Digital Cognitive Behavioral Therapy for Insomnia for Adolescents With Mental Health Problems: Feasibility Open Trial.

Bethany Cliffe,Megan Denne,Paul Stallard,Jacqueline Smith,Abigail Croker

doi:10.2196/14842

Abstract

BackgroundInsomnia in adolescents is common, persistent, and associated with poor mental health including anxiety and depression. Insomnia in adolescents attending child mental health services is seldom directly treated, and the effects of digital cognitive behavioral therapy (CBT) for insomnia (CBTi) on the mental health of adolescents with significant mental health problems are unknown.ObjectiveThis open study aimed to assess the feasibility of adding supported Web-based CBT for insomnia to the usual care of young people aged 14 to 17 years attending specialist child and adolescent mental health services (CAMHS).MethodsA total of 39 adolescents with insomnia aged 14 to 17 years attending specialist CAMHS were assessed and offered digital CBTi. The digital intervention was Sleepio, an evidence-based, self-directed, fully automated CBTi that has proven effective in multiple randomized controlled trials with adults. Self-report assessments of sleep (Sleep Condition Indicator [SCI], Insomnia Severity Scale, and Web- or app-based sleep diaries), anxiety (Revised Child Anxiety and Depression Scale [RCADS]), and depression (Mood and Feelings Questionnaire [MFQ]) were completed at baseline and post intervention. Postuse interviews assessed satisfaction with digital CBTi.ResultsAverage baseline sleep efficiency was very poor (53%), with participants spending an average of 9.6 hours in bed but only 5.1 hours asleep. All participants scored less than 17 on the SCI, with 92% (36/39) participants scoring 15 or greater on the Insomnia Severity Scale, suggesting clinical insomnia. Of the 39 participants, 36 (92%) scored 27 or greater on the MFQ for major depression and 20 (51%) had clinically elevated symptoms of anxiety. The majority of participants (38/49, 78%) were not having any treatment for their insomnia, with the remaining 25% (12/49) receiving medication. Sleepio was acceptable, with 77% (30/39) of the participants activating their account and 54% (21/39) completing the program. Satisfaction was high, with 84% (16/19) of the participants finding Sleepio helpful, 95% (18/19) indicating that they would recommend it to a friend, and 37% (7/19) expressing a definite preference for a digital intervention. Statistically significant pre-post improvements were found in weekly diaries of sleep efficiency (P=.005) and sleep quality (P=.001) and on measures of sleep (SCI: P=.001 and Insomnia Severity Index: P=.001), low mood (MFQ: P=.03), and anxiety (RCADS: P=.005).ConclusionsOur study has a number of methodological limitations, particularly the small sample size, absence of a comparison group and no follow-up assessment. Nonetheless, our findings are encouraging and suggest that digital CBTi for young people with mental health problems might offer an acceptable and an effective way to improve both sleep and mental health.International Registered Report Identifier (IRRID)RR2-10.2196/11324

Highlights

Adolescent Insomnia and Mental HealthInsomnia is a chronic dissatisfaction with sleep quantity or quality, despite an adequate opportunity to sleep [1]
One young person did not respond; 3 participants had other commitments they needed to prioritize; 2 participants no longer wanted to be involved; and the mental health of 2 participants had deteriorated with the sleep of 2 participants improving
This needs to be explored in further studies but may indicate that supported digital cognitive behavioral therapy for insomnia (CBTi) may be more appropriate for adolescents with less complex mental health presentations

Summary

Introduction

Insomnia is a chronic dissatisfaction with sleep quantity or quality, despite an adequate opportunity to sleep [1] It includes difficulties initiating, maintaining, or returning to sleep, with the sleep disturbance occurring at least three nights per week for 3 months and causing impairment in daytime functioning. Associations have been found between insomnia and increased risk of nonsuicidal self-injury [6], poor school performance [7], anxiety, mood disorders, behavioral difficulties, substance use, eating disorders, and suicidality [2]. The mechanisms underlying these relationships are complex and potentially involve sequential, parallel, and interacting biological, psychological, and social systems [8]. Insomnia in adolescents attending child mental health services is seldom directly treated, and the effects of digital cognitive behavioral therapy (CBT) for insomnia (CBTi) on the mental health of adolescents with significant mental health problems are unknown

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