CBT App Improves Sleep Quality in Insomnia Patients
APRIL 05, 2020
Chung-Ying Lin, PhD
Chung-Ying Lin, PhD, and colleagues compared the efficacy of the app in a group who used it for 6 weeks compared to those who only received patient education to examine the long-term effects of it. The team found that using the app improved sleep hygiene more than just patient education.
Lin, from the rehabilitation sciences department at Hong Kong Polytechnic University, and the team of investigators delivered the insomnia intervention on a smartphone app. The app was designed on a combination of theory of planned behavior, health action process approach, and cognitive behavioral therapy for insomnia.
The platform integrated behavior changing techniques, including information about health consequences; social and environmental consequences; habit formation and reversal; pros and cons of performing sleep hygiene behaviors; reconstructing the physical and social environment; self-monitoring of behavior; action planning; and problem solving.
Content of the app was designed to treat patients with insomnia individually using 6 weekly sessions, with each session lasting 1 hour.
Session 1 was provided using plain text; sessions 2-3 included a variety of relaxation tools through audio guided meditation and images; session 4 had information concerning sleep in plain text and tables to address misinformation about insomnia; and sessions 5-6 consisted of plain text and table to help participants plain their sleep hygiene behaviors.
To be eligible in the two-arm single-blind parallel-group trial, participants needed to be >18 years old, had an insomnia disorder according to DSM-5, had an Insomnia Severity Index score >10, understood Persian, and had access to a smartphone or desktop computer with internet access.
An independent investigator randomly assigned participants to the control or treatment group at a 1:1 ratio.
Participants in the treatment group had access to the app content each week. Each individual was assigned homework or an exercise and was encouraged to complete it weekly. A majority of the participants used the app as recommended, and a reminder text was sent to those who did not open the content on time.
Those in the control group received written information weekly on accurate and relevant information regarding insomnia symptoms in week 1; physiological controls of sleep (week 2); sleep hygiene practices (week 3); health sleep behaviors (week 4); and changing lifestyles to promote sleep health (week 5).
Information was unlocked on a weekly basis, and individuals in the control group were able to access the content on the app at the end of the study period.
Primary outcomes included sleep hygiene behavior, a reduction in the Insomnia Severity Index score, and an improved Pittsburgh Sleep Quality Index score. Additional measures included attitude toward good sleep hygiene, perceived behavioral control, behavioral intention, action and coping planning, and improved hospital anxiety and depression scale scores.
Investigators assessed app engagement using an online database that recorded the number of logins and the duration of each for all participants. Over the six-month study period, the mean number of logins for both groups was 41.21. Those in the intervention group had a higher number of logins (mean, 42.65) than the control group (mean, 40.93). The difference was not statistically significant (P=.38). Those in the app group had a significantly longer duration of use (mean, 1780.34 minutes) compared to the educational group (mean, 1370 minutes; P=.03).
The app had promising effects on the 3 primary outcomes. Sleep quality was improved among participants in the cognitive behavioral therapy for insomnia group compared to those in the control group at all follow-ups, according to the scores on the Pittsburgh Sleep Quality Index (P <.001 for 1, 3, and 6 months). Insomnia severity also improved in the app group compared to the control at 1, 3, and 6 months (P <.001).
Sleep hygiene also improved, as insomnia patients in the app group significantly engaged in more good sleep hygiene behaviors than those in the patient education group at 1 (P=.02), 3 (P=.04), and 6 (P=.02) months after the intervention.
For secondary outcomes, insomnia patients who used the app had better attitude at 1 month (P=.03) 3 months (P=.04), and 6 months(P=.03), stronger perceived behavioral control (P <.001 at 1, 3, and 6 months), higher intention to develop good sleep hygiene behavior (P <.001 at 1, 3, and 6 months), and were more likely to have formed relevant action and coping plans (P <.001 at 1, 3, and 6 months).
The findings indicated that the use of such an app could enhance the lives and outcomes of patients with insomnia.
The study, “Efficacy of a Theory-Based Cognitive Behavioral Technique App-Based Intervention for Patients With Insomnia: Randomized Controlled Trial,” was published online in the Journal of Medical Internet Research.