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Making the Best Treatment for Insomnia More Available

New apps can bring CBT for insomnia to the millions who need it.

Source: Tookapic/Pexels

Last night millions of men and women lay in bed staring at the ceiling, praying for sleep. If you're with two of your friends, odds are that one of you will have had sleep problems recently, and around one in ten individuals will meet full criteria for insomnia. Not surprisingly, sleep difficulty contributes to a wide range of mental and physical health conditions.

Cognitive behavioral therapy for insomnia (CBT-I) is the first-line treatment for chronic difficulty falling asleep or staying asleep. A few sessions of CBT-I can help a person fall asleep more quickly and easily and sleep more soundly through the night. Best of all, the treatment produces lasting improvements, with total sleep time continuing to increase after the treatment has ended.

Sounds great, right? So why do so many people continue to wrestle with insomnia? Part of the problem is that many people simply aren't aware CBT-I exists. They may have struggled with sleep for so long that they assume there's no alternative, as if insomnia is an unavoidable part of their constitution. Others may believe that medication is the only effective treatment, and yet find limited relief from taking it.

There are other barriers even for those who know about the treatment. Many people in the US and other parts of the world live hours from the nearest CBT-I provider. Even having a world-class sleep center next door is no guarantee a person can afford the treatment, which often costs hundreds of dollars and may not be covered by insurance (many CBT-I providers do not participate in insurance networks).

But there's reason to be hopeful even if a person doesn't have access to a CBT-I therapist, because CBT-I can be quite effective with or without a clinician's involvement.

CBT-I is in many ways an ideal candidate for self-guided treatment: It's straightforward, relies on a few basic principles, and it's easy to tell if it's helping. It also doesn't rely on a close emotional connection to a caring provider, and generally does not involve deep discussions about one's childhood or other complex issues.

I've reviewed the principles of CBT-I in a previous post; the main components are:

  • optimizing the time you spend in bed
  • setting a consistent bedtime and wakeup time
  • using the bed only for sleeping (and sex)
  • avoiding being in bed if you're not falling asleep
  • addressing thoughts that interfere with sleep
  • additional options like relaxation training as needed

A new "multimedia field test" examined some of the latest developments in online and mobile applications for delivering CBT-I, with encouraging results. (Disclaimer: the study authors declared they had no conflicts of interest, and I have no financial incentive to promote any of these products.)

kote baeza/Pexels
Source: kote baeza/Pexels

Jennifer Cowie and her colleagues at the Sleep and Anxiety Center of Houston focused primarily on SleepioTM, which is available online and as a mobile app. It starts with setting individualized sleep goals that will guide the treatment.

The program includes videos that convey the rationale for CBT-I, which is a key component of the treatment. Some parts of CBT-I are counterintuitive or just plain difficult, so having a solid explanation up front is essential. These videos cover topics including:

  • sleep scheduling
  • relaxation techniques
  • addressing problematic sleep-related thoughts
  • sleep hygiene
  • practicing mindfulness
  • a bedtime routine for winding down

Sleepio also provides an easy way to log nightly sleep (e.g., bedtime, length of time to fall asleep), and these numbers are the basis for recommended adjustments in sleep behaviors. The app also makes it easy to track progress over time, which the study authors point out can increase motivation to stick with the program.

Does it work? Multiple studies have shown that it does, including among individuals with a wide range of physical and mental health conditions. In the largest study to date, Sleepio led to:

  1. a 20% increase in sleep efficiency (sleep time divided by time spent in bed; e.g., sleeping 6 hours while being in bed for 8 would be a 75% sleep efficiency)
  2. a 26 minute decrease in time to fall asleep
  3. a 48 minute decrease in time awake in the middle of the night
  4. average insomnia scores in the healthy range
  5. increased energy
  6. better mood
  7. greater productivity

These effects are comparable to those of CBT-I with a therapist.

Cowie and colleagues note that Sleepio and similar programs are not for everyone. In particular it's not recommended for those who do shift work, people younger than 16 years, women who are pregnant, and people who require medical care. In general CBT-I is not recommended for those who have unstable medical or psychiatric conditions.

The cost of these programs is not insignificant, either—$300 for a 1-year period in the case of Sleepio. This price tag might seem outrageous at a time when we're accustomed to free apps, and we balk at paying $0.99 for the full version of an app.

At the same time, $300 could easily be the cost of just the initial evaluation with a professional, with the full treatment of 4-8 sessions costing hundreds of dollars more. And in the big picture, $300 is probably a lot less than the cost of untreated insomnia, both in terms of dollars and personal misery.

For those who've struggled with insomnia long enough, Sleepio or similar programs could be an effective and relatively affordable solution to fix their sleep.

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Looking for self-directed CBT for depression and anxiety? Retrain Your Brain: CBT in 7 Weeks is available in paperback and Kindle.

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Cowie, J. Bower, J. L., Gonzalez, R., & Alfano, C. A. (2017). Mutimedia field test: Digitalizing better sleep using the Sleepio program. Cognitive and Behavioral Practice. doi:10.1016/j.cbpra.2017.09.005

Espie, C. A., Kyle, S. D., Williams, C., Ong, J. C., Douglas, N. J., Hames, P., & Brown, J. S. (2012). A randomized, placebo-controlled trial of online cognitive behavioral therapy for chronic insomnia disorder delivered via an automated media-rich web application. Sleep, 35, 769-781.

Kyle, S. D., Morgan, K., & Espie, C. A. (2010). Insomnia and health-related quality of life. Sleep Medicine Reviews, 14, 69-82.

Morgenthaler, T., Kramer, M., Alessi, C., Friedman, L., Boehlecke, B., Brown, T., ... & Pancer, J. (2006). Practice parameters for the psychological and behavioral treatment of insomnia: An update. An American Academy of Sleep Medicine report. Sleep, 29, 1415-1419.

Morin, C. M., LeBlanc, M., Daley, M., Gregoire, J. P., & Merette, C. (2006). Epidemiology of insomnia: Prevalence, self-help treatments, consultations, and determinants of help-seeking behaviors. Sleep Medicine, 7, 123-130.