Continuous sleep tracking in digital CBT-I: Efficacy and insights from a naturalistic-environment study

Cognitive behavioral therapy for insomnia (CBT-I) has been shown to improve both sleep and depressive symptoms, but predictors of depression outcome following CBT-I have not been well examined. This study investigated how chronotype (i.e., morningness-eveningness trait) and changes in sleep efficiency (SE) were related to changes in depressive symptoms among recipients of CBT-I. Included were 419 adult insomnia outpatients from a sleep disorders clinic (43.20% males, age mean ± standard deviation = 48.14 ± 14.02). All participants completed the Composite Scale of Morningness and attended at least 4 sessions of a 6-session group CBT-I. SE was extracted from sleep diary; depressive symptoms were assessed using the Beck Depression Inventory (BDI) prior to (Baseline), and at the end (End) of intervention. Multilevel structural equation modeling revealed that from Baseline to End, SE increased and BDI decreased significantly. Controlling for age, sex, BDI, and SE at Baseline, stronger evening chronotype and less improvement in SE significantly and uniquely predicted less reduction in BDI from Baseline to End. Chronotype did not predict improvement in SE. In an insomnia outpatient sample, SE and depressive symptoms improved significantly after a CBT-I group intervention. All chronotypes benefited from sleep improvement, but those with greater eveningness and/or less sleep improvement experienced less reduction in depressive symptom severity. This suggests that evening preference and insomnia symptoms may have distinct relationships with mood, raising the possibility that the effect of CBT-I on depressive symptoms could be enhanced by assessing and addressing circadian factors.

Uncoupled sleep is a phenomenon characterised by a disconnect between sleep pattern and sleep complaint. This study examined the impact of uncoupled sleep on dysfunctional sleep beliefs and objective and subjective sleep outcomes in community-dwelling older adults following digitally delivered Cognitive Behavioural Therapy for Insomnia (CBT-I) to assess how these groups respond to CBT-I. Objective sleep was measured using wrist actigraphy, subjective sleep quality via sleep diaries and the Pittsburgh Sleep Quality Index (PSQI). Dysfunctional sleep beliefs were assessed by the Dysfunctional Beliefs and Attitudes about Sleep scale (DBAS-16). All measurements were taken prior to and following a 4-week online CBT-I program. Linear mixed model and generalised linear mixed model analyses were conducted to examine objective and subjective sleep onset latency, total sleep time, wake after sleep onset and number of awakenings as well as PSQI and DBAS-16 scores, respectively. Out of 80 enrolled participants, 62 participants (55 females, 89%; 16 complaining good sleepers, 26 complaining poor sleepers, 11 non-complaining good sleepers, and nine non-complaining poor sleepers) completed the study. CBT-I reduced dysfunctional sleep beliefs across all sleeper classifications. Objective and self-reported changes in sleep parameters were demonstrated in complaining poor sleepers without uncoupled sleep. Complaining good sleepers with uncoupled sleep only reported a decrease in the number of subjective sleep awakenings. There were no changes in sleep outcomes in non-complaining good and non-complaining poor sleepers. Online CBT-I was effective in improving the sleep outcomes of individuals who had both subjective and objective poor sleep. However, as the online CBT-I reduced dysfunctional sleep beliefs in all sleep groups, further examination of dysfunctional sleep beliefs and whether they mediate the outcomes of digital CBT-I in older adults will need to be conducted.

This study examines the impact of cognitive behavioral therapy for insomnia (CBT-I) and positive airway pressure (PAP) therapy for comorbid insomnia and sleep apnea on nocturnal sleep and daytime functioning. A partial factorial design was used to examine treatment pathways with CBT-I and PAP and the relative benefits of each treatment. One hundred eighteen individuals with comorbid insomnia and sleep apnea were randomized to receive CBT-I followed by PAP, self-monitoring followed by CBT-I concurrent with PAP, or self-monitoring followed by PAP only. Participants were assessed at baseline, PAP titration, and 30 and 90 days after PAP initiation. Outcome measures included sleep diary- and actigraphy-measured sleep, Flinders Fatigue Scale, Epworth Sleepiness Scale, Functional Outcome of Sleep Questionnaire, and cognitive emotional measures. A main effect of time was found on diary-measured sleep parameters (decreased sleep onset latency and wake after sleep onset; increased total sleep time and sleep efficiency) and actigraphy-measured sleep parameters (decreased wake after sleep onset; increased sleep efficiency) and daytime functioning (reduced Epworth Sleepiness Scale, Flinders Fatigue Scale; increased Functional Outcome of Sleep Questionnaire) across all arms (all P < .05). Significant interactions and planned contrast comparisons revealed that CBT-I was superior to PAP and self-monitoring on reducing diary-measured sleep onset latency and wake after sleep onset and increasing sleep efficiency, as well as improving Functional Outcome of Sleep Questionnaire and Flinders Fatigue Scale compared to self-monitoring. Improvements in sleep and daytime functioning were found with PAP alone or concomitant with CBT-I. However, more rapid effects were observed on self-reported sleep and daytime performance when receiving CBT-I regardless of when it was initiated. Therefore, concomitant treatment appears to be a favorable approach to accelerate treatment outcomes. Registry: ClinicalTrials.gov; Name: Multidisciplinary Approach to the Treatment of Insomnia and Comorbid Sleep Apnea (MATRICS); URL: https://clinicaltrials.gov/ct2/show/NCT01785303; Identifier: NCT01785303. Tu AY, Crawford MR, Dawson SC, etal. A randomized controlled trial of cognitive behavioral therapy for insomnia and PAP for obstructive sleep apnea and comorbid insomnia: effects on nocturnal sleep and daytime performance. J Clin Sleep Med. 2022;18(3):789-800.

BackgroundInsomnia and eveningness are common and often comorbid conditions in youths. While cognitive behavioural therapy for insomnia (CBT-I) has been suggested as a promising intervention, it remains unclear whether it is sufficient to also address circadian issues in youths. In addition, despite that light has been shown to be effective in phase-shifting one’s circadian rhythm, there has been limited data on the effects of bright light therapy and its combination with CBT-I on sleep and circadian outcomes in youths. The current protocol outlines a randomised controlled trial that examines the efficacy of CBT-I and CBT-I plus bright light therapy (BLT) in reducing insomnia severity, improving mood symptoms and daytime functioning (e.g. sleepiness, fatigue, cognitive function), and improving subjective and objective sleep and circadian measures compared to a waitlist control group.MethodsWe will carry out a randomised controlled trial (RCT) with 150 youths aged 12–24 who meet the criteria of insomnia and eveningness. Participants will be randomised into one of three groups: CBT-I with bright light therapy, CBT-I with placebo light, and waitlist control. Six sessions of CBT-I will be delivered in a group format, while participants will be currently asked to use a portable light device for 30 min daily immediately after awakening throughout the intervention period for bright light therapy. The CBT-I with light therapy group will receive bright constant green light (506 lx) while the CBT-I with placebo light group will receive the modified light device with the LEDs emitting less than 10 lx. All participants will be assessed at baseline and post-treatment, while the two active treatment groups will be additionally followed up at 1 month and 6 months post-intervention. The primary outcome will be insomnia severity, as measured by the Insomnia Severity Index. Secondary outcomes include self-reported mood, circadian, daytime functioning, and quality of life measures, as well as sleep parameters derived from actigraphy and sleep diary and neurocognitive assessments. Objective measures of the circadian phase using dim-light melatonin onset assessment and sleep parameters using polysomnography will also be included as the secondary outcomes.DiscussionThis study will be the first RCT to directly compare the effects of CBT-I and BLT in youths with insomnia and eveningness. Findings from the study will provide evidence to inform the clinical management of insomnia problems and eveningness in youths.Trial registrationClinicalTrials.gov NCT04256915. Registered on 5 February 2020.

BACKGROUND Over 20% of patients with primary brain tumors (PBT) report clinically significant insomnia, yet these symptoms are often undertreated. Our team conducted the first trial of Cognitive Behavioral Therapy for Insomnia (CBT-I)—the recommended, first-line treatment—in patients with PBT. Primary findings suggest this intervention was safe, feasible, and acceptable. Moreover, patients demonstrated improvements in self-reported insomnia severity, fatigue, and mood. The aim of this secondary analysis was to assess changes in subjectively- and objectively-derived sleep metrics using data from patients’ sleep diaries and wrist-worn actigraphy. METHODS Patients with PBT and insomnia (N=44) enrolled in a single-arm pilot trial of CBT-I and completed one-week subjective (Consensus Sleep Diary) and objective (wrist-worn actigraphy; Actigraph GT9X) sleep assessments at baseline (T0) and post-intervention (T1). Participants underwent six weekly group CBT-I telehealth sessions. Subjectively- and objectively-derived sleep metrics include total sleep time (TST), time in bed (TIB), sleep efficiency (SE), sleep onset latency (SOL), wake after sleep onset (WASO), number of awakenings (NOA), and perceived sleep quality (PSQ). We evaluated the accelerometer data using the GGIR package and conducted paired-sample t-tests to evaluate change in sleep metrics from T0 to T1. RESULTS Subjectively, data from participants’ sleep diaries revealed improvements in WASO (MΔ=-27.08, p&amp;lt;.001), SOL (MΔ=-27.04, p&amp;lt;.001), SE (MΔ=0.08, p&amp;lt;.001), NOA (MΔ=-5.42, p&amp;lt;.001), and PSQ (MΔ=0.60, p&amp;lt;.001). Both TIB (MΔ=-78.10, p&amp;lt;.001) and TST (MΔ=-36.64, p&amp;lt;.01) significantly decreased. Objectively, data from participants’ wrist-worn actigraphy revealed significant decreases in NOA (MΔ=-2.63, p&amp;lt;.001), SOL (MΔ=-19.46, p=.04), TIB (MΔ=-1.03, p&amp;lt;.001), and TST (MΔ=-0.90, p&amp;lt;.001). The accelerometer data did not reveal significant changes in WASO or SE (ps&amp;gt;.05). CONCLUSION CBT-I may lead to meaningful improvements in both subjective and objective sleep among patients with PBT. Larger, controlled trials are currently underway to confirm these preliminary findings and to further investigate discrepancies between subjective and objective sleep measures.

The purpose of this study was to compare the efficacy of individual and group cognitive behavioral therapy for insomnia (CBT-I) in outpatients with primary insomnia diagnosed by DSM-IV-TR. The participants were 20 individually treated (I-CBT-I) and 25 treated in a group therapy format (three to five patients per group) (G-CBT-I), which showed no significant difference regarding demographic variables between groups. The same components of CBT-I stimulus control therapy, sleep restriction therapy, cognitive therapy, and sleep hygiene education were applied on both groups. The short-term outcome (4 weeks after treatment) was measured by sleep logs, actigraphy, the Pittsburgh Sleep Quality Index (PSQI), and the Dysfunctional Beliefs and Attitudes about Sleep Scale (DBAS), and was compared between I-CBT-I and G-CBT-I. The results indicated that CBT-I was effective in improving subjective and objective sleep parameters and subjective sleep evaluations for both individual and group treatment. However, I-CBT-I resulted in significantly better improvements over G-CBT-I, in (i) objective and subjective sleep onset latency time, (ii) objective sleep efficacy and moving time during sleeping, (iii) overall sleep quality and duration of actual sleep time in PSQI, (iv) consequences of insomnia, control and predictability of sleep, sleep requirement expectation, and sleep-promoting practices in DBAS. The present study suggested the superiority of I-CBT-I over G-CBT-I in clinical settings, and further evaluations are necessary.

Cognitive behavioral therapy for insomnia (CBT-I) is a first-line therapy for insomnia disorders. We assessed changes in discrepancies between subjective and objective sleep measures and correlations between discrepancy changes and clinical insomnia severity for CBT-I in patients with primary insomnia METHODS: Fifty-two outpatients (mean age, 60.3years; 26 women) with primary insomnia were treated by individual CBT-I (50min, maximum six sessions, once every 1-2weeks). One week before and after CBT-I, patients recorded a sleep log and wore an actigraphy device. Subjective and objective time in bed (TIB), total sleep time (TST), sleep-onset latency (SOL), wake time after sleep onset (WASO), and sleep efficiency (SE) were evaluated by averaging 1-week records. Relative values of sleep discrepancy in TIB, TST, SOL, WASO, and SE were calculated for estimating effects of CBT-I. The therapeutic effects were also evaluated using psychological scales before and after CBT-I. Subjective and objective discrepancies in sleep measures decreased by 36, 25, and 37min in TST, SOL, and WASO, respectively, and 7% in SE (all P < 0.001) after CBT-I. Seven patients transitioned from underestimating SE before CBT-I to overestimating SE after CBT-I. Although CBT-I improved relative values of discrepancy in WASO and SE, alongside ISI, the improvement in insomnia severity only correlated with SOL discrepancy. CBT-I may reduce the discrepancy between subjective and objective sleep measures in patients with primary insomnia. However, a greater therapeutic effect of CBT-I was observed in reducing the ISI, which was slightly influenced by improvements in sleep discrepancies.

Individuals with insomnia disorder often exhibit differences between reported experiences of sleep and objectively measured sleep parameters; however, the implications of this subjective-objective sleep discrepancy during treatment remains unclear. The aim of this study was to investigate the impact of cognitive behavioural therapy for insomnia (CBT-I) on the discrepancy between objective and subjective measures of sleep, and to assess whether changes in clinical variables such as depression, anxiety, fatigue, and beliefs about sleep, were related to changes in discrepancy. Twenty-five participants with insomnia disorder were enrolled in group CBT-I. Sleep measures were continually sampled from baseline until 2 weeks post-treatment with both objective (i.e., actigraphy) and subjective (i.e., sleep diary) methods. The subjective-objective discrepancy significantly decreased from baseline early on in treatment (following the second session) and were maintained at post-treatment for sleep onset latency, wake after sleep onset (WASO) and sleep efficiency (SE). Total sleep time (TST) discrepancy and misperception decreased from baseline to post-treatment. Improvement in depression symptoms, fatigue symptoms, and negative beliefs about sleep were significantly correlated with the decrease in the discrepancy for WASO and SE. These findings suggest that CBT-I resolves the mismatch between objective and subjective sleep parameters early in treatment for adults with insomnia. Sleep misperception improved from underestimating to accurately estimating TST. Improvement of psychological symptoms were related to decrease in sleep discrepancies across treatment. Future research is needed to explore how feedback on objective and subjective sleep discrepancy may impact sleep perception across treatment with CBT-I.

Apport de la pleine conscience dans les thérapies cognitives et comportementales de l’insomnie

Objectives Cognitive Behavioral Therapy for Insomnia (CBTi) is a first-line treatment for a prevalent and impairing disorder. Digital CBTi programs increase access to internet-based self-directed care. However, the clinical effect of offering different forms of CBTi in a healthcare setting is not clearly understood. This study examines treatment engagement and clinical outcomes for individuals referred to either digital or provider-led CBTi. Methods Over two years, providers at a Veterans Health Administration (VHA) facility referred patients to digital CBTi with telephone coaching support or traditional provider-led CBTi. Characteristics of those referred, proportions engaging in and completing treatment, as well as insomnia severity were compared among those referred to each format. Results Providers referred 139 individuals to digital CBTi, 340 to provider-led CBTi, and 14 to both formats. Individuals referred to digital CBTi were older with less severe insomnia. Despite lower levels of program engagement and completion in the digital CBTi cohort, measures of insomnia symptom change were similar between the groups. Conclusions This is the first study to evaluate both digital and provider-led evidence-based treatments for insomnia disorder simultaneously deployed in a healthcare setting. While engagement in digital CBTi lagged that for provider-led CBTi, offering both formats may expand access to different groups, while fostering similar outcomes.

Previous meta-analyses have shown the effectiveness of cognitive behavioral therapy for insomnia (CBT-I). However, conclusive information about therapeutic effects (especially during follow-up), effect sizes of objective sleep parameters and self-rating scales, and the problem of publication bias has not been obtained. We conducted a meta-analysis focusing on these issues. We identified 14 randomized controlled studies published between 1990 and 2009 that fulfilled our selection criteria. Intra-group comparison of CBT-I and comparison between CBT-I and control groups were performed on these studies. The intra-group comparison revealed that the effect sizes of CBT-I for subjective sleep variables from sleep diaries were medium to large at the end point of treatment, and these effect sizes were favorably maintained on follow-up. A between-group comparison revealed that CBT-I was more effective than the control for subjective sleep variables at the end of treatment and that its effectiveness was also recognized on follow-up. With regard to self-rating scales, as compared to the control group, the effect sizes in the CBT-I group were medium to large both at the end of treatment and on follow-up. However, there were problems of publication bias in some of the subjective or objective sleep variables. The abovementioned results support the effectiveness of CBT-I for the treatment and prevention of relapse of primary insomnia despite the existence of a certain publication bias.

Efficacy of cognitive behavioral therapy for insomnia in geriatric primary care patients.

Cognitive behavioural therapy for insomnia (CBTi): From randomized controlled trials to practice guidelines to implementation in clinical practice.

Effects of cognitive behavioral therapy for insomnia on subjective and objective measures of sleep and cognition

BackgroundInsomnia affects up to one-third of US adults and is a significant health challenge with an estimated economic burden of up to $100 billion annually. Cognitive behavioral therapy (CBT) for insomnia (CBT-I) is the recommended first-line treatment, but access is limited due to a shortage of trained therapists. Digital CBT-I offers an effective alternative that may enhance accessibility and reduce higher healthcare costs associated with insomnia.ObjectiveTo evaluate the US healthcare cost-savings of digital CBT-I compared with standard-of-care control.MethodsA retrospective difference-in-differences analysis compared 1-year preinitiation and post-initiation healthcare costs for 11 027 individuals receiving SleepioRx (FDA-cleared digital CBT treatment for insomnia disorder) compared with 1:1 exact matched controls with insomnia receiving standard care (n = 10 770). Commercial and Medicare claims were adjusted for comorbidities, index year, and baseline utilization.ResultsDigital CBT-I was associated with statistically significant mean annual total cost savings of 2083(951508-$2657, P < .001) per person, equating to a 42% reduction in costs with SleepioRx relative to matched controls who received standard of care (medications for insomnia).DiscussionDigital CBT-I was associated with substantial cost savings for payers. The integration of guideline-concordant treatment through digital delivery into standard care pathways offers a promising strategy to address the clinical and economic challenges of insomnia, supporting more efficient resource allocation.ConclusionsFindings suggest that implementing digital CBT-I at scale may lead to decreased costs for healthcare payers, relative to the current standard of care, while improving access to effective insomnia treatment.