Digital Pathways to Better Sleep

Insomnia is a prevalent, impactful, and costly sleep condition. Prevalence of insomnia symptoms across Europe, Canada, and the United States range from 24.8% to 40%.

Disrupted sleep is seen across development and age—from infants to older adults. Medical conditions and life changes affect sleep, such as pregnancy and menopause, and chronic pain.^4-5 Since the onset of the global COVID-19 pandemic in 2020, insomnia symptoms greatly increased, and have not yet quite returned to pre-pandemic rates.⁶

The cost of insomnia is significant—not only in terms of quality of life and morbidity and mortality, but even in dollars and cents. It has been estimated that the direct and indirect healthcare costs associated with insomnia could total as much as $100 billion U.S. dollars per year.⁷  Early and effective intervention is key in loosening the stranglehold insomnia symptoms have on millions around the world.

National and international guidelines highlight cognitive behavior therapy for insomnia (CBT-I) as the first-line intervention.^8-10 CBT-I is a multi-component treatment that incorporates a number of approaches to address underlying psychological, behavioral, and physiological processes and factors that contribute to and perpetuate insomnia.¹¹ It’s an evidence-based, structured approach that includes psychoeducation, behavioral interventions, and cognitive interventions, typically administered by a clinician trained in behavioral sleep medicine.

Research and guidelines suggest that pharmacological treatment of insomnia should only be offered if CBT-I is not effective or available and should generally only be considered for time-limited use.¹² Despite these recommendations, medication is still the most prevalent treatment approach for insomnia, far surpassing CBT-I. Two reasons for this stand out:

1. lack of widespread knowledge of the CBT-I components
2. limited access to CBT-I

Increasing awareness and providing education regarding the time-limited, targeted effectiveness of CBT-I is important. In this article, we will talk about how technology is well poised to support greater access to CBT-I.

Expanded Stepped Care Model

Many people experience symptoms of insomnia, even if they do not meet full criteria for an insomnia disorder. According to the International Classification of Sleep Disorders, approximately 35% of the population will experience transient insomnia at some point in their lives, and 10% suffer from chronic insomnia.¹² It is best to address insomnia symptoms early on to reduce its negative impact.

While there is high volume of patients who need access to care, there is unfortunately a very limited number of qualified clinicians trained in the delivery of behavioral sleep medicine.¹² There’s been an increasing of studies that suggest a to insomnia treatment could make CBT-I more accessible and affordable for the general public.

The stepped care model is frequently illustrated as a pyramid, and the idea is that there are different levels of insomnia severity and intervention needs based on several metrics. Self-administered CBT-I is typically suggested as the entry-level treatment at the base of the pyramid, which intersects with the highest patient volume.¹³

In the digital age, the stepped care model has expanded to include digital, self-guided approaches to sleep challenges.¹⁴ Throughout the research, these have been referred to as internet-based CBT-I (iCBT-I) or more recently, digital CBT-I (dCBT-I).

dCBT-I includes technologies such as computer, internet, and smartphone applications. These programs can be fully automated, with personalized feedback based on user-inputted information, or they can incorporate feedback from a coach to augment the digital program’s clinical content.

What Digital CBT-I Is and Is Not

Before we talk about the essential components of evidence-based dCBT-I programs, let’s first talk about what dCBT-I is not.

We will not be using dCBT-I to refer to the telehealth delivery of CBT-I. Telehealth has become a popular avenue to deliver CBT-I, but the clinical protocol and sleep psychology provider is the same in both face-to-face and telehealth CBT-I delivery, making it a completely different approach than dCBT-I.

In addition, while there may appear to be some similarities and even some crossover between dCBT-I programs and general sleep applications, they are not the same. The main difference lies in their clinical focus and level of personalization. General sleep applications often include sleep tracking, relaxation techniques, or general sleep hygiene education, but they lack the therapeutic structure of dCBT-I programs.

In this article, we’re talking about evidence-based programs specifically designed to treat insomnia using the principles of CBT. They follow structured, clinically validated protocols and are often tailored to the user’s sleep patterns and behaviors, providing personalized feedback on their progress.

A Deeper Look at dCBT-I

dCBT-I programs leverage technology to deliver elements of CBT-I though smartphone applications or online programs. Some of these programs are designed to support users while they are working with a sleep clinician, while others are fully automated. Some programs offer a mix of both, where users work through a structured program and also have an option to consult with a professional.

The duration of digital CBT-I programs can vary, but they typically range from six to eight weeks. During this period, users engage with the program’s content regularly, often on a daily or weekly basis. Each week might focus on different CBT-I-based skills, gradually building a comprehensive toolkit for better sleep.

Here’s some typical components of an evidence-based dCBT-I program:

• Initial assessment: Most dCBT-I programs begin with an assessment of the user’s sleep patterns, behaviors, and specific insomnia issues. This can include sleep tracking and sleep-specific questionnaires.
• Sleep science education: The concepts of circadian rhythm, and predisposing, precipitating, perpetuating, and protective factors are outlined as they relate to sleep.
• Sleep hygiene education: Information is provided regarding sleep-related habits, bedroom environment, and dietary facts.
• Stimulus control: Users are informed of the importance of a strong relationship between sleep and their bed. They receive guidance about only using their bed for sleep and intimacy, and avoiding the bed for other activities such as work, watching television, or phone scrolling.
• Relaxation: Skills such as guided imagery, progressive muscle relaxation, mindfulness, meditation, and guided breathing are taught. Their practice during the day, and as part of a bedtime routine is encouraged.
• Sleep restriction: This component in traditional CBT-I is pivotal, so programs that include sleep restriction are incredibly helpful. After sufficient sleep tracking through sleep diaries, a restricted sleep schedule is provided. This schedule is then extended as sleep efficiency improves in the weeks that follow.
• Cognitive skills: Effort is made to identify unhelpful sleep thoughts and alter them to support good overnight sleep. This includes content surrounding sleep-related anxiety. Thought-journaling is also a frequent go-to option.
• Evaluation and relapse prevention: The final components involve reviewing all CBT-I based skills, and problem-solving future challenges.
• Coaching: Some dCBT-I applications allow you to connect with medical providers, psychologists, or certified coaches throughout the program. This can be helpful in problem-solving challenges, getting support, and remaining accountable.

Effectiveness of dCBT-I

dCBT-I has been found to be quite effective. In a meta-analysis that included 33 randomized controlled trials, researchers found that dCBT-I reduced an individual’s insomnia severity index (ISI) score, helped people fall asleep, stay asleep, and sleep for longer and more efficiently.¹⁵ It also revealed that the ISI improvements were sustained short-term and at follow-up one year later.¹⁵ These findings are incredibly exciting, suggesting an avenue for significantly improved access to CBT-I-based skills in the palm of the patient’s hand.

It should always be noted that not all dCBT-I programs are the same, and the ones reviewed in the meta-analysis might not be the one you find. Some easily available programs have been studied, and have seen similar positive results.^16-17

As always, there are limits to what a digital platform can do. Users may have technology barriers or cost concerns. Some insurance plans do cover certain dCBT-I programs, and some dCBT-I programs qualify as eligible expenses under Health Savings Accounts or Flexible Savings Accounts. It’s important to check with the insurance carrier and FSA/HSA administrator to determine coverage. Increasing HSA/FSA eligibility

Lastly, it is important that dCBT-I users inform their primary care provider (PCP) about the steps they’re taking to improve their sleep health. Some dCBT-I platforms include a pathway for sending user progress directly to their PCP, which streamlines that communication and the continuum of care.

Conclusion

Overall, dCBT-I is an effective and important component of the stepped care model for insomnia in our digital age. As technology continues to evolve, the potential for dCBT-I to reach even more people and improve sleep outcomes is promising and exciting.

By: Areti Vassilopoulos, PhD

Source: SleepWorld Magazine September/October 2024

References

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