Few people escape the occasional restless night of tossing and turning, followed by the inevitable crushing fatigue the following day. But for the as many as one in 10 adults who suffer from chronic insomnia, the experience is all too common.
In addition to the short-term harms of excessive daytime sleepiness and dysfunction, chronic insomnia — defined as disrupted sleep that occurs at least three nights a week, lasting for at least 3 months — has been linked in epidemiological studies to an increased risk for obesity, diabetes, heart disease, and other life-threatening chronic conditions.
Cognitive behavioral therapy (CBT) has been recognized as the gold standard therapy for adults with insomnia by the American Academy of Sleep Medicine and, more recently, the American College of Physicians (ACP).
In 2016 guideline revisions, ACP recommended CBT alone, without medication, as the first-line therapy for chronic insomnia. A 2015 meta-analysis of 20 randomized, controlled trials involving more than 1,100 participants showed CBT to be an effective therapy for chronic insomnia.
CBT for insomnia (CBT-I) consists of a combination of treatments that include cognitive therapy focused on sleep, behavioral interventions such as sleep restriction and stimulus control, and education to improve sleep hygiene.
Recognizing the shortage of medical practitioners available to deliver CBT-I, the ACP guideline committee noted that in addition to the primary care and individual or group therapy setting, “telephone- or Web-based modules, or self-help books may also be useful” for delivering cognitive behavioral therapy for insomnia.
“Most studies focused on in-person CBT-I; however, the data suggest that other delivery methods are also effective,” the committee wrote.
Enter the sleep entrepreneurs of Silicon Valley.
Sleep: Big Business Online
Insomnia has become big business on the internet, with apps like Sleepio and SHUTi delivering CBT-I online, for a price. Dozens of other apps and podcasts promise to help the sleep deprived in other ways.
Jason Ong, PhD, associate professor of neurology (sleep medicine), medical social sciences, and psychiatry and behavioral sciences at Northwestern University in Chicago, told MedPage Today that only a small fraction of people with chronic insomnia receive treatment. He said online CBT-I has the potential to deliver effective treatment to a much larger pool of patients.
“The value of these programs is accessibility,” he said. “We have an insufficient number of [CBT-I] providers. These programs can really fill a void.”
Studies of the commercially available CBT-I programs, most funded by the companies selling them, suggest that they work reasonably well.
Ong helped design Sleepio, and he was a principal investigator in a ecently reported trial of the online CBT-I program that included just over 1,700 internet-recruited participants with self-reported insomnia. Participants who received the Sleepio CBT-I intervention showed greater improvements in daytime and nighttime insomnia symptoms than participants who received digital therapy that emphasized sleep hygiene education alone (controls).
The trial, funded by Sleepio’s marketer Big Health, was among the first to assess the impact of a CBT-I program on daytime symptoms associated with insomnia, such as excessive sleepiness.
Although outcomes were positive, the study drop-out rate was high — only about half (48.4%) of patients randomized to the CBT-I arm of the study completed all six scheduled sessions.
In an early NIH-sponsored randomized trial of the SHUTi program of 44 adults, including 22 randomized to the CBT-I intervention, the CBT-I intervention group had significantly improved Insomnia Severity Index scores at the end of the intervention and 6 months later, while the control group did not.
John Torous, MD, director of the digital psychiatry division of Beth Israel Deaconess Medical Center in Boston, who was not involved with either study, told MedPage Today that digital CBT represents a novel strategy for the treatment of insomnia, but the fact that there have been no head-to-head comparisons of the commercially available products makes it impossible to recommend one over the other.
And the online programs are not cheap: A year’s subscription to Sleepio costs around $400; a 26-week subscription to SHUTi costs between $149 and $174.
Torous noted that a third online CBT-I program known as CBT-i Coach, offered by the Veteran’s Administration, is free.
“CBT-i Coach may not be as fancy as the commercial ones, but it is evidence-based and may work just as well,” he said.
Boring ‘Game of Thrones’ Recap
In addition to mobile phone apps delivering CBT, countless other free and commercial apps now address insomnia, utilizing strategies such as sleep meditation and relaxation, hypnosis, sound therapy, neurosensory conditioning, and circadian timing.
Podcasts that promise to be so boring and monotone that they will lull insomniacs to sleep have also proliferated in recent years. The popular “Sleep with Me” series, which began in 2013, has recorded more than 650 episodes and has more than two million monthly downloads.
The podcast Auracle promises to utilize a relaxation technique known as autonomous sensory meridian response (ASMR). Meditation podcasts, like Headspace, Meditation Minis, and The Daily Meditation Podcast aim to calm the racing, monkey mind.
And for fans of the TV show “Game of Thrones,” there’s Game of Drones, in which plotlines from the hugely popular fantasy series are discussed, along with wildly off-subject tangents, in a hypnotically boring cadence by a host named Scooter.
Few of the apps have undergone scientific testing. Ong noted that they might benefit people with occasional sleep problems, but they are not likely to do much for those with chronic insomnia.
“These apps use tricks or gimmicks to put people to sleep,” he said. “CBT helps to enhance the regulation of sleep over time, which is different from trying to knock yourself out with some intervention. My guess is that these apps, if they were to be studied, probably wouldn’t be a whole lot more effective than placebo.”
Ong disclosed serving as an investigator on the Sleepio study, and relevant relationships with Big Health.