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

Caregivers' Internet-Delivered Insomnia Intervention Engagement and Benefit: SHUTi-CARE Trial Primary Quantitative Analysis

BACKGROUND

Delivering insomnia treatment by the Internet holds promise for increasing care access to family caregivers, but their ability to adhere to and benefit from such fully-automated programs has not been rigorously tested.

PURPOSE

This fully-powered, single-group trial tested whether characteristics of the caregiving context influence high-intensity caregivers' engagement with and benefit from an empirically validated Internet intervention for insomnia.

METHODS

At baseline, caregivers providing unpaid time- and responsibility-intensive care who reported insomnia (N = 100; age M = 52.82 [SD = 13.10], 75% non-Hispanic white, 66% ≥college degree) completed questionnaires about caregiving context and sleep, then 10 prospectively-collected online daily sleep diaries. Caregivers then received access to SHUTi (Sleep Healthy Using the Internet), which has no caregiver-specific content, for 9 weeks, followed by post-assessment (questionnaires, diaries). Engagement was tracked by the SHUTi delivery system.

RESULTS

Sixty caregivers completed SHUTi, 22 initiated but did not complete SHUTi, and 18 did not initiate SHUTi. Caregivers were more likely to use SHUTi (than not use SHUTi) when their care recipient (CR) had worse functioning, and were more likely to complete SHUTi when supporting more CR activities of daily living (ADL; ps < .03). Higher caregiver guilt, more CR problem behaviors, and being bedpartners with the CR related to more improved sleep outcomes, whereas supporting more CR instrumental ADL related to less improvement (ps < .05).

CONCLUSIONS

Factors associated with greater caregiving burden, including greater CR impairment and caregiving guilt, were generally associated with better engagement and outcomes. Caregivers with substantial burdens can adhere to and benefit from a fully automated insomnia program without caregiver-specific tailoring.

Assessing the Short-Term Efficacy of Digital Cognitive Behavioral Therapy for Insomnia With Different Types of Coaching: Randomized Controlled Comparative Trial

BACKGROUND

Digital cognitive behavioral therapy for insomnia (dCBTi) is an effective intervention for treating insomnia. The findings regarding its efficacy compared to face-to-face cognitive behavioral therapy for insomnia are inconclusive but suggest that dCBTi might be inferior. The lack of human support and low treatment adherence are believed to be barriers to dCBTi achieving its optimal efficacy. However, there has yet to be a direct comparative trial of dCBTi with different types of coaching support.

OBJECTIVE

This study examines whether adding chatbot-based and human coaching would improve the treatment efficacy of, and adherence to, dCBTi.

METHODS

Overall, 129 participants (n=98, 76% women; age: mean 34.09, SD 12.05 y) whose scores on the Insomnia Severity Index [ISI] were greater than 9 were recruited. A randomized controlled comparative trial with 5 arms was conducted: dCBTi with chatbot-based coaching and therapist support (dCBTi-therapist), dCBTi with chatbot-based coaching and research assistant support, dCBTi with chatbot-based coaching only, dCBTi without any coaching, and digital sleep hygiene and self-monitoring control. Participants were blinded to the condition assignment and study hypotheses, and the outcomes were self-assessed using questionnaires administered on the web. The outcomes included measures of insomnia (the ISI and the Sleep Condition Indicator), mood disturbances, fatigue, daytime sleepiness, quality of life, dysfunctional beliefs about sleep, and sleep-related safety behaviors administered at baseline, after treatment, and at 4-week follow-up. Treatment adherence was measured by the completion of video sessions and sleep diaries. An intention-to-treat analysis was conducted.

RESULTS

Significant condition-by-time interaction effects showed that dCBTi recipients, regardless of having any coaching, had greater improvements in insomnia measured by the Sleep Condition Indicator (P=.003; d=0.45) but not the ISI (P=.86; d=-0.28), depressive symptoms (P<.001; d=-0.62), anxiety (P=.01; d=-0.40), fatigue (P=.02; d=-0.35), dysfunctional beliefs about sleep (P<.001; d=-0.53), and safety behaviors related to sleep (P=.001; d=-0.50) than those who received digital sleep hygiene and self-monitoring control. The addition of chatbot-based coaching and human support did not improve treatment efficacy. However, adding human support promoted greater reductions in fatigue (P=.03; d=-0.33) and sleep-related safety behaviors (P=.05; d=-0.30) than dCBTi with chatbot-based coaching only at 4-week follow-up. dCBTi-therapist had the highest video and diary completion rates compared to other conditions (video: 16/25, 60% in dCBTi-therapist vs <3/21, <25% in dCBTi without any coaching), indicating greater treatment adherence.

CONCLUSIONS

Our findings support the efficacy of dCBTi in treating insomnia, reducing thoughts and behaviors that perpetuate insomnia, reducing mood disturbances and fatigue, and improving quality of life. Adding chatbot-based coaching and human support did not significantly improve the efficacy of dCBTi after treatment. However, adding human support had incremental benefits on reducing fatigue and behaviors that could perpetuate insomnia, and hence may improve long-term efficacy.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05136638; https://www.clinicaltrials.gov/study/NCT05136638.

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.

Sleep-specific outcomes attributable to digitally delivered cognitive behavioral therapy for insomnia in adults with insomnia and depressive symptoms

OBJECTIVE

Randomized controlled trials (RCTs) of digitally delivered Cognitive Behavioral Therapy for insomnia (CBT-I) have demonstrated reductions in insomnia severity, depression symptoms, anxiety symptoms, and suicidal ideation. The present study aimed to evaluate the effectiveness of self-guided, digital CBT-I to improve sleep-specific outcomes.

METHOD

An RCT of Australian adults with insomnia and depressive symptoms (N = 1149) compared SHUTi, a digital CBT-I intervention, with HealthWatch, an attention-matched control internet program, at baseline, posttest (9 weeks) and at 6-, 12-, and 18-month follow-ups. Online sleep diaries were used to derive measures of sleep-onset latency (SOL), wake after sleep onset (WASO), sleep efficiency (SE), number of awakenings, sleep quality, and total sleep time (TST).

RESULTS

Participants in the SHUTi condition had greater improvements at posttest compared with control for: SOL, WASO, SE, number of awakenings, and sleep quality. These improvements were sustained at every follow-up (p < .02 for all outcomes except TST, in which statistically significant increases were observed only at 12- and 18-months).

CONCLUSIONS

Digitally delivered CBT-I produced lasting improvements in sleep outcomes among adults with insomnia and depressive symptoms. Findings provide further evidence of long-term improvements associated with a digital therapeutic for insomnia, compared to an attention-control condition.

Who benefits from indirect prevention and treatment of depression using an online intervention for insomnia? Results from an individual-participant data meta-analysis

BACKGROUND

Major depressive disorder (MDD) is highly prevalent and burdensome for individuals and society. While there are psychological interventions able to prevent and treat MDD, uptake remains low. To overcome structural and attitudinal barriers, an indirect approach of using online insomnia interventions seems promising because insomnia is less stigmatized, predicts MDD onset, is often comorbid and can outlast MDD treatment. This individual-participant-data meta-analysis evaluated the potential of the online insomnia intervention GET.ON Recovery as an indirect treatment to reduce depressive symptom severity (DSS) and potential MDD onset across a range of participant characteristics.

METHODS

Efficacy on depressive symptom outcomes was evaluated using multilevel regression models controlling for baseline severity. To identify potential effect moderators, clinical, sociodemographic, and work-related variables were investigated using univariable moderation and random-forest methodology before developing a multivariable decision tree.

RESULTS

IPD were obtained from four of seven eligible studies (N = 561); concentrating on workers with high work-stress. DSS was significantly lower in the intervention group both at post-assessment (d = -0.71 [95% CI-0.92 to -0.51]) and at follow-up (d = -0.84 [95% CI -1.11 to -0.57]). In the subsample (n = 121) without potential MDD at baseline, there were no significant group differences in onset of potential MDD. Moderation analyses revealed that effects on DSS differed significantly across baseline severity groups with effect sizes between d = -0.48 and -0.87 (post) and d = - 0.66 to -0.99 (follow-up), while no other sociodemographic, clinical, or work-related characteristics were significant moderators.

CONCLUSIONS

An online insomnia intervention is a promising approach to effectively reduce DSS in a preventive and treatment setting.

Cognitive, Behavioral, and Circadian Rhythm Interventions for Insomnia Alter Emotional Brain Responses

BACKGROUND

The highest risk of depression is conveyed by insomnia. This risk can be mitigated by sleep interventions. Understanding brain mechanisms underlying increased emotional stability following insomnia treatment could provide insight relevant to the prevention of depression. Here, we investigated how different sleep interventions alter emotion-related brain activity in people with insomnia at high risk of developing depression.

METHODS

Functional magnetic resonance imaging was used to assess how the amygdala response to emotional stimuli (negative facial expression) in 122 people with insomnia disorder differed from 36 control subjects and how the amygdala response changed after 6 weeks of either no treatment or internet-based circadian rhythm support (CRS), cognitive behavioral therapy for insomnia (CBT-I), or their combination (CBT-I+CRS). Effects on depression, insomnia and anxiety severity were followed up for 1 year.

RESULTS

Only combined treatment (CBT-I+CRS) significantly increased the amygdala response, compared with no treatment, CBT-I, and CRS. Individual differences in the degree of response enhancement were associated with improvement of insomnia symptoms directly after treatment (r = -0.41, p = .021). Moreover, exclusively CBT-I+CRS enhanced responsiveness of the left insula, which occurred in proportion to the reduction in depressive symptom severity (r = -0.37, p = .042).

CONCLUSIONS

This functional magnetic resonance imaging study on insomnia treatment, the largest to date, shows that a combined cognitive, behavioral, and circadian intervention enhances emotional brain responsiveness and might improve resilience in patients with insomnia who are at high risk of developing depression.

A pilot study of sleep scholar: A single-session, internet-based insomnia intervention for college students with a history of suicide ideation

OBJECTIVE

Establish the feasibility and acceptability of Sleep Scholar, a single-session, self-guided, internet-based insomnia intervention.

PARTICIPANTS

College students with a lifetime history of suicide ideation and at least subclinical insomnia symptoms.

METHODS

Participants (N = 38) completed pretreatment sleep diaries, Sleep Scholar, and post-treatment feasibility, acceptability, and clinical measures.

RESULTS

Approximately 33 students could be recruited per semester, the overall attrition rate was 47%, Sleep Scholar was completed in approximately 30 minutes, and the majority of treatment information was retained. Participants reported positive acceptability and satisfaction, and approximately half of participants adhered to their prescribed time in bed recommendations. Most clinical measures had adequate variability and internal consistency, and post-hoc analyses revealed clinically significant reductions in several mental health symptoms.

CONCLUSIONS

Sleep Scholar is feasible in college settings, acceptable for college students, and produced reductions in mental health symptoms during an uncontrolled trial. Implications for a randomized-controlled trial are discussed.

Improved resilience following digital cognitive behavioral therapy for insomnia protects against insomnia and depression one year later

BACKGROUND

While the negative consequences of insomnia are well-documented, a strengths-based understanding of how sleep can increase health promotion is still emerging and much-needed. Correlational evidence has connected sleep and insomnia to resilience; however, this relationship has not yet been experimentally tested. This study examined resilience as a mediator of treatment outcomes in a randomized clinical trial with insomnia patients.

METHODS

Participants were randomized to either digital cognitive behavioral therapy for insomnia (dCBT-I; n = 358) or sleep education control (n = 300), and assessed at pre-treatment, post-treatment, and 1-year follow-up. A structural equation modeling framework was utilized to test resilience as a mediator of insomnia and depression. Risk for insomnia and depression was also tested in the model, operationalized as a latent factor with sleep reactivity, stress, and rumination as indicators (aligned with the 3-P model). Sensitivity analyses tested the impact of change in resilience on the insomnia relapse and incident depression at 1-year follow-up.

RESULTS

dCBT-I resulted in greater improvements in resilience compared to the sleep education control. Furthermore, improved resilience following dCBT-I lowered latent risk, which was further associated with reduced insomnia and depression at 1-year follow-up. Sensitivity analyses indicated that each point improvement in resilience following treatment reduced the odds of insomnia relapse and incident depression 1 year later by 76% and 65%, respectively.

CONCLUSIONS

Improved resilience is likely a contributing mechanism to treatment gains following insomnia therapy, which may then reduce longer-term risk for insomnia relapse and depression.

Does insomnia treatment prevent depression?

Rates of major depressive disorder (MDD) are increasing globally, in part due to the coronavirus disease 2019 pandemic, contributing to disease burden. It has long been known that insomnia is intricately connected with depression as indicated by greater depression severity and lower treatment response. Furthermore, insomnia is a significant risk factor for new-onset depression. Treatment of insomnia is thus a logical target for prevention of incidents and recurrent MDD. This systematic review sought to evaluate the current evidence for the preventive effects of insomnia treatment on depression onset. A database search yielded 186 studies, six of which met criteria for inclusion in this review. All of the studies utilized cognitive behavioral treatment for insomnia (CBT-I) as the target intervention and most delivered treatment via a digital platform. Four of the studies found significantly lower rates of MDD onset in those who received CBT-I compared to a control condition. The two remaining studies failed to confirm these effects in primary analyses but secondary analyses suggested evidence of a preventive effect. There was significant methodologic heterogeneity across studies in terms of sample selection, outcomes, and follow-up periods, limiting the ability to draw firm conclusions. The evidence overall is in the direction of insomnia treatment reducing the risk for onset of MDD, but further research is warranted.

The efficacy of self-guided internet and mobile-based interventions for preventing anxiety and depression - A systematic review and meta-analysis

BACKGROUND

Anxiety and depression are highly prevalent mental disorders which are associated with a considerable personal and economic burden. As treatment alone has a minimal impact on prevalence, there is now a growing focus on interventions which may help prevent anxiety and depression. Internet and mobile based interventions have been identified as a useful avenue for the delivery of preventative programmes due to their scalability and accessibility. The efficacy of interventions that do not require additional support from a trained professional (self-guided) in this capacity is yet to be explored.

METHOD

A systematic search was conducted on the Cochrane Library, PubMed, PsycARTICLES, PsycINFO, OVID, MEDline, PsycEXTRA and SCOPUS databases. Studies were selected according to defined inclusion and exclusion criteria. The primary outcome was evaluating the effect of self-guided internet and mobile based interventions on incidence of anxiety and depression. The secondary outcome was effect on symptom severity.

RESULTS

After identifying and removing duplicates, 3211 studies were screened, 32 of which were eligible for inclusion in the final analysis. Nine studies also reported incidence data (depression = 7, anxiety = 2). The overall Risk Ratios for incidence of anxiety and depression were 0.86 (95% CI [0.28, 2.66], p = .79) and 0.67 (95% CI [0.48, 0.93], p = .02) respectively. Analysis for 27 studies reporting severity of depressive symptoms revealed a significant posttreatment standardised mean difference of -0.27 (95% CI [ -0.37, -0.17], p < .001) for self-guided intervention groups relative to controls. A similar result was observed for 29 studies reporting severity of anxiety symptoms with a standardised mean difference of -0.21 (95% CI [-0.31, -0.10], p < .001).

CONCLUSIONS

Self-guided internet and mobile based interventions appear to be effective at preventing incidence of depression, though further examination of the data suggests that generalisability of this finding may be limited. While self-guided interventions also appear effective in reducing symptoms of anxiety and depression, their ability to prevent incidence of anxiety is less clear. A heavy reliance on symptom measures in the data analysed suggests future research could benefit from prioritising the use of standardised diagnostic measuring tools to assess incidence. Future systematic reviews should aim to include more data from grey literature and reduce the impact of study heterogeneity.

Effectiveness of an App-Based Short Intervention to Improve Sleep: Randomized Controlled Trial

BACKGROUND

A growing body of evidence for digital interventions to improve sleep shows promising effects. The interventions investigated so far have been primarily web-based; however, app-based interventions may reach a wider audience and be more suitable for daily use.

OBJECTIVE

This study aims to evaluate the intervention effects, adherence, and acceptance of an unguided app-based intervention for individuals who wish to improve their sleep.

METHODS

In a randomized controlled trial, we evaluated the effects of an app-based short intervention (Refresh) to improve sleep compared with a waitlist condition. Refresh is an 8-week unguided intervention covering the principles of cognitive behavioral therapy for insomnia (CBT-I) and including a sleep diary. The primary outcome was sleep quality (insomnia symptoms) as self-assessed by the Regensburg Insomnia Scale (RIS). The secondary outcomes were depression (9-item Patient Health Questionnaire [PHQ-9] score) and perceived insomnia-related impairment.

RESULTS

We included 371 participants, of which 245 reported poor sleep at baseline. About 1 in 3 participants who were allocated to the intervention group never accessed the intervention. Active participants completed on average 4 out of 8 chapters. Retention rates were 67.4% (n=250) at postassessment and 57.7% (n=214) at the 6-month follow-up. At postintervention, insomnia symptoms in the intervention group had improved more than those in the waitlist group, with a small effect (d=0.26) in the whole sample and a medium effect (d=0.45) in the subgroup with poor sleep. Effects in the intervention group were maintained at follow-up. Perceived insomnia-related impairment also improved from pre- to postassessment. No significant intervention effect on depression was detected. Working alliance and acceptance were moderate to good.

CONCLUSIONS

An app-based, unguided intervention is a feasible and effective option to scale-up CBT-I-based treatment, but intervention uptake and adherence need to be carefully addressed.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN53553517; https://www.isrctn.com/ISRCTN53553517.

Guided Internet-Based Cognitive Behavioral Therapy for Insomnia: Prognostic and Treatment-Predictive Factors

Understanding which factors predict the outcome of internet-based cognitive behavioral therapy for insomnia (iCBT-I) may help to tailor this intervention to the patient's needs. We have conducted a secondary analysis of a randomized, controlled trial comparing a multicomponent iCBT-I (MCT) and an online sleep restriction therapy (SRT) for 83 chronic insomnia patients. The difference in the Insomnia Severity Index from pre- to post-treatment and from pre-treatment to follow-up at 6 months after treatment was the dependent variable. Prognostic and treatment-predictive factors assessed at baseline were analyzed with multiple linear regression. The shorter duration of insomnia, female gender, high health-related quality of life, and the higher total number of clicks had prognostic value for a better outcome. Other factors were found to be prognostic for outcome at the follow-up assessment: treatment with benzodiazepines, sleep quality, and personal significance of sleep problems. A high level of dysfunctional beliefs and attitudes about sleep (DBAS) was a moderator for better effects in the MCT at post-treatment assessment. Various prognostic factors (e.g., duration of insomnia, gender, or quality of life) may influence the success of treatment. The DBAS scale may be recommended to select patients for MCT rather than SRT.

Objective sleep markers of suicidal behaviors in patients with psychiatric disorders: A systematic review and meta-analysis

Close relationships have been reported between sleep alterations and suicidal behaviors, nevertheless few studies used objective measures of sleep. Such objective markers would be interesting in clinical practice to better screen and prevent suicide. We conducted a systematic review and meta-analysis of published studies examining the relationship between sleep markers and suicidal behaviors using PubMed, Cochrane Library, and Web of Science databases. Actigraphy, polysomnography, and nocturnal EEG were considered. The qualitative analysis retained 15 original studies, including 1179 participants (939 with a psychiatric disorder), and 11 studies were included for the meta-analysis. Current suicidal behaviors were associated with a decreased total sleep time (TST) (SMD = -0.35, [95% CI: -0.66 to -0.04], p = 0.026, I² = 39.8%). The evaluation of possible moderators shows that age, gender, and depression scores had no effects on the random effect model. No significant differences were observed regarding sleep efficiency, REM latency, or percentage of REM sleep. In conclusion, among candidate objective markers, decreased total sleep time seems associated with suicidal behaviors and could be easily used to assess suicide risk. Alterations of regular sleep duration should invite healthcare professionals to screen the cause and propose sleep interventions to prevent suicide.

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.

Comprehensive Analysis of Clinical Studies and Regulations of Therapeutic Applications in the United States and Japan

BACKGROUND

Digital therapeutics (DTx), the provision of treatment through mobile devices such as smartphones, have attracted great interest as a new medical modality. However, the number of authorized therapeutic applications in the US and Japan is low. Understanding the obstacles in obtaining regulatory authorizations will be the key in promoting timely development of therapeutic applications. Thus, we conducted a comprehensive analysis of the clinical study designs of therapeutic applications authorized in the US and Japan.

METHODS

Data on authorized therapeutic applications and the regulations involved were collated from the databases of the Food and Drug Administration (USA), Ministry of Health, Labour and Welfare (Japan), and Pharmaceuticals and Medical Devices Agency (Japan).

RESULTS

Most therapeutic applications authorized targeted neuropsychiatric disorders and used cognitive behavioral therapy (CBT)-based treatments. All the involved clinical trials were randomized-controlled studies. Various types of controls-such as standard care, sham application, digital control, and therapies delivered by healthcare providers-were used. Both subjective and objective indices were acceptable as the primary endpoints. Long-term efficacy was evaluated, and all adverse events were assessed comprehensively. The setting up of controls and the need to study long-term efficacy depend heavily on the applications functionality and the target disease characteristics.

CONCLUSIONS

This study reveals the points to be considered in planning clinical studies and regulatory strategies for authorizing therapeutic applications. Therapeutic applications can provide new therapy and have potential to solve unmet clinical needs. Our findings shed a light on efficient development and rapid commercialization of therapeutic applications.

Recent advances in sleep and depression

PURPOSE OF REVIEW

There is increasing interest in the connection between sleep disturbances and mood disorders. The purpose of this review is to summarize and evaluate current research on the role of sleep disturbance in the development of depression, as well as to describe recent advances in treatments that improve both sleep and depression symptoms.

RECENT FINDINGS

Relevant publications included in this review cover a wide range of topics related to sleep and depression. Data from large longitudinal studies suggest that insomnia and evening circadian preference are unique risk factors for depression. Depression treatment studies indicate poorer outcomes for those with comorbid sleep disturbances. A few recent trials of cognitive behavioral therapy for insomnia and triple chronotherapy in unipolar depression have shown promising results.

SUMMARY

Sleep disturbance is a modifiable risk factor in the development and maintenance of depression. In the context of current depression, although the data is mixed, some evidence suggests treating sleep disturbance can improve overall outcomes. Recent evidence also suggests that treating sleep disturbance may prevent the future depressive episodes.

Effectiveness of mindfulness-based cognitive therapy against suicidal ideation in patients with depression: A systematic review and meta-analysis

BACKGROUND

Mindfulness-based cognitive therapy (MBCT) can effectively prevent relapse of major depression, but there is currently insufficient evidence for efficacy against suicidal ideation during depressive episodes. We thus conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing MBCT to treatment as usual (TAU) for suppression of suicidal ideation in patients with current depression.

METHODS

We systematically searched PubMed, Embase, Cochrane, CNKI, and Wan Fang databases for RCTs published in English or Chinese between January 1, 2000, and August 30, 2021. Pooled data were compared between MBCT and TAU groups using a random-effects model.

FINDINGS

Seven RCTs with a total of 479 participants were included. Suicidal ideation and general depression scores were significantly improved following MBCT compared to TAU [Suicidal Ideation: standard mean difference (SMD) = -0.33, 95 % CI, -0.56 to -0.10; Depression: SMD = -0.96, 95%CI, -1.54 to -0.38].

INTERPRETATION

Mindfulness-based cognitive therapy is an effective intervention for reducing depressive symptoms and suicidal ideation in depressed patients.

TRIAL REGISTRATION

This meta-analysis was conducted in accordance with PRISMA guidelines and registered at PROSPERO https://www.crd.york.ac.uk/PROSPERO/ (CRD42021285016).

Self-efficacy in Insomnia Symptom Management after Digital CBT-I Mediates Insomnia Severity during the COVID-19 Pandemic

STUDY OBJECTIVES

Digital cognitive behavioral therapy for insomnia (dCBT-I) can reduce acute insomnia and depressive symptoms and prevent symptom recurrence. The current study evaluated self-efficacy in managing insomnia symptoms as a potential mediator of the relationship between prior dCBT-I and subsequent insomnia and depressive symptoms assessed during the coronavirus 2019 (COVID-19) pandemic.

METHOD

Participants were 208 adults who completed a randomized controlled trial of dCBT-I versus sleep education in 2016-2017 and also completed self-report assessments of insomnia, depression, and self-efficacy in managing insomnia symptoms. Data were collected in May 2020, five weeks into state-wide COVID-19 stay-at-home orders. Regression and mediation analyses were used to evaluate the extent to which self-efficacy accounted for the relationship between treatment condition and improvement in insomnia and depressive symptoms from pre-treatment to COVID-19 follow-up.

RESULTS

Prior dCBT-I predicted greater self-efficacy in managing insomnia symptoms. Self-efficacy accounted for 49% and 67% of the protective effect of dCBT-I against COVID-era insomnia and depressive symptoms, respectively.

CONCLUSIONS

This study affirms the importance of self-efficacy as a key intervention outcome and potential mechanism by which dCBT-I predicts future sleep and mental health. Future studies that evaluate the role of self-efficacy in treatment effectiveness and resilience can provide additional clues about how to optimize dCBT-I for maximum benefit to public health.

Pre-pandemic sleep reactivity prospectively predicts distress during the COVID-19 pandemic: The protective effect of insomnia treatment

The COVID-19 pandemic is a rare stressor that has precipitated an accompanying mental health crisis. Prospective studies traversing the pandemic's onset can elucidate how pre-existing disease vulnerabilities augured risk for later stress-related morbidity. We examined how pre-pandemic sleep reactivity predicted maladaptive stress reactions and depressive symptoms in response to, and during, the pandemic. This study is a secondary analysis of a randomised controlled trial from 2016 to 2017 comparing digital cognitive behavioural therapy for insomnia (dCBT-I) against sleep education (N = 208). Thus, we also assessed whether dCBT-I moderated the association between pre-pandemic sleep reactivity and pandemic-related distress. Pre-pandemic sleep reactivity was measured at baseline using the Ford Insomnia Response to Stress Test. In April 2020, participants were recontacted to report pandemic-related distress (stress reactions and depression). Controlling for the treatment condition and the degree of COVID-19 impact, higher pre-pandemic sleep reactivity predicted more stress reactions (β = 0.13, ± 0.07 SE, p = 0.045) and depression (β = 0.22, ± 0.07 SE, p = 0.001) during the pandemic. Further, the odds of reporting clinically significant stress reactions and depression during the pandemic were over twice as high in those with high pre-pandemic sleep reactivity. Notably, receiving dCBT-I in 2016-2017 mitigated the relationship between pre-pandemic sleep reactivity and later stress reactions (but not depression). Pre-pandemic sleep reactivity predicted psychological distress 3-4 years later during the COVID-19 pandemic, and dCBT-I attenuated its association with stress reactions, specifically. Sleep reactivity may inform prevention and treatment efforts by identifying individuals at risk of impairment following stressful events.

Effect of Culturally Tailored, Internet-Delivered Cognitive Behavioral Therapy for Insomnia in Black Women: A Randomized Clinical Trial

IMPORTANCE

Black women are at risk for insomnia disorder. Despite interest in addressing sleep health disparities, there is limited research investigating the efficacy of criterion-standard treatment (cognitive behavioral therapy for insomnia [CBT-I]) among this racial minority population.

OBJECTIVE

To compare the efficacy of a standard version of an internet-delivered CBT-I program, a culturally tailored version, and a sleep education control at improving insomnia symptoms.

DESIGN, SETTING, AND PARTICIPANTS

In this single-blind, 3-arm randomized clinical trial, participants in a national, longitudinal cohort (Black Women's Health Study [BWHS]) were recruited between October 2019 and June 2020. BWHS participants with elevated insomnia symptoms were enrolled and randomized in the current study.

INTERVENTIONS

Participants were randomized to receive (1) an automated internet-delivered treatment called Sleep Healthy Using the Internet (SHUTi); (2) a stakeholder-informed, tailored version of SHUTi for Black women (SHUTi-BWHS); or (3) patient education (PE) about sleep.

MAIN OUTCOMES AND MEASURES

The primary outcome was insomnia severity (Insomnia Severity Index [ISI]). Index score ranged from 0 to 28 points, with those scoring less than 8 points considered to not have clinically significant insomnia symptoms and a score of 15 points or higher suggesting insomnia disorder. An ISI score reduction of more than 7 points was considered a clinically significant improvement in insomnia symptoms. The SHUTi-BWHS program was hypothesized to be more effective at significantly decreasing insomnia severity compared with the SHUTi program and PE.

RESULTS

A total of 333 Black women were included in this trial, and their mean (SD) age was 59.5 (8.0) years. Those randomized to receive either SHUTi or SHUTi-BWHS reported significantly greater reductions in ISI score at 6-month follow-up (SHUTi: -10.0 points; 95% CI, -11.2 to -8.7; SHUTi-BWHS: -9.3 points; 95% CI, -10.4 to -8.2) than those randomized to receive PE (-3.6 points; 95% CI, -4.5 to -2.1) (P < .001). Significantly more participants randomized to SHUTi-BWHS completed the intervention compared with those randomized to SHUTi (86 of 110 [78.2%] vs 70 of 108 [64.8%]; P = .008). Participants who completed either intervention showed greater reductions in insomnia severity compared with noncompleters (-10.4 points [95% CI, -11.4 to -9.4] vs -6.2 points [95% CI, -8.6 to -3.7]).

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, both the SHUTi and SHUTi-BWHS programs decreased insomnia severity and improved sleep outcomes more than PE. The culturally tailored SHUTi-BWHS program was more effective at engaging participants with the program, as a greater proportion completed the full intervention. Program completion was associated with greater improvements in sleep.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03613519.

Treating Insomnia with High Risk of Depression Using Therapist-Guided Digital Cognitive, Behavioral, and Circadian Rhythm Support Interventions to Prevent Worsening of Depressive Symptoms: A Randomized Controlled Trial

INTRODUCTION

The global disease burden of major depressive disorder urgently requires prevention in high-risk individuals, such as recently discovered insomnia subtypes. Previous studies targeting insomnia with fully automated eHealth interventions to prevent depression are inconclusive: dropout was high and likely biased, and depressive symptoms in untreated participants on average improved rather than worsened.

OBJECTIVE

This randomized controlled trial aimed to efficiently prevent the worsening of depressive symptoms by selecting insomnia subtypes at high risk of depression for internet-based circadian rhythm support (CRS), cognitive behavioral therapy for insomnia (CBT-I), or their combination (CBT-I+CRS), with online therapist guidance to promote adherence.

METHODS

Participants with an insomnia disorder subtype conveying an increased risk of depression (n = 132) were randomized to no treatment (NT), CRS, CBT-I, or CBT-I+CRS. The Inventory of Depressive Symptomatology - Self Report (IDS-SR) was self-administered at baseline and at four follow-ups spanning 1 year.

RESULTS

Without treatment, depressive symptoms indeed worsened (d = 0.28, p = 0.041) in high-risk insomnia, but not in a reference group with low-risk insomnia. Therapist-guided CBT-I and CBT-I+CRS reduced IDS-SR ratings across all follow-up assessments (respectively, d = -0.80, p = 0.001; d = -0.95, p < 0.001). Only CBT-I+CRS reduced the 1-year incidence of clinically meaningful worsening (p = 0.002). Dropout during therapist-guided interventions was very low (8%) compared to previous automated interventions (57-62%).

CONCLUSIONS

The findings tentatively suggest that the efficiency of population-wide preventive strategies could benefit from the possibility to select insomnia subtypes at high risk of developing depression for therapist-guided digital CBT-I+CRS. This treatment may provide effective long-term prevention of worsening of depressive symptoms.

TRIAL REGISTRATION

the Netherlands Trial Register (NL7359).

Moderators of Cognitive Behavioral Treatment for Insomnia on Depression and Anxiety Outcomes

PURPOSE OF REVIEW

With a focus on reviewing adequately powered randomized controlled trials, we present recent research on the potential of cognitive behavioral therapy for insomnia (CBT-I) to improve depression and anxiety outcomes among patients with insomnia and one of the following comorbid psychiatric disorders: major depressive disorder (MDD), generalized anxiety disorder (GAD), or posttraumatic stress disorder (PTSD). We also examine potential moderators of CBT-I on depression and anxiety outcomes in this population.

RECENT FINDINGS

Despite high comorbidity rates, current behavioral and pharmacological treatments for MDD, GAD, and PTSD do not substantially target or improve insomnia symptoms; residual insomnia is exceedingly common even among patients who experience remission. Insomnia plays a critical role in the onset and maintenance of depression and anxiety, and treating insomnia with CBT-I may improve global outcomes for patients with MDD, GAD, and PTSD. CBT-I is superior to traditional depression/anxiety treatment in improving insomnia symptoms among patients with comorbid psychiatric disorders. Results are mixed on whether CBT-I (either alone or augmented with depression/anxiety treatment) is effective in improving overall MDD, GAD, and PTSD outcomes. Evening circadian preference and depression/anxiety symptom severity may moderate the effect of CBT-I on depression and anxiety outcomes.

Sleepless in COVID-19: racial disparities during the pandemic as a consequence of structural inequity

STUDY OBJECTIVES

Insomnia has been on the rise during the 2019 coronavirus disease (COVID-19) pandemic, which may disproportionately affect racial minorities. This study characterized racial disparities in insomnia during the pandemic and evaluated mechanisms for such disparities.

METHODS

Participants included 196 adults (48 Black) from a 2016-2017 clinical trial of insomnia treatment who were reevaluated in April 2020. Race was evaluated as a predictor of change in insomnia, impact of COVID-19, and COVID-19 stress. Mediation models using the PRODCLIN method evaluated the extent to which: (1) COVID-19 impact accounted for Black-White disparities in change in insomnia, and (2) COVID-19 stress accounted for associations between discrimination and change in insomnia.

RESULTS

Increases in insomnia symptoms during COVID-19 were greater in Black compared to White participants, with 4.3 times the odds of severe insomnia (Insomnia Severity Index ≥ 22). Symptom severity was associated with pre-pandemic experiences of discrimination. Black participants were also disproportionately impacted by COVID-19, with twice the odds of irreparable loss of income/employment and four times the rate of COVID-19 diagnoses in their sociofamilial network compared to White participants. The disproportionate impact of COVID-19 accounted for 69.2% of the relationship between race and change in insomnia severity, and COVID-19 related stress accounted for 66.5% of the relationship between prior history of racial discrimination and change in insomnia severity.

CONCLUSIONS

Black-White disparities in insomnia severity during COVID-19 may be driven by structural inequities resulting in the disproportionate impact of COVID-19 on Black Americans. Results lend support for the minority stress model in the context of sleep health.

CLINICAL TRIAL REGISTRATION

Sleep to Prevent Evolving Affecting Disorders (SPREAD). NCT number: NCT02988375. https://clinicaltrials.gov/ct2/show/NCT02988375.

Prognostic and predictive analysis of effectiveness of pharmacological and non-pharmaceutical treatment approaches for chronic insomnia

Background. Limited access to cognitive behavioral therapy for insomnia (CBT-I) which is the most effective and safe treatment approach for chronic insomnia leads to the elaboration of shortened and interned delivered CBT-I methods. Investigation of effectiveness predictors of the new methods is important for their better result. Aim. Investigation of effectiveness predictors for pharmacotherapy and CBT-I based brief behavioral therapy for insomnia (BBT-I). Materials and methods. The data for the analysis were acquired from a randomized study of 42 participants with chronic insomnia who received either zopiclone 7.5 mg or BBT-I for 2 weeks. The difference of the insomnia severity index from pre- to post-treatment was the main outcome measure. Potential predictors included demographic and medical history data, objective sleep characteristics, baseline scores of Beck depression inventory (BDI), Spielberger anxiety scale, Toronto alexithymia scale, sleep hygiene index, dysfunctional beliefs and attitudes about sleep scale, Epworth sleepiness scale. Univariate linear regression analysis was used for prognostic analysis. To identify predictors of treatment outcome after the treatment course and after the 2 weeks follow-up we used multiple linear regression models with interaction. Results. In the prognostic analysis higher amount of awakenings during the night and a higher proportion of the 1 stage NREM sleep measured objectively correlated with better outcome E=0.2202 (p=0.05) and E=0.55 (p=0.039) respectively. Older age and higher baseline BDI score significantly worsened the outcome: E=0.233 (p=0.047) and E=0.2 (р=1.55e-06) respectively. Clinical predictors of the BBT-I effectiveness were an absence of the sleep onset problems and absence of GABA hypnotics use in medical history and the higher baseline daytime sleepiness. Conclusion. Neurophysiological (frequency of awakenings, percentage of the sleep stage N1) and clinical (severity of depression, age, daytime sleepiness) predictors of the effectiveness of BBT-I were revealed. This findings will help to select the patients who should undergo a shortened course of CBT-I.

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

The comparative efficacy of various approaches of digital cognitive behavioral therapy for insomnia (CBTi) is still unclear. This network meta-analysis explored the comparative efficacy of digital CBTi approaches in adults with insomnia. Four electronic databases were searched from inception to June 27, 2020. Primary outcomes were self-reported total sleep time (TST), sleep onset latency (SOL), wake after sleep onset (WASO), sleep efficiency (SE), and insomnia symptoms; these were measured using sleep diaries or valid questionnaires. A random-effects network meta-analysis in a frequentist framework was used. Fifty-four randomized controlled trials comprising 11,815 participants were included. Compared with usual care, web-based CBTi with a therapist demonstrated significantly longer TST (mean difference [MD]: 23.19 min, 95% confidence interval [CI]: 18.98-27.39 min), shorter SOL (MD: -18.76 min, 95% CI -24.20 to -13.31 min), lower WASO (MD: -31.40 min, 95% CI: -36.26 to -26.55 min), and greater SE (MD: 10.37%, 95% CI: 8.08%-12.65%). The surface under the cumulative ranking curve indicates that web-based CBTi with therapists is most likely to be ranked the highest among all treatments, and thus, this network meta-analysis suggests that such a treatment is the optimal intervention for improving sleep duration and SE as well as the reductions in SOL and WASO. PROSPERO REGISTRATION NUMBER: CRD42020171134.

Internet-delivered CBT intervention (Space for Sleep) for insomnia in a routine care setting: Results from an open pilot study

Insomnia is a highly prevalent, often comorbid disorder associated with difficulties sleeping, remaining awake, and impaired quality of life. Internet-delivered Cognitive Behavioral Therapy for insomnia (ICBT-I) has the potential to help large numbers of people with sleep disorders. This study investigated the preliminary effects of an 8-week guided ICBT-I intervention within a routine stepped-care service. Fifty-six (N = 56) patients consented to participate. The primary outcome was assessed using the Insomnia Severity Index (ISI) and secondary outcome measures included the Patient Health Questionnaire 9-item (PHQ-9), Generalized Anxiety Disorder 7-item (GAD-7), and the Work and Social Adjustment Scale (WSAS), each administered at baseline and weekly thereafter. Intention-to-treat analyses indicated that ICBT-I produced statistically significant pre- to post- reductions in symptoms of insomnia, yielding within-group effects of d = 0.82 suggesting a potential for improved outcomes. Similar improvements were seen across secondary outcomes, with small-to-medium post-treatment within-group effects observed: depression (d = 0.63), anxiety (d = 0.39), and functional impairment (d = 0.31). These findings are supportive of the intervention's potential effectiveness and speak to the importance of several implementation factors that could enhance the effects of the intervention. The results contribute to the growing evidence base for digital interventions designed to help those with sleep difficulties and will inform the design of a future controlled evaluation of ICBT-I under routine clinical settings.

Do non-pharmacological sleep interventions affect anxiety symptoms? A meta-analysis

Research indicates a bidirectional relationship between sleep and anxiety, with findings suggesting anxiety can precede poor sleep and vice versa. Evidence suggests sleep-related thought processes associated with anxiety are involved in the maintenance of insomnia. Previous meta-analyses provide some evidence to suggest cognitive behavioural therapy for insomnia moderately improves anxiety, yet little research has investigated the effect of other sleep interventions on anxiety symptoms. The aim of this meta-analysis was to review whether non-pharmacological sleep interventions have an impact on anxiety symptoms immediately post-intervention. A systematic search of electronic databases was conducted to identify all randomized control trials (RCTs) investigating non-pharmacological sleep interventions that included anxiety symptoms as an outcome. Forty-three RCTs (n = 5945) met full inclusion criteria and were included in a random-effects meta-analysis model. The combined effect size of non-pharmacological sleep interventions on anxiety symptoms was moderate (Hedges' g = -0.38), indicating a reduction in symptoms. Subgroup analyses found a moderate effect for those with additional physical health difficulties (g = -0.46), a moderate effect for those with additional mental health difficulties (g = -0.47) and a moderate effect for those with elevated levels of anxiety at baseline (g = -0.43). A secondary meta-analysis found a large effect of non-pharmacological sleep interventions on sleep-related thought processes (g = -0.92). These findings indicate non-pharmacological sleep interventions are effective in reducing anxiety and sleep-related thought processes, and these effects may be larger in patients with anxiety. This has clinical implications for considering sleep interventions in the treatment of anxiety.

The Effect of Reducing Insomnia Severity on Work- and Activity-Related Impairment

OBJECTIVE/BACKGROUND

The effectiveness of Cognitive Behavioral Therapy for Insomnia (CBT-I) for alleviating sleep problems is well established. However, few studies have explored its impact on work productivity and activity.

PARTICIPANTS

Seventy-seven currently employed adults with insomnia disorder (59 females) recruited to a randomized trial of digital versus face-to-face CBT-I.

METHODS AND MATERIALS

The general health version of the Work Productivity and Activity Impairment questionnaire was used to measure absenteeism, presenteeism, total work impairment, and activity impairment. We assessed changes in work productivity and activity pre-to-post-therapy for the total sample and then for subgroups categorized according to response or remission of insomnia disorder (evaluated using the Insomnia Severity Index).

RESULTS

Study participants showed significant improvements in presenteeism (p = .001; Cohen's d= 0.46), total work impairment (p < .001; d= 0.48), and activity (p < .001; d= 0.66), but not absenteeism (p = .51; d= 0.084) between baseline and follow-up assessment. Individuals meeting criteria for remission showed significantly greater improvement in presenteeism (p = .002), total work impairment (p < .001), and activity (p = .006), but not absenteeism (p = .064).

CONCLUSION

This study suggests that the benefits of CBT-I extend beyond improvement in sleep to encompass moderate-to-large improvements in work productivity and activity levels particularly for individuals who achieve remission from insomnia. Given the importance of these behaviors, there is a need for future large-scale randomized trials and cohort studies which should strive to include objective measurement of daytime activity and work performance more frequently.

Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment

INTRODUCTION

The purpose of this systematic review is to provide supporting evidence for a clinical practice guideline on the use of behavioral and psychological treatments for chronic insomnia disorder in adult populations.

METHODS

The American Academy of Sleep Medicine commissioned a task force of 9 experts in sleep medicine and sleep psychology. A systematic review was conducted to identify randomized controlled trials that addressed behavioral and psychological interventions for the treatment of chronic insomnia disorder in adults. Statistical analyses were performed to determine if the treatments produced clinically significant improvements in a range of critical and important outcomes. Finally, the Grading of Recommendations Assessment, Development, and Evaluation process was used to evaluate the evidence for making specific treatment recommendations.

RESULTS

The literature search identified 1,244 studies; 124 studies met the inclusion criteria, and 89 studies provided data suitable for statistical analyses. Evidence for the following interventions is presented in this review: cognitive-behavioral therapy for insomnia, brief therapies for insomnia, stimulus control, sleep restriction therapy, relaxation training, sleep hygiene, biofeedback, paradoxical intention, intensive sleep retraining, and mindfulness. This review provides a detailed summary of the evidence along with the quality of evidence, the balance of benefits vs harms, patient values and preferences, and resource use considerations.

Trajectories of Change in an Open-access Internet-Based Cognitive Behavior Program for Childhood and Adolescent Anxiety: Open Trial

BACKGROUND

Although evidence bolstering the efficacy of internet-based cognitive behavioral therapy (iCBT) for treating childhood anxiety has been growing continuously, there is scant empirical research investigating the timing of benefits made in iCBT programs (eg, early or delayed).

OBJECTIVE

This study aims to examine the patterns of symptom trajectories (changes in anxiety) across an iCBT program for anxiety (BRAVE Self-Help).

METHODS

This study's participants included 10,366 Australian youth aged 7 to 17 years (4140 children aged 7-12 years; 6226 adolescents aged 12-17 years) with elevated anxiety who registered for the BRAVE Self-Help program. Participants self-reported their anxiety symptoms at baseline or session 1 and then at the commencement of each subsequent session.

RESULTS

The results show that young people completing the BRAVE Self-Help program tend to fall into two trajectory classes that can be reliably identified in terms of high versus moderate baseline levels of anxiety and subsequent reduction in symptoms. Both high and moderate anxiety severity trajectory classes showed significant reductions in anxiety, with the greatest level of change being achieved within the first six sessions for both classes. However, those in the moderate anxiety severity class tended to show reductions in anxiety symptoms to levels below the elevated range, whereas those in the high symptom group tended to remain in the elevated range despite improvements.

CONCLUSIONS

These findings suggest that those in the high severity group who do not respond well to iCBT on a self-help basis may benefit from the additional support provided alongside the program or a stepped-care approach where progress is monitored and support can be provided as necessary.

Information and Communication Technology Use in Suicide Prevention: Scoping Review

BACKGROUND

The use of information and communication technology (ICT) in suicide prevention has progressed rapidly over the past decade. ICT plays a major role in suicide prevention, but research on best and promising practices has been slow.

OBJECTIVE

This paper aims to explore the existing literature on ICT use in suicide prevention to answer the following question: what are the best and most promising ICT practices for suicide prevention?

METHODS

A scoping search was conducted using the following databases: PubMed, PsycINFO, Sociological Abstracts, and IEEE Xplore. These databases were searched for articles published between January 1, 2013, and December 31, 2018. The five stages of the scoping review process were as follows: identifying research questions; targeting relevant studies; selecting studies; charting data; and collating, summarizing, and reporting the results. The World Health Organization suicide prevention model was used according to the continuum of universal, selective, and indicated prevention.

RESULTS

Of the 3848 studies identified, 115 (2.99%) were selected. Of these, 10 regarded the use of ICT in universal suicide prevention, 53 referred to the use of ICT in selective suicide prevention, and 52 dealt with the use of ICT in indicated suicide prevention.

CONCLUSIONS

The use of ICT plays a major role in suicide prevention, and many promising programs were identified through this scoping review. However, large-scale evaluation studies are needed to further examine the effectiveness of these programs and strategies. In addition, safety and ethics protocols for ICT-based interventions are recommended.

Trajectories of change in depression symptoms and suicidal ideation over the course of evidence-based treatment for depression: Secondary analysis of a randomised controlled trial of cognitive behavioural therapy plus fluoxetine in young people

OBJECTIVES

Effective treatment of depression is a key target for suicide prevention strategies. However, only around one-third of young people with suicide risk respond to evidence-based treatments. Understanding the trajectory of suicidal ideation, as a marker of suicide risk, over the course of evidence-based treatment for depression might provide insight into more targeted and effective treatments.

METHODS

This is a secondary analysis of data from the multicentre Youth Depression Alleviation-Combined Treatment trial. A total of 153 young people aged 15-25 years diagnosed with major depressive disorder were randomly assigned in this double-blind, placebo-controlled trial to either cognitive behavioural therapy plus fluoxetine or cognitive behavioural therapy plus placebo. Participants were assessed for depression and suicidal ideation at baseline and at weeks 4, 8 and 12.

RESULTS

Using group-based trajectory modelling, we identified two distinct depression trajectories. The first (Improving; 54.9%; n = 83) comprised those who experienced a consistent decline in depression symptoms. The second (Persisting; 45.1%; n = 70) comprised those who, despite treatment, still had clinically significant levels of depression by the end of treatment. For suicidal ideation, we identified four distinct trajectories: Non-clinical (15.5%; n = 20), Low Improving (47.1%; n = 75), High Improving (24.8%; n = 38) and High Persisting (12.7%; n = 20). Treatment allocation was not significantly associated with trajectory membership for either depression or suicidal ideation.

CONCLUSION

Understanding the course of depression and suicidal ideation during treatment has important implications for managing suicide risk. The findings suggest that there is an identifiable group of young people for whom enhanced psychological and/or pharmacological intervention might be required to ensure a better treatment response. Specific interventions for those with suicidal ideation may also be prudent from the outset.

CLINICAL TRIAL REGISTRATION

The Youth Depression Alleviation-Combined Treatment trial was prospectively registered with the Australian and New Zealand Clinical Trials Registry (ACTRN12612001281886).

Digital cognitive behavioral therapy for insomnia promotes later health resilience during the coronavirus disease 19 (COVID-19) pandemic

STUDY OBJECTIVES

Stressful life events contribute to insomnia, psychosocial functioning, and illness. Though individuals with a history of insomnia may be especially vulnerable during stressful life events, risk may be mitigated by prior intervention. This study evaluated the effect of prior digital cognitive-behavioral therapy for insomnia (dCBT-I) versus sleep education on health resilience during the COVID-19 pandemic.

METHODS

COVID impact, insomnia, general- and COVID-related stress, depression, and global health were assessed in April 2020 in adults with a history of insomnia who completed a randomized controlled trial of dCBT-I (n = 102) versus sleep education control (n = 106) in 2016-2017. Regression analyses were used to evaluate the effect of intervention conditions on subsequent stress and health during the pandemic.

RESULTS

Insomnia symptoms were significantly associated with COVID-19 related disruptions, and those who previously received dCBT-I reported less insomnia symptoms, less general stress and COVID-related cognitive intrusions, less depression, and better global health than those who received sleep education. Moreover, the odds for resurgent insomnia was 51% lower in the dCBT-I versus control condition. Similarly, odds of moderate to severe depression during COVID-19 was 57% lower in the dCBT-I condition.

CONCLUSIONS

Those who received dCBT-I had increased health resilience during the COVID-19 pandemic in adults with a history of insomnia and ongoing mild to moderate mental health symptoms. These data provide evidence that dCBT-I is a powerful tool to promote mental and physical health during stressors, including the COVID-19 pandemic.

CLINICAL TRIAL REGISTRATION

NCT02988375.

Psycho-educational interventions focused on maternal or infant sleep for pregnant women to prevent the onset of antenatal and postnatal depression: A systematic review

AIMS

This systematic review aimed to evaluate randomized controlled trials (RCTs) to examine the effect of maternal and infant sleep intervention during women's pregnancy for the purpose of preventing perinatal depression.

METHOD

A systematic search (from inception to January 28, 2019) for RCTs using five electronic databases-the Cochrane Controlled Register of Trials (CENTRAL), Embase, PubMed, PsycINFO, and Ichushi Web (Japan Medical Abstracts Society)-was conducted. Twelve investigators independently conducted initial screenings based on title and abstract, and then, two researchers performed full-text reviews one by one. A meta-analysis would be conducted if at least three studies were found. However, only two articles that met inclusion criteria, and narrative data synthesis was conducted for these two articles. The study protocol has been registered at PROSPERO (CRD42019119999).

RESULT

A total of 13 654 studies were initially searched. After removing duplicates, 10 547 studies were screened, and finally, two studies met the inclusion criteria. In both studies, the intervention was a one-time face-to-face session during pregnancy to deliver the behavioral knowledge and skills for optimizing sleep hygiene for both infant and mother. Effectiveness of the intervention in improving maternal mood was not significant in one study. In the other, there was a significant difference in maternal mood between the intervention and control group. No mood comparison was made between baseline and postintervention.

CONCLUSION

This study found limited evidence to support the effectiveness of sleep intervention for all pregnant women, which means "universal intervention," to protect maternal mental health. Further well-designed RCTs are needed to confirm these findings.

Abnormal Sleep Signals Vulnerability to Chronic Social Defeat Stress

There is a tight association between mood and sleep as disrupted sleep is a core feature of many mood disorders. The paucity in available animal models for investigating the role of sleep in the etiopathogenesis of depression-like behaviors led us to investigate whether prior sleep disturbances can predict susceptibility to future stress. Hence, we assessed sleep before and after chronic social defeat (CSD) stress. The social behavior of the mice post stress was classified in two main phenotypes: mice susceptible to stress that displayed social avoidance and mice resilient to stress. Pre-CSD, mice susceptible to stress displayed increased fragmentation of Non-Rapid Eye Movement (NREM) sleep, due to increased switching between NREM and wake and shorter average duration of NREM bouts, relative to mice resilient to stress. Logistic regression analysis showed that the pre-CSD sleep features from both phenotypes were separable enough to allow prediction of susceptibility to stress with >80% accuracy. Post-CSD, susceptible mice maintained high NREM fragmentation while resilient mice exhibited high NREM fragmentation, only in the dark. Our findings emphasize the putative role of fragmented NREM sleep in signaling vulnerability to stress.

Profile of Somryst Prescription Digital Therapeutic for Chronic Insomnia: Overview of Safety and Efficacy

Introduction: Prescription digital therapeutics (PDTs) represent a new class of software-based medical devices authorized by the Food and Drug Administration (FDA) to treat disease. Somryst™, the first PDT for treating chronic insomnia, delivers cognitive behavioral therapy for insomnia (CBT-I) via a mobile application. CBT-I is the guideline-recommended, first-line treatment for chronic insomnia, but availability of CBT-I therapists is limited. Somryst addresses this need by providing asynchronous access to CBT-I treatment. As a contactless therapeutic medium, Somryst is also an ideal option when face-to-face therapy is not available or recommended for safety reasons (e.g. because of possible exposure to the SARS-CoV-2 virus). Areas covered: This review summarizes the mechanisms of action and technical features of Somryst, and describes safety and effectiveness data from the randomized trials on which FDA clearance was based. Expert opinion: Somryst demonstrates robust clinical efficacy with a favorable benefit-to-risk profile for treating adults with chronic insomnia. FDA clearance was based on data from 2 clinical trials of the first-generation web-based CBT-I platform Sleep Healthy Using the Internet (SHUTi). Somryst, and PDTs in general, are promising devices to address the need for greater accessibility to effective therapies.

Effectiveness of online psychological and psychoeducational interventions to prevent depression: Systematic review and meta-analysis of randomized controlled trials

Although evidence exists for the efficacy of interventions to prevent depression, little is known about its prevention through online interventions. We aim to assess the effectiveness of online psychological and psychoeducational interventions to prevent depression in heterogeneous populations. A systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted based on literature searches in eight electronic data bases and other sources from inception to 22 July 2019. Of the 4181 abstracts reviewed, 501 were selected for full-text review, and 21 RCTs met the inclusion criteria, representing 10,134 participants from 11 countries and four continents. The pooled SMD was -0·26 (95%CI: -0·36 to -0·16; p < 0.001) and sensitivity analyses confirmed the robustness of this result. We did not find publication bias but there was substantial heterogeneity (I² = 72%; 95%CI, 57% to 82%). A meta-regression including three variables explained 81% of the heterogeneity. Indicated prevention and interactive website delivery were statistically associated with higher effectiveness, and no association was observed with risk of bias. Online psychological and psychoeducational interventions have a small effect in reducing depressive symptoms in non-depressed and varied populations, and the quality of evidence is moderate. Given that these types of interventions are very accessible and can be applied on a wide scale, they should be further developed and implemented. Registration details: Registration number (PROSPERO): CRD42014014804.

Internet-Based Cognitive Behavioral Therapy for Insomnia in Appalachian Women: A Pilot Study

OBJECTIVE/BACKGROUND

Appalachian women are disproportionately affected by insufficient sleep but live in a healthcare shortage area with prevalent prescription drug abuse. A self-administered, non-pharmacologic intervention such as Internet-based cognitive behavioral therapy for insomnia (CBT-I) may be ideal in this population, but psycho-social characteristics (e.g., high depression rates) and cultural norms (e.g., suspicion of technology) necessitate a pilot study. We evaluated the effectiveness of Sleep Healthy Using the Internet (SHUTi) on insomnia severity, sleep quality, perceived stress, depression symptoms, and sleep aid use in Appalachian women ages 45 +.

PARTICIPANTS

Forty-six women enrolled; 38 completed the six-week intervention in 2018 (mean age 55 years).

METHODS

We employed a single group, pre/post-test, mixed-methods design. Participants completed an online survey and a qualitative interview pre- and post-intervention. Quantitative data were analyzed using one-way repeated measures ANOVA or generalized estimating equations. Interviews were qualitatively analyzed using a multi-stage coding process.

RESULTS

Positive and statistically significant (p < .01) improvements were observed on mean scores for the Insomnia Severity Index (15.1 to 6.5), the Pittsburgh Sleep Quality Index (12.1 to 8.5), the Perceived Stress Scale (20 to 14.6), and the Center for Epidemiologic Studies Depression Scale Revised (9.8 to 5.2). The odds of reporting sleep medication use post-intervention were significantly lower than pre-intervention (OR 0.28 [95% CI 0.11-0.74]). Interviews highlighted most and least helpful intervention components and suggested that participants benefitted from SHUTi.

CONCLUSIONS

Internet-based CBT-I may be a useful, non-pharmacologic treatment that reduces insomnia severity, perceived stress, depression symptoms, and sleep aid use in middle-aged Appalachian women.

Efficacy of digital cognitive behavioural therapy for insomnia: a meta-analysis of randomised controlled trials

OBJECTIVES

Although cognitive behavioural therapy for insomnia (CBT-I) has been recommended the initial therapy for insomnia, its clinical usage remains limited due to the lack of therapists. Digital CBT-I (dCBT-I) can potentially circumvent this problem. This meta-analysis aims to evaluate the short-term and long-term efficacy of dCBT-I for adults with insomnia.

METHODS

Systematic search of PubMed, EMBASE, PsycINFO, and CENTRAL from inception till 5 March 2020 was conducted. Randomised controlled trials (RCTs) comparing dCBT-I with controls (wait-list/treatment-as-usual/online education) in adults with insomnia were eligible. The primary outcome was insomnia severity index (ISI) at post-intervention, short-term follow-up (ranging 4 weeks to 6 months) and 1-year follow-up. Mean differences were pooled using the random-effects model.

RESULTS

94 articles were assessed full-text independently by two team members and 33 studies were included in this meta-analysis. 4719 and 4645 participants were randomised to dCBT-I and control respectively. dCBT-I significantly reduces ISI at post-intervention with mean difference -5.00 (95% CI -5.68 to -4.33, p < 0.0001) (I² = 79%) compared to control. The improvements were sustained at short-term follow-up, -3.99 (95% CI -4.82 to -3.16, p < 0.0001) and 1-year follow-up, -3.48 (95% CI -4.21 to -2.76, p < 0.0001). Compared to dCBT-I, face-to-face CBT-I produced greater improvement in ISI, 3.07 (95% CI 1.18 to 4.95, p = 0.001). However, this was within the non-inferiority interval of 4 points on ISI.

CONCLUSION

This meta-analysis provides strong support for the effectiveness of dCBT-I in treating insomnia. dCBT-I has potential to revolutionise the delivery of CBT-I, improving the accessibility and availability of CBT-I content for insomnia patients worldwide.

Effectiveness and Cost-Effectiveness of Internet-Based Cognitive Behavioral Therapy for Insomnia in Clinical Settings

BACKGROUND

Internet-delivered cognitive-behavior treatment for insomnia (iCBT-I) has the potential to fill the gap created by the discrepancy between insomnia cases and number of trained professionals. Although the effectiveness of this method was proven in multiple studies conducted in research settings, its feasibility in routine care is still unclear. Predictors, mediators, and moderators of treatment effect remain uncertain since previous studies often give contradictory results. The present study aims to investigate clinical effectiveness and cost-effectiveness of an internet-based CBT-I program Sleepsy in comparison with care as usual (CAU) among patients with CI recruited from clinical settings. Baseline data will be further analyzed to find predictors of treatment outcome.

METHODS/DESIGN

The proposed study is a parallel-group randomized controlled trial comparing CAU plus iCBT-I with CAU in a clinical setting. One hundred ten participants will be referred from the medical doctors in Moscow. Both groups will have access to CAU, which corresponds to the treatment prescribed by the referring doctor. Patients of the first group will additionally get access to the iCBT-I program with the opportunity to contact a specialist (guidance on request) in a secured environment. The primary outcome is insomnia severity change from pre- to post-treatment. Secondary outcomes include change of subjective sleep characteristics, life quality, fatigue, daytime sleepiness, comorbid affective disorders, dysfunctional beliefs about sleep, sleep hygiene, healthcare consumption, productivity losses, and longer term outcomes at 3 months follow-up. Predictor analysis will include baseline scores of the aforementioned outcomes along with treatment expectancies and personality traits.

DISCUSSION

The proposed study is one of the first studies evaluating whether iCBT-I also works in routine care. We expect that recruitment of the participants let us determine the target group more precisely and exclude health problems interfering with treatment. Using CAU as control condition may result in a loss of power to detect a meaningful difference. Nevertheless, this approach is reasonable since it reconstructs the clinical situation faced by practicing doctors.

Insomnia and depression: How much is the overlap?

BACKGROUND

Previous literature considers insomnia as one of the features, predictor, and also as a residual symptom of depression. However, chronic insomnia and major depressive disorder (MDD) have overlapping features making differentiation between two difficult.

MATERIALS AND METHODS

Forty subjects in each of the three categories-MDD, insomnia (I) and combined diagnoses (MDD-I) were recruited in this study after excluding potential confounders. Diagnosis of MDD was made following Diagnostic and Statistical Manual 5 edition (DSM-5), while the International Classification of sleep disorders 3 edition criteria of insomnia were used for diagnosing insomnia. The severity of insomnia and depression was assessed using the Insomnia Severity Index (ISI) and Patient Health Questionnaire-9 (PHQ-9), respectively. Fatigue was assessed using the Fatigue Severity Scale (FSS), which was translated in Hindi for this study. All subjects were also asked regarding effect of good sleep at night on daytime symptoms, especially on mood.

RESULTS

Subjects in MDD group were younger than the other two. Insomnia group was significantly different from the other two groups on most of the measures according to the DSM-5 criteria for MDD. MDD group had lesser frequencies of initial insomnia, middle insomnia, dissatisfaction with sleep and overall distress during the day. MDD-I group had a higher prevalence of daytime sleepiness and hyperactivity/impulsivity. PHQ-9 score was the lowest in the insomnia group. Despite statistically significantly different, ISI score was clinically comparable. The severity of fatigue was comparable across three groups. Contrary to the MDD group, subjects in insomnia and MDD-I group reported significant improvement in daytime symptoms after a good sleep for even one night.

CONCLUSION

There is considerable overlap of symptoms between insomnia and MDD. Subjects having insomnia report significant improvement in daytime and mood symptoms after good sleep, contrary to subjects with MDD.

Depression prevention via digital cognitive behavioral therapy for insomnia: a randomized controlled trial

STUDY OBJECTIVES

Insomnia is a common precursor to depression; yet, the potential for insomnia treatment to prevent depression has not been demonstrated. Cognitive behavioral therapy for insomnia (CBT-I) effectively reduces concurrent symptoms of insomnia and depression and can be delivered digitally (dCBT-I); however, it remains unclear whether treating insomnia leads to sustained reduction and prevention of depression. This randomized controlled trial examined the efficacy of dCBT-I in reducing and preventing depression over a 1-year follow-up period.

METHODS

Patients with Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) insomnia disorder were randomly assigned to receive dCBT-I or an attentional control. The follow-up sample included 358 patients in the dCBT-I condition and 300 patients in the online sleep education condition. The primary outcome measure was relative rate ratios for depression at 1-year follow-up. Insomnia responses to treatment were also tested as predictors of incident depression at the 1-year follow-up.

RESULTS

At 1-year follow-up, depression severity continued to be significantly lower in the dCBT-I condition relative to control. In addition, the number of individuals who reported no depression at 1-year follow-up was 51% higher in the dCBT-I condition relative to control. In those with minimal to no depression at baseline, the incident rate of moderate-to-severe depression at 1-year follow-up was reduced by half in the dCBT-I condition relative to the control condition.

CONCLUSION

dCBT-I showed robust effects as an intervention that prevents depression. Future research should examine dose-response requirements and further characterize mechanisms of action of dCBT-I for depression prevention.

CLINICAL TRIAL

Sleep to Prevent Evolving Affective Disorders; NCT02988375.

Digital Delivery of Cognitive Behavioral Therapy for Insomnia

PURPOSE OF REVIEW

Digital cognitive behavioral therapy (dCBT) has been available for over a decade. We reviewed the evidence that accumulated over the past 5 years and discuss the implications for introducing dCBT into standard healthcare.

RECENT FINDINGS

Studies have consistently supported the use of dCBT to treat insomnia. Evidence is now demonstrating large short-term effects and smaller long-term effects up to 1.5 years after treatment across populations with various co-occurring health problems. The effects also extend into a range of psychological well-being factors. Mediators and moderators have been studied to understand mechanisms and create new opportunities to enhance effectiveness and reduce dropout. Incorporating personalized guidance in dCBT may further enhance effectiveness. The evidence for dCBT for insomnia is strong and suggests that dCBT is ready for application in standard healthcare. Further research, digital innovation, and development of effective implementation methods are required to ensure dCBT fulfills its potential.

Pilot evaluation of the Sleep Ninja: a smartphone application for adolescent insomnia symptoms

OBJECTIVES

The aim of this study was to test the feasibility, acceptability and preliminary effects of a recently developed smartphone application, Sleep Ninja, for adolescent sleep difficulties.

SETTING

The study was conducted online with Australian individuals recruited through the community.

PARTICIPANTS

Participants were 50 young people aged 12-16 years with sleep difficulties.

DESIGN

A single-arm pre-post design was used to evaluate feasibility, acceptability and sleep and mental health variables at baseline and postintervention.

INTERVENTION

Cognitive-behavioural therapy for insomnia informed the development of the Sleep Ninja. The core strategies covered by the app are psychoeducation, stimulus control, sleep hygiene and sleep-related cognitive therapy. It includes six training sessions (lessons), a sleep tracking function, recommended bedtimes based on sleep guidelines, reminders to start a wind-down routine each night, a series of sleep tips and general information about sleep. Users progress through each training session and conclude the 6-week programme with a black belt in sleep.

OUTCOME MEASURES

Feasibility was evaluated based on consent rates, adherence and attrition, acceptability was assessed using questionnaires and a poststudy interview, and sleep, depression and anxiety variables were assessed at baseline and postintervention.

RESULTS

Data indicated that the Sleep Ninja is a feasible intervention and is acceptable to young people. Findings showed that there were significant improvements on sleep variables including insomnia (within-group effect size d=-0.90), sleep quality (d=-0.46), depression (d=-0.36) and anxiety (d=-0.41).

CONCLUSIONS

The Sleep Ninja is a promising intervention that could assist adolescents who experience sleep difficulties. A follow-up randomised controlled trial is now warranted.

TRIAL REGISTRATION NUMBER

ACTRN12617000141347.

Efficacy of digital CBT for insomnia to reduce depression across demographic groups: a randomized trial

BACKGROUND

Insomnia and depression are highly comorbid and mutually exacerbate clinical trajectories and outcomes. Cognitive behavioral therapy for insomnia (CBT-I) effectively reduces both insomnia and depression severity, and can be delivered digitally. This could substantially increase the accessibility to CBT-I, which could reduce the health disparities related to insomnia; however, the efficacy of digital CBT-I (dCBT-I) across a range of demographic groups has not yet been adequately examined. This randomized placebo-controlled trial examined the efficacy of dCBT-I in reducing both insomnia and depression across a wide range of demographic groups.

METHODS

Of 1358 individuals with insomnia randomized, a final sample of 358 were retained in the dCBT-I condition and 300 in the online sleep education condition. Severity of insomnia and depression was examined as a dependent variable. Race, socioeconomic status (SES; household income and education), gender, and age were also tested as independent moderators of treatment effects.

RESULTS

The dCBT-I condition yielded greater reductions in both insomnia and depression severity than sleep education, with significantly higher rates of remission following treatment. Demographic variables (i.e. income, race, sex, age, education) were not significant moderators of the treatment effects, suggesting that dCBT-I is comparably efficacious across a wide range of demographic groups. Furthermore, while differences in attrition were found based on SES, attrition did not differ between white and black participants.

CONCLUSIONS

Results provide evidence that the wide dissemination of dCBT-I may effectively target both insomnia and comorbid depression across a wide spectrum of the population.