighted the training, care pathway and financial models required to realise the potential for translating findings from efficacy studies for DHIs into primary care to optimise sleep health.

Emerging applications of objective sleep assessments towards the improved management of insomnia

Self-reported sleep difficulties are the primary concern associated with diagnosis and treatment of chronic insomnia. This said, in-home sleep monitoring technology in combination with self-reported sleep outcomes may usefully assist with the management of insomnia. The rapid acceleration in consumer sleep technology capabilities together with their growing use by consumers means that the implementation of clinically useful techniques to more precisely diagnose and better treat insomnia are now possible. This review describes emerging techniques which may facilitate better identification and management of insomnia through objective sleep monitoring. Diagnostic techniques covered include insomnia phenotyping, better detection of comorbid sleep disorders, and identification of patients potentially at greatest risk of adverse outcomes. Treatment techniques reviewed include the administration of therapies (e.g., Intensive Sleep Retraining, digital treatment programs), methods to assess and improve treatment adherence, and sleep feedback to address concerns about sleep and sleep loss. Gaps in sleep device capabilities are also discussed, such as the practical assessment of circadian rhythms. Proof-of-concept studies remain needed to test these sleep monitoring-supported techniques in insomnia patient populations, with the goal to progress towards more precise diagnoses and efficacious treatments for individuals with insomnia.

Understanding the research on tracking, diagnosing, and intervening in sleep disorders using mHealth apps: Bibliometric analysis and systematic reviews

Objectives

In solving the global challenge of sleep disorders, Mobile Health app is one of the important means to monitor, diagnose, and intervene in sleep disorders. This study aims to (1) summarize the status and trends of research in this field; (2) assess the production and usage of sleep mHealth apps; (3) calculate the conversion rate of grants that the proportion of newly developed apps from being funded and developed to published on application stores.

Methods

Using bibliometric and content analysis methods, based on "Research Paper-Product Output-Product Application" chain and considering the "Research Grants" of articles, we conducted a systematic review of eight databases, to identify relevant studies over the last decade.

Results

Over the past decade, 1399 authors published 313 papers in 182 journals and conferences. The number of publications increased with an average annual growth of 41.6%. The current focus area is research using cognitive behavioral therapy to intervene in sleep. Sleep-staging tracking is a shortcoming of this field. A total 368 sleep mHealth apps (233 newly developed and 135 existing) were examined in 313 papers; 323 grants supported 178 articles (56.9%). Only 12 of the newly developed apps are used in the real world, resulting in a 9% grant conversion rate.

Conclusions

In the last decade, the field of tracking, diagnosing, and intervening in sleep disorders using mHealth apps has shown a trend of rapid development. However, the conversion rate of products from being funded and developed for use by end-users is low.

Blended care to discontinue BZRA use in patients with chronic insomnia disorder: a pragmatic cluster randomized controlled trial in primary care

STUDY OBJECTIVES

International guidelines recommend using benzodiazepine receptor agonists (BZRA) for maximally four weeks. Nevertheless, long-term use for chronic insomnia disorder remains a common practice. This study aimed to test the effectiveness of blended care for discontinuing long-term BZRA use in general practice.

METHODS

A pragmatic cluster randomized controlled superiority trial compared blended care to usual care through urine toxicology screening. In the intervention, care by the general practitioner (GP) was complemented by an interactive e-learning program, based on cognitive behavioral therapy for insomnia. Adults using BZRA daily for minimally six months were eligible. Participants were clustered at the level of the GP surgery for allocation (1:1). Effectiveness was measured as the proportion of patients who had discontinued at one-year follow-up. Data analysis followed intention-to-treat principles.

RESULTS

In total, 916 patients in 86 clusters, represented by 99 GPs, were randomized. Primary outcome data was obtained from 727 patients (79%). At one-year follow-up, 82 patients (18%) in blended care, compared to 91 patients (20%) in usual care, had discontinued. There was no statistically significant effect for the intervention (OR: 0·924; 95% CI: 0·60, 1·43). No adverse events were reported to the research team.

CONCLUSIONS

The findings did not support the superiority of blended care over usual care. Both strategies showed clinical effectiveness, with an average of 19% of patients having discontinued at one-year follow-up. Further research is important to study the effect of structurally implementing digital interventions in general practice.

Effectiveness of mobile-delivered, therapist-assisted cognitive behavioral therapy for insomnia in nationwide routine clinical care in Finland

STUDY OBJECTIVES

Internet-delivered cognitive behavioral therapies (iCBTs) are efficacious for insomnia. Few studies have as yet reported their effectiveness in routine care. The objective of this study was to examine the effectiveness of the new Finnish 7-session HUS Helsinki University Hospital-iCBT for Insomnia (HUS-iCBTI) program in nationwide routine care.

METHODS

We studied 2,464 physician-referred patients in therapist-supported iCBTI. Treatment was free of charge for patients. The primary measure was the Insomnia Severity Index (ISI); the Patient Health Questionnaire, 4-item version (PHQ-4), and the Alcohol Use Disorders Identification Test (AUDIT-C) were also administered.

RESULTS

As many as 75.4% completed the treatment, with the ISI scores declining, on average, by -7.04 points during treatment. Altogether, 91.1% of the completers improved in terms of having a lower ISI score in phase 7 than in phase 1 and 34.0% of the completers achieved remission by phase 7 (ISI score < 8); 46.0% responded to treatment (ISI-score reduction of ≥ 8 points from phase 1). The Cohen's effect size (ISI-score decline) was d = -1.449, showing a large effect.

CONCLUSIONS

We observed large benefits for this publicly funded therapist-supported treatment in its naturalistic setting as a part of routine care. Effect sizes were comparable to randomized controlled trials reported earlier. HUS-iCBTI appears to be effective as a treatment for insomnia and may also reduce the risk of other adverse health consequences associated with poor sleep.

CITATION

Stenberg J-H, Ritola V, Joffe G, Saarni S, Rosenström T. Effectiveness of mobile-delivered, therapist-assisted cognitive behavioral therapy for insomnia in nationwide routine clinical care in Finland. J Clin Sleep Med. 2022;18(11):2643-2651.

Network meta-analysis comparing the effectiveness of a prescription digital therapeutic for chronic insomnia to medications and face-to-face cognitive behavioral therapy in adults

OBJECTIVE

The purpose of this study was to compare the effectiveness of the only Food and Drug Administration-authorized prescription digital therapeutic (PDT) Somryst versus face-to-face cognitive behavioral therapy for insomnia (CBT-I), or FDA-approved prescription medications for insomnia.

METHODS

A systematic literature review was undertaken to identify relevant studies. A Bayesian network meta-analysis (NMA) was conducted to examine (1) mean change in insomnia severity index (ISI); (2) proportional change in ISI remitters; (3) mean change in wake after sleep onset (WASO); and (4) mean change in sleep onset latency (SOL).

RESULTS

Twenty studies provided data on the PDT, CBT-I, CBT-I in combination with self-help (SH), or two prescription medications (eszopiclone and zolpidem). The PDT was associated with significant mean change in ISI (-5.77, 95% Credible Interval [CrI] - 8.53, -3.07) and ISI remitters (OR 12.33; 95% CrI 2.28, 155.91) compared to placebo, and had the highest probability of being the most effective treatment overall for ISI mean change (56%), and ISI remitters (64%). All evaluated interventions significantly outperformed placebo for WASO but no significant differences were observed for SOL (five interventions). Sensitivity analyses excluding medications and meta-regression (assessing type, duration, delivery method for CBT-I) did not affect NMA results.

CONCLUSIONS

This network meta-analysis demonstrated that a PDT delivering CBT-I had the highest probability of being most effective compared to face-to-face CBT-I, prescription sleep medications, or placebo, as measured by reductions in mean ISI score from baseline and ISI-determined remittance.

Comparative efficacy and acceptability of psychotherapies, pharmacotherapies, and their combination for the treatment of adult insomnia: A systematic review and network meta-analysis

This study aims to explore the comparative efficacy and acceptability of psychotherapies, pharmacotherapies, and their combinations for insomnia. MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, PsycINFO, CINAHL, and ClinicalTrials.gov were searched for randomized clinical trials (RCTs) examining the comparative efficacy in which a psychotherapy and a pharmacotherapy for insomnia were directly compared with each other, or in which a combination of psychotherapy and pharmacotherapy was compared with either alone. The analysis included data from 23 RCTs. In 18 of 23 studies, cognitive behavior therapy for insomnia (CBT-I) was the psychotherapy. At post-treatment, CBT-I showed higher subjective sleep efficiency (SE), and lower subjective wake time after sleep onset (WASO) and insomnia severity index (ISI) score. Compared with CBT-I plus pharmacotherapy, pharmacotherapy showed lower subjective SE, and higher subjective sleep latency (SL), PSG measured SL, subjective WASO, and ISI score. Overall, the findings derived from post-treatment data suggested that CBT-I is more beneficial in treating insomnia compared with pharmacotherapy. CBT-I combined with pharmacotherapy is beneficial in improving some sleep parameters (i.e., subjective SE, SL, WASO, and PSG measured SL) compared with pharmacotherapy alone. Daily clinical decisions should consider these findings on the relative efficacy of the principal approaches to insomnia treatment.

The Efficacy of Digital Cognitive–Behavioral Interventions in Supporting the Psychological Adjustment and Sleep Quality of Pregnant Women with Sub-Clinical Symptoms: A Systematic Review and Meta-Analysis

The present meta-analysis investigated the overall and differential efficacy of digital cognitive–behavioral therapies (CBTs) vs. third-generation CBTs deployed to pregnant women in reducing sub-clinical depression, anxiety, and stress symptoms while fostering sleep quality and quality of life. A PRISMA-guided systematic search was used, including randomized controlled trials (RCTs) evaluating the above-mentioned interventions. Data were pooled using either the mean difference (MD) or standardized MD (SMD). Sub-group analyses were carried out when appropriate. The primary outcomes were depression, anxiety, and stress symptoms, as well as sleep quality and quality of life. The interventions’ acceptability was evaluated through the odds ratio (OR) of drop-out rates. Seven RCTs were included, comprising 1873 pregnant women. The results showed the interventions’ efficacy in terms of reducing depression symptoms (SMD = −0.36, CI = 0.61, −0.11, k = 9) at the endpoint, although it was not maintained at follow-up during the postpartum period. The interventions’ efficacy in terms of reducing anxiety symptoms (SMD = 1.96, CI = −2.72, −1.21, k = 3) at the endpoint was also significant, while having no effect on sleep quality. The interventions were well accepted (OR = 1.68; 95% CI = 0.84, 3.35; k = 7). Although no sound conclusions can be drawn concerning the joint or differential efficacy of the considered interventions, this study was useful in highlighting the need to develop evidence-based digital prevention programs for pregnant women with sub-clinical symptoms.

Effects of a hybrid digital cognitive-behavioural therapy for insomnia and emotion regulation in the workplace (SLEEP): study protocol for a randomised waitlist control trial

INTRODUCTION

This trial tests the efficacy of implementing a hybrid digital cognitive-behavioural therapy for insomnia (dCBT-I) and emotion regulation (ER) in the workplace. The study protocol follows the SPIRIT (Standard Protocol Items: Recommendations for Intervention Trials) 2013 recommendations.

METHODS AND ANALYSIS

This is a mixed methods evaluation with a two-arm randomised waitlist control design of a 6-week dCBT-I+ER intervention through self-guided online platform and four videoconferencing therapy sessions. A process evaluation will examine the fidelity of delivery and experiences of the intervention. The primary outcomes are the Insomnia Severity Index, the Patient Health Questionnaire-9 and the Generalised Anxiety Disorder-7. The secondary outcomes are job productivity, job satisfaction, well-being, quality of life, self-reported (sleep diary data) and objective (actigraphy) sleep parameters, and usage of online intervention platform. Assessments take place at baseline (T0), week 8 post-treatment (T1) and week 12 postrandomisation (T2). We will recruit 156 workers with sleep and ER problems ranging from subclinical to clinical levels not engaged in treatment at the time of the trial.

ETHICS AND DISSEMINATION

Full approval was given by the University of Warwick Biomedical and Research Ethics Committee (BSREC 45/20-21). The current protocol version is 2.9_Dec21. Publication of results will inform the scientific, clinical and business communities through peer-reviewed articles, webinars, conferences and newsletters.

TRIAL REGISTRATION NUMBER

ISRCTN13596153.

Insomnia disorder: State of the science and challenges for the future

Insomnia disorder comprises symptoms during night and day that strongly affect quality of life and wellbeing. Prolonged sleep latency, difficulties to maintain sleep and early morning wakening characterize sleep complaints, whereas fatigue, reduced attention, impaired cognitive functioning, irritability, anxiety and low mood are key daytime impairments. Insomnia disorder is well acknowledged in all relevant diagnostic systems: Diagnostic and Statistical Manual of the American Psychiatric Association, 5th revision, International Classification of Sleep Disorders, 3rd version, and International Classification of Diseases, 11th revision. Insomnia disorder as a chronic condition is frequent (up to 10% of the adult population, with a preponderance of females), and signifies an important and independent risk factor for physical and, especially, mental health. Insomnia disorder diagnosis primarily rests on self-report. Objective measures like actigraphy or polysomnography are not (yet) part of the routine diagnostic canon, but play an important role in research. Disease concepts of insomnia range from cognitive-behavioural models to (epi-) genetics and psychoneurobiological approaches. The latter is derived from knowledge about basic sleep-wake regulation and encompass theories like rapid eye movement sleep instability/restless rapid eye movement sleep. Cognitive-behavioural models of insomnia led to the conceptualization of cognitive-behavioural therapy for insomnia, which is now considered as first-line treatment for insomnia worldwide. Future research strategies will include the combination of experimental paradigms with neuroimaging and may benefit from more attention to dysfunctional overnight alleviation of distress in insomnia. With respect to therapy, cognitive-behavioural therapy for insomnia merits widespread implementation, and digital cognitive-behavioural therapy may assist delivery along treatment guidelines. However, given the still considerable proportion of patients responding insufficiently to cognitive-behavioural therapy for insomnia, fundamental studies are highly necessary to better understand the brain and behavioural mechanisms underlying insomnia. Mediators and moderators of treatment response/non-response and the associated development of tailored and novel interventions also require investigation. Recent studies suggest that treatment of insomnia may prove to add significantly as a preventive strategy to combat the global burden of mental disorders.

Thematic trends and knowledge structure on cognitive behavior therapy for insomnia: A bibliometric and visualization analysis

OBJECTIVE

To find publications trend about cognitive behavior therapy for insomnia (CBTI) using bibliometric and visualization analysis. In this study, the authors sought to identify the publication trends of peer-reviewed articles about CBTI.

MATERIALS AND METHODS

Analyses were focused on the past 18 years from 2004 to 2021. All searches were performed on the Web of Science Core Collection database. The search was repeated to include structural cognitive behavior therapy for insomnia. Quantitative analysis was assessed using the bibliometric tool. Visualization analysis was carried out using VOSviewer.

RESULTS

In the 736 articles reviewed, the number of publications has been increasing every year for the past 18 years. Behavioral sleep medicine and sleep were the most active journals published on CBTI. The United States and Canada had the highest scientific publications in the field. Morin CM and Espie CA were the most active authors. The study type mostly observed were randomized controlled trials, meta-analyses, and epidemiological. Publications on digital-based cognitive behavior therapy and accessibility to primary care settings represent the future trends of research on CBTI.

CONCLUSION

Possible explanations for CBTI publication trends were discussed, including the emergence of the evidence-based therapy, feasibility, and scalability. Potential CBTI publications trends in the future and clinical implications were also discussed.